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Advances in Experimental Medicine and Biology 1425
Panagiotis Vlamos Editor
GeNeDis
2022
Neuroscientific Advances

Advances in Experimental Medicine
and Biology
Volume 1425
Series Editors
Wim E. Crusio, Institut de Neurosciences Cognitives et Intégratives
d’Aquitaine, CNRS and University of Bordeaux, Pessac Cedex, France
Haidong Dong, Departments of Urology and Immunology, Mayo Clinic,
Rochester, MN, USA
Heinfried H. Radeke, Institute of Pharmacology and Toxicology, Clinic of
the Goethe University Frankfurt Main, Frankfurt am Main, Hessen,
Germany
Nima Rezaei, Research Center for Immunodeciencies, Children's Medical
Center, Tehran University of Medical Sciences, Tehran, Iran
Ortrud Steinlein, Institute of Human Genetics, LMU University Hospital,
Munich, Germany
Junjie Xiao, Cardiac Regeneration and Ageing Lab, Institute of
Cardiovascular Sciences, School of Life Science, Shanghai University,
Shanghai, China

Advances in Experimental Medicine and Biology provides a platform for
scientic contributions in the main disciplines of the biomedicine and the life
sciences. is series publishes thematic volumes on contemporary research in
the areas of microbiology, immunology, neurosciences, biochemistry,
biomedical engineering, genetics, physiology, and cancer research. Covering
emerging topics and techniques in basic and clinical science, it brings together
clinicians and researchers from various elds.
Advances in Experimental Medicine and Biology has been publishing
exceptional works in the eld for over 40 years, and is indexed in SCOPUS,
Medline (PubMed), EMBASE, BIOSIS, Reaxys, EMBiology, the Chemical
Abstracts Service (CAS), and Pathway Studio.
2021 Impact Factor: 3.650 (no longer indexed in SCIE as of 2022)

Panagiotis Vlamos
Editor
GeNeDis 2022
Neuroscientic Advances

ISSN 0065-2598 ISSN 2214-8019 (electronic)
Advances in Experimental Medicine and Biology
ISBN 978-3-031-31985-3 ISBN 978-3-031-31986-0 (eBook)
https://doi.org/10.1007/978-3-031-31986-0
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Editor
Panagiotis Vlamos
Department of Informatics
Ionian University
Corfu, Greece

To Ada, who gave me the chance to
embrace the joys of maturity, the spirit
of teenage adventure, and the wonder of
childhood, simultaneously.

vii
I would like to thank Konstantina Skolariki for her invaluable assistance in
editing and compiling the conference proceedings. Her contribution, dedica-
tion, and attention to detail have been instrumental in the success of our
conference.
Acknowledgements

ix
1 Public’s Attitudes Toward Mentally Ill Offenders
in Greece�� 1
S. Martinaki, K. Athanasiadis, A. Gkontolia, E. Karachaliou,
A. Karaiskos, E. Sakellariou, Th. Tsiapla,
and F. Chatzinikolaou
1.1 Introduction�� 2
1.2 Methods�� 3
1.2.1 Sample and Procedure�� 3
1.2.2 Measurement Instruments�� 3
1.2.3 Data Analysis�� 3
1.3 Results�� 4
1.4 Discussion�� 8
1.5 Conclusions�� 10
References�� 11
2 Pythagorean Self-Awareness Intervention Promoted
Healthy Dietary Patterns, Controlled Body Mass Index,
and Reduced Self-Reported Stress Levels of Primary
School Children: Α One-Arm Pilot Study�� 13
Marilena Panagiotou, Ioanna Maria Velegraki,
Orsalia Gerakini, Flora Bacopoulou, Maria
Charalampopoulou, Maya Louvardi, Xanthi Tigani,
Aimilia Mantzou, Dimitrios Vlachakis,
Christina Kanaka-Gantenbein, George P. Chrousos,
and Christina Darviri
2.1 Introduction�� 14
2.2 Subjects and Methods�� 15
2.2.1 Study Design�� 15
2.2.2 P�� 15
2.2.3 Measurements�� 15
2.2.4 Pythagorean Self-Awareness Intervention
for Children and Adolescents�� 16
2.2.5 Statistical Methods�� 17
2.3 Results�� 17
2.4 Discussion�� 19
2.5 Conclusions�� 20
References�� 20
Contents

x
3 The Effect of Psychological Resilience
and Coping Strategies on Mental Health of Nurses�� 23
Evangelos C. Fradelos, Ioanna V. Papathanasiou,
Chrysoula Dafogianni, Evdokia Misouridou,
Ioannis Koutelekos, Evangelos Dousis, Eugenia Vlachou,
Eleni Evangelou, Victoria Alikari, Georgia Gerogianni,
Maria Polikandrioti, and Afroditi Zartaloudi
3.1 Introduction�� 24
3.2 Material and Method�� 24
3.2.1 Ethics�� 25
3.2.2 Measurement Tools�� 25
3.2.3 Statistical Analysis�� 25
3.3 Results�� 25
3.4 Discussion�� 27
3.4.1 Limitations�� 28
3.5 Conclusions�� 29
References�� 29
4 Anxiety and Depression in Parents of Children
Undergoing Hematopoietic Stem Cell Transplant (HSCT)�� 31
Alexandra Papasarantopoulou, Maria Polikandrioti,
Evangelos Dousis, Eleni Evagelou, Aphrodite Zartaloudi,
Chrisoula Dafogianni, Evdokia Misouridou, Niki Pavlatou,
Kostantinos Mintzaridis, and Ioannis Koutelekos
4.1 Introduction�� 32
4.2 Methods and Material�� 32
4.2.1 Design, Setting, and Period of the Study�� 32
4.2.2 Sample: Inclusion and Exclusion Criteria�� 32
4.2.3 Data Collection and Procedure�� 33
4.2.4 Research Instrument�� 33
4.2.5 Assessment of Anxiety/Depression�� 33
4.2.6 Ethical Considerations�� 33
4.2.7 Statistical Analysis�� 34
4.3 Results�� 34
4.3.1 Sample Description�� 34
4.3.2 Anxiety/Depression Levels�� 34
4.3.3 Factors Associated with Parents’
Anxiety/Depression�� 35
4.3.4 Impact of Parents’ Characteristics
on Anxiety/Depression�� 37
4.4 Discussion�� 39
4.4.1 Limitations of the Study�� 44
4.5 Conclusions�� 44
References�� 44

xi
5 Investigation of Anxiety and Health Locus
of Control in Patients Undergoing Hemodialysis�� 47
Soa Kalini, Afroditi Zartaloudi, Anna Kavga,
Angeliki Stamou, Victoria Alikari, Evangelos C. Fradelos,
and Georgia Gerogianni
5.1 Introduction�� 47
5.2 Materials and Methods�� 48
5.2.1 Instruments�� 48
5.2.2 Data Analysis�� 49
5.3 Results�� 49
5.3.1 Sample Characteristics�� 49
5.3.2 Association of Anxiety Scale with Patient
Characteristics�� 50
5.4 Discussion�� 51
5.4.1 Limitations of the Study�� 55
5.5 Conclusions�� 55
References�� 56
6 The Effect of Pythagorean Self-Awareness Intervention
on Stress and Mental Health Characteristics
of Civil Servants in Crete, Greece�� 59
Christina Darviri, Eleni Zigkiri, Dimitrios S. Simos,
Maria Charalampopoulou, Ioulia Kokka, Dimitrios Vlachakis,
Flora Bacopoulou, and George P. Chrousos
6.1 Introduction�� 60
6.2 Subjects and Methods�� 60
6.2.1 Study Design, Setting, and Participants�� 60
6.2.2 Intervention�� 61
6.2.3 Measurements�� 61
6.2.4 Statistical Analysis�� 62
6.3 Results�� 62
6.4 Discussion�� 62
6.5 Conclusion�� 65
References�� 66
7 Coping Strategies in Greek Parents of Children
with Cancer�� 69
Ioannis Koutelekos, Maria Polikandrioti, Panagiota Krokou,
Evangelos Dousis, Chrisoula Ntafogianni, Eleni Evagelou,
Eugenia Vlachou, Vasiliki Ntre, Stella Geronikolou,
Dimitris Koukoularis, and Aphrodite Zartaloudi
7.1 Introduction�� 70
7.2 Material and Method�� 70
7.3 Results�� 71
7.4 Discussion�� 71
7.4.1 Limitations of the Study�� 76
7.5 Conclusion�� 76
References�� 76
ContentsContents

xii
8 Validation of the Greek Version of the State Shame
and Guilt Scale (SSGS)�� 79
Ioanna Tzelepi, Lida Sotiropoulou, Flora Bacopoulou,
Maria Charalampopoulou, Eleni Zigkiri, Dimitrios S. Simos,
Dimitrios Vlachakis, George P. Chrousos,
and Christina Darviri
8.1 Introduction�� 80
8.2 Subjects and Methods�� 82
8.2.1 T�� 82
8.2.2 P�� 82
8.2.3 Ethical Considerations�� 82
8.2.4 Measures�� 83
8.3 Statistical Analysis�� 83
8.4 Results�� 83
8.5 Discussion�� 85
References�� 89
9 Factors Contributing to Stress and Well-Being
Among Trainee Psychiatrists in Victoria, Australia�� 93
Rhoda Lai, Kevin Teoh, and Christos Plakiotis
9.1 Introduction�� 93
9.2 Methods�� 94
9.2.1 P�� 94
9.2.2 Data Analysis�� 94
9.3 Results�� 95
9.3.1 P�� 95
9.3.2 Theme 1: Sources of Stress�� 95
9.3.3 Theme 2: Sources of Support and Well-Being�� 97
9.4 Discussion�� 98
Appendix: Interview Schedule��100
References��103
10 Family Recovery from Addiction and Trauma:
An Interpretative Phenomenological Analysis
of Mothers’ Lived Experience��105
E. Missouridou, E. Segredou, E. Stefanou, V. Sakellaridi,
M. Gremou, E. Kritsiotakis, P. Kokori, E. Roditi,
V. Karahaliou, I. Rizavas, A. Vasiliou, S. Patseas,
and S. Parissopoulos
10.1 Introduction��106
10.2 Method��107
10.2.1 Data Analysis��107
10.2.2 Introducing the Participants��107
10.3 Results��110
10.4 Discussion��115
References��116
Contents

xiii
11 Post-traumatic Stress Disorder as a Risk Factor
for the Development of Risky Behavior Among
Adolescent Offenders: A Systematic Review��119
Eleni Zaverdinou, Maria Katimertzi, George P. Chrousos,
Christina Darviri, Dimitrios Vlachakis,
Christina Kanaka-Gantenbein, and Flora Bacopoulou
11.1 Introduction��120
11.2 Methods��120
11.2.1 Search Strategy��120
11.2.2 Eligibility Criteria��120
11.3 Results��121
11.3.1 Study Characteristics��121
11.3.2 Sampling��121
11.3.3 Evaluation Tools��122
11.3.4 Outcomes��126
11.4 Discussion��126
11.4.1 General Findings��127
11.4.2 Limitations��128
11.4.3 Short- and Long-Term Effects��128
11.5 Conclusions��128
References��128
12 Depression and Atherosclerotic Cardiovascular
Disease (ASCVD) Risk Estimator in Women��131
Moschoula-Mina Iordani, Maria Polikandrioti,
Theodore Kapadohos, Andriana Maggita, Kallirrhoe Kourea,
Ioannis Koutelekos, Evangelos Dousis,
and Afroditi Zartaloudi
12.1 Introduction��131
12.2 Material and Methods��132
12.2.1 Instruments��132
12.2.2 Statistical Analysis��133
12.3 Results��133
12.3.1 Sample Description��133
12.3.2 Depression Levels��133
12.3.3 Association Between Patients’
Self-Reported Characteristics
and Depression��133
12.3.4 Effects of Patients’ Characteristics
on Depression Questionnaire��134
12.4 Discussion��134
12.4.1 Limitations of the Study��137
12.5 Conclusions��137
References��138
Contents

xiv
13 Greek Adaptation and Validation of the Bad
Sobernheim Stress Questionnaire-Brace
and the Bad Sobernheim Stress
Questionnaire-Deformity��141
A. Kastrinis, G. Koumantakis, M. Tsekoura, E. Nomikou,
M. Katsoulaki, M. Takousi, N. Strimpakos,
and Z. Dimitriadis
13.1 Introduction��142
13.2 Methods��142
13.2.1 Procedures��143
13.2.2 Participants��143
13.3 Results��144
13.3.1 Translation��144
13.4 Discussion��145
13.5 Conclusion��147
References��148
14 Burnout in General Surgeons. A Systematic Review��151
Petros Loukas Chalkias, Georgia Goulidaki Vosynioti,
Maria Charalampopoulou, Dimitrios Vlachakis,
Christina Darviri, George P. Chrousos, and Flora Bacopoulou
14.1 Introduction��152
14.2 Materials and Methods��153
14.2.1 Search Strategy��153
14.2.2 Eligibility Criteria��153
14.2.3 Bias Assessment��153
14.3 Results��153
14.3.1 Study Selection��153
14.3.2 Data Extraction��153
14.4 Discussion��153
14.5 Conclusion��158
References��158
15 When the “Scytale” of Alcohol Runs in a Family
and Alcohol Use Becomes a Transgenerational Issue:
Case Report of a Father and Son Attending the Same
Therapeutic Program��161
Eirini Segredou, Vasiliki Sakellaridi, Paraskevi Nikolaidou,
Kyriaki Therapou, Stamatia Lagou, Aikaterini Filippi,
Evangelos Poulis, Konstantina Thanopoulou,
Marilena Gkremou, Maria Tzaferi, and Evdokia Missouridou
15.1 Introduction��162
15.2 F��163
15.3 Purpose��163
15.4 Method��163
15.5 P��163
15.6 V��165
15.7 Discussion��165
15.8 Conclusions��168
References��168
Contents

xv
16 Pathways to Mental Health Care in a Defined
Geographic Area of Athens��171
Afroditi Zartaloudi
16.1 Introduction��171
16.2 Materials and Methods��172
16.2.1 Measures��173
16.2.2 Data Analysis��173
16.3 Results��173
16.4 Discussion��178
16.4.1 Limitations of the Research��179
16.5 Conclusion��179
References��180
17 Cultural Adaptation and Validation of the Spiritual
Coping Strategies Scale (SCSS) for Greece��183
E. Missouridou, P. Mangoulia, V. Pavlou, K. Kasidi,
S. Parissopoulos, P. Apostolara, E. Roditi, V. Sakellaridi,
I. Koutelekos, G. Fasoi, and E. Fradelos
17.1 Introduction��184
17.2 Methods��185
17.3 Results��186
17.4 Discussion��187
17.5 Conclusion��189
References��190
18 The Validation of the COmprehensive Score for Financial
Toxicity (COST) Scale in Greek Language��191
Evangelos C. Fradelos, Paraskevi Maria Prapa,
Konstantinos Tsaras, Dimitrios Papagiannis, Maria Chatzi,
Ioanna V. Papathanasiou, Bob Guillen, Maria Saridi,
and Kyriakos Souliotis
18.1 Introduction��192
18.2 Objectives��193
18.3 Methods��193
18.3.1 Study Sample��193
18.3.2 Instruments��193
18.3.3 The 12-Item Health Survey (SF-12)��193
18.3.4 Content and Face Validation��193
18.4 Statistical Analyses��194
18.5 Results��194
18.6 Construct Validity of the Greek Version
of FACIT-COST��194
18.7 Con��194
18.8 Reliability of FACIT-COST��194
18.9 Discussion��195
18.10 Conclusions��196
References��196
Contents

xvi
19 The Impact of Changes in Mental Health Legislation
on Psychiatry Trainee Stress in Victoria, Australia��199
Rhoda Lai, Kevin Teoh, and Christos Plakiotis
19.1 Introduction��199
19.2 Methods��200
19.2.1 Participants and Procedures��200
19.2.2 Data Analysis��200
19.3 Results��201
19.3.1 Participants��201
19.3.2 Impact on Workload��201
19.3.3 Positive Aspects of the MHA��202
19.4 Discussion��202
References��204
20 Mindfulness and Academic Performance of College
and University Students: A Systematic Review��207
Ioanna Tzelepi, Flora Bacopoulou, George P. Chrousos,
Lida Sotiropoulou, Dimitrios Vlachakis, and Christina Darviri
20.1 Introduction��208
20.2 Methods��209
20.2.1 Data Sources��209
20.2.2 Study Selection��209
20.3 Results��209
20.4 Discussion��212
20.5 Conclusions��213
References��214
21 Investigating Mobbing Syndrome’s Incidence
in the Working Environment of a Public
and a Private Greek Hospital��217
Panagiotis Theodorou, Charitomeni Matzoula,
Psomiadi Maria-Elissavet, Platis Charalampos,
and Bellali Thalia
21.1 Background��217
21.2 Materials and Methods��218
21.2.1 Study Population��218
21.2.2 Research Tool��218
21.2.3 Statistical Analysis��219
21.3 Results��219
21.4 Discussion��223
21.4.1 Limitations��224
21.5 Conclusions��225
References��225
22 How Does Meditation Affect the Default Mode
Network: A Systematic Review��229
Dimitrios Zagkas, Flora Bacopoulou, Dimitrios Vlachakis,
George P. Chrousos, and Christina Darviri
22.1 Introduction��230
Contents

xvii
22.2 Methods��231
22.2.1 Search Strategy of Literature��231
22.2.2 Selection Criteria��231
22.2.3 Data Extraction and Quality Assessment��231
22.3 Results��231
22.3.1 Study Selection��231
22.3.2 Quality Assessment��231
22.4 Discussion��242
22.5 Conclusion��243
References��243
23 Job Satisfaction of Nurses Versus Other Mental Health
Professionals Working in Psychosocial
Rehabilitation Services��247
Loukia Karvouni, Theodoula Adamakidou,
Marianna Mantzorou, Alexandra Mantoudi,
Dimitrios Christopoulos, Georgia Fasoi,
and Afroditi Zartaloudi
23.1 Introduction��248
23.2 Material and Methods��248
23.2.1 Ethics��248
23.2.2 Measurement Tools��249
23.2.3 Statistical Analysis��249
23.3 Results��249
23.4 Discussion��252
23.4.1 Limitations��254
23.5 Conclusions��255
References��255
24 Depressive Symptoms and Anger Expression
Among Survivors After Stroke��257
Anastasia Papadopoulou, Panagiotis Papadopoulos,
Eirini Grammatopoulou, Anna Kavga, Alexandra Koreli,
Alexandra Mantoudi, Angeliki Stamou, Georgia Gerogianni,
and Afroditi Zartaloudi
24.1 Introduction��257
24.2 Methodology��258
24.2.1 Data Collection��258
24.2.2 Instruments��258
24.2.3 Statistical Analysis��259
24.3 Results��260
24.4 Discussion��262
24.4.1 Limitation of the Study��263
24.5 Conclusions��263
References��264
Contents

xviii
25 Correlation of Cancer Caregiver’s Burden, Stress,
and Their Quality of Life��267
Theodora Fellia, Pavlos Saras, Axilleas Bouletis,
Vasileios Tzenetidis, Iokasti Papathanasiou,
Theodora-Paisia Apostolidi, Niki Gkena,
Athanasios Nikolentzos, Anna Patsopoulou,
and Maria Malliarou
25.1 Introduction��268
25.2 Material and Method��269
25.3 Statistical Analysis��269
25.4 Results��269
25.5 Discussion��271
25.6 Conclusions and Suggestions��272
References��272
26 Changes in Smoking Habits in Greece During
the Lockdown Measures Due to COVID-19��275
Ioannis C. Lampropoulos, Paraskevi Kirgou,
Dimitrios G. Raptis, Erasmia Rouka, Ourania Kotsiou,
Dimitrios Papagiannis, Zoe Daniil,
Konstantinos I. Gourgoulianis, and Foteini Malli
26.1 Background��276
26.2 Methods��276
26.3 Results��277
26.4 Discussion��278
References��280
27 Assessment of Burden in Family Caregivers
of Chronic Hemodialysis and Peritoneal Dialysis
Patients During the Pandemic Period of COVID-19��283
Pantelis Stergiannis, Maria Christoforaki, Charalampos Platis,
Eleni Lahana, Aikaterini Niki Oikonomou, and George Intas
27.1 Introduction��284
27.2 Materials and Methods��284
27.2.1 Statistical Analysis��285
27.3 Results��285
27.4 Discussion��288
27.4.1 Characteristics of Caregivers��288
27.4.2 Quality of Life, Burden, and Fear
Due to COVID-19��288
27.4.3 Characteristics, Quality of Life,
Burden, and Fear Due to COVID-19��289
27.5 Conclusions��289
References��289
Contents

xix
28 Attitudes of Employees in Unaccompanied Children’s
Shelters and Work-Related Stress During
the COVID-19 Pandemic��291
Eirini-Chrysovalandou Αndravizou, Emmanouil Zoumakis,
Dimitrios Vlachakis, Christina Kanaka-Gantenbein,
and Flora Bacopoulou
28.1 Introduction��292
28.1.1 Introductory Statistics on the
Refugee Issue��292
28.1.2 COVID-19 Impact��293
28.1.3 Stress and Impact on Employees��293
28.1.4 Burnout of Employees in Shelters
for Unaccompanied Minors��294
28.2 Methods��294
28.2.1 Methods and Procedure��294
28.2.2 Participants��294
28.2.3 Inclusion Criteria��295
28.2.4 Exclusion Criteria��295
28.2.5 Ethical Considerations��295
28.2.6 Measures��295
28.2.7 Statistical Analysis��296
28.3 Results��296
28.4 Discussion��298
References��301
29 Perceived Social Support in Parents of Hospitalized
Children During COVID-19��303
Dimitra Mourdoukouta, Maria Polikandrioti,
Evangelos Dousis, Eleni Evangelou, Afrodite Zartaloudi,
Chrysoula Dafogianni, Georgia Toulia, Niki Pavlatou,
Vasiliki Tsoulou, and Ioannis Koutelekos
29.1 Introduction��304
29.2 Method and Material��304
29.2.1 Design, Setting, and Period of the Study��304
29.2.2 Sample: Inclusion and Exclusion Criteria��304
29.2.3 Data Collection and Procedure��305
29.2.4 Assessment of Perceived Social Support��305
29.2.5 Ethical Considerations��305
29.2.6 Statistical Analysis��305
29.3 Results��306
29.3.1 Sample Description��306
29.4 Discussion��309
References��315
Contents

xx
30 Investigation of the Level of Burnout in Health
Care Professionals in COVID-19 Pandemic Conditions��319
Aspasia Valavani, Eleftheria Garavela,
Ioanna V. Papathanasiou, Konstantinos Tsaras,
Evangelos C. Fradelos, Dimitrios Papagiannis,
Paraskevi Kirgou, Dimitrios G. Raptis,
Konstantinos I. Gourgoulianis, and Foteini Malli
30.1 Introduction��319
30.2 Methods��320
30.2.1 Sample��320
30.2.2 Statistical Analysis��321
30.3 Results��321
30.4 Discussion��322
30.5 Conclusions��323
References��324
31 Moderate Severity SARS-CoV-2 (COVID-19) Affects
Ocular Vergence Indices: Eye Tracking-Based Study��325
Alex O. Tromov, Darya I. Agarkova, Kseniia A. Tromova,
Kyrill Lidji-Goryaev, and Denis E. Bragin
31.1 Introduction��326
31.2 Materials and Methods��326
31.2.1 Study Design and Population��326
31.2.2 Eye Tracking Conguration��327
31.2.3 Statistical Analysis��328
31.3 Results��328
31.4 Discussion��328
31.5 Limitation of the Study��329
31.6 Conclusion��330
References��330
32 Interdisciplinary Collaboration and Communication
Among Doctors and Nurses in ICUs During the COVID-19
Pandemic and Their Importance in Professional
Life Quality Improvement��331
Charalampos Platis, Arvanitidis Theodoros,
Maria-Elissavet Psomiadi, and Panagiotis Theodorou
32.1 Background��331
32.2 Materials and Methods��332
32.2.1 Study Population��332
32.2.2 Research Tool��332
32.2.3 Statistical Analysis��333
32.3 Results��333
32.4 Discussion��334
32.4.1 Limitations��339
32.5 Conclusions��341
References��341
Contents

xxi
33 Job Satisfaction and Burnout Levels of the Human
Resources of a Public Oncology Hospital During
the COVID-19 Pandemic��345
Panagiotis Theodorou, Maria Georgantoni,
Psomiadi Maria-Elissavet, Platis Charalampos,
and Bellali Thalia
33.1 Background��345
33.2 Materials and Methods��346
33.2.1 Study Population��346
33.2.2 Research Tool��346
33.2.3 Statistical Analysis��347
33.3 Results��347
33.4 Discussion��349
33.4.1 Limitations��350
33.5 Conclusions��350
References��350
34 Investigation of Physical Activity Levels and Associated
Factors of Greek Older Adults During COVID-19
Pandemic: A Community-Based Cross-Sectional Study��353
Maria Tsekoura, K. Fousekis, M. Roukounaki,
E. Giannoulatou, G. Kolokithas, Α. Sakellaropoulou,
An Gridelas, A. Kastrinis, E. Billis, and E. Tsepis
34.1 Introduction��354
34.2 Material and Methods��354
34.2.1 Study Design and Participants��354
34.2.2 Measures��355
34.2.3 Physical Activity��355
34.2.4 Anxiety/Depression��355
34.2.5 Ethics��355
34.2.6 Statistical Analyses��355
34.3 Results��355
34.4 Discussion��355
34.5 Strengths and Limitations��357
34.6 Conclusions��357
References��357
35 Better Understand to Better Predict Subjective
Well-Being Among Older Greeks in COVID-19 Era:
Depression, Anxiety, Attitudes Towards eHealth,
Religiousness, Spiritual Experience, and Cognition��359
Vaitsa Giannouli and Konstantinos Giannoulis
35.1 Introduction��359
35.2 Methods��360
35.2.1 Participants��360
35.2.2 2.2 Measures and Procedure��360
35.3 Results��361
35.4 Discussion��361
References��363
Contents

xxii
36 Distance Under Pandemic Conditions (COVID-19):
Professional Burnout of Primary and Secondary
Grade Teachers��365
Evgenia Polimeri, Sophia Martinaki, Pentagiotissa Stefanatou,
and Konstantinos Kontoangelos
36.1 Introduction��365
36.2 Purpose��367
36.2.1 Research Questions��368
36.2.2 Sample��368
36.2.3 Sampling��368
36.2.4 Research Tool��368
36.2.5 Data Collection and Analysis��369
36.3 Results��369
36.4 Discussion��371
36.5 Conclusions��374
References��374
37 Nursing Students’ Computer Anxiety and Attitudes
Before and During the COVID-19 Pandemic��377
Ioanna V. Papathanasiou, Dimitrios Mantzaris,
Evangelos C. Fradelos, Nikolaos G. Christodoulou,
Ka Yiu Lee, Areti Tsaloglidou, Eleni Albani, Foteini Malli,
and Konstantinos I. Gourgoulianis
37.1 Introduction��378
37.2 Methods��379
37.2.1 Study Design and Sample��379
37.2.2 Instrument��379
37.2.3 Data Analysis��380
37.2.4 Ethics��380
37.3 Results��380
37.4 Discussion��388
37.4.1 Limitations of the Study��389
37.5 Conclusion��389
References��389
38 COVID-19 Pandemic and Health and Social Inequalities
Worldwide: Impact and Response Measures in Greece��393
Maria Malliarou, Athanasia Gagamanou, Axilleas Bouletis,
Vasileios Tzenetidis, Iokasti Papathanasiou,
Maria Theodoropoulou, Theodora-Paisia Apostolidi,
Vaios Grammatis, Anna Patsopoulou, and Pavlos Saras
38.1 Introduction��394
38.2 Material and Methods��394
38.3 Results��395
38.3.1 Health: Social Iniquities Due
to Pandemic COVID-19��395
38.3.2 Implications and Measures of Addressing
the Pandemic Consequences��395
38.4 Discussion: Conclusions��398
References��398
Contents

xxiii
39 Quality of Life in Patients Receiving Medical Cannabis��401
Iliana Tsampoula, Afroditi Zartaloudi, Evangelos Dousis,
Ioannis Koutelekos, Niki Pavlatou, Georgia Toulia,
Antonia Kalogianni, and Maria Polikandrioti
39.1 Introduction��401
39.2 Materials and Methods��402
39.2.1 Measurement Tools��402
39.2.2 Statistical Analysis��403
39.3 Results��403
39.4 Discussion��405
39.4.1 Limitations of the Study��414
39.5 Conclusions��414
References��414
40 Self-Care and Compliance with Medication and Their
Relationship to the Quality of Life of Patients with
Heart Failure��417
Malliarou Maria, Kokoi Panagiota, Tzenetidis Vasileios,
Papathanasiou Iokasti, Georgios Tsioumanis,
Tzenetidis Nikolaos, Apostolidi Nikoletta, Bouletis Axilleas,
Apostolakis Ioannis, and Saras Pavlos
40.1 Introduction��418
40.2 The Effect of Self-Care on the Quality of Life
of Patients with Heart Failure��419
40.2.1 Aim of the Study��419
40.2.2 Questionnaire��420
40.2.3 Minnesota Living with Heart Failure Questionnaire
(MLHFQ)��420
40.2.4 European Heart Failure Self-Care
Behavior Scale (EHFScBS)��420
40.2.5 SCHFI v.6��421
40.2.6 Morisky Green Levine Adherence
Scale (MAQ)��421
40.2.7 Sample and Data Collection��421
40.2.8 Analysis��421
40.3 Results��422
40.3.1 Minnesota Living with Heart Failure
Questionnaire��422
40.4 Discussion��424
40.5 Limitations of the Study��426
References��426
41 Investigating the Needs of Patients Suffering from Chronic
Diseases: A Cross-Sectional Study��429
Aggeliki Katsarou, George Intas, Evgenia Polydoropoulou,
Charalambos Platis, and George Pierrakos
41.1 Introduction��429
41.2 Materials and Methods��430
41.2.1 Study Sample and Data Collection��430
41.2.2 Instrument for Data Collection��430
Contents

xxiv
41.2.3 Data Analyses��430
41.3 Results��430
41.4 Conclusions��434
References��434
42 Investigation of Factors That Affect the Quality
of Life After a Stroke��437
Maria Malliarou, Christina Tsionara, Anna Patsopoulou,
Axilleas Bouletis, Vasileios Tzenetidis, Iokasti Papathanasiou,
Evangelia Kotrotsiou, Mary Gouva, Athanasios Nikolentzos,
and Pavlos Saras
42.1 Introduction��438
42.2 Material and Method��438
42.2.1 Description of Research Process��438
42.3 Results��440
42.4 Conclusions��440
References��442
43 The Experience of Dancing Among Individuals
with Cerebral Palsy at an Inclusive Dance Group:
A Qualitative Study��443
Lydia Lentzari, Evdokia Misouridou, Vicky Karkou,
Marianthe Paraskeva, Chrysoula Tsiou, Ourania Govina,
Antonia Kalogianni, and Stelios Parissopoulos
43.1 Introduction��444
43.1.1 Background��444
43.2 Methods��445
43.2.1 Study Design��445
43.2.2 Aim and Objective��445
43.2.3 Participants and Procedure��445
43.2.4 Data Collection and Ethics Approval��446
43.2.5 Data Analysis��446
43.2.6 Trustworthiness��447
43.3 Findings��447
43.3.1 Subtheme A: The Therapeutic Aspect
of Dance and Dancing: “Unlocking
the Body”��447
43.3.2 Subtheme B: The Artistic Aspect
of Dance—“Acquiring the Identity
of a Dancer”��451
43.4 Discussion��452
43.5 Limitations��454
43.6 Conclusion��454
References��454
Contents

xxv
44 Brain Activity of Professional Dancers During Audiovisual
Stimuli Exposure: A Systematic Review��457
Kyriaki Angelopoulou, Dimitrios Vlachakis, Christina Darviri,
George P. Chrousos, Christina Kanaka-Gantenbein,
and Flora Bacopoulou
44.1 Introduction��458
44.2 Methods��458
44.2.1 Literature Research��458
44.2.2 Selection Criteria��458
44.2.3 Data Extraction��459
44.3 Results��459
44.3.1 Studies Included��459
44.3.2 Characteristics of Studies��459
44.3.3 Quality Synthesis��460
44.3.4 Synthesis of Results��463
44.4 Discussion��464
44.5 Conclusion��466
References��466
45 The Effect of Schroth Method on Postural Control
and Balance in Patients with Adolescent Idiopathic
Scoliosis: A Literature Review��469
A. Kastrinis, G. Koumantakis, M. Tsekoura, E. Nomikou,
M. Katsoulaki, E. Theodosopoulos, N. Strimpakos,
and Z. Dimitriadis
45.1 Introduction��470
45.2 Search Strategy and Selection Criteria��470
45.3 Study Findings��470
45.4 Discussion��471
45.5 Clinical Signicance of the Study��474
45.6 Conclusions��474
References��475
46 Illiteracy, Neuropsychological Assessment,
and Cognitive Rehabilitation: A Narrative Review��477
Maria Petri, Lambros Messinis, Panayiotis Patrikelis,
Anastasia Nousia, and Grigorios Nasios
46.1 Introduction��478
46.2 Method��478
46.2.1 Database and Search Terms��478
46.2.2 Inclusion and Exclusion Criteria��478
46.3 Results��479
46.3.1 Neuropsychological Assessment��479
46.3.2 Cognitive Rehabilitation��481
46.4 Discussion��481
46.5 Limitations��481
46.6 Future Perspectives��482
46.7 Conclusions��482
References��482
Contents

xxvi
47 Telerehabilitation and Fall Prevention in Older Adults��485
M. Tsekoura, A. Kastrinis, E. Nomikou, and M. Katsoulaki
47.1 Introduction��485
47.2 Methods��486
47.3 Results��486
47.4 Discussion��486
47.5 Conclusions��488
References��488
48 Relationship of Ηand Grip Strength, Physical Activity,
and Anthropometric Characteristics in a Sample
of Male and Female Physiotherapy Students��491
M. Tsekoura, S. Bakirtzi, S. Papadimitropoulou, E. Billis,
K. Fousekis, A. Kastrinis, and E. Tsepis
48.1 Introductions��491
48.2 Material and Methods��492
48.2.1 Study Design and Participants��492
48.2.2 Data Collection��493
48.2.3 Outcome Measurement Tools��493
48.2.4 Statistical Analysis��493
48.3 Results��494
48.3.1 Correlations of HGS and Other Variables��494
48.3.2 Predictors of HGS in Male and Female University
Students��494
48.4 Discussion��496
48.4.1 Clinical Relevance��498
48.4.2 Limitations��498
48.5 Conclusions��499
References��499
49 The Effects of Exercise in Older Adults with Hyperkyphotic
Posture��501
M. Tsekoura, M. Katsoulaki, A. Kastrinis, E. Nomikou,
K. Fousekis, E. Tsepis, and E. Billis
49.1 Introduction��501
49.2 Search Strategy and Selection Criteria��502
49.3 Studies’ Findings��502
49.4 Discussion��502
49.4.1 Clinical SigniΗcance of This Study��505
49.5 Conclusion��505
References��505
50 Water Quality Analysis Using Physicochemical Parameters
and Estimation of Pesticides in Water from Various
Sources of Tirupati, Andhra Pradesh, India��507
K. Swathi, B. Nikitha, M. Malleswari, M. Munisankar,
S. D. Meena, and A. Roja
50.1 Introduction��508
50.2 Experimental Materials, Methods, Results
and Discussions of Selected Study Area��508
Contents

xxvii
50.3 Selection of Sampling Points��508
50.4 Conclusions��511
References��512
51 Method Development and Validation of Gallic Acid
in Liquid Dosage Form by Using RP-HPLC Method��513
Aavula Roja, Peram Uma Maheshwari,
Ramapuram Munemma, and Konda Swathi
51.1 Introduction��513
51.1.1 Experimental Work��514
51.1.2 General Preparations��514
51.1.3 Syrup Formulation��515
51.1.4 Preparation Accuracy Sample Solutions��516
51.1.5 Degradation Studies��517
51.2 Results and Discussion��518
51.3 Analytical Method Validation (HPLC)��518
51.4 Conclusion��521
References��532
52 Investigating Physical Activity Habits and Sleep
Disorders in the Nursing Staff of Greece During
the COVID-19 Pandemic: A Multicenter Cross-Sectional
Correlational Study��535
Evgenia Polydoropoulou, George Intas, Charalampos Platis,
Pantelis Stergiannis, and George Panoutsopoulos
52.1 Introduction��536
52.2 Materials and Methods��536
52.2.1 Aim��536
52.2.2 Study Design��536
52.2.3 Participants��536
52.2.4 Tools��536
52.2.5 Statistical Analysis��537
52.3 Results��537
52.3.1 Physical Exercise��537
52.3.2 Sleep Habits��538
52.3.3 COVID-19 Fear Scale��538
52.3.4 Nurses vs Nursing Assistants��538
52.3.5 Shift Work Versus Non-shift Work��539
52.3.6 Exercise Intensity (Inactive Vs. Active)��539
52.3.7 Beginning of the Pandemic Versus Two Years After
the Beginning of the Pandemic��540
52.4 Discussion��541
52.5 Conclusions��542
References��542
Contents

xxviii
53 A Systematic Review on the Adult Alpha Brainwave
Activity After Essential Oil Inhalation��545
Asimina Komini, Ioulia Kokka, Dimitrios Vlachakis,
George P. Chrousos, Christina Kanaka-Gantenbein,
and Flora Bacopoulou
53.1 Introduction��546
53.2 Materials, Methodologies, and Techniques��547
53.2.1 Inclusion and Exclusion Criteria��547
53.2.2 Search Strategy��547
53.2.3 Data Extraction��547
53.3 Results��547
53.3.1 Study Selection��547
53.3.2 Basic Characteristics of Included Studies��548
53.4 Discussion��549
References��552
54 Perceptions of Teamwork and Knowledge Attitudes
of Hemodialysis Unit Nurses on Infection Prevention��555
Evangelia Prevyzi, Stavros Patrinos, Georgios Intas,
Ioannis Elefsiniotis, Emmanouil Velonakis, and Eirini Grapsa
54.1 Introduction��556
54.2 Materials and Methods��557
54.2.1 Aim��557
54.2.2 Study Design��557
54.2.3 Participants��557
54.2.4 Tools��557
54.2.5 Methodology��557
54.2.6 Statistical Analysis��557
54.3 Results��558
54.4 Discussion��559
54.5 Conclusions��564
References��564
55 Noninvasive Brain Stimulation in Primary Progressive
Aphasia: A Literature Review��567
Konstantinos Papanikolaou, Grigorios Nasios,
Anastasia Nousia, Vasileios Siokas, Lambros Messinis,
and Efthimios Dardiotis
55.1 Introduction��567
55.2 Materials and Method��568
55.2.1 Literature Search��568
55.2.2 Eligibility Criteria��568
55.2.3 Data Extraction��568
55.3 Results��568
55.3.1 rTMS Studies in PPA��568
55.3.2 tDCS Studies in PPA��569
55.4 Discussion��569
55.5 Conclusion��573
References��573
Contents

xxix
56 The Regulatory Landscape of New Health Technologies and
Nanotechnologies: The Role of Complexity of Nanosystems��575
Nikolaos Naziris and Costas Demetzos
56.1 Introduction to New Health Technologies (NHTs)��575
56.2 The European Approach on NHT Regulation��577
56.2.1 Denition and Approach��577
56.2.2 The Map for Regulating NHTs��577
56.2.3 The Frames of NHT Regulation��578
56.3 Adv��579
56.3.1 Denition and Elements of ATMPs��579
56.3.2 Classication of ATMPs��580
56.3.3 Authorized ATMPs��581
56.4 Nanomedicines and Nanosimilars��582
56.4.1 Denition and Elements of Nanomedicines��582
56.4.2 Types of Nanoparticles and Authorized
Nanomedicines��582
56.4.3 The Follow-On “Nanosimilars”��583
56.5 The ��585
56.6 Conclusions��586
References��586
57 Octenidine Versus Dispase Gels for Wound Healing
After Cryosurgery Treatment in Patients with
Basal Cell Carcinoma��591
Nektarios Stratidakis, Anna Tagka, Styliani A. Geronikolou,
Efstathios Giannakopoulos, Antonios Panagiotopoulos,
Evdokia Malachia, Andreas Vitsos, Evangelos Karalis,
Paraskevas Dallas, Alexandros Stratigos, and Michail Rallis
57.1 Introduction��592
57.2 Materials and Methods��592
57.2.1 Subjects Enrolled and Study Design��592
57.2.2 Treatments��593
57.2.3 Measurements��593
57.2.4 Data Analysis��595
57.3 Results��595
57.4 Discussion��595
References��600
58 Nurses’ Knowledge Concerning Prevention
and Treatment of Pressure Ulcers��603
Panagiota Eirinidou, Georgia Gerogianni,
Georgios Vasilopoulos, Ioannis Kalemikerakis,
Antonia Kalogianni, Evridiki Kaba, Georgia Fasoi,
Afroditi Zartaloudi, and Martha Kelesi
58.1 Introduction��603
58.2 Materials and Methods��604
58.3 Statistical Analysis��604
58.4 Results��605
58.5 Nurses’ Knowledge About Prevention and Treatment
of Pressure Ulcers��605
Contents

xxx
58.6 Correlation of Correct Answers with Nurses’
Academic Education��605
58.7 Correlation of Correct Answers with Nurses’
Working Department��605
58.8 Discussion��605
58.9 Conclusions��607
References��607
59 European Projects for Patients with Dementia
and Their Caregivers��609
M. Tsolaki, M. Makri, M. Tsatali, and Β. Teichmann
References��618
60 Repetitive Transcranial Magnetic Stimulation
in Post-stroke Aphasia: Comparative Evaluation
of Inhibitory and Excitatory Therapeutic Protocols:
Narrative Review��619
Chrysanthi Ntasiopoulou, Grigorios Nasios,
Lambros Messinis, Anastasia Nousia, Vasileios Siokas,
and Efthimios Dardiotis
60.1 Introduction��620
60.2 Method��620
60.2.1 Literature Search and Eligibility Criteria��620
60.3 Results��621
60.3.1 Inhibitory rTMS of the Right Pars Triangularis
During the Subacute Phase After the Stroke��621
60.3.2 Inhibitory rTMS of the Right Pars Triangularis
During the Chronic Phase After the Stroke��623
60.3.3 Inhibitory rTMS of the Right Pars Triangularis
After Stroke (Subacute and Chronic Phases)��623
60.3.4 Studies That Combined Inhibitory and Excitatory
rTMS in Aphasic Stroke Patients��623
60.3.5 Excitatory rTMS of the Unaffected Areas
of the Left Hemisphere During the Chronic
Phase After the Stroke��624
60.3.6 Effect of rTMS in Connectivity and Activation
of Language Networks��624
60.4 Discussion��626
60.5 Conclusions��627
References��627
61 On Net Water Uptake in Posttraumatic Ischemia Foci��629
A. TroΒmov, D. Agarkova, K. TroΒmova, C. Lidji-Goryaev,
D. Atochin, and D. Bragin
61.1 Introduction��630
61.2 Materials and Methods��630
61.2.1 Study Population��630
61.2.2 Image Acquisitions��631
61.2.3 Statistical Analysis��631
Contents

xxxi
61.3 Results��631
61.4 Discussion��632
61.5 Conclusion��633
References��633
62 Proposal for Monitoring Students’ Self-Efficacy Using
Neurophysiological Measures and Self-Report Scales��635
Maria Gerostathi and Spyridon Doukakis
62.1 Introduction��635
62.2 The ��636
62.3 Self-Efcacy and STEM��637
62.4 Measuring Self-Efcacy in Education��638
62.4.1 Self-Report Measure��638
62.4.2 Neurophysiological Measurements��639
62.4.3 Need to Explore the Use of Neurophysiological
Measurements in the Educational Process��641
62.5 Conclusion��641
References��642
63 The Impact of Smokers’ Information-Seeking Behavior
on Smoking Cessation��645
Petros Kostagiolas, Soa Parnavela,
and Panagiotis Theodorou
63.1 Introduction��646
63.2 Methods: Questionnaire Development��647
63.3 Results��648
63.4 Discussion��651
63.5 Conclusions and Further Research for Investigating
Smoking Cessation Behavior of Individuals
at Risk of Cognitive Decline��654
Appendices��655
Appendix I: Descriptive Statistics�� 655
Appendix II: Principal Components Analysis Results
for the Study Constructs�� 657
References��659
64 Qualitative Bioinformatics: Towards a Public
Understanding of Neurodegenerative Disease
Research through BioArt, Data-Art, Hands-on
BioMedia Workshops, Immersive Environments,
and Artists in Labs��663
Adam Zaretsky
65 Personalized Music Playlists and Headphones
in People with Dementia: A Literature Review��665
Notis Paraskevopoulos
66 Neuroeducation and Genetics��667
Georgia Tzortsou
Index�� 669
Contents

1
1
Public’s Attitudes Toward Mentally
Ill Oenders in Greece
S. Martinaki, K. Athanasiadis, A. Gkontolia,
E. Karachaliou, A. Karaiskos, E. Sakellariou,
Th. Tsiapla, and F. Chatzinikolaou
Abstract
Mentally ill offenders constitute a vulnerable
population group with unique characteristics,
and have endured multiple public stigmatiza-
tions, which has not been suf ciently studied.
The purpose of this study was to capture atti-
tudes of the public toward mentally ill offend-
ers in relation to their perceptions of mental
illness in general, as well as their degree of
familiarity with it. Our sample of 2059 people
can be overall described as a men preponder-
ance, married, with mean value age of
26 years, higher educational level, and
medium or higher socio-economic status.
Participants completed the ATMIO, CAMI,
and Familiarity scales online. The total famil-
iarity index value with mental illness was
found to be 4.88, which counts as moderate to
low. It was also concluded that women and
those with a high educational level sustained
more positive attitudes toward mentally ill
offenders. However, negative stereotypes
(with a mean value of 26.20), stigmatizing
attitudes related to risk in the community
(mean 16.10), and reduced responsibility for
actions (mean 9.45) were recorded, while
some (mean 16.50) showed compassion and
emphasized on the mentally ill need of reha-
bilitation. The youngest people were the ones
who recorded the most absolute and harsh
attitudes. These ndings validate the need of
raising awareness and informing, especially,
the young public about issues of mental
health, including the need to oppose preju-
dices with everyday measures, which can be
S. Martinaki (*)
Faculty of Administrative, Economics and Social
Sciences, Department of Social Work, University of
West Attica, Athens, Greece
e-mail: [email protected]
K. Athanasiadis
1st Psychiatric Clinic – Eginitio Hospital, National
and Kapodistrian University of Athens,
Athens, Greece
A. Gkontolia
Hellenic Police, Security Division of Thessaloniki,
Thessaloniki, Greece
E. Karachaliou
Psychiatric Hospital of Attica (Dafni), Athens, Greece
A. Karaiskos
Law Association of Katerini, Katerini, Greece
E. Sakellariou
Psychiatric Clinic, University Hospital of Larissa,
Larisa, Greece
T. Tsiapla
Ippokrateio General Hospital of Thessaloniki,
Thessaloniki, Greece
F. Chatzinikolaou
Lab of Forensic Medicine and Toxicology, School of
Medicine, Aristotle University of Thessaloniki,
Thessaloniki, Greece
e-mail: [email protected]
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
P. Vlamos (ed.), GeNeDis 2022, Advances in Experimental Medicine and Biology 1425,
https://doi.org/10.1007/978-3-031-31986-0_1

2
accessible to the new generation. Besides, we
should extend research to various profes-
sional groups that come in contact with men-
tally ill offenders in order to collect data,
which could contribute for intervening poli-
cies and formulating different sets of strate-
gies for those people.
Keywords
Mentally ill offenders · Familiarity · Stigma ·
Attitudes · Stereotypes · Mental illness
1.1 Introduction
Both the stigma of mental illness and negative
attitudes toward people with mental disorders are
principally barricading and resentfully affecting
prevention, early detection, treatment, rehabilita-
tion, rights, and inescapably the quality of life of
the mentally ill people [22].
Stigma and negative attitudes toward the men-
tally ill represent a global phenomenon with vari-
ous variations in intensity and manifestation of
the reactions between the respective countries.
The most prevailing stereotypes and prejudices
associate the mentally ill with violence, danger-
ousness, unpredictable behaviors, communica-
tion adversities, and inability to contribute to
society, causing fear, avoidance, social distance,
and segregation [14].
The general population’s attitudes toward the
mentally ill are predisposed by a variety of fac-
tors, intertwined with psychiatric diagnosis,
socio-demographic characteristics, and degree of
familiarity with mental illness.
Despite research on the general population’s
stigma and attitudes toward mental illness has
been somewhat systematic, research on attitudes
toward mentally ill offenders is still limited.
Mentally ill offenders represent a particularly
vulnerable population with mental illnesses in
the criminal justice system. These patients expe-
rience repercussions of dynamic interaction of a
double objective regarding mental illnesses and
their dangerousness as well as the stereotype of
being a criminal offender [20].
Research, which has been conducted on
stigma and attitudes toward mentally ill offend-
ers, is limited and studies mainly attitudes of pro-
fessionals and students and less of the public.
Notably, regarding the attitudes of the general
population, research shows that people are
negatively biased against mentally ill offenders in
different levels.
In Greece, attitudes toward mentally ill offend-
ers have not been studied and fully explored yet,
despite the fact that, as documented, the attitudes
of the general population exert a particular inu-
ence on the formulation of similar rehabilitative
or punitive policies for mentally ill offenders, and
the attitudes of justice professionals, the correc-
tional system, as well as the mental health system
may inuence their sentencing decisions, care,
appropriate treatment, and rehabilitation pros-
pects [2].
It is alluded that in Greece the psychiatric
forensic system is underdeveloped with a com-
plete lack of psychiatric forensic structures
indexed in terms of the level of security and
custody (high, medium, low), and the peniten-
tiary system faces serious problems of over-
crowding in prisons, lack of staff, and limited
access to psychiatric services. According to
international epidemiological data, it is esti-
mated that of the total 11,300 inmates of the
country’s prisons [1], 26% of those people,
approximately 3000, are classi ed as mentally
ill offenders. That ever-increasing value is
equal to the total number of mentally ill patients
treated by the country’s psychiatric service sys-
tem, which con rms the opinion of Weaver [19]
that “prisons have become the new de facto psy-
chiatric hospitals.”
The present study investigates the attitudes
of the general population toward mentally ill
offenders in Greece in relation to the degree of
familiarity with mental illness and socio-demo-
graphic data. The conclusions of the study nd-
ings may increase our understanding of attitudes
toward mentally ill offenders in this country,
which hopefully may be enhanced toward a bet-
ter management of their multiple problems in
relation to safety, care, treatment, and
rehabilitation.
S. Martinaki et al.

3
1.2 Methods
1.2.1 Sample and Procedure
The survey was conducted via an online platform
by a non-probability sampling method through
voluntary respond sampling. In total, data were
collected from 2059 people in Greece by July
2022 for this survey. The age of the participants
ranges from 17 to 65 and all participants com-
pleted a four-part online questionnaire. The pro-
cedure of the survey was pretty straightforward,
and questionnaires were uploaded at the date
interval described above and the participants
completed them at their own time but continu-
ously. All participants, before completing the
questionnaires, were informed about the purpose
of the study and were provided with explanations
of the terminologies mental illness and mentally
ill offenders.
1.2.2 Measurement Instruments
The rst part of the questionnaire was the
Familiarity Level Scale developed by Corrigan
et al. [6]. The Greek version was translated and
back-translated by two bilingual professionals
[3]. The internal consistency (Cronbach’s
alpha) of the instrument was found to be accept-
able at 0.97. This questionnaire includes 11
statements/situations about familiarity with
mental illness. The items have an inherent rank-
ing based on the degree of intimacy that they
express. Each statement can be answered by
yes or no. A score of 11 corresponds to the most
intimate contact with a person with mental ill-
ness, 7 is regarded as indicating medium inti-
macy, and 1 indicates little intimacy. If more
than one statement is af rmative, the item
ranked as expressing the highest level of inti-
macy is used. Reliability and validity of this
instrument have been described by Corrigan
et al. [6].
The second part was the Attitudes Toward the
Mentally Ill Offenders (ATMIO) scale, with nal
form of 23 items. The AΤΜΙΟ scale was devel-
oped by Brannen et al. [5]. It produces a nal
score and four factor scores. These factor scores
can be described below: Negative Stereotypes,
Rehabilitation/Compassion, Community Risk,
and Diminished Responsibility. Each item ranges
from totally disagree to (5) totally agree on a
5-point Likert scale. The following 13 items/
questions are reverse scored: 3, 4, 5, 6, 7, 9, 12,
13, 16, 17, 18, 20, and 21. The items that con-
clude each factor are: Negative Stereotypes (6, 7,
9, 12, 13, 16, 17, 18, 20, 21 [10 items]),
Rehabilitation/Compassion (2, 3, 8, 14, 23 [5
items]), Community Risk (4, 5, 10, 11, 22 [5
items]), and Diminished Responsibility (1, 15, 19
[3 items]).
In the third part, the CAMI scale was intro-
duced to the participants. That questionnaire
quanti es the qualitative Attitudes of the
Community Toward the Mentally Ill (CAMI) and
is developed by Taylor and Dear [16] and been
translated into Greek [7]. It is a 40-item scale;
each item requires a rating of the participant’s
degree of agreement/disagreement on a 5-point
Likert scale (1 = strongly disagree to 5 = strongly
agree). The CAMI consists of four subscales or
dimensions: (1) Authoritarianism, (2)
Benevolence, (3) Social Restrictiveness, and (4)
Community Mental Health Ideology. In this sur-
vey scale, reliabilities range from α = 0.68–0.99
with a positive internal validity.
The fourth part was about the demographic
data. That questionnaire is informative about
quantitative values of the participants, like sex,
age, marital status, residence, political positions,
socio-economic status, and parental educational
level, and can be correlated with the ATMIO and
CAMI scale results.
1.2.3 Data Analysis
In this survey R programming language, which
is an open code system environment for statisti-
cal computing and graphics supported by the R
Core Team and the R Foundation, was used. R
can provide a wide variety of statistical tools
(linear and nonlinear modeling, classical statisti-
cal tests, time-series analysis, classi cation,
clustering, etc.) and is highly extensible. In our
1 Public?s Attitudes Toward Mentally Ill OΜenders inΤGreece

4
Table 1.2 Descriptive statistics of the CAMI subcategories
Variables Minimum Maximum Mean SD
Authoritarianism 2.00 47.00 30.41 4.83
Social restrictiveness 1.00 49.00 30.10 4.16
Benevolence 1.00 49.00 30.38 3.99
Community mental health ideology 1.00 50.00 31.25 4.48
survey, quantitative variables are expressed as
mean values (standard deviation [SD]).
Qualitative variables are expressed as absolute
and relative frequencies. Student’s t-tests were
computed for the comparison of mean values
both in CAMI and ATMIO scale samples
between sex, and analysis of variance (ANOVA)
was used for the comparison of mean values
between marital status, educational level, resi-
dence, and educational level of household’s
leader. Moreover, the Pearson correlation coef-
cients were used to measure the association
between two continuous variables, age and the
familiarity index score, of the participants.
Multiple stepwise regression models were used
in this data analysis. In our sample, the
Authoritarianism independent predictor factors
were female sex (β = −1.089; standard error
[SE] = 2.083; p = 0.000515), familiarity score
(β = 0.349; SE = 0.06116; p = 0.0000000152),
and age (β = 0.03018; SE = 0.01081;
p = 0.005362). The same goes for the Social
Restrictiveness independent predictor factors:
female sex (β = −0.64275; SE = 0.3073;
p = 0.0367), age (β = 0.04035; SE = 0.1044;
p = 0.000118), and the familiarity score
(β = 0.3644; SE = 0.05948; p = 0.00000000128);
and the Benevolence independent predictor fac-
tors were female sex (β = −0.77569;
SE = 0.29418; p = 0.0085) and the familiarity
index (β = 0.36436; SE = 0.05747;
p = 0.000000000344), but not the age. For the
Community, independent predictor was only the
familiarity score (β = 0.310061; SE = 0.062538;
p = 0.000000834). Lastly, note that adjusted
regression coef cients stand for β with standard
errors (SE), which were computed from the
results of the linear regression analyses. All
reported p-values are two-tailed and the statisti-
cal signi cance is set at p < 0.05.
1.3 Results
The sample of 2059 people includes 1056 men
(52.3%) and 1003 women (48.7%), with mean
age 26.0 years (SD = 14.2 years). The sex ratio of
the sample is a bit higher for men and different
from the total population ratio in Greece of men
versus women. The large predominance of peo-
ple in our sample are married and have completed
a university level of education (74%), master
degree or higher (PhD). Also, 55% of them either
live in Athens or in major cities. Moreover, the
sample’s socio-economic status is best described
as middle class and upper middle class (65%) and
their political position stands by one-third into
Liberalism (Table 1.1).
For the CAMI scale subscales, the mean value
was found at 30.41 for Authoritarianism
(SD = 4.83), 30.10 for Social Restrictiveness
(SD = 4.16), 30.38 for Benevolence (SD = 3.99),
and 31.25 for Community Mental Health
Ideology (SD = 4.48) (Table 1.2).
For the ATMIO scale subscales, the mean
value was set at 26.60 for Negative Stereotypes
(SD = 7.35), 16.50 for Rehabilitation/Compassion
(SD = 3.05), 16.10 for Community Risk
(SD = 3.03), and 9.45 for Diminished
Responsibility (SD = 2.40) (Table 1.3).
The familiarity index of the sample shows
how familiar are the participants with the men-
tally ill population. The most frequent response
(70%) was “I know at least one person who has
mental illness,” followed by “A family friend of
mine has mental illness” (69%). More than half
of the participants (53%) had the response “A
relative of mine has mental illness,” and “I have
observed, in passing, people with mental illness”
stood at 58%, while only 9% of the participants
identi ed themselves as ?having a serious mental
S. Martinaki et al.

5
Table 1.1 Sample characteristics
Variables N (%)
Sex
Men 1056 (52.3)
Women 1003 (48.7)
Age, mean (SD) 26 (14.4)
Educational level
No answer/not available 26 (1.3)
Primary education 62 (3.0)
High school 448 (21.8)
University/master or PhD 1525 (73.9)
Marital status
Single 350 (17.0)
Married 1201 (58.3)
Separated/divorced 233 (11.3)
Partnered/civil union 173 (8.4)
Widowed 60 (2.9)
No answer/not available 44 (2.1)
Residence
Athens 742 (36.0)
Thessaloniki 267 (13.0)
Major urban centers/cities 426 (21.0)
Minor urban centers/cities 325 (16.0)
Villages 289 (14.0)
Educational level of household’s leader
None 9 (0.4)
Primary education 51 (2.5)
Lower secondary education 53 (2.6)
Upper secondary education 379 (18.4)
Short-cycle tertiary education/post-secondary non-tertiary
education
460 (22.3)
Bachelor’s degree or equivalent 566 (30.6)
Master’s degree or equivalent 365 (17.7)
No answer/not available 114 (5.5)
Political position
Liberalism: Lefts 644 (31.3)
Moderates: Center 404 (19.6)
Conservatism: Right 552 (26.8)
No answer/not available 525 (25.5)
Socio-economic status
Upper middle class/upper class 659 (32.0)
Middle class 680 (33.0)
Lower middle class/lower class 397 (19.3)
No answer/not available 325 (15.8)
illness.” The familiarity index mean score was
4.88, which is categorized as a below average
familiarity score with a low standard deviation of
2.5 (Table 1.4).
The associations of the four CAMI subcatego-
ries with demographics and familiarity index are
shown below. Authoritarianism factor shows that
sex is a statistically important factor (p = 0.05)
with women being less authoritative than men
(~1%), but their correlation is quite insigni cant.
Positive correlation is demonstrated between
Authoritarianism and the educational level of the
1 Public?s Attitudes Toward Mentally Ill Oenders inGreece

6
Table 1.3 Descriptive statistics of the ATMIO subcategories
Variables Minimum Maximum Mean SD
Negative stereotypes 1.00 50.00 26.60 7.35
Rehabilitation/compassion3.00 25.00 16.50 3.05
Community risk 2.00 25.00 16.10 3.03
Diminished responsibility1.00 15.00 9.45 2.40
Table 1.4 Descriptive statistics for the familiarity index
Variables N (%)
I know at least one person who has mental illness1446 70
A relative of mine has mental illness 1089 53
A family friend of mine has mental illness 1411 69
I know people with mental illness close to me 810 39
I have observed, in passing, people with mental illness1195 58
I have watched actors portraying mentally ill people in movies1254 61
I have watched documentary about mental illness on television
or online
817 40
I have observed people with mental illness frequently872 42
I have worked with a person with mental illness 704 34
My job includes services for people with mental illness262 13
I have a serious mental illness 190 9
Familiarity index, mean, SD 4.88 2.5
participants and the householder. Also, lower
authoritarianism mean values are in Athens,
Thessaloniki, and surprisingly enough in vil-
lages. In the Social Restrictiveness category, the
educational as well as the householder level are
positively correlated meaning that as the social
restrictiveness rises so does the educational level.
Also, age as a factor highlights some importance
but their correlation is thin. In the Benevolence
category only the educational level and the
householder level can be related. Although, the
age mean value (−0.03) indicates a negative cor-
relation between the two dimensions, it is not sig-
ni cantly important. The same refers to the
Community mental health ideology dimension,
in which age is also negatively correlated, but not
so important (Table 1.5).
Conclusively, education and the education
of the householder are important through all
the CAMI subcategories as well as the
Familiarity index, which being statistically
important as it is, was surprisingly positively
associated with all subcategories of the CAMI
scale. The associations of the ATMIO subcate-
gories with demographics and familiarity index
resulted that not only sex but also the familiar-
ity index is correlated with all dimensions and
showed that men have more negative stereo-
types, are less compassionate, fear more the
risk of a mentally ill offender being at their
community, and believe that mentally ill
offenders are responsible for their actions than
women. Also, age showcases a positive corre-
lation with the negative stereotypes and the
community risks but negative correlation in
rehabilitation factor and diminished responsi-
bility, which means that as age progresses peo-
ple’s attitudes tend to be smoother than in a
younger age. However, age is statistically sig-
ni cant only in diminished responsibility. On
the other hand, greatly signi cant is shown to
be the residence of participants, educational
level, and education of the householder
throughout the four dimensions in negative ste-
reotypes, rehabilitation, community risk, and
diminished responsibility. Lastly, note again in
this table that the Familiarity index, as statisti-
cally important as it is, was positively associ-
ated with all subcategories of the ATMIO scale
(Table 1.6).
S. Martinaki et al.

7
Table 1.5 Association of the CAMI subcategories with demographics and familiarity index
Variable Authoritarianism:
mean (SD)
p Social restrictiveness:
mean (SD)
p
Sex
Men 30.9 (5.2) 0.005*30.5 (4.2) 0.09*
Women 29.9 (4.4) 29.7 (4.0)
Age, mean (SD) 0.08 0.008+0.08 0.010+
Educational level
No answer/not available 26.9 (9.4) <0.001**27.1 (8.5) <0.001**
Primary education 33.1 (4.9) 32.2 (4.2)
Some secondary education 30.7 (5.3) 30.5 (4.5)
Post-secondary education/higher30.2 (4.5) 29.9 (3.9)
Residence
Athens 30.3 (4.6) 0.73**29.9 (4.3) 0.79**
Thessaloniki 30 (4.8) 29.9 (4.0)
Major urban centers/cities30.4 (5.4) 30.6 (4.7)
Minor urban centers/cities30.5 (4.8) 30.0 (4.1)
Villages 30.7 (4.8) 30.3 (3.5)
Educational level of household’s leader
None 32 (7.9) 0.001**29.5 (13.3) 0.038**
Primary education 30.4 (4.2) 31.4 (3.5)
Lower secondary education32.4 (4.9) 30.2 (6.4)
Upper secondary education30.6 (5.2) 30.4 (4.6)
Short-cycle tertiary education/
post-secondary non-tertiary
education
30.6 (4.6) 30.0 (3.6)
Bachelor’s degree or equivalent30.3 (4.6) 30.2 (3.8)
Master’s degree or equivalent30.2 (3.9) 29.5 (3.8)
No answer/not available 28.6 (6.8) 29.8 (4.6)
Familiarity index 0.14 <0.001+0.12 <0.001+
Benevolence: mean
(SD)
p Community mental health
ideology: mean (SD)
p
Sex
Men 31.0 (4.3) 0.10* 31.3 (4.97) 0.69*
Women 30.0 (3.6) 31.2 (3.94)
Age, mean (SD) −0.03 0.28+ −0.02 0.45+
Educational level
No answer/not available 25.3 (10.4) <0.001**28.6 (7.63) <0.001**
Primary education 32.3 (4.7) 32.6 (6.5)
Some secondary education 30.5 (4.5) 31.6 (4.5)
Post-secondary education/higher30.3 (3.4) 31.1 (4.3)
Residence
Athens 30.3 (3.6) 0.90**31.048 (4.4) 0.61**
Thessaloniki 30.0 (3.9) 31.0 (4.3)
Major urban centers/cities30.6 (4.7) 31.9 (4.2)
Minor urban centers/cities30.4 (4.7) 31.2 (4.3)
Villages 30.5 (3.1) 31.3 (5.1)
(continued)
1 P

8
Table 1.5 (continued)
Educational level of household’s leader
None 31.3 (15.1) 0.016**35.4 (7.9) <0.001**
Primary education 32.0 (3.6) 32.0 (3.9)
Lower secondary education30.9 (4.1) 31.5 (6.3)
Upper secondary education30.5 (4.5) 31.7 (4.6)
Short-cycle tertiary education/
post-secondary non-tertiary
education
30.4 (3.4) 31.3 (4.5)
Bachelor’s degree or equivalent30.3 (3.7) 31.2 (3.3)
Master’s degree or equivalent30.3 (3.1) 31.2 (4.0)
No answer/not available 29.4 (5.5) 28.8 (7.3)
Familiarity index 0.17 <0.001+0.12 <0.001+
*Student’s t-test; **ANOVA; +Pearson’s correlation coef cient (r)
1.4 Discussion
The present study examines public’s attitudes
toward mentally ill offenders correlated to per-
ceptions of mental illness generally and accord-
ingly their degree of familiarity.
In Greece, in the last 2 years or so, following
periods of con nement due to the COVID-19
pandemic crisis, a particularly high number of
femicides have been recorded, as well as various
other concerning violent incidents, which have
divided public’s opinion regarding the mental
state of the perpetrators, due to their choice of
victims, their violence, and their ferocity. This
study was conducted under the shadow of these
incidents, which generated social attention and
increased public debate. Our results fully con rm
ndings of previous studies regarding gender and
educational level as being important factors as
well as that women and those with a high educa-
tional level are maintaining more positive atti-
tudes toward mentally ill offenders [23]. On the
contrary, men, as in Skorjanc’s [15] study, and
those with low educational level seem to uphold
more authoritarianist positions and greater ten-
dency for social restriction on these patients,
while as the educational level of the individuals
increases, so does their desire for social restric-
tion upon patients decrease. Regarding age, and
contrary to existing studies [11, 21], in our sam-
ple younger participants were found to have more
negative stereotypes and harsher and absolute
attitudes. They considered these patients a danger
to society, held them fully responsible for their
actions, and did not wish for their rehabilitation.
Such nding is justi able by the moderate to low
familiarity rates (4.88) recorded in our sample.
Therefore, it is con rmed, as described in other
studies [8, 13], that lower levels of knowledge
and familiarity with mental illness, as well as
lower contact and interpersonal relationship with
the mentally ill patients, contribute to the increase
in stigma and the manifestation of negative
behaviors and attitudes. Only a small percentage,
which was above average in age, showed a greater
tendency to express kindness and compassion
similar to other studies [6, 8, 13].
Regarding the mentally ill offenders, ndings
of Thielo et al. [17] and Tucker and Yuen [18] are
partially con rmed, while the patient’s rehabili-
tation is supported by some small extent, though
restrictions like “I want to know if such a patient
lives in my area” still exist. This dimension is
also mentioned in other research where an
inversely proportional relationship between atti-
tudes and behaviors has been demonstrated, with
Lehmann et al. [10] nding that while attitudes
were positive, behaviors were negative, and
Hirsch eld and Piquero [9] nding the opposite.
However, our participants had some type of con-
tact or interpersonal experience, direct or indi-
rect, with a mentally ill person or a mentally ill
offender that did not alter into positively affect-
ing their attitudes about them. Resulting in mod-
erate to low levels, as shown by the familiarity
index of 4.88, and in relation to authoritarian atti-
S. Martinaki et al.

9
Table 1.6 Association of the ATMIO subcategories with demographics and familiarity index
Variable Negative
stereotypes: mean
(SD)
p Rehabilitation/
compassion: mean (SD)
p
Sex
Men 27.12 (7.29) 0.03* 16.81 (3.02) 0.002*
Women 25.99 (7.39) 16.15 (3.06)
Age, mean (SD) 0.045 0.15+ −0.03 0.27+
Educational level
No answer/not available 27.12 (11.1) <0.001**13.88 (7.49) 0.001**
Primary education 34.18 (6.5) 17.71 (2.97)
Some secondary education 26.88 (7.57) 16.42 (2.84)
Post-secondary education/higher26.23 (7.14) 16.50 (3.03)
Residence
Athens 26.74 (7.38) 0.0008**16.56 (2.84) 0.006**
Thessaloniki 24.91 (6.78) 15.7 (3.91)
Major urban centers/cities 27.93 (6.86) 16.55 (2.8)
Minor urban centers/cities 26.12 (7.24) 16.75 (2.76)
Villages 26.84 (8.32) 16.63 (3.36)
Educational level of household’s leader
None 30.67 (9.81) 0.0001**17 (1) 0.0001**
Primary education 29.73 (6.36) 17.06 (2.86)
Lower secondary education 28.87 (9.19) 17 (4.06)
Upper secondary education 27.23 (7.31) 16.29 (2.67)
Short-cycle tertiary education/
post-secondary non-tertiary
education
27.47 (7.01) 16.7 (2.74)
Bachelor’s degree or equivalent25.97 (7.03) 16.62 (2.94)
Master’s degree or equivalent25.03 (7.24) 16.4 (3.21)
No answer/not available 25.87 (9.35) 15.24 (4.76)
Familiarity index 0.08 0.004+0.24 <0.001+
Variable Community risk:
mean (SD)
p Diminished
responsibility: mean
(SD)
p
Sex
Men 16.49 (3.05) 0.0003*9.71 (2.24) 0.0005*
Women 15.66 (2.95) 9.17 (2.55)
Age, mean (SD) 0.03 0.29+ −0.07 0.02+
Educational level
No answer/not available 15.12 (7.12) 0.02**8.62 (4) 0.31**
Primary education 17.39 (2.92) 9.54 (2.17)
Some secondary education 16.04 (2.98) 9.42 (2.6)
Post-secondary education/higher16.07 (2.98) 9.47 (2.35)
Residence
Athens 16.18 (2.97) 0.05**9.47 (2.37) 0.46**
Thessaloniki 15.67 (3.53) 9.26 (2.7)
Major urban centers/cities 16.23 (2.79) 9.37 (2.37)
Minor urban centers/cities 16.22 (2.59) 9.61 (2.36)
Villages 15.9 (3.56) 9.5 (2.33)
(continued)
1 Public?s Attitudes Toward Mentally Ill Oenders inGreece

10
Table 1.6 (continued)
Educational level of household’s leader
None 18 (1) 0.02**11.67 (1.15) 0.001**
Primary education 16.61 (2.86) 9.45 (2.14)
Lower secondary education 16.57 (4.47) 9.23 (2.69)
Upper secondary education 16.04 (2.92) 9.1 (2.55)
Short-cycle tertiary education/
post-secondary non-tertiary
education
16.43 (2.49) 9.59 (2.29)
Bachelor’s degree or equivalent16.08 (3.2) 9.56 (2.32)
Master’s degree or equivalent15.71 (3.22) 9.59 (2.47)
No answer/not available 15.49 (3.42) 8.9 (2.71)
Familiarity index 0.24 <0.001+0.18 <0.001+
*Student’s t-test; **ANOVA; +Pearson’s correlation coef cient (r)
tudes, negative stereotyping, attribution of blame,
and moderate tendency to rehabilitate mentally
ill offenders are troubling. An attainable explana-
tion for that could be the prevailing atmosphere
under which the sample was gathered at the given
time where the various events, thus presented by
the media and social networks, blamed mental
illness. Correspondingly, society’s trust was
affected and disturbed and stirred up negative
feelings of fear, anger, and insecurity. Mental ill-
ness presence ultimately did not act as a “mitigat-
ing factor” in the eyes of the public, something
Sutton also points out. Additionally, also to be
noted is that in Greece the economic crisis inter-
rupted the development of the mental health sec-
tor and the evolution of the psychiatric reform,
which resulted negatively in various public
awareness actions, which were ultimately sus-
pended. Finally, it should be highlighted that nei-
ther an informative nor an awareness campaign
has been carried out in our country, which spe-
ci cally concerns mentally ill offenders.
Strengths of our study include the volume of
the sample, which ensured the anonymity of the
responses and therefore their validity. Also, there
was an equal distribution of gender, age, educa-
tional level, income, and place of residence
among the sample. However, the study is also
characterized by a number of limitations. The
rst limitation concerns the overall sample, in
which people over 65 could not participate. This
can be attributed to ignorance, dif culties, or
prejudices displayed by this population group in
the use of new technologies. The second con-
cerns the choice of “labels” used, the use of gen-
eral characteristics rather than a speci c scenario,
and failure to identify speci c diagnosis or crimi-
nal offenses, which may have led to more nega-
tive responses toward mentally ill offenders.
Certain diagnoses (e.g., schizophrenia) or types
of offending (e.g., domestic violence, sexual
offenses) have been found to elicit more negative
reactions [4, 12].
1.5 Conclusions
Findings of this study demonstrate negative ste-
reotypes, authoritarian attitudes, desire for social
isolation, and low levels of familiarity with men-
tal illness. These results provide valuable evi-
dence, which contribute to understanding of the
general population’s prejudices and discrimina-
tions toward mentally ill offenders and demon-
strate the extent to which these perceptions may
inuence intervention policies and strategies for
these patients. Simultaneously, they highlight the
need for new antistigma campaigns, perhaps in
more ways familiar and accessible using technol-
ogy to younger audiences. In addition, our study
provides important data that could form the basis
for future research in other elds (health, mental
health, penal system, penitentiary, etc.), during
the time professionals employed with them come
into contact with this particular population group
of mentally ill offenders.
S. Martinaki et al.

11
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1 Public’s Attitudes Toward Mentally Ill Oenders in Greece

13
2
Pythagorean Self-Awareness
Intervention Promoted Healthy
Dietary Patterns, Controlled Body
Mass Index, and Reduced
Self-Reported Stress Levels
of Primary School Children: Α
One-Arm Pilot Study
Marilena Panagiotou, Ioanna Maria Velegraki,
Orsalia Gerakini, Flora Bacopoulou,
Maria Charalampopoulou, Maya Louvardi,
Xanthi Tigani, Aimilia Mantzou,
Dimitrios Vlachakis, Christina Kanaka-
Gantenbein, George P. Chrousos,
and Christina Darviri
Abstract
Stress is common in childhood and an impor-
tant factor that affects behavior later in adult-
hood. The aim of this study was to assess the
effects of the Pythagorean Self-Awareness
Intervention (PSAI), a holistic “cognitive
reconstruction” technique to assess primary
school children’s stress levels, adherence to
the Mediterranean diet, and body mass index.
Secondary outcome measures included rela-
tions with peers, sleep, and hair cortisol con-
centrations. This one-arm pilot study took
place in a primary school, from February to
June 2019. Participants were 32 pupils attend-
ing the second grade of primary school who
received the 8-week PSAI to adopt healthy
behaviors and lifestyle. Self-report measures
were applied for the evaluation of various
variables at the beginning and the end of the
eight-week intervention. There were statisti-
cally signi cant reductions in stress levels
(p = 0.00), nightmares’ frequency (p = 0.00),
body mass index (p = 0.03), and bully scale
(p = 0.00), and improvement in Mediterranean
diet quality (p = 0.00). Hair cortisol concen-
trations increased (p = 0.02). The social scale
signi cantly increased. Bedtime remained the
M. Panagiotou · I. M. Velegraki · O. Gerakini ·
M. Charalampopoulou · M. Louvardi · X. Tigani ·
C. Darviri
School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
F. Bacopoulou (*)
Center for Adolescent Medicine and UNESCO Chair
in Adolescent Health Care, First Department of
Pediatrics, School of Medicine, National and
Kapodistrian University of Athens, Aghia Sophia
Children’s Hospital, Athens, Greece
e-mail: [email protected]
A. Mantzou
First Department of Pediatrics, Aghia Sophia
Children’s Hospital, Athens, Greece
e-mail: [email protected]
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
P. Vlamos (ed.), GeNeDis 2022, Advances in Experimental Medicine and Biology 1425,
https://doi.org/10.1007/978-3-031-31986-0_2

14
same after the intervention. This pilot trial
showed that the PSAI promoted healthy
dietary patterns, controlled children’s body
mass index, and reduced their self-reported
stress levels. Further research on the imple-
mentation of this holistic program on children
is suggested, in well-powered randomized
controlled trials.
Keywords
Body mass index · BMI · Intervention ·
Pythagorean self-awareness · Stress · Healthy
lifestyle · Bullying · Children · Students ·
Mediterranean diet
2.1 Introduction
Research on stress demonstrates that it can have
both bene cial and harmful effects on health,
wellbeing, and performance [1]. In fact, stress
experienced by children each day can inuence a
plethora of complex and interacting physiologi-
cal reactions. These reactions affect many organ
systems within the body. For instance, emotional
stress can stimulate the autonomic nervous sys-
tem, mainly the sympathetic branch, and alter
heart rhythm patterns, ultimately altering the
activity pattern in the afferent neurological infor-
mation transmitted from the heart to the brain.
Matthews, Gump, Block, and Allen [2] also
found that children with signi cant sources of
ongoing stress in their lives exhibited increased
physiological activation in response to acute lab-
oratory stressors. Negative affect was also found
to be linked to increased resting blood pressure
levels in adolescents [3]. Similarly, Matthews
et al. found that children who had chronic or
ongoing stressors present in their lives exhibited
higher diastolic blood pressure responses to acute
laboratory stress tasks when compared to chil-
dren with less background stress in their lives.
Exposure to chronic and acute life stressors
can disrupt the neuroendocrine stress regulation
system. The increased production of cortisol can
result in epigenetic changes in the structure of
regions of the brain responsible for emotion regu-
lation and other important functions, and pro-
mote obesogenic eating behavior and dietary
patterns, as well as lifestyle factors (e.g., distur-
bance in daily routine, poor sleep, low physical
activity) that may increase obesity risk [4–7].
One step further, it has been reported that
overweight or obese children are more likely to
experience bullying victimization in school set-
tings across different countries [8]. On the other
hand, it has been reported that bullied children
exhibit a greater risk of becoming overweight or
obese [9], while obesity has been found to be
associated with psychosocial maladjustment
including increased anxiety, depressive feelings,
loneliness, lowered self-esteem, and behavior
problems.
The above data support the notion that ongo-
ing stress and improper management not only
affects a child’s health status in the present but
also may have cumulative and long-term effects.
In examining the present effects of stress,
research has also supported the idea that the pres-
ence of stress in children can impair cognitive
processes involved in learning [10] as well as
appropriate social interactions with others.
Parents, on the other hand, may not be able to
identify children’s stress and its impact on their
children, as it is suggested by Breiner et al. [11],
D. Vlachakis
Laboratory of Genetics, Department of
Biotechnology, School of Applied Biology and
Biotechnology, Agricultural University of Athens,
Athens, Greece
e-mail: [email protected]
C. Kanaka-Gantenbein
First Department of Pediatrics, School of Medicine,
National and Kapodistrian University of Athens,
Aghia Sophia Children’s Hospital, Athens, Greece
e-mail: [email protected]
G. P. Chrousos
University Research Institute of Maternal and Child
Health & Precision Medicine, and UNESCO Chair in
Adolescent Health Care, National and Kapodistrian
University of Athens, Aghia Sophia Children’s
Hospital, Athens, Greece
M. Panagiotou et al.

15
and it has also been suggested that many parents
believe that the child is seeking attention or being
dif cult, rather than recognize their behaviors as
a result of stress.
School settings with the collaboration of par-
ents, teachers, and health professionals can ide-
ally be used for the implementation of health
promotion programs to primarily manage stress
and prevent its adverse effects on children.
Traditionally, school-based programs for over-
weight and obese children have focused only on
the training of healthy eating and increase in
physical activity [12]. However, there is a need
for school-based intervention programs to reduce
stress and its effects. Multicomponent school-
based interventions promoting adherence to the
Mediterranean diet (MD) have the potential to
combat obesity [13].
Based on the aforementioned, we present the
effects of the Pythagorean Self-Awareness
Intervention (PSAI), a novel holistic stress man-
agement program that combines evidence-based
lifestyle recommendations (Mediterranean diet,
sleep routine, physical activity, limited use of
screens, etc.) and cognitive reconstruction based
on the teaching of the ancient Greek philosopher,
Pythagoras.
The PSAI has demonstrated favorable physi-
cal, metabolic, and mental health outcomes in
children and adults in Greece. In the school set-
ting, Kalogiratou et al. [14] found that PSAI
decreased emotional eating and promoted well-
being in third grade primary school children.
PSAI has also demonstrated amelioration of
stress and aging biomarkers in a sample of type II
diabetes mellitus and healthy adults [15]. In addi-
tion, the PSAI showed positive results in decrease
in weight in a sample of obese adults as well as in
a community sample [16, 17]. Furthermore, the
implementation of PSAI had positive outcomes
in a sample of patients with major depression
[18].
The primary aim of the study was to investi-
gate the effects of the PSAI on primary school
students’ stress levels, adherence to the
Mediterranean diet, and body mass index (BMI).
Secondary outcome measures included relations
with peers, sleep, and hair cortisol concentration
(HCC).
2.2 Subjects and Methods
2.2.1 Study Design
A one-arm pilot study took place at the 4th
Primary School of Chalandri, Municipality of
Attica Province (Greece), from February to June
2019. The program received ethics approval by
the Ministry of Education Φ.2.1/ΣΔ/43813/Δ7
for the academic year 2019–2020.
2.2.2 Participants
Pupils attending the second grade of primary
school with good comprehension of the Greek
language were eligible to participate in the study
intervention for eight weeks. Children were
excluded from the study if they practiced other
stress management techniques. Written consent
forms were obtained from children’s parents
before inclusion in the study.
2.2.3 Measurements
2.2.3.1 Socio-demographic Data
Sex, age, family members, and siblings were
recorded for each study participant. Measurements
took place in the classroom after completion of
school’s schedule.
Measurements were performed by a health
professional trained in the science of stress.
Children completed the questionnaires on their
own in the presence of the stress scientists in case
they had any queries. The following measures
were assessed at baseline and after the
intervention.
2.2.3.2 Anthropometric Data
Body weight and height were measured at school
with the use of a calibrated digital scale and a
stadiometer, in the minimum clothing possible.
Body mass index (BMI) was estimated.
2 Pythagorean Self-Awareness Intervention Promoted Healthy Dietary Patterns, Controlled Body Mass…

16
2.2.3.3 Hair Cortisol
A sample of hair (3 cm) was obtained from each
participant for measurement of hair cortisol con-
centration (HCC). A lock of hair as thick as a
pencil was cut by scissors from the posterior ver-
tex as close as possible to the scalp. As hair has a
predictable growth rate of about 1 cm/month, the
closest part of 1 cm to the scalp approaches the
production of last month’s cortisol. Hair samples
were stored in paper envelops at room tempera-
ture pending analysis. The rst three centimeters
of hair proximal to the scalp were cut and pulver-
ized with a ball mill. Cortisol was extracted into
methanol. Hair cortisol analysis took place at the
Choremeio Research Laboratory, Unit of Clinical
and Translational Research in Endocrinology of
the First Department of Pediatrics, School of
Medicine, National and Kapodistrian University
of Athens, Greece. Physiological mean concen-
tration of hair cortisol in healthy children aged
eight to nine years has been reported to be 6.7 pg/
mg [19].
Stress in Children Questionnaire (SIC): The
Stress in Children Questionnaire consists of 21
questions that examine the stress that children
may encounter in many aspects of their life and
has been used with children aged between 8 and
12 years. Higher scores indicate higher levels of
stress [20].
KIDMED Index: The Mediterranean Diet
Quality Index for Children and Adolescents
(KIDMED) is based on the principles of
Mediterranean dietary patterns and comprises 16
“yes” or “no” questions that could be self-
administered or conducted by interview. Overall
score ranges from 0 to 12 and it is derived from
the summation of the values, which is classi ed
into three levels: (1) >8, optimal adherence to
Mediterranean Diet; (2) 4–7, improvement
needed to adjust intake to Mediterranean pat-
terns; and (3) ≤3, very low diet quality. The
instrument has been used in children and adoles-
cents aged 3–18 years [21].
Peer Relation Questionnaire for Children
(PRQ): The Peer Relation Questionnaire (short
form) for children measures the bullying phe-
nomenon consisting of 12 items with 3 subscales
(tendency to bully others, tendency to be victim-
ized by others, and tend to act in a pro-social or
cooperative manner). The instrument has been
validated in children and adolescents aged
8–14 years [22].
Sleep: A series of questions were asked to
measure the bedtime and the frequency of night-
mares. Mean scores were calculated.
2.2.4 Pythagorean Self-Awareness
Intervention for Children
and Adolescents
Pythagorean Self-Awareness Intervention for
Children and Adolescents (PSAI-CA) is a holistic
“cognitive reconstruction” technique of stress
management and improvement in the quality of
life, sleep, and memory. The technique was
developed by the Medical School of Athens at
National and Kapodistrian University based on
the new concept of Evidence-Based Lifestyle
Medicine [23] and World Health Organization
(WHO) data for adolescents [9]. The technique
relied on the philosophy of an ancient Greek phi-
losopher Pythagoras of Samos (c. 570 e c. 495
BCE) [24]. As Pythagoras stated, self-awareness
and eudemonia are achieved through constant
introspection and self-control. The purpose of the
technique is to increase self-awareness using a
moral reference for this critical appraisal. The
analysis of the neurophysiology of the technique
refers to the activation of the Default Mode
Network (DMN), a large-scale functional brain
network. The DMN is activated when the indi-
vidual focuses on internal self-relevant mental
processes such as memory retrieval of autobio-
graphical events, envisioning future actions, and
being aware of the perspectives of others [25,
26].
The technique of PSAI-CA is mainly prac-
ticed shortly before night sleep and the individual
must follow three cognitive processes. A rule
referred to “The Twelve Virtues” has been devel-
oped as a moral reference to accomplish the chil-
dren?s self-awareness by following ve simple
steps, which are presented in Table 2.1.
Pythagorean virtues are: (1) fairness, (2) truthful-
ness, (3) charity and spirituality, (4) decent
M. Panagiotou et al.

17
behavior, (5) discipline and respect for the law,
(6) order and accuracy, (7) industriousness, (8)
cooperation, (9) contribution to the general good,
(10) courage, (11) cleanliness and perfect appear-
ance, and (12) temperance. Events or choices of
personal relationships are judged freely by the
individual since the primary goal is to enhance
self-awareness and not to criticize them [27].
2.2.4.1 PSAI-CA Implementation
Eight sessions were part of the program and
numerous pieces of advice were included about
healthy nutrition, sleep, physical activity, bully-
ing, and screens (mobile-tablet-PC). Sessions
were held once per week (90 min) over eight
weeks. The rst session included information
about the stress system, symptoms, and effects.
Students were trained individually in diaphragm
breathing using the Biofeedback software. The
ve tricks were presented to the students.
Pedometers were provided as a motivation for
exercising. In the second session, participants
received instructions on the practice of
Pythagorean Self-Awareness and the 12 virtues
were taught. In the following sessions guidelines
and advice on the Mediterranean diet, physical
activity, sleep, use of screens, and bullying were
given to the students. During sessions, they were
encouraged to discuss practical issues or ideas
that might have emerged during the previous
days. In each session, a weekly activity logbook
(self-report measure of compliance to the PSAI),
reading materials, and homework assignments
were provided.
2.2.5 Statistical Methods
The data were analyzed by non-parametric tests
due to the small study sample. Adjusted means
were calculated through paired sample t-test. The
level of signi cance was set at 0.05. BMI was
calculated as the ratio of body weight to the
square of height (kg/m
2
). BMI z-scores were
calculated based on World Health Organization
(WHO) growth charts. The SPSS statistical soft-
ware version 22.0 for Windows was used to per-
form statistical analyses (SPSS Inc., Chicago,
IL). The sample size was not calculated prior to
the intervention. However, post-hoc power analy-
sis was performed. Power exceeded 90% based
on calculations performed in R software using
the pwr package [28].
2.3 Results
A total of 32 pupils participated in the study and
there was one dropout due to change of school.
The owchart of study participants is depicted in
Fig. 2.1.
Full participation in all sessions and full com-
pliance with PSAI were assessed in the weekly
diaries. The mean age of the participants was
8 years, with 53.1% of participants being girls,
46.9% boys, and 84.4% had siblings, while most
of the participants’ families had 4 members.
Finally, BMI z-scores of the participants were
within normal range. Descriptive statistics are
presented in Table 2.2.
Table 2.3, presents the study’s results. There
was a statistically signi cant reduction in stress
levels (SIC, p = 0.00), nightmares (p = 0.00),
BMI z-scores (p = 0.02), and HCC (p = 0.02).
Adherence to Mediterranean diet was also
found to have statistical improvement;
KIDMED (p = 0.00) was also improved after
Table 2.1 The ve steps of PSAI-CA applied daily for
30 minutes by each participant
1stBefore night sleep sitting on a chair, breathe
diaphragmatically for 10 min
2ndRead the 12 virtues then turn your attention
inwards and assume the role of the observer
3rdRecall every event of the day in the exact time
sequence it happened
4thObserve your day like a video timeline
Choose the events that seem important to you
and assess your actions (reward, detest) using 3
questions based on the 12 virtues and the
instructions for a healthy lifestyle you were
taught:
What have I done right?
What have I done wrong?
What have I omitted that I ought to have
done?
5thThe next day make a quick review of the
previous day and set your new goals
2 Pythagorean Self-Awareness Intervention Promoted Healthy Dietary Patterns, Controlled Body Mass…

18
Fig. 2.1 Flowchart of
the study participants
Table 2.2 Baseline socio-demographic and anthropometric characteristics of study’s participants
Referential measurements N = 32
Sex
Boys 15 (46.9%)
Girls 17 (53.1%)
Mean age in years (SD) 8.03 (0.18)
Min-max age range in years 8–9
Siblings
Yes 27 (84.4%)
No 5 (15.6%)
Family members
3 3 (9.4%)
4 25 (78.1%)
5+ 4 (12.5%)
Anthropometric measures
Median weight in kilograms (iqr) 26.90 (6.05)
Mean height in cm (SD) 1.24 (0.06)
BMI z-score 0.94 ± 0.64
Descriptive statistics of the study’s participants
BMI body mass index, iqr interquartile range, SD standard deviation
the intervention program. Hair cortisol concen-
trations statistically increased (HCC, p = 0.02).
Statistical decrease was also noticed in
the Bully scale of the bullying questionnaire
(PRQ-Bully, p = 0.00) while the social scale
was statistically increased (PRQ-Presocial,
p = 0.00). No statistically signicant changes
were observed in the PRQ-Victim scale
(p = 0.11) and bedtime (p = 0.82).
M. Panagiotou et al.

19
Table 2.3 Baseline and post-intervention measurements of the study participants
Measurements
Pre-intervention Post-intervention
p-ValueN = 32 N = 32
Primary outcomes
SIC 2.29 ± 0.70 1.40 ± 0.49 <0.001*
KIDMED 6.41 ± 1.87 10.61 ± 1.39 <0.001*
BMI z-scores 0.94 ± 0.64 0.60 ± 0.81 <0.05
Secondary outcomes
Bedtime 21.03 ± 1.75 21.30 ± 0.54 0.82
Nightmares 1.33 ± 1.16 0.52 ± 0.90 <0.001
PRQ-Bully 8.15 ± 2.55 8 ± 2.62 <0.001
PRQ-Presocial 12.6 ± 1.96 13.81 ± 2.03 <0.001
PRQ-Victim 8.45 ± 2.31 7.42 ± 1.62 0.11
HCC 4.22 ± 1.98 5.68 ± 3.18 <0.05
SIC Stress in Children Questionnaire, KIDMED Mediterranean Diet Quality Index for Children and Adolescents, PRQ
Peer Relations Questionnaire for Children, HCC Hair Cortisol Concentrations, BMI Body Mass Index
Measurements are presented in mean?standard deviation. *Level of signi cance: p < 0.05
2.4 Discussion
The study aimed to assess the effectiveness of a
novel holistic cognitive stress management pro-
gram, PSAI-CA, which included consults of
stress, quality of life, sleep, eating behavior, and
bullying behavior of children. The hypothesis
that PSAI-CA is effective to reduce stress and
adopt a healthy lifestyle has been con rmed.
After the intervention program, stress levels,
nightmares, and BMI were statistically reduced.
In the bullying scale, the bully, which represents
the physical and psychological maltreatment of
one child from another, was diminished. The
social scale was increased as well as hair cortisol
concentration. Bedtime and PRQ-Victim scale
were still the same after the intervention
program.
The reduction in stress levels can be explained
by the fact that the participants were able to con-
trol any stressful factor applying the PSAI tech-
nique. The program reduced stress levels and
negative emotions and favored a less reward-
seeking behavior (e.g., recreational habits) and
more healthy choices daily [29–32]. Study par-
ticipants changed their BMI because of the nutri-
tion guidelines based on the Mediterranean diet,
which is considered one of the healthiest dietary
models. Kalogiratou et al. found that the imple-
mentation of the PSAI had positive effects on a
sample of primary school attendants’ emotional
eating and psychological state [14]. In recent
studies, the Mediterranean diet had a bene cial
effect on certain body systems [33–35]. Children
and adolescents may be the age groups with the
most unfavorable Mediterranean diet pro le [36].
The PSAI has also been used in overweight/
obese adults as an effective method for reduction
in BMI, body fat, emotional and external eating
behavior, as well as adverse metabolic indices
[16].
The main reason behind bullying’s reduction
is the full compliance of children with PSAI, an
item of which was the Pythagorean Virtues.
While nding more ways to cooperate, children
managed to decrease conicts. Anger?s control
was managed through the virtue of temperance.
Instead of counting on conicts, they solved their
disputes through dialogue and mutual under-
standing. Many anti-bullying programs are effec-
tive, because intervention programs reduced peer
victimization and increased school safety in 14
schools [34, 37, 38]. Therefore, anti-bullying
programs appeared to be substantial in encourag-
ing children to change their behavior for the bet-
ter [39, 40].
As per the study’s results, the social scale was
increased, which means that peer relations were
improved among children. Social skills were also
improved by supporting each other. The relation-
ships between them ameliorated and they became
more cooperative.
2 Pythagorean Self-Awareness Intervention Promoted Healthy Dietary Patterns, Controlled Body Mass…

20
The elementary students who suffered con-
stant nightmares have reported a decrease in
them. Even though our sample was not obese,
this nding is similar to the study of Mazurak
et al. [41] who compared sleep quality of chil-
dren and adolescents with obesity versus a
healthy sample and suggested that sleep hygiene
education, as part of weight-loss therapy, may
provide both physical and psychological bene ts
to this population. The effectiveness of the PSAI
has been con rmed by the reduction in anxiety
and an improvement in sleep, diet, and exercise
[42].
Our results are consistent with cognitive
behavioural therapy (CBT) studies that also
improved sleep and reduced insomnia [43–45].
Cortisol is a measure of stress as an end-
product of the hypothalamic-pituitary-adrenal
(HPA) axis. Hair cortisol is considered superior
to the serum and urine cortisol for the evaluation
of chronic stress, as it reects cortisol aggrega-
tion over the previous months. Hair cortisol has
been associated with physical and mental ill-
nesses in children and adolescents [46]. In our
study hair cortisol concentrations were increased,
which could indicate the activation of HPA axis
[47]. This could be explained by increasing atten-
tion and emotional effort through cognitive reap-
praisal [29]. The frontal lobe can be activated via
gnostic reconstruction. The technique was effec-
tive using the moral reference and critical
appraisal whereas most intervention programs
use a speci c technique. Pupils embraced the 12
virtues and learned how to evaluate themselves,
discerning what is right and what is wrong. They
acquired self-control, self-discipline, and
restraint. The role of the observer gives the pos-
sibility of self-review and self-evaluation [30].
The children were equipped with skills such as
self-discipline and self-control and are now capa-
ble of using them for their bene t on their way to
development. Those skills will also assist them in
spiritual improvement, academic performance,
and wellness, which in turn lead to social wellbe-
ing [32].
Besides that, to reduce stress and obesity
mindfulness interventions have been imple-
mented. When children received mindfulness
training, they reported lower stress [48] and posi-
tive results [49]. Furthermore, intervention pro-
grams showed that BMI had a signi cant
bene cial alteration [50–53]. A meta-analysis of
19 studies (total participants = 4063) of educa-
tional interventions in children and adolescents
evaluating social–emotional training, relaxation
programs, problem-solving, and stress manage-
ment showed a positive effect on reducing the
symptoms of stress and strengthening coping
skills [54]. Environmental, cognitive, and behav-
ioral factors work together to inuence children?s
knowledge of nutrition, self-ef cacy, and healthy
behavior choices. Both have been shown to con-
tribute to children’s eating behavior [36].
However, this study faces some limitations
including small and random sample size, lack of
control group and short follow-up, small duration
of the intervention, and lack of other age groups.
Furthermore, compliance to the intervention was
assessed by children’s self-reports without paren-
tal reassurance that all recommendations were
followed. Thus, the results of the study cannot be
generalized.
2.5 Conclusions
This pilot study showed that the PSAI-CA
reduced stress levels and established healthy
behaviors and lifestyle in a sample of second
grade primary school students. Further research
on the implementation of the PSAI on school
children is needed to verify these ndings,
through a well-powered randomized controlled
trial.
Acknowledgments We thank all students for participat-
ing in the study, as well as the headmaster, Mrs. Bassia
Athena Spyridoula, and the teachers Mrs. Petropoulou
Petroula and Mrs. Argyri Eleni of the 4th Primary School
of Chalandri, Municipality of Attica, Greece.
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hundreds of thousands of dollars depended upon the arrival of big
consignments of dutiable goods within the time limit. The demand
for space on the North German Lloyd line was so great that on one
of the ships due to arrive in New York just before the new law went
into effect, when shippers could not obtain room in the hold, several
state-rooms were hired, and filled full of cutlery and other goods on
which there was a considerable advance of duty. It will be
remembered that in some instances tugs were sent out beyond
Sandy Hook to meet steamships and sailing vessels which had been
delayed, and hasten their arrival. The Etruria reached Quarantine at
11 é.m. on October 4, 1890. Captain Haines was taken off on a tug,
which ploughed her way up the Bay. At the Battery a team of fast
horses was waiting, and the captain rushed breathless into the
Custom House, with barely one minute to spare, before midnight,
when the new law went into effect. Thousands of dollars were saved
by the timely arrival of the Etruria. The Zaandam, which had been
chartered to bring over a large cargo of Sumatra tobacco, on which
the duty was advanced $1.25 per pound, arrived a few hours late,
although she sailed three days ahead of the Werkendam, of the
same line, with a similar cargo, which arrived in time to save the
increased duty.
Every nation is interested in the extension of its ocean freight-
carrying business. The welfare of the farmer, the artisan, and the
merchant is interwoven with that of men who live on the sea.
Commerce and the industries go hand in hand, and the magnificent
showing that the former makes is only an indication of the prosperity
of the latter. No more apt illustration of the growth of the American
nation in the last quarter of a century can be pointed out than the
development of her ocean traffic.

W
STEAMSHIP LINES OF THE WORLD.
By LIEUTENANT RIDGELY HUNT, U. S. NAVY.
Iméortant Part Taken by the United States in Establishing Ocean Routes—
Rivalry in Sailing Vessels with England—Effect of the Discovery of
Gold in California —The Caée Horn Route—Australian Packet Lines—The
Problem of a Short Route to India—Four Main Routes of Steamshié
Traffic—Characteristics of the Regular Service between Euroée and the
East—Port Said and the Suez Canal—Scenes at Aden and at Bombay—
The Run to Colombo, Ceylon—Some of the By-ways of Travel from
Singaéore —The Pacific Mail—From Yokohama to San Francisco —Two
Routes from Panama to New York—South American Ports—Magnificent
Scenery of the Magellan Straits—Beauties of the Port of Rio—The
Great Ocean Route from London to Australia .
RITERS of maritime history give to the United States the credit
of establishing long lines of communication by sea with far-
distant countries. As early as 1789 the merchants of Boston
despatched their ships direct to China and the East Indies, some
time before England entered on this trade; for the American vessels
not only brought their cargoes to the home markets, but also trans-
shipped spices, silks, teas, sugar, coffee, and cotton to Europe. In
those times a skipper felt satisfied if he made the outward voyage of
15,000 miles, by way of the Cape of Good Hope, in 150 days, and
came back via Cape Horn, some 17,000 miles, in the same time.
The development of the resources of the East by the East India
Company, and the richness of the freights carried by the United
States vessels—the proceeds of a single voyage often defraying the
first cost of the ship—induced England to enter into competition;
thus starting that rivalry between the sailing fleets of the two nations
that was long the admiration of the world. In 1845 the American
clippers, long, low, of good beam, very fine lines, and with yards so
square and spars so lofty as to set a greater spread of canvas in

proportion to their tonnage than any ship hitherto sailed, entered
the race and left all rivals far astern. Then followed the days of
which the old “sad sea-dogs” still love to tell, when every stitch of
sail was carried until the fierce wind blew it from the bolt-ropes;
when for weeks the lee scuppers lay buried in the seething waters
and the flying jibboom plunged deep into the white-capped waves;
when the good ship Sovereign of the Seas came into port 90 days
from Hong-Kong, and the town gathered on the wharf to welcome
the daring navigators; while the cargo of teas and coffees was sold
at fabulous prices. And these old salts still discuss the dinner given
to the bold captain that night, when the log of the voyage would be
read and men would sit amazed at hearing that in 22 days the ship
had sailed over 5,391 miles, that for four days her daily run had
been 341.8 miles, and that in one day she had done 375 miles, at
the rate of 15.6 knots.
The discovery of gold in California started a line of travel 14,000
miles long from Europe and the Eastern seaboard of the United
States via Cape Horn to the western coast of North America. Ships
on this line took out merchandise of every description to be used in
building and maintaining the city of San Francisco, and after landing
this freight, for which they received $25 a ton, they sailed for China,
whence, after loading with teas and sugars at $25 and $30 a ton for
freight, they returned direct to the United States or England.
In the meantime Australia had been opened up, and the Australian
packet lines, leaving London for Melbourne 12,000 miles away, were
making 100-days voyages by way of the Cape, “with a chance of
being drowned.” This line carried many passengers, but it was not
until 1850 that this traffic began to assume such importance that
vessels were run on regular schedules for its accommodation. During
the time of the Crimean war this trade was enormous, and the
Liverpool packet lines between England and New York reaped a rich
remuneration in spite of serious accidents. It is reported that in the
year 1854 no less than nine emigrant ships foundered at sea.

The day of the sailing ship on short routes was now closing, for
the steamship entering into competition, gradually absorbed the
lucrative passenger traffic and much of the more valuable freight.
In looking over the history of the lines of the world, none is found
to have exerted more influence upon subsequent progress than the
old route between India and England. This route at first doubled the
Cape of Good Hope—a distance of 14,000 miles, so long and
uncertain that the East India Company frequently sent their
despatches by way of the Persian Gulf and then overland between
Bagdad and Constantinople. The successful crossing of the Atlantic
Ocean by the steamship Savannah suggested the possibility of a like
means of communication with India. Accordingly, the English side-
wheel steamship Enterprise, of 470 tons, 122 feet long, bark-rigged,
left Falmouth in the year 1825 and reached Calcutta, after a voyage
of 13,700 miles, in 113 days, of which 64 were steaming days. This
result, though unsatisfactory, stimulated efforts looking toward
remunerative steam navigation in the East. The first steamship
arrived at Macao, China, in 1830. As an inducement to people to
choose this novel mode of travelling, a Canton paper contained the
following notice of a steamer: “She carries a crew, a surgeon, a
band of music, and has rooms elegantly fitted up for cards and
opium smoking.”
The problem of a short route to Europe from India was practically
solved in 1830, by sending a steamer from Bombay to Suez, a
distance of 3,000 miles, in 25 days. In a few years a regular line was
established between the two places, connecting with steamers at
Alexandria by means of a camel service across the desert. The camel
post was succeeded by four-horse vans, and later these were
followed by the Suez Canal and the railway.
With the progress of time sailing-ships have given way to
steamships, and the routes of communication which they, after years
of navigation, did so much to establish, have become the highways
of an enormous trade, along which large and swift steamships are

constantly going to and fro with the certainty and regularity of
railway trains. A steamer to-day leaves her wharf at the moment of
time set forth in her schedule, and arrives at the terminus of her
voyage—it may be many thousand miles away—with almost equal
promptitude.
Like railway traffic, steamer traffic follows certain main routes or
grand trunk lines, having numerous feeders or subsidiary lines. The
great ocean thoroughfares of the world are:
1. The route across the Atlantic, through the Mediterranean Sea,
Suez Canal, and Red Sea, to India, China, Australia, and eastern
Africa.
2. The route by the Pacific Ocean to Japan, China, and Australia.
3. The route by the Atlantic Ocean down the east coast of South
America, and around Cape Horn, to western America and
Australasia; and
4. The route down the Atlantic and the west coast of Africa,
around the Cape of Good Hope, to East Africa, Australasia, and the
East. The number of steamers traversing these grand routes, and
those tributary to them, is estimated to be more than 11,000. In
order to emphasize the importance of ocean navigation, the
appended table
20
of the number of steam vessels, their money
value, and the value of the merchandise they carry, is given for the
five greatest nations of the globe:

Number
of Steam
Vessels.
Gross
Tons.
Value of
Vessels.
Value of
Trade carried
in Vessels.
Great Britain 6,4038,235,854$550,000,000$3,476,500,000
Germany 741928,91163,500,0001,624,000,000
France 526809,59848,500,0001,471,000,000
United States 416517,39442,000,0001,462,500,000
Italy 212300,62522,000,000415,000,000
Russia 236106,15512,500,000 60,000,000

CHART OF THE WORLD
SHOWING THE
Principal Steamship Routes.
Larger image (209 kB)
Owing to the various lines of communication which have been
opened up, the traveller is now offered the choice of a number of
routes, each vying with the other in attractiveness and interest. For
instance, the whole journey from London to Constantinople can be
performed with no more than 17 hours of sea-passage; or, if a more
leisurely way be preferred, the whole journey can be made by water.
Therefore the first thing to be done is to determine the route to be
followed, and the time to be given the trip. Then the dates of sailing
should be settled. These preliminaries concluded, there comes the
question of the selection of steamers. If England is to be visited,
passage must be booked on some line bound to that country. If,
however, the objective point be on the Continent, a room should be
engaged on some line bound for Germany, France, Spain, or the
Mediterranean.

The number of steamers engaged in the regular passenger service
between the Eastern seaboard of the United States and the Old
World is probably greater than most travellers imagine. At the
present time there are upward of thirty-five distinct lines, each with
a larger or smaller fleet of steamers regularly engaged in Atlantic
transport. Six of these, the Cunard, the White Star, the Anchor, the
Guion, the National, and the Inman, sail between New York and
Liverpool. Four others, the Norddeutscher Lloyd, the Hamburg-
American Packet Company, the Union line, and the Baltic line, trade
between New York and German ports. The National line, the Hill line,
and the Wilson line go to London; two others, the Allan-State and
the Anchor, to Glasgow. Two French lines, the General Transatlantic
and the French Commercial Steamship Company sail for Havre and
Marseilles. Two lines communicate with Dutch ports, the
Netherlands-American Steam Navigation Company, and the Royal
Netherlands Steamship Company; two more, the Red Star and the
White Cross lines, leave for Antwerp; one line, the Thingvalla,
steams to Copenhagen, and the General Italian Navigation Company,
and the Anchor line, make Italian ports.
The regular service by steam between Europe and the rich and
varied East, by way of the Mediterranean, Suez Canal, and India, is
carried on by several different companies, the best known of which
are the Peninsular & Oriental Company of England, the Messageries
Maritimes of France, the Norddeutscher Lloyd of Germany, and the
Austrian Lloyd of Austria. Each of these mail lines offers to travellers
all that can be desired in the way of food, quarters, comforts, and
facilities for seeing strange lands and peoples; so the selection of
any particular one must be decided by personal considerations.
The P. & O. (as the Peninsular & Oriental Steam Navigation
Company is commonly called) is one of the most extensive
steamship organizations in the world, the yearly distance run on all
its lines, main and subsidiary, exceeding 2,500,000 miles. In 1840
the company began the carrying of English mails in steamers
between Alexandria and London, receiving for this service a subsidy
of $160,000 a year. To-day the fleet numbers 50 vessels, which

touch at ports of importance in the Mediterranean, Egypt, the Indian
Ocean, China, Japan, and Australia, and the subsidy received for the
transportation of mails to and from all these parts is $1,750,000 per
annum.
If the traveller wishes to go by this line, he may commence his
journey from either London or Plymouth, cross the Bay of Biscay,
where the chances of getting an ugly sea and perhaps a gale of
wind are about even, and entering the Mediterranean, make
Gibraltar his first port, 5 days and 1,300 miles distant from London.
A stay of 4 hours will allow a short run on shore. A drive around the
superb Rock is worth the taking, also a visit to the battery, where
the 16-inch 100-ton guns keep watch over the threshold of the blue
sea. Loquacious guides tell of an under-the-sea tunnel between the
fortress and Apes Hill, Africa, through which monkeys have passed,
and that once upon a time five venturesome sailors started down
this subway; three of them soon turned back, those remaining—but
“that is another story.”
Deck Quoits on a P. and O. Liner.

From Gibraltar the P. & O. steamers steer for Malta, 980 miles
away, generally through a smooth sea, though in winter
northwesters blow at times with great violence off the Sicilian coast,
raising a heavy sea in the channel. In summer the winds are from
the southward, hot, humid, and prostrating, but they are not of
frequent occurrence nor of long duration. On the fourth day the
traveller is landed in Valetta, with 8 or 10 hours at his disposal. He
should see the interior of the Church of St. John, where the floor is
made of mosaic tablets in memory of the old knights, each tablet
bearing a coat of arms formed by the most skilful inlaying of marble
tiles.
From Malta to Port Said is 935 miles, made in 4 days. In winter
there may be a norther. The traveller has now, after having gone
3,200 miles in 13 days, reached the port to which all ships bound
southward make their way. Here will be found P. & O. steamers that
have come from Brindisi with the Indian mails, having stopped at
Alexandria to ship them by rail to Suez. This route, known as the
Indian Mail, is the quickest of all between Europe and India. The
train service runs from London to Brindisi in less than 50 hours.
From Brindisi, where the steamer is waiting, and where the mails
and passengers are hurried aboard, the run is made to Alexandria,
825 miles away, in 3
1
⁄
2
days. At Alexandria mails and through
passengers are transported by rail to Suez in 16 hours, and from
Suez a steamer leaves for Bombay via Aden, arriving 12 days later;
the whole journey from London to Bombay, 4,020 miles, having
taken 18 days.
A second great English line that makes for Port Said is the British
India Steam Navigation Company, incorporated in 1856 to open up
the coasting trade of India. This organization, upon the opening of
the Suez Canal, despatched the first steamer through to London that
carried an Indian cargo. Shortly afterward regular routes were
inaugurated between London, Aden, and the Persian Gulf; and
between Aden and the African coast to Zanzibar. Also a trunk route
was established for the various coasting lines of India, extending

from London to Calcutta. A further extension was begun about ten
years ago, when Batavia, Thursday Island, Brisbane, and Sydney in
Australia were added to its itinerary. The British India Steam
Navigation Company employs on its main and auxiliary routes a fleet
of over 100 vessels, large and small, that traverse about 3,000,000
miles a year.
If the traveller has reached Port Said from Marseilles, he has
doubtless come in the Messageries Maritimes steamer. This great
French undertaking began its first over-sea contract in 1851,
carrying mails as far as Egypt. The next extension of operations was
a line to Brazil and the Rio de la Plata. Finally a mail contract
established the route to India, China, and Australia. To-day the
Messageries fleet comprises 65 superb vessels that have cost about
$27,000,000; and the aggregate distance they steam amounts to
2,520,000 miles every year. The ships bound for China leave
Marseilles and Naples, and make the ports of Aden, Colombo,
Singapore, Saigon, Hong-Kong, and Shanghai. A second main line
stretches from Aden down to the Seychelles Islands, Mauritius,
Melbourne, Sydney, and New Caledonia. The Messageries Company
also operates lines to the West Indies and South America.
To Port Said comes also the Norddeutscher Lloyd Imperial
Steamship Company, better known as the German Mail. The East
Asian mail line of this company was established only in 1886, and is
rapidly growing in importance and favor. The steamers leave
Bremen, call at Antwerp, Southampton, and Genoa, thence through
the canal to Aden, Colombo, Singapore, and Hong-Kong, to
Shanghai. The mail route to Australasia reaches the ports of
Adelaide, Melbourne, and Sydney, whence a branch line leads to the
Samoan Islands and Tongatabu. The German Lloyd also operate a
line from Trieste via Brindisi to Alexandria. For carrying the mails on
the above three lines, in accordance with government stipulations,
the German Lloyd receives a subsidy of $1,047,619 per annum.
Some of the other long lines operated by this efficient
organization, which owns more than 75 ocean steamers, are those

between Bremen and the United States, between Bremen and Brazil,
and between Bremen and Montevideo and Buenos Ayres.
Table of Distances, Days, and Approximate Prices from London
Eastward by Sea to San Francisco.
From New York to London is 3,000 miles, 7-8 days, and $100.
From San Francisco to New York by rail is 3,000 miles, 6
days, and $200.
London.
Miles.Days.Price.
1,2995$45Gibraltar.
   Miles.D.Price.
2,2809 759814$30 Malta.
      Miles.D.Price.
3,215131001,9168609354$35Port Said.

4,610201253,311151252,33011120 Aden.

6,274272504,975222403,99418220Bombay.

6,703312505,404262504,42322240Colombo.

8,362382907,063332706,08229250Singapore.

9,799453408,500403407,51936340Hong-Kong.

11,6015339010,302483909,32144390Yokohama.

16,6007159015,7806659014,80062580San Francisco.
Port Said.
Miles.Days.Price.
1,3957$120 Aden.
   Miles.D.Price.
3,059142001,6647$90Bombay.
      Miles.D.Price.
3,488182302,093111008754$40Colombo.

5,147253003,752182202,53411130Singapore.

6,584323405,189252503,97118190Hong-Kong.

8,386403706,991333005,77326240Yokohama.

13,8605855012,4605145010,77544360San Francisco.
Colombo.
Miles.Days.Price.
1,6597$90Singapore.
   Miles.D.Price.
3,096141501,4377$60Hong-Kong.
      Miles.D.Price.
4,898222003,239151001,8028$70Yokohama.

9,900403358,240332506,80026200San Francisco.
Yokohama.
Miles.Days.Price.
5,00018$200San Francisco.
The Austro-Hungarian Lloyd’s Steam Navigation Company, the
fourth great main line passing through the Suez Canal, was
organized about the year 1840, with 7 steamers for Mediterranean
trade. In time, the company prolonged its lines, until, under a liberal
government bounty, routes were established between Trieste and
Hong-Kong, and between Trieste and Brazil. For the proper
performance of all these services the Austrian Lloyds are paid an
annuity by the Government amounting to $800,000. The fleet, all
told, numbers 75 ships, valued at about $10,000,000, and steams
over 1,300,000 miles every year.
Of the different steamship corporations that despatch their vessels
by way of the Suez Canal to Australia, the Orient Steam Navigation
Company of London deserves special mention. In 1878 it founded a
first-class line to Australia, which to-day is a formidable rival of the
Peninsular & Oriental Company, receiving a like subsidy of $425,000
for transporting the mails between Naples and Adelaide in 32 days, a

distance of 9,000 miles. There are many other companies sending
vessels, via the Canal, to India, to China, and to Australasia; on
nearly all of them the traveller can find comfort and good cheer,
should he desire to be longer at sea and longer in port. The names
of a few of the most important of these companies are as follows:
Under the English flag: the Ducal, the Hall, the Harrison, the Clan, the
Star, the City, the Direct, the MacIver, and the Anchor lines; the National
Navigation Company of France; the Navigatione Generale Italiana (Italian
mail) of Genoa; the Compañia Trasatlantica, from Barcelona, Spain; the
Nederland India line from Amsterdam; a Russian line; and a Turkish line.
Some of these steamers make the east coast of Africa for cargoes;
some go to Australia; some to the Spice Islands, Java and the
Philippines; some go no farther than India; and, finally, some reach
Japan, Corea, and Vladivostock.
Entrance to the Suez Canal at Port Said.
Port Said, the product of the canal, is built on the flat sands at the
entrance of the Suez Canal. Its harbor, formed by two long

breakwaters, contains one of the largest coaling depots in the world,
where vessels are supplied at the rate of 200 tons an hour. The
place is noted for its wickedness; it abounds in French cafés and
dance-halls where wine, women, and music continue the night long.
The traveller should purchase a white helmet at Port Said; these
hats are cheap, and add considerably to personal comfort.
The steam traffic of the place is enormous; last year 3,389 vessels
traversed the canal. The average time of transit by day is 24 hours;
by night with electric lights it is 19 hours, and has been done in 15
hours. In order to navigate by night, a vessel must light the way by
carrying an electric projector at her bow as close to the water as
possible, and pay the closest attention to the orders from the
passing stations or gares. Three white lights shown vertically
indicate “slow down;” then the display of two white lights is the
order to stop and haul in to the gare. The steamer presently hauls
in, makes fast, puts out all lights, and lies snug in her berth
alongside the desert, while the oncoming vessel, looking like a
locomotive at night, passes by. One white light from the gare and
lines are let go, and the journey continued until Suez is reached.
Suez is an uninteresting collection of shipping-houses and squalid
native huts, with a few tumble-down mosques. Donkeys and
donkey-boys swarm along the docks, and if the vessel stop an hour
or two the novelty of such a ride may be enjoyed. The heat of the
day is intense, but the nights, especially in the canal, have a “soft,
warm witchery” about them that is delicious.
After leaving Suez the way lies through the Gulf of the same
name, into the Red Sea, where the water is blue, the background
light brown, the hazy atmosphere pink, and the temperature red-
hot. Vessels spread double awnings and hang up side curtains, but
there is no escaping the intolerable heat experienced day and night
going down this sea with the wind aft. Far away to the left, in the
dim distance, is the fast-receding brown peak of Mount Sinai; other
well-remembered biblical places stretch along the indistinct coast
line; the ship speeds southward; the constellations in the blue

heavens of night begin to change; the Straits of Bab-el-Mandeb are
passed; and as the four points of the Southern Cross arise bright
and sparkling, the anchor is let go off Aden, in Arabia.
Aden, on its rocky and bare volcanic peninsula, is the Gibraltar of
the Red Sea. It interests the traveller because of the big black
Somalis, the oily, avaricious Jews, and the thin, ungainly camels
moving up and down the streets. The town is too hot for enjoyment;
it is better to stay on board ship, buy an imitation ostrich feather
from a cheating Jew, and throw coppers into the water for little
shave-headed naked negro boys to dive after.
The Port of Aden, Arabia.
During a stay of a few hours vessels fill up with coal and fresh
provisions, land a small cargo of naval stores, cotton, and cotton-
twist, and after taking on board coffee (nearly all Mocha is shipped

here), dye-stuffs, feathers, dates, etc., depart for Bombay, for
Colombo, for Australia, and for Africa.
The weather along the highways of the Indian Ocean is generally
fair and warm, with a smooth sea, though, during the southwest
monsoon, from May to September, there is a perceptible swell, and
when this trade-wind sets in, in May, it is sure to bring gales, rain,
lightning and thunder. August is the best summer month for cruising
in the Indian Ocean. The northeast monsoon, the winter trade-wind,
is less violent than the southwest, and has clear skies and a milder
temperature. However, in going round the world, passengers, like
ships, should take their chances with the weather, for having it fair
at Bombay may bring it foul at Calcutta.
A Deck-bath in the Tropics.
Vessels make Bombay, 1,670 miles eastward of Aden, in 7 days,
and go alongside the docks when the tide permits. The traveller

should at once hurry ashore to gaze with wonder at the infinite
variety before him. For here are congregated Indian princes dressed
in flowing robes of richest colors; Brahmins and Buddhists with
turbans of softest texture bound about their brows; Parsees in long,
white, full-skirted coats and odd-shaped-high hats; Turks in fezzes;
Chinamen in silks; Persians in white trousers, loose alpaca coats, and
shako astrakhan hats; effeminate Cinghalese, Jews, Mohammedans,
and Europeans from England, France, Germany, and Russia. Along
the water front pass unceasingly women, straight as javelins, tall,
lithe, and graceful, their breasts covered by tight sleeveless tunics,
their waists and hips wound in light flowing gauze. Silver bangles
adorn their arms and legs, and rings glisten in their noses and ears,
and on their toes and fingers. Bare-legged, bare-footed, their black
hair tucked loosely up upon their shapely heads, on which are poised
high brass water-jugs burnished like gold, these graceful creatures
walk the streets like the queens of an Oriental fable.
Many lines of vessels converge at Bombay: the P. & O., the British
India, and three or four others of less importance; two French lines,
a German line, the Austrian Lloyd, the Italian Mail, and a Dutch line,
are some of those to be seen during a stay of a fortnight. The British
India offers the largest number of routes to the sight-seeing
traveller. One of its lines leads to Kurrachee, the northern port of
India; another goes to Calcutta, stopping at way ports; a third
extends to Zanzibar and Mozambique, and a fourth reaches places
on the Persian Gulf. This fourth route the tourist should certainly
take if he has the time, though it carry him into the most trying
climate imaginable. Before starting he should get Moore’s “Lalla
Rookh,” it can be bought at an excellent English bookstore in
Bombay, and read it on the way, as some of the scenes are laid in
these waters.
The passengers on these Gulf steamers are of as many types as
those seen on Change in Bombay. It is not unlikely that of the
twenty or more who sit down to dinner, no two will be of the same
color, costume, nationality, or religion. Even the crew ceases to be

European; Chinamen usually cook and wait, and Indians handle
cargo and work the ship.
About 600 miles and 4 days from, Kurrachee, Ormuz is made,
dirty, dilapidated, with absolutely no remains of its historic wealth.
The first place of importance is Bushire, 300 miles farther up. It is
the principal seaport of Persia, and does considerable trade, long
caravans of camels transporting merchandise to and from the
interior. Persian cats can be got here; a pair offered for $25 was sold
finally for $5; with more time they could have been bought for $2.
From Bushire to Bassorah, on the Euphrates, is 180 miles. A
narrow canal-like stream leads from the river to the native village
where Sindbad the Sailor is said to have roamed. Connection can be
made at Bassorah with a steamboat going up the river past the
Garden of Eden, a disappointing, flat, uncared-for plain, to Bagdad;
and thence, by camel to points in the interior. Steamers in the
Persian Gulf trade take in dates, grain, and wool, leaving cotton
fabrics, rice, opium, etc.
On returning to Kurrachee, the traveller would do well to take the
railway to Agra, and the Taj, Benares, and other places, and so back
again to Bombay and the ocean highways.
Henceforth, the character of the passengers on board ship
changes somewhat; many of the Europeans leave for extended tours
by rail to Calcutta and other Indian cities, their places being taken by
Parsee merchants, rich Indians, and enterprising Chinamen, bound
away on business.
The run to Colombo, Ceylon, 875 miles to the southward, is made
over a warm, smooth sea, and on the evening of the fifth day the
harbor is entered. Colombo is a steamship centre where all the
vessels of the long trunk lines rendezvous to coal, provision,
exchange passengers and frequently freight. They come from the
four quarters of the globe, from Calcutta and Bombay in the north,
from China and Singapore in the east, from Australia, Mauritius, and
Africa in the south, and from Aden and the Suez Canal in the west.

Colombo has much to attract a traveller during the 24 or 48 hours
the steamer stays, but usually the Oriental Hotel claims his time and
attention, for this is the place of meeting of all who go upon the
waters, and high wassail is apt to be the order of the night.
The dining-room of the Oriental is the refreshment-room at the
intersection of the chief steam lines of the world. It is, as it were,
the restaurant of a Union depot where everyone must go for a meal;
at its tables travellers from opposite points of the world meet,
Chinese bound for Europe, Englishmen to report for Indian duty,
French soldiers en route for Saigon, and Australians making the
grand tour.
If the traveller has stayed in the same ship all the way from
London, he has, by the time he arrives at Colombo, been 30 days en
voyage and navigated a distance of 6,700 miles. By whatever line he
has come, he should have enjoyed his life on board ship, for after
the first day or two out from port acquaintances are made that
rapidly ripen into good fellowship. Deck cricket, quoits, and cock-
fighting enliven the forenoons; a novel and a nap wear away the
afternoons; an innocent rubber with the ladies brightens the
evenings; a good chorus begins the nights merrily, and a small game
of draw shortens the dying hours.

Promenade Deck of an Orient Liner.
At Colombo often the best of friends must part, some to stay in
the country, others to go to a different ship; for the choice of routes
is varied, there being some 15 steamship lines radiating hence
toward the attractive countries of Australia, Africa, the Dutch East
Indies, China, Japan, India, and Europe.
The run up the coast from Ceylon past the French settlement of
Pondicherry, where the French steamers touch, to Madras, 614 miles
to the northward, is smooth sailing if the monsoon months of April,
June, November, and December be avoided. A day in port is
sufficient for landing the cargo, brought off in lighters manned by
stalwart lascars, naked except for the narrowest of breech-clouts
and the most enormous of turbans. The traveller, while at Madras,
should see the Indian jugglers, and to do this comfortably, should
make arrangements to have the exhibition held on board ship. Two
or three natives, sitting on the open deck at his feet, place a mango-

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Genedis 2022 Neuroscientific Advances 1st Ed 2023 Panagiotis Vlamos

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