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See detailWhat research agenda could be generated from the European General Practice Research Network concept of Multimorbidity in Family Practice?
Le Reste, J. Y.; Nabbe, P.; Lingner, H. et al

in BMC family practice (2015), 16(1), 125

BACKGROUND: Multimorbidity is an intuitively appealing, yet challenging, concept for Family Medicine (FM). An EGPRN working group has published a comprehensive definition of the concept based on a ... [more ▼]

BACKGROUND: Multimorbidity is an intuitively appealing, yet challenging, concept for Family Medicine (FM). An EGPRN working group has published a comprehensive definition of the concept based on a systematic review of the literature which is closely linked to patient complexity and to the biopsychosocial model. This concept was identified by European Family Physicians (FPs) throughout Europe using 13 qualitative surveys. To further our understanding of the issues around multimorbidity, we needed to do innovative research to clarify this concept. The research question for this survey was: what research agenda could be generated for Family Medicine from the EGPRN concept of Multimorbidity? METHODS: Nominal group design with a purposive panel of experts in the field of multimorbidity. The nominal group worked through four phases: ideas generation phase, ideas recording phase, evaluation and analysis phase and a prioritization phase. RESULTS: Fifteen international experts participated. A research agenda was established, featuring 6 topics and 11 themes with their corresponding study designs. The highest priorities were given to the following topics: measuring multimorbidity and the impact of multimorbidity. In addition the experts stressed that the concept should be simplified. This would be best achieved by working in reverse: starting with the outcomes and working back to find the useful variables within the concept. CONCLUSION: The highest priority for future research on multimorbidity should be given to measuring multimorbidity and to simplifying the EGPRN model, using a pragmatic approach to determine the useful variables within the concept from its outcomes. [less ▲]

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See detailA randomized controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website (EFAR-FVG): preliminary results
Struzzo, Pierluigi; Vedova, Roberto; Ferrante, Donatella et al

in Addiction Science & Clinical Practice (2015), 10(Suppl 2), 29

Background The effectiveness of brief interventions for risky drinkers by GPs is well documented.[1] However, implementation levels remain low. Facilitated access to an alcohol reduction website offers an ... [more ▼]

Background The effectiveness of brief interventions for risky drinkers by GPs is well documented.[1] However, implementation levels remain low. Facilitated access to an alcohol reduction website offers an alternative to standard face-to-face intervention, but it is unclear whether it is as effective.[2] This study evaluates whether online brief intervention, through GP facilitated access to an alcohol reduction website for risky drinkers, is not inferior to the face-to-face brief intervention conducted by GPs. Material and methods In a northern Italy region participating GPs actively encouraged all patients age 18 attending their practice, to access an online screening website based on AUDIT-C.[3] Those screening positive underwent a baseline assessment with the AUDIT-10[4] and EQ-5D[5] questionnaires and subsequently, were randomly assigned to receive either online counselling on the alcohol reduction website (intervention) or face-to-face intervention based on the brief motivational interview[6] by their GP (control). Follow-up took place at 3 and 12 months and the outcome was calculated on the basis of the proportion of risky drinkers in each group according to the AUDIT-10. Results More than 50% (n= 3974) of the patients who received facilitated access logged-on to the website and completed the AUDIT-C. Just under 20% (n = 718) screened positive and 94% (n= 674) of them completed the baseline questionnaires and were randomized. Of the 310 patients randomized to the experimental Internet intervention, 90% (n = 278) logged-on to the site. Of the 364 patients of the control group, 72% (263) were seen by their GP. A follow-up rate of 94% was achieved at 3 months. Conclusions The offer of GP facilitated access to an alcohol reduction website appears to be an effective way of identifying risky drinkers and enabling them to receive brief intervention. [less ▲]

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See detailCross-Cultural Validation of the Definition of Multimorbidity in the Bulgarian Language.
Assenova, Radost S.; Le Reste, Jean Yves; Foreva, Gergana H. et al

in Folia medica (2015), 57(2), 127--132

INTRODUCTION: Multimorbidity is a health issue with growing importance. During the last few decades the populations of most countries in the world have been ageing rapidly. Bulgaria is affected by the ... [more ▼]

INTRODUCTION: Multimorbidity is a health issue with growing importance. During the last few decades the populations of most countries in the world have been ageing rapidly. Bulgaria is affected by the issue because of the high prevalence of ageing population in the country with multiple chronic conditions. The AIM of the present study was to validate the translated definition of multimorbidity from English into the Bulgarian language. MATERIALS AND METHODS: The present study is part of an international project involving 8 national groups. We performed a forward and backward translation of the original English definition of multimorbidity using a Delphi consensus procedure. RESULTS: The physicians involved accepted the definition with a high percentage of agreement in the first round. The backward translation was accepted by the scientific committee using the Nominal group technique. DISCUSSION: Some of the GPs provided comments on the linguistic expressions which arose in order to improve understanding in Bulgarian. The remarks were not relevant to the content. The conclusion of the discussion, using a meta-ethnographic approach, was that the differences were acceptable and no further changes were required. CONCLUSIONS: A native version of the published English multimorbidity definition has been finalized. This definition is a prerequisite for better management of multimorbidity by clinicians, researchers and policy makers. [less ▲]

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See detailThe European general practice research network presents the translations of its comprehensive definition of multimorbidity in family medicine in ten European languages.
Le Reste, Jean Yves; Nabbe, Patrice; Rivet, Charles et al

in PloS one (2015), 10(1), 0115796

BACKGROUND: Multimorbidity, according to the World Health Organization, exists when there are two or more chronic conditions in one patient. This definition seems inaccurate for the holistic approach to ... [more ▼]

BACKGROUND: Multimorbidity, according to the World Health Organization, exists when there are two or more chronic conditions in one patient. This definition seems inaccurate for the holistic approach to Family Medicine (FM) and long-term care. To avoid this pitfall the European General Practitioners Research Network (EGPRN) designed a comprehensive definition of multimorbidity using a systematic literature review. OBJECTIVE: To translate that English definition into European languages and to validate the semantic, conceptual and cultural homogeneity of the translations for further research. METHOD: Forward translation of the EGPRN's definition of multimorbidity followed by a Delphi consensus procedure assessment, a backward translation and a cultural check with all teams to ensure the homogeneity of the translations in their national context. Consensus was defined as 70% of the scores being higher than 6. Delphi rounds were repeated in each country until a consensus was reached. RESULTS: 229 European medical expert FPs participated in the study. Ten consensual translations of the EGPRN comprehensive definition of multimorbidity were achieved. CONCLUSION: A comprehensive definition of multimorbidity is now available in English and ten European languages for further collaborative research in FM and long-term care. [less ▲]

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See detailInternational Exchanges in Family Medicine: the Hippokrates Exchange Programme.
Rigon, Sara; Lygidakis, Charilaos UL; Pettigrew, Luisa et al

in Education for primary care : an official publication of the Association of Course Organisers, National Association of GP Tutors, World Organisation of Family Doctors (2015), 26(4), 282-4

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See detailDefinizione della multimorbidità in MG: una revisione sistematica
Marzo, Carla; Lygidakis, Charilaos UL; Rigon, Sara et al

in M.D. Medicinae Doctor (2014)

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See detailSay it in Croatian--Croatian translation of the EGPRN definition of multimorbidity using a Delphi consensus technique.
Lazic, Durdica Kasuba; Le Reste, Jean-Yves; Murgic, Lucija et al

in Collegium antropologicum (2014), 38(3), 1027-32

Patients coming to their family physician (FP) usually have more than one condition or problem. Multimorbidity as well as dealing with it, is challenging for FPs even as a mere concept. The World Health ... [more ▼]

Patients coming to their family physician (FP) usually have more than one condition or problem. Multimorbidity as well as dealing with it, is challenging for FPs even as a mere concept. The World Health Organization (WHO) has simply defined multimorbidity as two or more chronic conditions existing in one patient. However, this definition seems inadequate for a holistic approach to patient care within Family Medicine. Using systematic literature review the European General Practitioners Research Network (EGPRN) developed a comprehensive definition of multimorbidity. For practical and wider use, this definition had to be translated into other languages, including Croatian. Here presented is the Croatian translation of this comprehensive definition using a Delphi consensus procedure for forward/backward translation. 23 expert FPs fluent in English were asked to rank the translation from 1 (absolutely disagreeable) to 9 (fully agreeable) and to explain each score under 7. It was previously defined that consensus would be reached when 70% of the scores are above 6. Finally, a backward translation from Croatian into English was undertaken and approved by the authors of the English definition. Consensus was reached after the first Delphi round with 100% of the scores above 6; therefore the Croatian translation was immediately accepted. The authors of the English definition accepted the backward translation. A comprehensive definition of multimorbidity is now available in English and Croatian, as well as other European languages which will surely make further implications for clinicians, researchers or policy makers. [less ▲]

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See detailInfluence of smoking on medication efficacy
Zagà, Vincenzo; Lygidakis, Charilaos UL

in Advances in Smoking Cessation (2013)

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See detailThe European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature.
Le Reste, Jean Yves; Nabbe, Patrice; Manceau, Benedicte et al

in Journal of the American Medical Directors Association (2013), 14(5), 319-25

BACKGROUND: Multimorbidity is a new concept encompassing all the medical conditions of an individual patient. The concept links into the European definition of family medicine and its core competencies ... [more ▼]

BACKGROUND: Multimorbidity is a new concept encompassing all the medical conditions of an individual patient. The concept links into the European definition of family medicine and its core competencies. However, the definition of multimorbidity and its subsequent operationalization are still unclear. The European General Practice Research Network wanted to produce a comprehensive definition of multimorbidity. METHOD: Systematic review of literature involving eight European General Practice Research Network national teams. The databases searched were PubMed, Embase, and Cochrane (1990-2010). Only articles containing descriptions of multimorbidity criteria were selected for inclusion. The multinational team undertook a methodic data extraction, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS: The team identified 416 documents, selected 68 abstracts, included 54 articles, and found 132 definitions with 1631 different criteria. These criteria were aggregated into 11 themes that led to the following definition: Multimorbidity is defined as any combination of chronic disease with at least one other disease (acute or chronic) or biopsychosocial factor (associated or not) or somatic risk factor. Any biopsychosocial factor, any risk factor, the social network, the burden of diseases, the health care consumption, and the patient's coping strategies may function as modifiers (of the effects of multimorbidity). Multimorbidity may modify the health outcomes and lead to an increased disability or a decreased quality of life or frailty. CONCLUSION: This study has produced a comprehensive definition of multimorbidity. The resulting improvements in the management of multimorbidity, and its usefulness in long term care and in family medicine, will have to be assessed in future studies. [less ▲]

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See detailInfluenza del fumo di tabacco sui trattamenti farmacologici
Zagà, Vincenzo; Lygidakis, Charilaos UL; Pozzi, Paolo et al

in Tabaccologia (2013), (1), 35-47

Cigarette smoke, that contains more than 4.000 substances, may directly or indirectly influences the efficacy and the tolerability of many medications through complex pharmacokinetic and pharmacodinamic ... [more ▼]

Cigarette smoke, that contains more than 4.000 substances, may directly or indirectly influences the efficacy and the tolerability of many medications through complex pharmacokinetic and pharmacodinamic interactions. In fact, cigarette smoke, and in particular polycyclic aromatic hydrocarbons, nicotine, carbon monoxide and heavy metals, powerful enzymatic inducers, determines modifications of the sistemic and local bioavailability of several drugs. Therefore, in patients who are currently assuming any therapy, the clinicians should consider adjustments of dosages either when a smoker patient starts a new drug or when he quits smoking. The purpose of this review is to examine the main drug interactions with tobacco smoke clinically relevant that can be of particular importance especially in patients with multiple comorbidities, with a closer look on those who developed respiratory, cardiovascular, oncologic or psychiatric diseases. [less ▲]

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See detailA research group from the European General Practice Research Network (EGPRN) explores the concept of multimorbidity for further research into long term care.
Le Reste, Jean Yves; Nabbe, Patrice; Lygidakis, Charilaos UL et al

in Journal of the American Medical Directors Association (2013), 14(2), 132-3

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See detailA randomised controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website (EFAR-FVG): the study protocol.
Struzzo, Pierluigi; Scafato, Emanuele; McGregor, Richard et al

in BMJ open (2013), 3(2),

INTRODUCTION: There is a strong body of evidence demonstrating the effectiveness of brief interventions by primary care professionals for risky drinkers. However, implementation levels remain low because ... [more ▼]

INTRODUCTION: There is a strong body of evidence demonstrating the effectiveness of brief interventions by primary care professionals for risky drinkers. However, implementation levels remain low because of time constraints and other factors. Facilitated access to an alcohol reduction website offers primary care professionals a time-saving alternative to standard face-to-face intervention, but it is not known whether it is as effective. METHODS AND ANALYSIS: A randomised controlled non-inferiority trial for risky drinkers comparing facilitated access to a dedicated website with standard face-to-face brief intervention to be conducted in primary care settings in the Region of Friuli Giulia Venezia, Italy. Adult patients will be given a leaflet inviting them to log on to a website to complete the Alcohol Use Disorders Identification Test (AUDIT-C) alcohol screening questionnaire. Screen positives will be requested to complete an online trial module including consent, baseline assessment and randomisation to either standard intervention by the practitioner or facilitated access to an alcohol reduction website. Follow-up assessment of risky drinking will be undertaken online at 1 month, 3 months and 1 year using the full AUDIT questionnaire. Proportions of risky drinkers in each group will be calculated and non-inferiority assessed against a specified margin of 10%. Assuming a reduction of 30% of risky drinkers receiving standard intervention, 1000 patients will be required to give 90% power to reject the null hypothesis. ETHICS AND DISSEMINATION: The protocol was approved by the Isontina Independent Local Ethics Committee on 14 June 2012. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations and public events involving the local administrations of the towns where the trial participants are resident. REGISTRATION DETAILS: Trial registration number NCT: 01638338. [less ▲]

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See detailAn Online Platform as a Tool for Surveys by Patient Associations
Lygidakis, Charilaos UL; Vögele, Claus UL; Cambiaso, Silvio et al

in Global Telemedicine and eHealth Updates: Knowledge Resources (2013), 6

Patients are increasingly interested in sharing their experiences and learning about their conditions, their prevention and treatments, and are more frequently turning into advocates. The connectivity and ... [more ▼]

Patients are increasingly interested in sharing their experiences and learning about their conditions, their prevention and treatments, and are more frequently turning into advocates. The connectivity and the wide availability of data have been shown to support this development enabling patients to play an active role in healthcare. The “Lumos!” platform is a web-based solution that has been designed to facilitate teams of researchers conducting multicentre studies, especially in countries and contexts with low research capacity. Nevertheless, it can be modified and tailored as a tool for research studies carried out by patient organisations. The aim of this study is to assess the feasibility of an online platform as a tool for anonymous surveys conducted by a patient organisation. Methods: A questionnaire is currently being distributed in the Region of Emilia Romagna (Italy) by the Regional Federation of Diabetics with the aim to study the needs of patients that use self-check-up devices. This observational study has been designed online with the use of the “Lumos!” platform, which enables the creation of the questionnaire with adjustable fields and variables, using the expertise of the participants and the creation of reports. Furthermore, a URL and a QR code linking to the questionnaire are being published on Social Networks and websites inviting people to participate in the study. Several data will be retrieved from the logs of the platform, such as the time required to complete a questionnaire by a patient, the number and types of errors, and the percentage of completed items. These variables will be analysed taking into account the demographic characteristics of the patients. Conclusions: By studying the indicators of the implementation and the characteristics of the participants, it will be possible to optimise participation rates and achieve higher engagement from the participants in the future. We expect that with the help of the online platform, patient associations will be supported in their quest to conduct surveys and, as a secondary outcome; they will empower their members to play a more active role in healthcare. [less ▲]

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See detailRandomised controlled non-inferiority trial of primary care based facilitated access to an alcohol reduction website (EFAR-FVG)
Wallace, Paul; Struzzo, Piero; della Vedova, Roberto et al

in Addiction Science & Clinical Practice (2013)

Introduction There is a strong body of evidence demonstrating effectiveness of brief interventions by primary care professionals for risky drinkers but implementation levels remain low. Facilitated access ... [more ▼]

Introduction There is a strong body of evidence demonstrating effectiveness of brief interventions by primary care professionals for risky drinkers but implementation levels remain low. Facilitated access to an alcohol reduction website constitutes an innovative approach to brief intervention, offering a time-saving alternative to face to face intervention, but it is not known whether it is as effective. Objective To determine whether facilitated access to an alcohol reduction website is equivalent to face to face intervention. Methods Randomised controlled non-inferiority trial for risky drinkers comparing facilitated access to a dedicated website with face to face brief intervention conducted in primary care settings in the Region of Friuli Venezia-Giulia, Italy. Adult patients are given a leaflet inviting them to log on to a website to complete the AUDIT-C alcohol screening questionnaire. Screen positives are requested to complete an online trial module including consent, baseline assessment and randomisation to either standard intervention by the practitioner or facilitated access to an alcohol reduction website. Follow up assessment of risky drinking is undertaken online at 1 month, 3 months and 1 year using the full AUDIT questionnaire. Proportions of risky drinkers in each group will be calculated and non-inferiority assessed against a specified margin of 10%. The trial is being undertaken as an initial pilot and a subsequent main trial. Results 12 practices have participated in the pilot, and more than 1300 leaflets have been distributed. 89 patients have been recruited to the trial with a one month follow-up rate of 79%. Discussion The findings of the pilot study suggest that the trial design is feasible, though modifications will be made to optimize performance in the main trial which will commence in January 2014. Plans are concurrently underway to replicate the trial in Australia, and potentially in the UK and Spain. [less ▲]

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See detailPolonium and Cancer
Zagà, Vincenzo; Lygidakis, Charilaos UL

in Kretsinger, Robert H.; Uversky, Vladimir N.; Permyakov, Eugene A. (Eds.) Encyclopedia of Metalloproteins (2013)

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See detailLa Comunicazione con il paziente in Medicina Generale
Rigon, Sara; Lygidakis, Charilaos UL

in Italian Journal of Primary Care (2011), 3(3),

Patient communication plays an essential role in everyday clinical practice in General Practice (GP). It is possible to observe the communication skillstechniques in European countries, during the ... [more ▼]

Patient communication plays an essential role in everyday clinical practice in General Practice (GP). It is possible to observe the communication skillstechniques in European countries, during the exchange programmes for GP trainees, which are organised by the Vasco da Gama Movement. The patientagenda often does not match the physician’s and sometimes is also neglected or misinterpreted. This may lead to low patient satisfaction and suboptimalclinical practice. Knowing how to approach the patient’s problems and fears, besides managing his/hers expectations, is of high importance in order toenhance satisfaction and quality of care. Furthermore, GP’s unique position should be considered, as he/she can discuss difficult and sensible topicswith his/her patients. The ICE (Ideas, Concerns and Expectations) model is an example of holistic and patient-centred approach, which is appropriatefor GPs, and explores the patient’s point of view concerning diagnosis and treatment. The importance of medical communication is also emphasised ineducation. For instance, a correct and consistent assessment of the communication skills in GP is possible with the use of the MAAS-Global scale. [less ▲]

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See detailPolonium 210: is it possible to decrease the risk for smokers?
Zaga, Vicenzo; Lygidakis, Charilaos UL

in Tabaccologia (2011), (1), 5-7

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See detailPolonium and lung cancer.
Zaga, Vincenzo; Lygidakis, Charilaos UL; Chaouachi, Kamal et al

in Journal of oncology (2011), 2011

The alpha-radioactive polonium 210 (Po-210) is one of the most powerful carcinogenic agents of tobacco smoke and is responsible for the histotype shift of lung cancer from squamous cell type to ... [more ▼]

The alpha-radioactive polonium 210 (Po-210) is one of the most powerful carcinogenic agents of tobacco smoke and is responsible for the histotype shift of lung cancer from squamous cell type to adenocarcinoma. According to several studies, the principal source of Po-210 is the fertilizers used in tobacco plants, which are rich in polyphosphates containing radio (Ra-226) and its decay products, lead 210 (Pb-210) and Po-210. Tobacco leaves accumulate Pb-210 and Po-210 through their trichomes, and Pb-210 decays into Po-210 over time. With the combustion of the cigarette smoke becomes radioactive and Pb-210 and Po-210 reach the bronchopulmonary apparatus, especially in bifurcations of segmental bronchi. In this place, combined with other agents, it will manifest its carcinogenic activity, especially in patients with compromised mucous-ciliary clearance. Various studies have confirmed that the radiological risk from Po-210 in a smoker of 20 cigarettes per day for a year is equivalent to the one deriving from 300 chest X-rays, with an autonomous oncogenic capability of 4 lung cancers per 10000 smokers. Po-210 can also be found in passive smoke, since part of Po-210 spreads in the surrounding environment during tobacco combustion. Tobacco manufacturers have been aware of the alpha-radioactivity presence in tobacco smoke since the sixties. [less ▲]

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See detailIs appropriate management of atrial fibrillation in primary care a utopia?
Lygidakis, Charilaos UL; Argyriadou, Stella; Lygera, Anastasia

in Journal of primary care & community health (2010), 1(1), 17-21

OBJECTIVE: The authors aimed at reporting on whether or not primary care doctors follow atrial fibrillation (AF) treatment protocols, and on the mental distress of such patients. METHODS: A total of 138 ... [more ▼]

OBJECTIVE: The authors aimed at reporting on whether or not primary care doctors follow atrial fibrillation (AF) treatment protocols, and on the mental distress of such patients. METHODS: A total of 138 patients with first detected or recurrent AF were examined in a health center. Demographic data were collected and their lifestyle and medical history for rhythm-related pathologies and chronic medication were investigated. Physical examination, electrocardiogram (EKG), and in selected cases, lab analysis were carried-out. CHADS2 index was used for assessing the stroke risk in patients with AF, while the General Health Questionnaire-12 (GHQ-12) for personal health perception was performed in all patients. RESULTS: According to CHADS2 the majority of the patients had at least 1 risk factor and half of those receiving oral vitamin K antagonists presented an out-of-range international normalized ratio (INR). In 24 cases, patients used both aspirin and oral anticoagulants, while in 41 cases, medication was corrected according to index. GHQ-12 seemed to be significantly worse in paroxysmal and persistent cases, as well as in women with recurrent AF. Many paroxysmal AF patients under 75 years continued caffeine intake, whereas an extensive use of benzodiazepines was noticed in the majority of patients. CONCLUSIONS: Shortages and limitations of the peripheral or rural units and health centers and inadequate knowledge and application of the guidelines, seemed to be major factors responsible for mismanaging AF patients. More education in prehospital cardiology may contribute in improving management of arrhythmias in primary care. [less ▲]

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See detailA web-based versus paper questionnaire on alcohol and tobacco in adolescents.
Lygidakis, Charilaos UL; Rigon, Sara; Cambiaso, Silvio et al

in Telemedicine journal and e-health : the official journal of the American Telemedicine Association (2010), 16(9), 925-30

OBJECTIVE: Our study was aimed at comparing health behavior data collected from a Web-based self-administered questionnaire (Web SAQ) versus a paper-and-pencil self-administered questionnaire and ... [more ▼]

OBJECTIVE: Our study was aimed at comparing health behavior data collected from a Web-based self-administered questionnaire (Web SAQ) versus a paper-and-pencil self-administered questionnaire and assessing the feasibility of the application. MATERIALS AND METHODS: One hundred and ninety (n = 190) pupils (ages 14-16 years) of senior high schools anonymously completed a questionnaire, with demographics and queries about lifestyle, alcohol, and tobacco use. For each class, the adolescents were randomly assigned to complete either the paper version of the questionnaire or the equivalent Web-based one, which used a customized platform developed for the purposes of this survey. RESULTS: Females who filled out the Web SAQ required significantly less time and completed a significantly higher percentage of its items. Although the majority of questions on tobacco and alcohol did not differ significantly across the two administration modes, there were gender-related differences in some sensitive information. Male adolescents on the Web SAQ accounted higher per hour drink consumption (r = 0.27, p = 0.015) and more numerous episodes of inebriety (r = 0.26, p = 0.010), whereas females seemed to state a younger age of alcohol onset (r = 0.33, p = 0.002). Females were more likely to report being monthly smokers on the Web SAQ (odds ratio = 0.37). Adolescents felt significantly less observed and females referred being more independent while compiling the Web SAQ. CONCLUSIONS: The findings of the study suggest that differences in reporting of some behavior of adolescents when using a Web SAQ do exist, despite the small-to-medium effect sizes. Exploiting the Web requires further investigation for extensive comprehension of the reasons for such differences. [less ▲]

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