Socioeconomic inequalities in avoidable mortality in Italy: results from a nationwide longitudinal cohort.

BACKGROUND: Disparities in avoidable mortality have never been evaluated in Italy at the national level. The present study aimed to assess the association between socioeconomic status and avoidable mortality. METHODS: The nationwide closed cohort of the 2011 Census of Population and Housing was followed up for 2012-2019 mortality. Outcomes of preventable and of treatable mortality were separately evaluated among people aged 30-74. Education level (elementary school or less, middle school, high school diploma, university degree or more) and residence macro area (North-West, North-East, Center, South-Islands) were the exposures, for which adjusted mortality rate ratios (MRRs) were calculated through multivariate quasi-Poisson regression models, adjusted for age at death. Relative index of inequalities was estimated for preventable, treatable, and non-avoidable mortality and for some specific causes. RESULTS: The cohort consisted of 35,708,459 residents (48.8% men, 17.5% aged 65-74), 34% with a high school diploma, 33.5% living in the South-Islands; 1,127,760 deaths were observed, of which 65.2% for avoidable causes (40.4% preventable and 24.9% treatable). Inverse trends between education level and mortality were observed for all causes; comparing the least with the most educated groups, a strong association was observed for preventable (males MRR = 2.39; females MRR = 1.65) and for treatable causes of death (males MRR = 1.93; females MRR = 1.45). The greatest inequalities were observed for HIV/AIDS and alcohol-related diseases (both sexes), drug-related diseases and tuberculosis (males), and diabetes mellitus, cardiovascular diseases, and renal failure (females). Excess risk of preventable and of treatable mortality were observed for the South-Islands. CONCLUSIONS: Socioeconomic inequalities in mortality persist in Italy, with an extremely varied response to policies at the regional level, representing a possible missed gain in health and suggesting a reassessment of priorities and definition of health targets.

Barriers to Accessing Primary Care and Appropriateness of Healthcare Among Immigrants in Italy.

INTRODUCTION: The health status and health care needs of immigrant populations must be assessed. The aim of this study was to evaluate barriers to accessing primary care and the appropriateness of health care among resident immigrants in Italy, using indicators regarding maternal health, avoidable hospitalization, and emergency care. METHODS: Cross-sectional study using some indicators of the National Monitoring System of Health Status and Healthcare of the Immigrant Population (MSHIP), coordinated by the National Institute for Health, Migration and Poverty (INMP), calculated on perinatal care, hospital discharge, and emergency department databases for the years 2016-2017 in nine Italian regions (Piedmont, Trento, Bolzano, Emilia-Romagna, Tuscany, Umbria, Latium, Basilicata, Sicily). The analyses were conducted comparing immigrant and Italian residents. RESULTS: Compared to Italian women, immigrant women had fewer than five gynecological examinations (8.5 vs. 16.3%), fewer first examinations after the 12th week of gestational age (3.8 vs. 12.5%), and fewer than two ultrasounds (1.0 vs. 3.8%). Compared to Italians, immigrants had higher standardized rates (× 1,000 residents) of avoidable hospitalizations (males: 2.1 vs. 1.4; females: 0.9 vs. 0.7) and of access to emergency departments for non-urgent conditions (males: 62.0 vs. 32.7; females: 52.9 vs. 31.4). CONCLUSIONS: In Italy, there appear to be major issues regarding accessing services and care for the immigrant population. Policies aimed at improving socioeconomic conditions and promoting integration can promote healthy lifestyles and appropriate access to health care, counteracting the emergence of health inequities in the immigrant population.

Education inequalities in cardiovascular and coronary heart disease in Italy and the role of behavioral and biological risk factors.

BACKGROUND AND AIMS: Behavioral and biological risk factors (BBRF) explain part of the variability in socioeconomic differences in health. The present study aimed at evaluating education differences in incidence of cardiovascular disease (CVD) and coronary heart disease (CHD) in Italy and the role of BBRF. METHODS AND RESULTS: All subjects aged 30-74 years (n = 132,686) who participated to the National Health Interview Surveys 2000 and 2005 were included and followed-up for ten years. Exposure to smoking, physical activity, overweight/obesity, diabetes and hypertension at baseline was considered. Education level was used as an indicator of socioeconomic status. The outcomes were incident cases of CVD and CHD. Hazard ratios by education level were estimated, adjusting for sociodemographic covariates and stratifying by sex and geographic area. The contribution of BBRF to education inequalities was estimated by counterfactual mediation analysis, in addition to the assessment of the risk attenuation by comparing the models including BBRF or not. 22,214 participants had a CVD event and 6173 a CHD event. After controlling for sociodemographic factors, the least educated men showed a 21% higher risk of CVD and a 17% higher risk of CHD compared to the most educated (41% and 61% among women). The mediating effect (natural indirect effect) of BBRF between extreme education levels was 52% for CVD and 84% for CHD among men (16% among women for CVD). CONCLUSIONS: More effective strategies aiming at reducing socioeconomic disparities in CVD and CHD are needed, through programs targeting less educated people in combination with community-wide initiatives.

The 2008 Financial Crisis and Changes in Lifestyle-Related Behaviors in Italy, Greece, Spain, and Portugal: A Systematic Review.

Italy, Greece, Spain, and Portugal have all been strongly affected by the 2008 financial crisis, which has had a negative impact on health. We systematically evaluated the effects of the crisis on lifestyle and socioeconomic inequalities. We conducted a literature search using MEDLINE, Embase, the Cochrane Library, and health economics databases for studies reporting quantitative comparisons before and after (or during) the crisis on the following risk behaviors: alcohol consumption, smoking habit, healthy diet, physical activity, and psychotropic drugs and substance abuse, without setting any age restrictions. We selected 34 original articles published between 2011 and 2020. During/after the crisis, alcohol consumption and substance abuse decreased, while psychotropic drug use increased. We also observed a deterioration in healthy eating behavior, with a reduction in fruit and vegetable consumption. Smoking habit and physical activity showed a more complex, controversial trend. Socioeconomic inequalities were affected by the recession, and the negative effects on unhealthy lifestyle tended to be more pronounced among the disadvantaged. These results suggest the need to implement health policies and interventions aimed at monitoring risk behaviors, with special regard to disadvantaged people, and considering the potential additional impact of the COVID-19 pandemic.

Avoidable Hospitalization for Heart Failure Among a Cohort of 18- to 64-Year-Old Italian Citizens and Immigrants: Results From the Italian Network for Longitudinal Metropolitan Studies.

BACKGROUND: Heart failure (HF) represents a severe public health burden. In Europe, differences in hospitalizations for HF have been found between immigrants and native individuals, with inconsistent results. Immigrants face many barriers in their access to health services, and their needs may be poorly met. We aimed to compare the rates of avoidable hospitalization for HF among immigrants and native individuals in Italy. METHODS: All 18- to 64-year-old residents of Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome between January 1, 2001 and December 31, 2013 were included in this multicenter open-cohort study. Immigrants from high migratory pressure countries (divided by area of origin) were compared with Italian citizens. Age-, sex-, and calendar year-adjusted hospitalization rate ratios and the 95% CIs of avoidable hospitalization for HF by citizenship were estimated using negative binomial regression models. The hospitalization rate ratios were summarized using a random effects meta-analysis. Additionally, we tested the contribution of socioeconomic status to these disparities. RESULTS: Of the 4 470 702 subjects included, 15.8% were immigrants from high migratory pressure countries. Overall, immigrants showed a nonsignificant increased risk of avoidable hospitalization for HF (hospitalization rate ratio, 1.26 [95% CI, 0.97-1.68]). Risks were higher for immigrants from Sub-Saharan Africa and for males from Northern Africa and Central-Eastern Europe than for their Italian citizen counterparts. Risks were attenuated adjusting for socioeconomic status, although they remained consistent with nonadjusted results. CONCLUSIONS: Adult immigrants from different geographic macroareas had higher risks of avoidable hospitalization for HF than Italian citizens. Possible explanations might be higher risk factors among immigrants and reduced access to primary health care services.

Avoidable hospitalisation for diabetes mellitus among immigrants and natives: Results from the Italian Network for Longitudinal Metropolitan Studies.

BACKGROUND AND AIMS: Italy has experienced a relevant increase in migration inflow over the last 20 years. Although the Italian Health Service is widely accessible, immigrants can face many barriers that limit their use of health services. Diabetes mellitus (DM) has a different prevalence across ethnic groups, but studies focusing on DM care among immigrants in Europe are scarce. This study aimed to compare the rates of avoidable hospitalisation (AH) between native and immigrant adults in Italy. METHODS AND RESULTS: A multi-centre open cohort study including all 18- to 64-year-old residents in Turin, Venice, Reggio-Emilia, Modena, Bologna and Rome between 01/01/2001 and 31/12/2013-14 was conducted. Italian citizens were compared with immigrants from high migratory pressure countries who were further divided by their area of origin. We calculated age-, sex- and calendar year-adjusted rate ratios (RRs) and 95% confidence intervals (95% CIs) of AH for DM by citizenship using negative binomial regression models. The RRs were summarized using a random effects meta-analysis. The results showed higher AH rates among immigrant males (RR: 1.63, 95% CI: 1.16-2.23), whereas no significant difference was found for females (RR: 1.14, 95% CI: 0.65-1.99). Immigrants from Asia and Africa showed a higher risk than Italians, whereas those from Central-Eastern Europe and Central-Southern America did not show any increased risk. CONCLUSION: Adult male immigrants were at higher risk of experiencing AH for DM than Italians, with differences by area of origin, suggesting that they may experience lower access to and lower quality of primary care for DM. These services should be improved to reduce disparities.

Geographic Inequalities in Breast Cancer in Italy: Trend Analysis of Mortality and Risk Factors.

We calculated time trends of standardised mortality rates and risk factors for breast cancer (BC) from 1990 to 2016 for all women resident in Italy. The age-standardised mortality rate in Italy decreased from 4.2 in 1990 to 3.2 (×100,000) in 2016. While participation in organised screening programmes and age-standardised fertility rates decreased in Italy, screening invitation coverage and mammography uptake, the prevalence of women who breastfed and mean age at birth increased. Although southern regions had favourable prevalence of protective risk factors in the 1990s, fertility rates decreased in southern regions and increased in northern regions, which in 2016 had a higher rate (1.28 vs. 1.32 child per woman) and a smaller increase in women who breastfed (+4% vs. +30%). In 2000, mammography screening uptake was lower in southern than in northern and central regions (28% vs. 52%). However, the increase in mammography uptake was higher in southern (203%) than in northern and central Italy (80%), reducing the gap. Participation in mammographic screening programmes decreased in southern Italy (-10%) but increased in the North (6.6%). Geographic differences in mortality and risk factor prevalence is diminishing, with the South losing all of its historical advantage in breast cancer mortality.

Socioeconomic and citizenship inequalities in hospitalisation of the adult population in Italy.

BACKGROUND: Higher levels of hospital admissions among people with lower socioeconomic level, including immigrants, have been observed in developed countries. In Europe, immigrants present a more frequent use of emergency services compared to the native population. The aim of our study was to evaluate the socioeconomic and citizenship differences in the hospitalisation of the adult population in Italy. METHODS: The study was conducted using the database created by the record linkage between the National Health Interview Survey (2005) with the National Hospital Discharge Database (2005-2014). 79,341 individuals aged 18-64 years were included. The outcomes were acute hospital admissions, urgent admissions and length of stay (1-7 days, > = 8 days). Education level, occupational status, self-perceived economic resources and migratory status were considered as socioeconomic determinants. A multivariate proportional hazards model for recurrent events was used to estimate the risk of total hospital admissions. Logistic models were used to estimate the risk of urgent hospitalisation as well as of length of stay. RESULTS: Low education level, the lack of employment and negative self-perceived economic resources were conditions associated with the risk of hospitalisation, a longer hospital stay and greater recourse to urgent hospitalisation. Foreigners had a lower risk of hospitalisation (HR = 0.75; 95% CI:0.68-0.83) but a higher risk of urgent hospitalisation (OR = 1.36; 95% CI:1.18-1.55) and more frequent hospitalisations with a length of stay of at least eight days (OR = 1.19; 95% CI:1.02-1.40). CONCLUSIONS: To improve equity in access, effective primary, secondary and tertiary prevention strategies must be strengthened, as should access to appropriate levels of care.

[Evaluating health care of the immigrant population in Italy through indicators of a national monitoring system]. / Valutazione dell'assistenza sanitaria della popolazione immigrata in Italia attraverso alcuni indicatori di un sistema nazionale di monitoraggio.

OBJECTIVES: to evaluate maternal and child healthcare, avoidable hospitalisation, access to emergency services among immigrants in Italy. DESIGN: cross sectional study of some health and health care indicators among Italian and foreign population residing in Italy in 2016-2017. SETTING AND PARTICIPANTS: indicators based on the national monitoring system coordinated by the Italian National Institute for Health, Migration and Poverty (INMP) of Rome, calculated on perinatal care (CedAP), hospital discharge (SDO), emergency services (EMUR) archives for the years 2016-2017, by of the following regions: Piedmont, Trento, Bolzano, Emilia-Romagna, Tuscany, Umbria, Lazio, Basilicata, Sicily. MAIN OUTCOME MEASURES: number and timeliness of pregnancy visits, number of ultrasounds, invasive prenatal investigations; perinatal mortality rates, birth weight, Apgar score at 5 minutes, need for neonatal resuscitation; standardized rates of avoidable hospitalisation and access to emergency services by triage code. RESULTS: more often than Italians, immigrant women have during pregnancy: less than 5 gynaecological examination (16.3% vs 8.5%), first examination after the 12th week of gestational age (12.5% vs 3.8%), less than 2 ultrasounds (3.8% vs 1.0%). Higher perinatal mortality rates among immigrants compared to Italians (3.6 vs 2.3 x1,000). Higher standardized rates (x1,000) among immigrants compared to Italians of avoidable hospitalisation (men: 2.1 vs 1.4; women: 0.9 vs 0.7) and of white triage codes in emergency (men: 62.0 vs 32.7; women: 52.9 vs 31.4). CONCLUSIONS: study findings show differences in access and outcomes of healthcare between Italians and immigrants. National monitoring system of indicators, coordinated by INMP, represents a useful tool for healthcare intervention policies aimed to health equity.

A systematic review of economic evaluations of neonatal and maternal healthcare in immigrant and ethnic minority women.

BACKGROUND: less access to appropriate care during pregnancy for immigrant/ethnic minority women can lead to worse health outcomes and higher costs for health services. OBJECTIVES: to conduct a systematic review of studies on the economic evaluation of maternal and child healthcare among immigrants and racial/ethnic minority groups in advanced economy countries. METHODS: the main biomedical/economic bibliographic databases and institutional sources were searched. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: encouraging breastfeeding and reducing inappropriate hospital use/length of hospital stay proved potentially able to reduce costs. Most studies showed a cost reduction if immigrant and ethnic minority women were included both in national and targeted programmes, such as nutritional programmes or case management. Screening campaigns targeting immigrants and ethnic minority groups were more cost-effective than broader, universal or non-screening strategies. Screenings were cost-effective when extended to newborns/relatives of pregnant women (Chagas disease) and were cost-effective for unvaccinated women in low-vaccination rates regions (rubella), immigrant women reporting no/uncertain vaccination history (varicella), and first-generation immigrants (HCV). DISCUSSION: promoting inclusion in pregnancy healthcare programmes or in targeted screening campaigns could be effective in cost saving for health services.

Sociodemographic Characteristics Associated with Harmful Use of Alcohol Among Economically and Socially Disadvantaged Immigrant Patients in Italy.

In many contexts, individuals with lower socioeconomic status, especially immigrants, have a higher burden of negative alcohol-related consequences and a higher probability of receiving a psychiatric diagnosis. This study aimed at exploring sociodemographic and clinical characteristics associated with harmful use of alcohol (HUA) among immigrant patients. A cross-sectional study was conducted in Rome (Italy) on a sample of 330 immigrant patients admitted to the gastroenterology outpatient clinic of the INMP (March 2013-October 2014). HUA was evaluated through the Alcohol Use Disorders Identification Test (AUDIT) questionnaire. The presence of psychiatric disorders was diagnosed through SCID I-II interviews. The association between sociodemographic characteristics and psychiatric disorders and HUA was evaluated through a multivariate log-binomial regression model. HUA was associated with unemployment, longer stay in Italy, mood disorder and not being married, especially among African immigrants. We provide original findings about a selected, hard-to-investigate population, suggesting priorities in interventions on HUA among specific vulnerable subgroups.

[Immigrants' health and socioeconomic inequalities of overall population residing in Italy evaluated through the Italian network of Longitudinal Metropolitan Studies]. / Salute degli immigrati e disuguaglianze socioeconomiche nella popolazione residente in Italia valutate attraverso la rete degli Studi Longitudinali Metropolitani.

INTRODUCTION: Describing and monitoring socioeconomic inequalities in health are the prerequisite for planning equity policies. In Italy, some cities have integrated personal information from the municipal registries with Census data and with data from healthcare information systems to set up Longitudinal Metropolitan Studies (LMS). Under the coordination of the Italian National Institute for Health, Migration, and Poverty (NIHMP), six cities in the LMS network have contributed to the present monograph: Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome. MORTALITY RESULTS. Significant socioeconomic differences by level of education were seen in all the participating centres. People who live alone or in single-parent households are more likely to die, as are those living in a substandard dwelling. Immigrants resident in the six cities included in the study showed lower all-cause mortality than Italians (males: MRR 0.83; 95%CI 0.78-0.90 - females: MRR 0.70; 95%CI 0.64-0.77). Sub-Saharan Africans experienced a significant higher mortality than Italians (males: MRR 1.33; 95%CI 1.12-1.59 - females: MMR 1.69; 95%CI 1.31-2.17). Immigrants had a neonatal and post-neonatal mortality risk about 1.5 times higher than Italians (neonatal: OR 1.71; 95%CI 1.22-2.39 - post-neonatal: OR 1.63; 95%CI 1.03-2.57). A difference between Italians and immigrants was also observed for mortality in children aged 1-4 years, though less marked (OR 1.24; 95%CI 0.73-2.11). Excesses concerned particularly immigrants from North Africa and from sub-Saharan Africa as well as those residing in Italy for >5 years. HOSPITALISATION RESULTS. Hospitalisation rates are lower for immigrants than for Italians, except when due to infectious diseases, blood disorders, and, among women, for reasons linked to pregnancy and childbirth. Avoidable hospitalisation rates of adults from low migratory pressure Countries are lower than or equal to those of Italians. On the contrary, adults from low migratory pressure Countries show higher avoidable hospitalisation rates compared to Italians in every cohort, with the exception of Rome (RR 0.81; 95%CI 0.78-0.85), with RR ranging from 1.08 (95%CI 0.96-1.22) in Venice to 1.64 (95%CI 1.47-1.83) in Modena. CONCLUSIONS: Maternal and child health is the most critical area of health for immigrant population. Considering the importance that the issue of health equity has taken on in the political agenda, the data presented in this volume are a great asset, particularly in light of the long recession and the social crisis that have impacted the Country.

The geography and economics of forgoing medical examinations or therapeutic treatments in Italy during the economic crisis.

BACKGROUND: In Italy, the number of individuals who have forgone medical examinations or treatments for economic reasons is one of the highest in Europe. During the global economic crisis of 2008, the restrictive policies concerning access to healthcare and the quality of these services, which differs widely throughout the country, may have accentuated the territorial differences in unmet needs, thereby penalizing the more disadvantaged segments of the population. The study aimed at evaluating the geographical and socioeconomic differences, in particular the risk of poverty, that influence forgoing healthcare services in Italy. METHODS: Cross-sectional Italian data from the 2004-2015 European Survey on Income and Living Conditions (EU-SILC) were used. Hierarchical logistic models were tested, using as the outcome unmet needs for medical examinations or treatment in the preceding 12 months, and as risk factor the condition of being at risk of poverty. Age, sex, citizenship, educational level, presence of chronic or severely limiting diseases and self-perceived health were used as adjustment factors. Analyses were stratified over three time periods: pre-crisis (2004-2007), initial phase of the crisis (2008-2012) and second phase of the crisis (2013-2015). RESULTS: In Central Italy and particularly in Southern Italy, a marked increase (9.9% in 2013-2015) was seen in the overall rate of unmet needs as well as in that of unmet needs due to economic reasons. The probability of unmet needs was higher, and increased over time, for those at risk of poverty (aOR = 1.54 in 2004-07, aOR = 1.70 in 2008-12, aOR = 2.21 in 2013-15). Individuals with a low educational level, who had a chronic or severely limiting disease, who perceived their health as not good and immigrants had a higher risk of forgoing healthcare. The regions in Southern Italy had a significantly higher probability of unmet needs. CONCLUSIONS: A strong association was found between the probability of forgoing medical examination or treatment and being at risk of poverty. Study results underline the need for healthcare policies aimed at facilitating access to healthcare services, particularly in the South, by developing a progressive mechanism of contribution to healthcare costs proportional to income and by guaranteeing free access to the poor.

Comparison of early childhood vaccination coverage and timeliness between children born to Italian women and those born to foreign women residing in Italy: A multi-centre retrospective cohort study.

BACKGROUND: Compared to hosting populations, immigrants are usually considered more vulnerable to communicable diseases, many of which are vaccine-preventable. This study aims to estimate vaccination coverage (VC) and timeliness in children born to women from high migratory pressure countries (HMPC) and to evaluate factors affecting differences with children born to Italian women or women from advanced development countries (ITA + ADC). METHODS: We retrospectively analysed data of children born in 2009-2014 and resident in areas served by three local health units in the cities of Rome (n = 40,284), Turin (n = 49,600), and Treviso (n = 20,080). Data were retrieved through record-linkage of the population, vaccination, and birth registries. We used the Kaplan-Meier method to estimate VCs at different ages for the 3rd dose of vaccine against tetanus and the 1st dose of vaccines against measles and meningococcal group C. Factors affecting differences in VCs by citizenship were evaluated using log-binomial models. RESULTS: In Rome, VCs at 2 years of age were consistently higher in children born to ITA + ADC women than in children born to HMPC women, while differences in VCs by citizenship varied according to antigen and birth-cohort in Turin and Treviso, respectively. Where differences were observed, these were only partially explained by the mother's socio-demographic characteristics, level of utilisation of health-services during pregnancy, and maternal, perinatal, and neonatal outcomes. Finally, we observed a reduction of VCs in recent birth cohorts (2012-14 vs. 2009-11), especially in children born to ITA + ADC women. CONCLUSIONS: Differences in VCs by citizenship were not homogeneous and varied according to geographical context, antigen, and birth-cohort. These differences are likely to be also affected by informal barriers (e.g., linguistic and cultural barriers), which should be addressed in implementing strategies to increase vaccine uptake in foreign children. Moreover, our results suggest that effective strategies to promote vaccinations in the autochthonous population are also needed.

Italian Atlas of mortality inequalities by education level. / Atlante italiano delle disuguaglianze di mortalità per livello di istruzione.

OBJECTIVES: To evaluate the geographical and socioeconomic differences in mortality and in life expectancy in Italy; to evaluate the proportion of mortality in the population attributable to a medium-low education level through the use of maps and indicators. DESIGN: Longitudinal design of the population enrolled in the 2011 Italian Census, following the population over time and registering any exit due to death or emigration. SETTING AND PARTICIPANTS: The study used the database of the Italian National Institute of Statistics (Istat) developed by linking the 2011 Census with the Italian National Register of Causes of Death (2012-2014) for 35 groups of causes of death. Age, sex, residence, and education level information were collected from the Census. MAIN OUTCOME MEASURES: Life expectancy at birth was calculated by sex, Italian region, and education level. For the population aged 30-89 years, the following items were developed by sex: 1. provincial maps showing, for each cause of death, the distribution in quintiles of smoothed standardized mortality ratio (SMR), adjusted for age and education level and estimated with Bayesian models for small areas (spatial conditional autoregressive model); 2. regional maps of population attributable fraction (PAF) for low and medium education levels, calculated starting from age-standardized mortality ratios; 3. tables illustrating for each region standardized mortality rates and standardized years of life lost rate by age (standardized YLL rate), and mortality rate ratios standardized by age (MMRs). RESULTS: Males with a lower education level throughout Italy show a life expectancy at birth that is 3 years less than those with higher education; residents in Southern Italy lose an additional year in life expectancy, regardless of education level. Social inequalities in mortality are present in all regions, but are more marked in the poorer regions of Southern Italy. Geographical differences, taking into account the different population distributions in terms of age and education level, produce mortality differences for all causes: from -15% to +30% in women and from -13% to +26% in men, compared to the national average. Among the main groups of causes, the geographical differences are greater for cardiovascular diseases, respiratory diseases, and accidents, and lower for many tumour sites. A clear mortality gradient with an excess in Southern Italy can be seen for cardiovascular diseases: there are some areas where mortality for people with higher education level is higher than that for residents in Northern Italy with low education level. The gradient for "All tumours", instead, is from South to North, as it is for most single tumour sites. Population attributable fraction for low education level in Italy, taking into account the population distribution by age, is 13.4% in women and 18.3% in men. CONCLUSIONS: The study highlighted important geographical differences in mortality, regardless of age and socioeconomic level, with a more significant impact in the poorer Southern regions, revealing a never-before-seen health advantage in the regions along the Adriatic coast. A lower education level explains a considerable proportion of mortality risk, although with differing effects by geographical area and cause of death. There are still mortality inequalities in Italy, therefore, representing a possible missed gain in health in our Country; these inequalities suggest a reassessment of priorities and definition of health targets. Forty years after the Italian National Health Service was instituted, the goal of health equity has not yet been fully achieved.

[Differences in mortality by educational level in Italy (2012-2014)]. / Differenze nella mortalità per livello di istruzione in Italia (2012-2014).

OBJECTIVES: to evaluate socioeconomic inequalities in mortality by educational level in Italy. DESIGN: cohort study based on the record linkage between the 2012-2014 archives of mortality and the 2011 Italian population Census. SETTING AND PARTICIPANTS: Italian population registered in the 2011 Census. MAIN OUTCOME MEASURES: life expectancy by educational level, age-standardized mortality rates, mortality rate ratios (MRRs) for overall mortality, and 12 groups of causes of death. RESULTS: life expectancy at birth was 80.3 years among men and 84.9 among women. High-educated men were expected to live 3 years longer than lower educated men, while the gap was narrower in women (1.5 years). Lower educated men had a higher mortality from any cause (MRR: 1.34; 95%CI 1.33-1.35) with larger differentials for lung, upper aerodigestive, and liver cancers, respiratory system diseases, AIDS and accidents. Socioeconomic inequalities were larger in the North-West of the Country for lung and liver cancer. Educational inequalities were smaller among women for all-cause mortality, but remarkably larger for circulatory system diseases (MRR: 1.40; 95%CI 1.38-1.42), particularly in the South (MRR: 1.46; 95%CI 1.42-1.50). CONCLUSIONS: this study documented socioeconomic inequalities in mortality in Italy for many causes of death; some of them resulted heterogeneous by area of residence. Most of the inequalities can be counteracted with specific measures aimed to improve behavioural risk factors among less educated people.

Cohort profile: the Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS), a multicentre cohort for socioeconomic inequalities in health monitoring.

PURPOSE: The Italian Network of Longitudinal Metropolitan Studies (IN-LiMeS) is a system of integrated data on health outcomes, demographic and socioeconomic information, and represents a powerful tool to study health inequalities. PARTICIPANTS: IN-LiMeS is a multicentre and multipurpose pool of metropolitan population cohorts enrolled in nine Italian cities: Turin, Venice, Reggio Emilia, Modena, Bologna, Florence, Leghorn, Prato and Rome. Data come from record linkage of municipal population registries, the 2001 population census, mortality registers and hospital discharge archives. Depending on the source of enrolment, cohorts can be closed or open. The census-based closed cohort design includes subjects resident in any of the nine cities at the 2001 census day; 4 466 655 individuals were enrolled in 2001 in the nine closed cohorts. The open cohort design includes subjects resident in 2001 or subsequently registered by birth or immigration until the latest available follow-up (currently 31 December 2013). The open cohort design is available for Turin, Venice, Reggio Emilia, Modena, Bologna, Prato and Rome. Detailed socioeconomic data are available for subjects enrolled in the census-based cohorts; information on demographic characteristics, education and citizenship is available from population registries. FINDINGS TO DATE: The first IN-LiMeS application was the study of differentials in mortality between immigrants and Italians. Either using a closed cohort design (nine cities) or an open one (Turin and Reggio Emilia), individuals from high migration pressure countries generally showed a lower mortality risk. However, a certain heterogeneity between the nine cities was noted, especially among men, and an excess mortality risk was reported for some macroareas of origin and specific causes of death. FUTURE PLANS: We are currently working on the linkage of the 2011 population census data, the expansion of geographical coverage and the implementation of the open design in all the participating cohorts.

Skin cancer risk assessment in dark skinned immigrants: the role of social determinants and ethnicity.

OBJECTIVES: Dark-skinned people have a lower incidence rate of skin cancer, in particular melanoma, which is detected at more advanced stages leading to poorer prognoses and long-term outcomes compared to whites. The gap in survival is due to some difficulty in melanoma detection, lack of attention from doctors and awareness by patients. This study aims to assess skin cancer risk awareness in dark-skinned immigrants and to determine the influence of socioeconomic factors and ethnic origin on behaviors. DESIGN: This is a cross-sectional health facility based study carried out in a 12-month period. A semi-structured questionnaire to assess skin cancer risk awareness and a dermatological examination was offered to dark-skinned immigrants consecutively attending the dermatology department of the National Institute for Health, Migration and Poverty in Rome. RESULTS: 147 dark-skinned immigrants were enrolled, of which 54.4% were males, coming from Africa (53.1%). They were mainly young, aged 18-34 (56.5%). The level of education and length of stay in Italy was significantly related to the awareness about skin cancer: people with a high educational level (OR: 8.1 95% CI: 3.2-23.4) or immigrated more than 4 years before the interview (OR: 2.1 95% CI: 1.0-4.4) have a greater knowledge about skin cancer. CONCLUSIONS: Education level is the strongest predictive factor of skin cancer awareness, whereas cultural behaviours and personal experience of sunburns are the main factors determining sunlight avoidance. Health promotion programs targeting immigrants must consider cultural differences related to ethnicity and country of origin, and adopt a transcultural approach.

[Self-perceived health status among immigrants in Italy]. / Capitolo 2: Lo stato di salute percepito della popolazione immigrata in Italia.

OBJECTIVES: to evaluate self-perceived health status of immigrants in Italy. DESIGN: cross-sectional study based on the representative national samples of the multipurpose surveys "Health conditions and use of health services" conducted in 2005 and 2013 by the Italian National Institute of Statistics (Istat). SETTING AND PARTICIPANTS: the study was conducted on the age group of 18-64: No. 80,661 in 2005, among which 3.2% were immigrants, and No. 72,476 in 2013, among which 7.1% were immigrants. MAIN OUTCOME MEASURES: prevalence rate ratios (PRR) calculated through log-binomial regression models, stratified by survey edition and gender, by evaluating the association between the Physical Component Score (PCS), the Mental Component Score (MCS), and the overall health index and citizenship. Adjustment for the following confounding factors was performed: age, educational level, working condition, perceived economic resources, body mass index (BMI). RESULTS: in 2005, immigrants had a lower probability of poor-perceived physical health, both among men (PRR: 0.79; 95%CI 0.70-0.89) and women (PRR: 0.89; 95%CI 0.82- 0.97), compared to Italians. In 2013, the perceived health advantage of immigrants was reduced for both genders (PRR males: 0.87; 95%CI 0.80-0.95; PRR females: 0.94; 95%CI 0.88-0.99). In the considered period, the prevalence of people with worse mental health conditions increases, with lower PRR among immigrants, compared to Italians. Higher probability of «NOT good¼ overall perceived health was also observed among immigrants residing in Italy for at least 10 years (PRR men: 1.24; PRR women: 1.15) and among immigrants men from America (PRR: 1.35). CONCLUSIONS: from 2005 to 2013, immigrants seemed to maintain a better perception of health status than Italians. Nevertheless, study results show a decrease in self-perceived health, particularly mental health, in the considered period - apart from demographic, socioeconomic, and lifestyle factors - as well as a worse overall self-perceived health status among immigrants who stayed in Italy longer. Such results lead to suppose that the "healthy migrant effect" tends to disappear over time, maybe due to the world financial crisis. Unemployment increases and lower income also made the access to medical care more difficult, particularly among the most fragile population groups, including migrants. In this context, it is essential to promote health policies supporting equity of access to healthy lifestyles and effective health services, which are fundamental to reduce health inequalities.

[Factors associated to medical visits: comparison among Italians and immigrants resident in Italy]. / Capitolo 6: Fattori associati al ricorso a visite mediche: confronto tra cittadini italiani e stranieri residenti in Italia.

OBJECTIVES: to evaluate the role of factors potentially associated with the use of medical visits by the immigrant population living in Italy, making a comparison with the Italian population. DESIGN: cross-sectional study based on the representative sample of the population residing in Italy considered in the Survey "Health and use of health services" conducted by the Italian National Institute of Statistics (Istat) in 2013. SETTING AND PARTICIPANTS: the study was conducted on a sample of citizens aged 18-64 years (72,476 individuals) representing a population of 37,290,440 residents in Italy (33.9 million Italians and 3,390,440 foreigners) in 2013. MAIN OUTCOME MEASURES: an indicator on the use of medical visits has been used as an outcome, based on people who had replied affirmatively to the question: «In the last four weeks, have you been examined by the family doctor, by the pediatrician, or by medical specialists, as an eye doctor, dentist, etc.?¼. Starting from this outcome, the question «Can you indicate the main reason of the visits made in the last 4 weeks?¼ was used to build two additional outcome variables for separately evaluating the use of medical examinations for "diseases or disorders" from the use of medical examination for "health check in the absence of diseases or disorders". For each outcome, a logistic regression model was fitted, considering as independent variables information related to socioeconomic status and to the respondent's health condition. RESULTS: 21.4% of foreigners (18-64 years) living in Italy used medical visits during the four weeks before the interview, a percentage lower than the one recorded among Italian citizens (27.0%). Taking into account the socioeconomic characteristics, lifestyle and health status of respondents, the results of logistic regression models showed that foreigners have a lower probability than Italians to make a medical examination, both for visits motivated by any health problems (OR: 0.80; 95%CI 0.73-0.87), and in case of medical examination carried out for preventive purposes (OR: 0.72; 95%CI 0.64-0.82). CONCLUSION: the more the time living in the host Country increases, the more immigrants residing in Italy tend to have the same health problems of the most disadvantaged groups of the autochthonous population, maybe beacuse of the deterioration of the so-called "healthy immigrant effect". In this context, they should be considered as more vulnerable in terms of health, and special attention must be paid to prevention. The lower use of medical visits highlights inequities in access to services. In order to reduce health inequalities, barriers that affect equitable access to health care should be removed, taking into account the heterogeneity of these sub-groups, characterized by different cultures and attitudes towards the health system.