[Tackle health inequality in prevention: state of the art through an assessment of 21 Regional preventive plan 2014-2018]. / Contrastare le disuguaglianze sociali di salute nella programmazione nazionale e regionale: evidenze empiriche dalla valutazione dei Piani regionali della prevenzione 2014-2018.

BACKGROUND: the Italian health policies awareness on health inequalities (HI) issues is increasing. The National Plan for health prevention and promotion (2014-2018) (PNP) introduced in 2014 a clear political commitment aimed at reducing HI. During 2015, each Italian regions (IRs) elaborated and approved by law its prevention plan (PRP), according to the PNP. To support this process, a factsheet describing educational inequalities (EIs) in the exposure to risk factors (RFs) was provided with training for many IRs. OBJECTIVES: an evaluation of the 21 PRPs was performed to assess the level of adherence to the national direction and to investigate the impact of the availability of regional health inequalities data. METHOD: a checklist for the evaluation of the PRP was developed and discussed with experts. Frequency of success was calculated for each dimension investigated in the 21 PRPs. An overall score assessing the regional level of adherence to the national recommendation was computed. RESULTS: 21 PRPs and 194 programmes were assessed. 13 PRPs considered the need to address HIs and 8 declared to have used quantitative information on HIs for priority setting; 8 PRPs monitored the magnitude of HIs, but only 6 decided to set specific actions tackling such disparities. Overall, 4 IRs failed to comply with the national recommendation to include equity in the PRP, while 14 faced the challenge with different level of engagement in equity. There is an association between the adherence to the equity recommendation and the availability of a regional factsheet. CONCLUSIONS: thanks to the national commitment and to the effort of dissemination of evidence on HIs tailored to each IR, it has been possible to bring many IRs to incorporate in some way the issue of equity in prevention in the majority of their PRP. However, evidence of high level of HI is neither sufficient nor necessary to encourage decision makers to raise equity in their agenda.

The impact of level of education on adherence to breast and cervical cancer screening: Evidence from a systematic review and meta-analysis.

OBJECTIVE: To assess the inequalities in adherence to breast and cervical cancer screening according to educational level. METHODS: A systematic review was carried out between 2000 and 2013 by querying an electronic database using specific keywords. Studies published in English reporting an estimation of the association between level of education and adherence to breast and/or cervical cancer screening were included in the study. Two different meta-analyses were carried out for adherence to breast and cervical cancer screening, respectively: women with the highest level of education and women with the lowest level of education were compared. The level of heterogeneity was investigated and subgroup analyses were carried out. RESULTS: Of 1231 identified articles, 10 cross-sectional studies were included in the analysis. The meta-analyses showed that women with the highest level of education were more likely to have both screenings with an overall OR=1.61 (95% CI 1.36-1.91; I(2)=71%) for mammography and OR=1.96 (95% CI 1.79-2.16; I(2)=0%) for Pap test, respectively. Stratified meta-analysis for breast cancer screening included only studies that reported guidelines with target age of population ≥50 years and showed a reduction in the level of heterogeneity and an increase of 36% in the adherence (95% CI 1.19-1.55; I(2)=0%). CONCLUSIONS: This study confirms and reinforces evidence of inequalities in breast and cervical cancer screening adherence according to educational level.

The impact of regional co-payment and national reimbursement criteria on statins use in Italy: an interrupted time-series analysis.

BACKGROUND: Statins are among the most commonly prescribed drugs worldwide in the prevention of cardiovascular diseases and their effectiveness is largely acknowledged. The consumption of statins increased four-fold during the 2000-2010 decade in Italy and national and regional control policies were developed. Restrictions to reimbursement were fixed at the national level, whereas co-payment was introduced in some, but not all, regions. The aim of the present study is to assess the impact of such policies on the consumption of statins in Italy between 2001-2007 among outpatients. METHODS: The statin use was measured in terms of defined daily doses per 1,000 inhabitants per day (DDD/1000 inh. day) from May 2001 to December 2007. The study was conducted in 17 out of 21 regions, nine of which had implemented a co-payment policy. Time trends in consumption before and after the introduction of co-payment policies and reimbursement criteria were examined using segmented regression analysis of interrupted time-series, adjusting for seasonal components. RESULTS: The consumption of statins increased by 22.9 DDD/1000 inh. day in May 2001 to 54.7 DDD/1000 inh. day in December 2007. On average, there was a 1.7% increase in statin use each month before the national guideline changed while the increase was about 0.5% afterwards. The revision of the reimbursement criteria was associated with a significant decrease in level (coefficient = -2.80, 95% CI -3.70 to -1.90 p-value <0.001) and trend (coefficient = -0.33, 95% CI -0.37 to -0.29 p-value <0.001). The introduction of co-payment was associated with a significant change in trend of consumption so that the overall use of the drug increased by 0.04 (95% CI 0.02 to 0.07, p-value < 0.001) DDD/1000 inh. day per month in the post-intervention period, but there was no evidence of a change in level of consumption (p-value = 0.163). CONCLUSIONS: Consumption of statins in Italy increased almost three-fold during the study period. The restriction to reimbursement Interventions was associated with an immediate drop and a decrease in trend of statin use, while the regional copayment was associated with a small increase in trend of statin use.

[Features and developments of Primary Care in a Public Health perspective]. / Caratteristiche e Sviluppi dell'Assistenza Primaria in una prospettiva di Public Health.

In recent years, substantial changes of the population structure have occurred, both at the national and international levels, due to several factors, including demographic changes and technological progress. At the same time, an epidemiological transition is occurring, characterized by a shift from diseases with an acute onset and a rapid resolution, to chronic-degenerative conditions which require more long-term care solutions. This shift seems to contribute to an increased life expectancy of the population, and a larger proportion of elderly individuals having complex health needs. The above described changes of the population structure, in combination with the current economic and financial crisis, require a redefinition of health system priorities at different levels, and the identification of specific intervention approaches. Today Primary Care is generally considered to have a key role in the progress of health systems and governments and international agencies, including the World Bank and the World Health Organisation have already increased investments and introduced reforms of Primary Care. However, there still remains much to be done, particularly with regards to the definition of specific aspects related to Primary Care. In this article the characteristics and developments of two main concepts, Primary Care (PC), which describes the delivery of Primary Care services, and Primary Health Care (PHC), which is more broadly defined by a level of governance or stewardship, are described. The distinction between PC and PHC implies the need for a characterization of system governance or stewardship, and of governance for care delivery. The first entails decision-making mechanisms for protecting the health both of individuals and of communities, by setting health, appropriateness and economic sustainability goals. These decisionmaking mechanisms further take into account the consequent responsibilities and risks compared to the achieved results toward citizens. The second relates to decision-making mechanisms for the delivery of services. Some examples are given of the application of system governance for primary healthcare at the national level and of characteristics of aggregations of professionals and/or structures for PC delivery. Finally, ideas and proposals for the development of an integrated approach for the delivery of Primary Care and prevention services, in a Public Health perspective are presented.

Knowledge and attitudes regarding sexually transmitted infections among healthcare workers.

BACKGROUND: Healthcare workers have a fundamental role in providing care and education on sexually transmitted infections (STIs). However, their knowledge is often worryingly limited. This study aimed to assess the real knowledge and attitude regarding STIs among healthcare workers of the IRCCS Ospedale Policlinico San Martino, Genoa, Italy. METHODS: The recruited subjects were asked to complete a 31-item questionnaire, divided into 3 sections: socio-demographic context, knowledge about STIs, and personal sexual behavior. RESULTS: We enrolled 140 subjects, employed as nurses (52.9%), physicians (12.9%), laboratory technicians (7.1%), or other workers (27.1%). Despite the generalized erroneous belief of having a good level of knowledge on the matter, only one-third of the subjects could correctly identify STIs among a list of diseases, and less than one-third correctly recognize all possible ways of transmission. Human immunodeficiency virus (HIV) was the most frequently recognized STI (97%), but only 39.2% of healthcare workers were correctly informed about the body fluids that can transmit the virus. Most participants (93.5%) correctly identified condoms as effective in preventing STIs but did not indicate complete abstinence as the only way to guarantee protection against STIs. Most participants were informed on the oncogenic potential of human papillomavirus (HPV) infections (82%), the usefulness of the Pap test (85.7%), and the existence of vaccines against some STIs (63.5%). CONCLUSIONS: Overall, healthcare workers have limited knowledge about STIs. Creating specific educational programs aimed at healthcare providers should become a priority.

Syndromic Surveillance in Public Health Emergencies: A Systematic Analysis of Cases Related to Exposure to 2023 Floodwaters in Romagna, Italy.

BACKGROUND: In May 2023, Romagna, Italy, faced a devastating flood resulting in 16 fatalities, forced displacement of 26,000 citizens, and significant economic losses. Due to potential water contamination, implementing public health strategies became imperative for the Local Health Authority to mitigate the health consequences, analyze the flood's impact on the local population's health, and detect early anomalies requiring timely public health interventions. METHODS: Between June and July 2023, general practitioners who were part of the RespiVirNet surveillance network completed weekly structured forms. These forms collected data on individuals exposed or not to floodwaters and clinical syndromes. Rates per 1000 resident population aged > 14 were stratified by district, week of observation, and symptomatology. Missing data were addressed by imputation using second-order autoregressive modeling. RESULTS: An incidence of 3.52 syndromes potentially related to flood water exposure per 1000 individuals (95% CI 2.82-4.35) was estimated. Ravenna, the city most affected by the flood, recorded the highest rate (6.05 per 1000, 95% CI 4.59-7.82). Incidence decreased in the weeks post-event. Anxiety, or trauma and stress symptoms, exhibited higher rates among the exposed, diminishing over weeks. The incidence for the non-exposed (12.76 per 1000, 95% CI 10.55-15.29) showed no significant territorial differences compared to the exposed ones. CONCLUSIONS: Syndromic surveillance provided timely information on the flood's health impact, revealing a higher incidence of individual syndromes among the non-exposed. This study contributes to guiding the implementation of future public health preparedness and response strategies for populations facing similar natural disasters.

Herpes Zoster Vaccine Uptake and Active Campaign Impact, a Multicenter Retrospective Study in Italy.

The Herpes Zoster (HZ) vaccination has proven both safe and effective in alleviating conditions related to HZ, leading to significant cost savings in national healthcare and social systems. In Italy, it is recommended and provided free of charge to individuals aged 65 and older. To achieve broad vaccination coverage, alongside ordinary immunization campaigns, active and catch-up campaigns were implemented. This retrospective observational study aimed to observe the vaccination coverage achieved in the Romagna Local Health Authority (LHA) during the 2023 active campaign, with a secondary goal of assessing the impact of the 2022 catch-up campaign and the 2023 active campaign compared to ordinary campaigns. As of 3 July 2023, an overall vaccine uptake of 13.5% was achieved among individuals born in 1958, with variations among the four LHA centers ranging from 10.2% to 17.7%. Catch-up and active campaigns together contributed to nearly half of the achieved coverage in Center No. 1 and a quarter in Center No. 2. Notably, individuals born in 1957, not included in the Center No. 2 catch-up campaign, reached significantly lower vaccination coverage compared to other cohorts and centers. Analyzing the use of text messages for active campaigns, it was observed that cohort groups did not show substantial differences in text-message utilization for warnings. However, having relatives who had experienced HZ-related symptoms significantly reduced the reliance on text messages as warnings. These results highlighted how catch-up and active campaigns effectively increased vaccine coverage. Nevertheless, differences in uptake among different centers within the same LHA and the limited contribution of other information sources compared to text messages suggest the necessity of designing campaigns involving all available channels and stakeholders to maximize vaccine uptake.

Impact of regional copayment policy on selective serotonin reuptake inhibitor (SSRI) consumption and expenditure in Italy.

PURPOSE: The continuous growth of antidepressant consumption and expenditure, especially for selective serotonin reuptake inhibitors (SSRIs), has led to the adoption of several policy measures directed toward cost control in Western countries. In Italy, copayment policies have been heterogeneously introduced at a regional level as part of a strategy designed to reduce drug consumption. The aim of our study was to evaluate whether regional copayment policies have affected trends in the consumption of and expenditure for SSRIs from 2001 to 2007. METHODS: The consumption of SSRIs was measured in terms of defined daily doses per 1,000 inhabitants (DDD/1000) per day from May 2001 to December 2007. Time trends in consumption and expenditure before and after the introduction of copayment policies were examined using segmented regression analysis of interrupted time-series, adjusting for seasonal components. The study was conducted for 17 regions, nine of which had implemented a copayment policy. RESULTS: The overall consumption of SSRIs in Italy increased during the study period, from a monthly consumption of 12.85 DDD/1000 per day in May 2001 to 23.40 DDD/1000 per day in December 2007. The average monthly increase in SSRI use was 0.82 % in regions with a copayment policy versus 0.77 % in regions without a copayment policy (P = 0.329). According to the multivariable analysis, copayment was associated with a 1 % reduction in the monthly growth rate of SSRI consumption (P = 0.01). The impact of copayment on expenditure was statistically significant (P < 0.005) on both the level and the trend, even though the estimate of the effect was negligible. CONCLUSIONS: The implementation of copayment policies in Italy affected both the use and expenditure of SSRIs between 2001 and 2007 to only to a minor extent.

Tuberculosis case finding based on symptom screening among immigrants, refugees and asylum seekers in Rome.

BACKGROUND: In Italy the proportion of cases of tuberculosis in persons originating from high-prevalence countries has been increasing in the last decade. We designed a study to assess adherence to and yield of a tuberculosis screening programme based on symptom screening conducted at primary care centres for regular and irregular immigrants and refugees/asylum seekers. METHODS: Presence of symptoms suggestive of active tuberculosis was investigated by verbal screening in migrants presenting for any medical condition to 3 free primary care centres in the province of Rome. Individuals reporting at least one symptom were referred to a tuberculosis clinic for diagnostic workup. RESULTS: Among 2142 migrants enrolled, 254 (11.9%) reported at least one symptom suggestive of active tuberculosis and 176 were referred to the tuberculosis clinic. Of them, 80 (45.4%) did not present for diagnostic evaluation. Tuberculosis was diagnosed in 7 individuals representing 0.33% of those screened and 7.3% of those evaluated for tuberculosis. CONCLUSION: The overall yield of this intervention was in the range reported for other tuberculosis screening programmes for migrants, although we recorded an unsatisfactory adherence to diagnostic workup. Possible advantages of this intervention include low cost and reduced burden of medical procedures for the screened population. Further evaluation of this approach appears to be warranted.

[Global Health: teaching approaches in Italian and foreign University Faculties of Medicine]. / Salute Globale: offerta formativa nelle facoltà di medicina italiane e straniere.

Global Health is an academic subject which focuses on the importance of social, economic, political, demographic and environmental determinants on health. This narrative review examines undergraduate and postgraduate teaching approaches to Global Health in the main Faculties of Medicine in Europe, America and Asia. Differences were found in contents, methods and general approaches to teaching medical students about Global Health in the faculties examined.

Adherence to Herpes Zoster (Shingles) Catch-Up Campaign at the Romagna Local Health Authority (Italy), a Multi-Center Retrospective Observational Study.

Herpes Zoster (shingles) is an infection that occurs when varicella-zoster virus reactivates from the latent state. Incidence and severity of Herpes Zoster disease increase with age. Antiviral drugs are the elective treatment; however, prevention of disease reactivation through effective and safe vaccines is available in Italy out-of-pocket from age 65 onwards. The Romagna Local Health Authority (northern Italy) administered catch-up vaccinations in March-May 2022 for immunizations not performed during the COVID-19 pandemic. In this study, adherence rates to the catch-up campaign and recall activities adopted in two centers were investigated. The uptakes for only the catch-up vaccinations were 11.4% and 12.4%. Having suffered from Herpes Zoster or having family members who suffered from it would not seem to be drivers of increased uptake. Although sending text-messages to all involved patients was the main motivation for vaccine uptake (85.7-95.1%), word of mouth and web/news advertising also contributed to adoption in Center No. 2. In both centers, the need for greater synergy between public health departments and general practitioners to engage their patients emerged, as did the need for additional recall measures. Studying the main drivers of vaccine hesitancy, especially at the local level, can help in targeting campaigns and catch-up activities in order to achieve widespread acceptance.

[Impact of the lockdown on children and families: a survey of family pediatricians within a community.] / Impatto del lockdown sui bambini e sulle famiglie: un'indagine dei pediatri di famiglia all'interno di una comunità.

OBJECTIVES: The recent lockdown, resulting from the SARS-CoV-2 pandemic, has had a strong social and psychological impact on the most fragile individuals and family structures. In the present work we investigated the experience of families without specific elements of social or health vulnerability during the quarantine period that occurred in the spring of 2020. MATERIALS AND METHODS: Between May and July 2020, 22 primary care pediatricians belonging to AUSL Romagna administered to a number of families a questionnaire to detect changes that occurred, during the lockdown, in family environment, school attendance and personal attitudes. RESULTS: A total of 721 questionnaires were collected, analyzing the associations between variables relating to home environment, daily rhythms, school and warning signs in relation to the age of children. As a result of the lockdown, family habits changed in 31% of cases, with a greater presence of the reference figure in 68% of these. Three out of four families reported they had sufficient domestic spaces, and nine out of ten had access to an outdoor, private or condominium space. Daily rhythms were preserved in 56.7% of cases; mood disorders appeared in 30% of adolescent children, followed by sleep, appetite and psychosomatic disorders. One in three children has made progress in terms of evolution and behavior, and one in 5 children has seen their relationships improve. The overall resilience of families during the lockdown period was considered good in 66.3%, sufficient in 31.3% and not satisfactory in only 2.4% of cases. CONCLUSIONS: Our data show that, in the interviewed families, the simultaneous presence of adults and children at home has generally intensified. Families refer, on the whole, a positive and resilient behavior in the lockdown period, even if initial emotional problems are reported in one out of three children-adolescents. The ability to maintain a family organized structure seems to be partially compromised. Forced cohabitation leads to competition for the same resources of time and space and affects the entire family unit. The school institution emerges as a protective factor for children, young people and also for the well-being of families themselves.

Influence of socioeconomic factors on hospital readmissions for heart failure and acute myocardial infarction in patients 65 years and older: evidence from a systematic review.

PURPOSE: Cardiovascular diseases are the leading cause of death and disability worldwide. Among these diseases, heart failure (HF) and acute myocardial infarction (AMI) are the most common causes of hospitalization. Therefore, readmission for HF and AMI is receiving increasing attention. Several socioeconomic factors could affect readmissions in this target group, and thus, a systematic review was conducted to identify the effect of socioeconomic factors on the risk for readmission in people aged 65 years and older with HF or AMI. METHODS: The search was carried out by querying an electronic database and hand searching. Studies with an association between the risk for readmission and at least one socioeconomic factor in patients aged 65 years or older who are affected by HF or AMI were included. A quality assessment was conducted independently by two reviewers. The agreement was quantified by Cohen's Kappa statistic. The outcomes of studies were categorized in the short-term and the long-term, according to the follow-up period of readmission. A positive association was reported if an increase in the risk for readmission among disadvantaged patients was found. A cumulative effect of socioeconomic factors was computed by considering the association for each study and the number of available studies. RESULTS: A total of eleven articles were included in the review. They were mainly published in the United States. All the articles analyzed patients who were hospitalized for HF, and four of them also analyzed patients with AMI. Seven studies (63.6%) were found for the short-term outcome, and four studies (36.4%) were found for the long-term outcome. For the short-term outcome, race/ethnicity and marital status showed a positive cumulative effect on the risk for readmission. Regarding the educational level of a patient, no effect was found. CONCLUSION: Among the socioeconomic factors, mainly race/ethnicity and marital status affect the risk for readmission in elderly people with HF or AMI. Multidisciplinary hospital-based quality initiatives, disease management, and care transition programs are a priority for health care systems to achieve better coordination.

Quality of dementia clinical guidelines and relevance to the care of older people with comorbidity: evidence from the literature.

PURPOSE: The aim of this paper was to explore the applicability of dementia clinical guidelines (CGs) to older patients, to patients with one or several comorbidities, and to both targets in order to evaluate if an association between the applicability and quality of the CGs exists. MATERIALS AND METHODS: A systematic search strategy conducted on electronic databases identified CGs on diagnosis and treatment of dementia published from 2000 to 2013. In addition, websites of organizations devoted to the treatment and awareness of dementia were searched. The quality of evidence was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. Two investigators independently scored the relevance of the CGs by means of a specific tool. Descriptive and inferential analyses were performed (Mann-Whitney test, 0.05 α-level). RESULTS: Twenty-two CGs met our inclusion criteria. On average, the quality of the CGs was higher than 70% in three of six domains measured by the AGREE tool. The domains with lower mean scores (less than 50%) were "Applicability" and "Editorial independence". Considering applicability to older patients, 20 CGs (91%) addressed issues of treatment for older patients, five of them (23%) classified older patients by age, and 13 CGs (60%) addressed issues of comorbidity. Only seven (32%) discussed the quality of evidence for patients with multiple comorbid conditions. Thirteen CGs (60%) reported recommendations for patients with at least one comorbid condition, while seven of them (32%) reported on several comorbid conditions. No statistically significant association between CG quality and relevance to care of older people with or without comorbidity was found (P>0.05). CONCLUSION: This study showed that dementia CGs poorly address treatment for older patients with comorbidities, regardless of their quality. Therefore, they scarcely satisfy the need of modern clinical practice.

Survey on knowledge, attitudes, and training needs of Italian residents on genetic tests for hereditary breast and colorectal cancer.

OBJECTIVES: The aim of the study was to assess knowledge and attitudes of medical residents working in Università Cattolica del Sacro Cuore, Rome, Italy, on genetic tests for breast and colorectal cancer. METHODS: We distributed self-administered questionnaire to the residents. Logistic regression models were used to evaluate the determinants of knowledge and attitudes towards the tests. RESULTS: Of 754 residents, 364 filled in questionnaire. Around 70% and 20% answered correctly >80% of questions on breast and colorectal cancer tests, respectively. Knowledge on tests for breast cancer was higher among residents who attended course on cancer genetic testing during graduate training (odds ratio (OR): 1.72; 95% confidence interval (CI): 1.05-2.82) and inversely associated with male gender (OR: 0.55; 95% CI: 0.35-0.87). As for colorectal cancer, residents were more knowledgeable if they attended courses on cancer genetic testing (OR: 2.08; 95% CI: 1.07-4.03) or postgraduate training courses in epidemiology and evidence-based medicine (OR: 1.95; 95% CI: 1.03-3.69). More than 70% asked for the additional training on the genetic tests for cancer during the specialization school. CONCLUSION: The knowledge of Italian residents on genetic tests for colorectal cancer appears to be insufficient. There is a need for additional training in this field.

A systematic review on the effectiveness of group versus single-handed practice.

BACKGROUND: Since the 1970s, many countries have employed the use of the General practitioner group practice, but there is contrasting evidence about its effectiveness. A systematic review was performed to assess whether group practice has a more positive impact compared with the single-handed practice on different aspects of health care. METHODS: A systematic review was conducted by querying electronic databases and reviewing articles published between 1990 and 2012. A quality assessment was performed. The effect of group practice was evaluated by collecting all items analysed by the articles into four main categories: (1) studies of quality (measured in terms of clinical processes) and productivity (measured in terms of throughput), named "Clinical process measures and throughput"; (2) studies exploring physician's opinion--"Doctor's perspective"; (3) studies looking into the use of innovation, information and communication technology (ICT) and quality assurance--"Innovation, ICT and quality assurance"; (4) studies focused on patient's opinion--"Patient's perspective". The results were synthesized according to three levels of scientific evidence. RESULTS: A total of 26 studies were selected. The most studied category was Clinical process measures and throughput (58%). A positive impact of group medicine on "Clinical process measures and throughput", "Doctor's perspective", "Innovation, ICT and quality assurance" was found. There was contrasting evidence considering the "Patient's perspective". CONCLUSIONS: Group practice might be a successful organizational requirement to improve the quality of clinical practice in Primary Health Care. Further comparative studies are needed to investigate the impact of organizational and professional determinants such as physician's economic incentives, mode of payment, size of the groups and multispecialty on the effectiveness of medical primary care.