[Immigrants' health: proposals for further studies]. / Approfondire le conoscenze sulla salute degli immigrati: alcune proposte per il futuro.

The monograph on immigrants' health recently published by Epidemiologia & Prevenzione provides an updated contribution to this subject by the Italian Network of Longitudinal Metropolitan Studies. This paper suggests methodological and thematic aspects that should be addressed by future studies in order to provide the knowledge relevant to social and health policies: networking with researchers and with the subjects dealing in various ways with immigration as well as the preparation of a communication plan aimed at the community and at decision makers are the methodological aspects on which the possibility of studies generating actions depends. Among the objects of investigation the health of the second generations, the study of drug prescriptions and of the access to Emergency Room as well as the evaluation of the interventions implemented by each municipality seem the most relevant. The need of a timely and periodic monitoring of the health outcomes is also underlined and the possibility of a study on the health of migrants during their migrant journey is proposed.

Understanding the association between mother's education level and effectiveness of a child obesity prevention intervention: a secondary analysis of an RCT.

OBJECTIVES: to explain differences in effectiveness of paediatrician-led motivational interviewing (MI) in decreasing body mass index (BMI) between children of mothers with low or high education level. DESIGN: secondary analysis of a randomised control trial. SETTING AND PARTICIPANTS: individually randomized controlled trial previously conducted from 2011 to 2013 in the province of Reggio Emilia (Emilia-Romagna Region, Northern Italy). Eligible participants included in the trial were 372 (187 in the MI group and 185 in the control group) overweight children (BMI percentile >= 85th and < 95th) aged between 4 and 7 years, residing in the province of Reggio Emilia and under the care of paediatrician for >= 12 months. The intervention included 5 MI sessions based on the transtheoretical model of addiction and behavioural change delivered at 1, 4, 7, and 12 months after the baseline visit, when families had to define specific goals in changing physical activity (PA) and diet behaviours. MAIN OUTCOME MEASURES: primary: BMI score variation (ΔBMI) from baseline to 12 months; secondary: percentage of changes in parent-reported PA and dietary behaviours. RESULTS: a significant effect of MI on ΔBMI in children whose mothers had high education level (ΔBMI = -0.62; 95%CI -0.92;-0.32) were observed. Children of women with high education level in MI group had more improvements in set unstructured PA, decreasing screen time and sweet snacks consumption, while children with less educated mothers had improvements in consuming more vegetable soup and less desserts, sweet snacks, and sugary beverages. Highly educated mothers chose for their children to drink fewer sugary beverages and to increase PA. Less educated mothers most frequently chose as goals having breakfast, eating more fruit and vegetables, eating fewer snacks, and having less screen time. Overall achievement was similar in the two strata for diet goals, but higher for PA goals in the high education level stratum. CONCLUSIONS: MI intervention was not effective in reducing BMI in children of mothers with low education level. This does appear to be weakly or not associated with goal choices and achievement within MI, it is rather an effect of unmeasured behaviours which possibly mediate association between MI and BMI reduction.

Motivational Interviewing to Treat Overweight Children: 24-Month Follow-Up of a Randomized Controlled Trial.

BACKGROUND: Pediatrician-led motivational interviewing can be an effective way of controlling BMI in overweight children in the short term. Its long-term efficacy is unknown. The primary aim was to determine whether the short-term (12-month) impact of family pediatrician-led motivational interviews on the BMI of overweight children could be sustained in the long term (24 months), in the absence of any other intervention. METHODS: Children were recruited in 2011 by family pediatricians working in the province of Reggio Emilia, Italy, and randomly allocated to receive either 5 interviews delivered over a 12-month period or usual care. Eligible participants were all 4- to 7-year-old overweight children resident in the province of Reggio Emilia who had been receiving care from the pediatrician for ≥ 12 months. The primary outcome of this study was individual variation in BMI between the baseline visit and the 24-month follow-up, assessed by pediatricians not blinded to treatment group allocation. RESULTS: Of 419 eligible families, 372 (89%) participated; 187 children were randomized to receive intervention and 185 to usual care. Ninety-five percent of the children attended the 12-month follow-up, and 91% attended the 24-month follow-up. After the 12-month intervention period, BMI in the intervention group increased less than in the control group (0.46 and 0.78, respectively; difference -0.32; P = .005). At the 24-month follow-up, the difference had disappeared (1.52 and 1.56, respectively; difference -0.04; P = .986). CONCLUSIONS: The intervention lost its effectiveness within 1 year of cessation. Sustainable boosters are required for weight control and obesity prevention.

Public and private pregnancy care in Reggio Emilia Province: an observational study on appropriateness of care and delivery outcomes.

BACKGROUND: In industrialized countries, improvements have been made in both maternal and newborn health. While attention to antenatal care is increasing, excessive medicalization is also becoming more common.The aim of this study is to compare caesarean section (CS) frequency and ultrasound scan utilization in a public model of care involving both midwives and obstetricians with a private model in which care is provided by obstetricians only. DESIGN: Observational population-based study. SETTING: Reggio Emilia Province. POPULATION: 5957 women resident in the province who delivered between October 2010 and November 2011. MAIN OUTCOME MEASURES: CS frequency and ultrasound scan utilization, stillbirths, and other negative perinatal outcomes. Women in the study were searched in the public family and reproductive health clinic medical records to identify those cared for in the public system. Outcomes of the two antenatal care models were compared through multivariate logistic regression adjusting for maternal characteristics and, for CS only, by stratifying by Robson's Group. RESULTS: Compared to women cared for in private services (N = 3,043), those in public service (N = 2,369) were younger, less educated, more frequently non-Italian, and multiparous. The probability of CS was slightly higher for women cared for by private obstetricians than for those cared for in the public system (31.8% vs. 27.1%; adjusted odds ratio: 1.10; 95% CI: 0.93-1.29): The probability of having more than 3 ultrasound scans was higher in private care (89.6% vs. 49.8%; adjusted odds ratio: 5.11; 95% CI: 4.30-6.08). CS frequency was higher in private care for all Robson's classes except women who underwent CS during spontaneous labour. Among negative perinatal outcomes only a higher risk of pre-term birth was observed for pregnancies cared for in private services. CONCLUSIONS: The public model provides less medicalized and more guidelines-oriented care than does the private model, with no increase in negative perinatal outcomes.

Does breast cancer screening level health inequalities out? A population-based study in an Italian region.

BACKGROUND: Although population-based screening has the potential to reduce inequalities in breast cancer survival, evidence on this topic is controversial. The objective of this study was to evaluate whether the full implementation of a mammography screening programme in Emilia-Romagna in Italy had an impact on variations in breast cancer survival by educational level. METHODS: A cohort study was performed, including all women <70 years and residing in Emilia-Romagna who had infiltrating breast cancer registered in 1997-2000 (transitional screening period) or 2001-03 (consolidation screening period). Cancer cases were retrieved from the regional Breast Cancer Registry and followed up for 5 years. Educational level was determined from census data and allocated to cancer cases by individual record linkage. Age at diagnosis was classified into two groups (30-49, 50-69: screening target population). RESULTS: A total of 9639 cases were analyzed. In the 1997-2000 period, low-educated women had significantly lower survival compared with high-educated women, both in the younger and in the older age-groups. After the full implementation of the screening programme, these differences decreased in both age-groups, until disappearing completely among women in the age-group invited to screening. CONCLUSIONS: Our findings suggest that a fee-free population-based organized mammography screening programme with active invitation of the whole target population could be effective in reducing differences in survival in the population targeted by the screening.

Effects of immigrant status on Emergency Room (ER) utilisation by children under age one: a population-based study in the province of Reggio Emilia (Italy).

BACKGROUND: The primary aim of this study was to assess the effect of immigrant status on Emergency Room (ER) utilisation by children under age one, considering all, non-urgent, very urgent, and followed by hospitalisation visits. The second aim was to investigate the role played by mother's educational level in the relationship between citizenship and ER utilisation. METHODS: The cohort study included all healthy singleton live births in the years 2008-2009 and residing in the province of Reggio Emilia, followed for the first year of life in order to study their ER visits. The outcomes were the ER utilisation rate for all, non-urgent, very urgent, and followed by hospitalisation visits. The main explanatory variable was mother's citizenship. Other covariates were mother's educational level, maternal age, parity, and child gender. Multivariate analyses (negative binomial regression and zero inflated when appropriate) were performed. Adjusted utilisation Rate Ratios (RR) and their 95% Confidence Intervals (95% CI) were calculated. Trend for age in months by citizenship is depicted. RESULTS: There were 3,191 children (36.4%) with at least one ER visit in the first year of life. Adjusted RR show a significantly greater risk of ER visit for immigrants than for Italians: (RR 1.51; 95% CI 1.39-1.63). Immigrants also had a higher risk of non-urgent visits (RR 1.72; 95% CI 1.48-2.00) and for visits followed by hospitalizations (RR 1.58; 95% CI 1.33-1.89). For very urgent visits, the immigrants had a slightly higher risk compared to Italians (RR 1.25; 95% CI 0.98-1.59).The risk of ER visits is higher in the first two months of life (RR(1st vs 3rd-12th) 2.08; 95% CI 1.93-2.24 and RR(2nd vs 3rd-12th) 1.45; 95% CI 1.33-1.58, respectively). Considering all visits, the ER utilisation rate was inversely related with maternal education only for Italians (low educational level 44.0 and high educational level 73.9 for 100 children; p value for trend test < 0.001). CONCLUSIONS: Our study observed a higher use of ER services by immigrant children and, to a lesser extent, by children of less educated Italian mothers. In immigrants, the excess is mostly due to non-urgent visits and only slightly to high acute conditions.

Pediatrician-led motivational interviewing to treat overweight children: an RCT.

OBJECTIVE: The aim of this study was to evaluate the effect of family pediatrician-led motivational interviews (MIs) on BMI of overweight (85th ≥ BMI percentile ≥ 95 th) children aged 4 to 7 years. METHODS: All the family pediatricians working in Reggio Emilia Province (Italy) were invited to participate in the study; 95% accepted. Specific training was provided. Parents were asked to participate in the trial if they recognized their child as overweight. Children were individually randomly assigned to MIs or usual care. All children were invited for a baseline and a 12-month visit to assess BMI and lifestyle behaviors. The usual care group received an information leaflet, and the intervention group received 5 MI family meetings. The primary outcome was the individual variation of BMI, assessed by pediatricians unblinded to treatment groups. RESULTS: Of 419 eligible families, 372 (89%) participated; 187 children were randomized to MIs and 185 to the usual care group. Ninety-five percent of the children attended the 12-month visit. The average BMI increased by 0.49 and 0.79 during the intervention in the MI and control groups, respectively (difference: -0.30; P = .007). MI had no effect in boys or in children whose mothers had a low educational level. Positive changes in parent-reported lifestyle behaviors occurred more frequently in the MI group than in the control group. CONCLUSIONS: The pediatrician-led MI was overall effective in controlling BMI in these overweight children aged 4 to 7 years, even though no effect was observed in male children or when the mother's education level was low.

Air pollution from incinerators and reproductive outcomes: a multisite study.

BACKGROUND: The few studies that have investigated the relationship between emissions from municipal solid-waste incinerators and adverse pregnancy outcomes have had conflicting results. We conducted a study to assess the effects of air emissions from the eight incinerators currently in operation in the Emilia-Romagna Region of Italy on reproductive outcomes (sex ratio, multiple births, preterm births, and small for gestational age [SGA] births). METHODS: We considered all births (n = 21,517) to women residing within a 4-km radius of an incinerator at the time of delivery during the period 2003-2010 who were successfully linked to the Delivery Certificate database. This source also provided information on maternal characteristics and deliveries. Each newborn was georeferenced and characterized by a specific level of exposure to incinerator emissions, categorized in quintiles of PM10, and other sources of pollution (NOx quartiles), evaluated by means of ADMS-Urban system dispersion models. We ran logistic regression models for each outcome, adjusting for exposure to other pollution sources and maternal covariates. RESULTS: Incinerator pollution was not associated with sex ratio, multiple births, or frequency of SGA. Preterm delivery increased with increasing exposure (test for trend, P < 0.001); for the highest versus the lowest quintile exposure, the odds ratio was 1.30 (95% confidence interval = 1.08-1.57). A similar trend was observed for very preterm babies. Several sensitivity analyses did not alter these results. CONCLUSIONS: Maternal exposure to incinerator emissions, even at very low levels, was associated with preterm delivery.

A population based cohort study to assess the safety of pandemic influenza vaccine Focetria in Emilia-Romagna region, Italy - part two.

INTRODUCTION: A two phases post authorization safety and effectiveness study of individuals vaccinated with the MF59-adjuvanted A/H1N1 influenza vaccine, Focetria (Novartis Vaccines & Diagnostics, Siena, Italy), was conducted in Emilia-Romagna region, Italy during the 2009 A/H1N1 influenza pandemic. The second phase study aim was to detect short- and long-term adverse events of special interest (AESIs) following vaccination, and to measure vaccine effectiveness in term of hospital admissions. STUDY DESIGN AND METHOD: A population-based cohort study using record linkage of automated healthcare databases is described. Focetria was administered to 127,522 subjects between October 2009 and February 2010. Vaccinated subjects were generally less healthy than unvaccinated ones. Propensity to be vaccinated was calculated for each subject, and vaccinated and unvaccinated subjects were matched accordingly (103,642 subjects in each group). AESIs were validated against clinical records. RESULTS: In the overall (pre-matching) cohort, a total of 504 short-term incident AESIs (28 in 127,522 vaccinated and 476 in 3,967,917 unvaccinated subjects) were registered (unadjusted OR: 1.8; 95% CI: 1.2, 2.7). No fatalities were recorded. In the matched cohort, a total of 26 short-term incident AESIs (11 in the vaccinated and 15 in the unvaccinated group) were registered, with no differences between groups (OR: 0.7; 95% CI: 0.3, 1.6). Most frequent short-term incident AESIs were convulsions (4 out of 11), and demyelinating diseases (3 out of 11). In the long-term a total of 121 incident AESIs (60 in the vaccinated and 61 in the unvaccinated group) were registered, with no differences between groups (OR: 1.0; 95% CI: 0.7, 1.4). Most common long-term incident AESIs were demyelinating diseases (21 out of 60), and vasculitis (13 out of 60). Vaccine effectiveness was not assessed as the majority of subjects were vaccinated at the end of the pandemic peak and few cases (<0.1%) had laboratory confirmation. CONCLUSIONS: This population-based cohort study using automated databases suggests that Focetria is not associated with an increase in AESIs.

An early (3-6 weeks) active surveillance study to assess the safety of pandemic influenza vaccine Focetria in a province of Emilia-Romagna region, Italy - part one.

INTRODUCTION: An observational, non-comparative, prospective, surveillance study of individuals vaccinated with the MF59-adjuvanted A/H1N1 influenza vaccine, Focetria, (Novartis Vaccines & Diagnostics, Siena, Italy), was performed in Italy during the 2009 A/H1N1 influenza pandemic. METHOD: This study assessed the short-term (six-week) safety profile of the investigational vaccine in real time. After vaccination (N=7943), adverse events (AE) were assessed using both active (telephone) and passive (healthcare database) follow-up in enrolled vaccinated subjects, including infants (6-23 months), pregnant women, and the immunosuppressed. The treating physicians of all subjects experiencing AEs post-vaccination were consulted for clinical information on the conditions reported. All AEs were coded according to ICD-10. RESULTS: A total of 1583 AEs occurred during the study, 67 (4.2%) of which were serious adverse events (SAEs). One SAE was considered to be possibly related to vaccination (transitory and ill-defined neurologic disorder experienced by a 16-year-old asthmatic male). Three adverse events of special interest (AESI) were identified (convulsions experienced by two epileptic subjects), none of which were considered to be vaccine-related. Six individuals died during the study period, in each case the cause of death was not related to vaccination (four cases of severe underlying co-morbidity, one case of psychoactive drug misuse, and one case of acute myocardial infarction). CONCLUSIONS: No cases of clinically relevant AEs, SAEs, or AESI were observed within a six-week period of vaccine administration. In accordance with existing clinical and post-marketing safety data, the results of this active surveillance study demonstrate a good safety profile for the MF59-adjuvanted A/H1N1 vaccine, Focetria, within the general population.