A blended training programme for healthcare professionals aimed at strengthening territorial networks for the prevention and contrast of gender-based violence.

OBJECTIVES: a blended training programme combining residential meetings (de visu) and distance training course (DTC) have been developed in order to provide the key elements for prevention, individuation, and care of women victims of violence. DESIGN: the Project involved the identification and testing of a systematic methodology of blended training addressed to social and health operators of 28 Emergency Room (ER) Units in 4 Italian regions (Lombardy - Northern Italy, Lazio - Central Italy, Campania and Sicily - Southern Italy). Tuscany region (Central Italy) collaborated through experts in the field from the Grosseto Task Force. This training approach specifically aimed to increase the professional competences for diagnosis, management and treatment of gender-based violence, as well as to strengthen multidisciplinary territorial networks against violence. SETTING AND PARTICIPANTS: in this Project, 28 ERs in the four Italian regions mentioned above were selected because of their involvement in managing gender-based violence. This selection was performed by a coordinator, one for each region, who also coordinated the recruitment of personnel to be involved in the training programme. The programme has therefore been proposed to social and health operators and police officers in the ERs recruited. In each ER, two referents were identified (a doctor and a nurse) in order to ensure a constant connection between the course participants and the experts involved in the management of the Project and the DTC platform. MAIN OUTCOME MEASURES: evaluation of the increase of knowledge relatively to gender-based violence issue in the ER professionals who have concluded the blended training programme. A systematic analysis and comparison of all accesses concerning women aged ≥14 years in the period 1 July-31 December 2014 (before the blended training programme) and in the period 1 July-31 December 2016 (after the blended training program). RESULTS: among the 866 registered professionals, 636 participants (73.5%) completed the course, 202 (23.3%) professionals did not complete it, 21 (2.4%) did not pass the certification test, and 7 (0.8%) participated as Auditors. Among the participants who completed the course, most of them (70.8%) were females; the average age was 45 for both males and females. The most represented professional role was the nurse (61%), followed by the medical doctor (27.2%). Based on our data, in the post-training period, an increased number of cases of violence were correctly recorded in comparison to the pre-training period. CONCLUSION: the Project allowed to define a training strategy for health professionals of the ERs who respond daily to the health needs of women who are victims of violence. The blended training programme combining residential meetings (de visu) and distance training course has been developed in order to provide the key elements for prevention, individuation, and care of women victims of violence. The observed improvement in the recording and management of cases of gender-based violence is probably due to a greater competence in the awareness and use of specific diagnostic codes by ER professionals.

Meat consumption reduction in Italian regions: Health co-benefits and decreases in GHG emissions.

INTRODUCTION: Animal agriculture has exponentially grown in recent decades in response to the rise in global demand for meat, even in countries like Italy that traditionally eat a Mediterranean, plant-based diet. Globalization related dietary changes are contributing to the epidemic of non-communicable diseases and to the global climate crisis, and are associated with huge carbon and water footprints. The objective of the study is to assess inequalities in health impacts and in attributable greenhouse gases-GHG emissions in Italy by hypothesizing different scenarios of reduction in red and processed meat consumption towards healthier consumption patterns more compliant with the recommendations of the Mediterranean food pyramid. METHODS: We used demographic and food consumption patterns from national surveys and risk relationships between meat intake and cardiovascular and colorectal cancer mortality from IARC and other meta-analyses. From the baseline data (year 2005-2006, average 406 gr/week beef and 245 gr/week processed meat), we considered hypothetical meat reduction scenarios according to international dietary guidelines such as the Mediterranean pyramid targets. For each geographical area (Northwest, Northeast, Centre, and South) and gender, we calculated the number of avoidable deaths from colorectal cancer, and cardiovascular disease among the adult population. Moreover, years of life gained by the adult population from 2012 to 2030 and changes in life expectancy of the 2012 birth cohort were quantified using gender-specific life tables. GHG emission reductions under Mediterranean scenario were estimated only for beef by applying the Global Warming Potential (GWP) coefficient to total consumption and to a low carbon food substitution in adult diet. RESULTS: The deaths avoidable (as percentage change compared to baseline) according to the three reduction scenarios for beef consumption were between 2.3% and 4.5% for colorectal cancer, and between 2.1% and 4.0% for cardiovascular disease; higher benefits would be observed in Northwestern areas and among males. In parallel, 5% and 6.4% of colorectal cancer and CVD deaths would be avoided if the Italian population ate the advised quantity of processed meat. Life table analysis suggests that the scenario that is fully compliant with the Mediterranean diet model would save 5 million years of life lost prematurely among men and women over the next 18 years and would increase average life expectancy of future generations by over 7 months. Considering the environmental impact, emissions associated with the actual total intake of beef range from 12,900 to 21,800 Gg CO2 eq; emissions saved according to the Mediterranean scenario are in the range 8000-14000 Gg CO2 eq per year. The per capita reduction is 263 KgCO2eq/year/person with higher reductions in Northwestern and Central areas. CONCLUSIONS: In Italy, scenarios for reducing beef consumption are consistent with significant health and environmental co-benefits on current and future generations. Results support introducing policies to promote healthier behavior towards red and processed meat in the adult population within an overall balanced and healthy dietary pattern. Interventions should address gender, vulnerable population groups, and geographical differences in order to be more effective.

Gestational age and hospital utilization: three-years follow-up of an area-based birth cohort.

OBJECTIVE: To investigate differences by gestational age in emergency department visits and re-hospitalizations during the three years following childbirth discharge. METHODS: We performed a historical cohort study in Lazio Region, Italy, for infants born in 2007-2008 to resident mothers. Health administrative data were used. Analysis was performed by multinomial logistic regression. RESULTS: Of 90 545 infants, more than 50% had at least one emergency department visit, and 18.8% at least one re-hospitalization. After the exclusion of infants with congenital anomalies, relative risk ratios of re-hospitalization and, to a lesser extent, of emergency department visits increased by decreasing gestational age; the two events were also higher for mothers ≤35 years of age, with low education and of Italian nationality. Residency outside the metropolitan area was associated with an increased risk of re-hospitalization and a decreased risk of emergency department visits. CONCLUSION: During the three years following childbirth discharge, re-hospitalizations and, to a lesser extent, emergency department use are inversely related to gestational age at birth; socio-demographic factors have an effect on the risk of infant use of hospital resources independent of gestational age.

Health care costs and functional outcomes of road traffic injuries in the Lazio region of Italy.

The economic consequences of road traffic injuries (RTIs) are very important in terms of health care costs. The aim of this study is to provide estimates of health care costs of non-fatal RTIs and to estimate functional outcomes using in-hospital rehabilitation data. We identified all emergency department (ED) visits related to RTI during 2008 and then linked them with hospital discharges and rehabilitation admissions, health care costs following RTI were estimated from the integrated database. We performed an epidemiological evaluation of RTI with a comprehensive description of functional outcomes at 6 months. Health care costs have been estimated at about €80 million with a per person cost of €522. About 18% of the total cost was due to rehabilitation treatments. In multivariate analysis the variables that correlated better with higher total health care costs were: older age, injury severity, presence of spinal lesion. Patients requiring rehabilitation were: the elderly, patients suffering from a spinal cord injury and leg injuries. This study provides consistent health care cost estimates of RTI using administrative databases and it shows a picture of functional outcomes after RTI. Further research is needed for the estimation of other components of the total cost of RTI.

Piccolipiù, a multicenter birth cohort in Italy: protocol of the study.

BACKGROUND: The fetal and infant life are periods of rapid development, characterized by high susceptibility to exposures. Birth cohorts provide unique opportunities to study early-life exposures in association with child development and health, as well as, with longer follow-up, the early life origin of adult diseases. Piccolipiù is an Italian birth cohort recently set up to investigate the effects of environmental exposures, parental conditions and social factors acting during pre-natal and early post-natal life on infant and child health and development. We describe here its main characteristics. METHODS/DESIGN: Piccolipiù is a prospective cohort of expected 3000 newborns, who will be recruiting in six maternity units of five Italian cities (Florence, Rome, Trieste, Turin and Viareggio) since October 2011. Mothers are contacted during pregnancy or at delivery and are offered to participate in the study. Upon acceptance, their newborns are recruited at birth and followed up until at least 18 years of age. At recruitment, the mothers donate a blood sample and complete a baseline questionnaire. Umbilical cord blood, pieces of umbilical cord and heel blood spots are also collected. Postnatal follow-up currently occurs at 6, 12, and 24 months of age using on-line or postal self administered questionnaire; further questionnaires and medical examinations are envisaged. Questionnaires collect information on several factors, including mother's and/or child's environmental exposures, anthropometric measures, reproductive factors, diet, supplements, medical history, cognitive development, mental health and socioeconomic factors. Health promotion materials are also offered to parents. DISCUSSION: Piccolipiù will broaden our understanding of the contribution of early-life factors to infant and child health and development. Several hypotheses on the developmental origins of health can be tested or piloted using the data collected from the Piccolipiù cohort. By pooling these data with those collected by other existing birth cohorts it will be possible to validate previous findings and to study rare exposures and outcomes.

How socioeconomic status influences road traffic injuries and home injuries in Rome.

Road traffic injuries (RTI) and home injuries (HI) are a relevant public health problem, especially among people living in deprived areas. The objective of this study was to explore the relationship between morbidity, hospitalisation, mortality from RTI and HI, and socioeconomic status (SES) of the area of residence. RTI and HI surveillance based on the Emergency Information System, the Hospital Information System and the Mortality Registry of Lazio region are the three sources of this study to create a unique surveillance system. For each subject, the SES index (5 levels) of its census tract of residence was obtained. The study population included emergency department admissions (year 2005) of residents in Rome, Italy. Incidence Rate Ratios (IRRs) have been estimated using Poisson Regression. The rates of RTI and HI emergency department visits were higher among the most deprived level of SES (IRR = 1.27, 95% CI: 1.24-1.30; IRR = 1.33, 95% CI: 1.29-1.37, respectively) compared to the most privileged ones; a similar result was found for hospitalisation (IRR = 1.19, 95% CI: 1.08-1.32; IRR = 1.11, 95% CI: 1.01-1.22). A strong relation was found between RTI mortality rates and poor level of SES. The study concluded that RTI and HI incidence were associated to sociodemographic factors.

Morbidity experience in populations residentially exposed to 50 hz magnetic fields: methodology and preliminary findings of a cohort study.

A morbidity study of the population of a district of Rome built in part under a 60 kV electric distribution line, included 345 subjects resident in the study area in any period between 1954 and 2003, excluding those deceased before 1998. Residential magnetic field levels were estimated based on current load, line characteristics, and distance of the dwellings from the power line, and the study area was divided into sub-areas with differing magnetic field levels. Standardized morbidity ratios were computed from hospital discharge records dated 1998-2003. Non statistically significant increases were observed for all and primary cancers; primary cancers were significantly increased among subjects with > 30 years' residence and latency. A significant increase for all, primary, and secondary cancers, and a two-fold increase for ischaemic diseases, was observed in subjects in the sub-area with the highest exposure. No increase was seen in neoplastic haematological diseases.

Defining a common set of indicators to monitor road accidents in the European Union.

BACKGROUND: currently road accidents are mostly monitored through mortality and injury rates. This paper reports the methodology and the results of a project set forth by the European Union (EU) and coordinated by the WHO aimed at identifying and evaluating a core set of indicators to monitor the causal chain of road accident health effects. The project is part of the ECOEHIS (Development of Environment and Health Indicators for European Union Countries). METHODS: a group of experts (WG), identified 14 indicators after a review of the information collected at the EU level, each of them representing a specific aspect of the DPSEEA (Driving, Pressure, State, Exposure, Effect, Action) model applied and adapted to the road accidents. Each indicator was scored according to a list of 16 criteria chosen by the WG. Those found to have a high score were analysed to determine if they were compatible with EU legislation and then tested in the feasibility study. RESULTS: 11 of the 14 indicators found to be relevant and compatible with the criteria of selection were proposed for the feasibility study. Mortality, injury, road accident rate, age of vehicle fleet, and distance travelled are the indicators recommended for immediate implementation. CONCLUSION: after overcoming the limitations that emerged (absence of a common definition of death by road accident and injury severity, underestimation of injuries, differences in information quality) this core set of indicators will allow Member States to carry out effective internal/external comparisons over time.

Understanding non-compliance to colorectal cancer screening: a case control study, nested in a randomised trial [ISRCTN83029072].

BACKGROUND: The major limit to colorectal cancer screening effectiveness is often low compliance. We studied the reasons for non compliance and determinants of compliance to faecal occult blood tests in Lazio, Italy. METHODS: This is a case-control study nested within a trial that tested the effect of type of test and provider on colorectal cancer screening compliance. Non compliant trial subjects were classified as cases, and compliant subjects were classified as controls. We sampled 600 cases and 600 controls matched by their general practitioner, half were invited for screening at the hospital, and the other half directly at their general practitioner's office. Cases and controls answered questions on: distance from test provider, logistical problems, perception of colorectal cancer risk, confidence in screening efficacy, fear of results, presence of colorectal cancer in the family, and gastrointestinal symptoms. RESULTS: About 31% of cases never received the letter offering free screening, and 17% of the sampled population had already been screened. The first reported reason for non-compliance was "lack of time" (30%); the major determinant of compliance was the distance from the test provider: odds ratio > 30 minutes vs < 15 minutes 0.3 (95% CI = 0.2-0.7). The odds ratio for lack of time was 0.16 (95% IC 0.1-0.26). The effect was stronger if the hospital (0.03 95% CI = 0.01-0.1) rather than the general practitioner (0.3 95% CI = 0.2-0.6) was the provider. Twenty-two percent of controls were accompanied by someone to the test. CONCLUSION: To increase compliance, screening programmes must involve test providers who are geographically close to the target population.

The immunochemical faecal occult blood test leads to higher compliance than the guaiac for colorectal cancer screening programmes: a cluster randomized controlled trial.

INTRODUCTION: We conducted a cluster-randomized trial aimed at assessing the effect of the type of faecal occult blood, guaiac or immunochemical test on screening compliance. METHODS: We sampled 130 general practitioners (GPs) who consented to participate in the trial. We randomly allocated half of them to the guaiac (Hemo-Fec) and half to the immunochemical test (OC-Hemodia). We sampled 2/10 of the GPs' 50-75-year-old patients (n=7332) and randomly divided this population into half. One half was invited to be screened at the GP's office and the other to the nearest gastroenterology ward. The principal outcome was the percentage of returned tests. RESULTS: The immunochemical test had a compliance of 35.8% and the guaiac of 30.4% (relative risk [RR] 1.20; 95% confidence interval [CI] 1.02-1.44). The difference was mostly due to a higher probability of returning the sample: 93.8% and 88.6% for immunochemical and guaiac, respectively (RR 1.06; 95% CI 1.02-1.10). The guaiac test had a higher prevalence of positives (10.3% versus 6.3%, RR 0.603; 95% CI 0.433-0.837). There was a higher variability in the results obtained with the guaiac test compared with the immunochemical (F[1, 12] = 16.25; P=0.0017). CONCLUSIONS: Compliance is more likely with the immunochemical than the guaiac test, independent of the provider. Guaiac tests show a higher variability of the results among centres. The successful implementation of a screening programme requires a period of standardization of the test reading in order to avoid unexpected work overload for colonoscopy services.