The Italian Behavioral Risk Factor Surveillance System PASSI

The Italian Behavioral Risk Factor Surveillance System – PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia) www. epicentro. iss. it/passi Pirous Fateh-Moghadam for the PASSI Coordinating Group National Centre for Epidemiology, Surveillance and Health Promotion

Background • 57 million inhabitants • 21 regions • Universal health care and preventive services – Local Health Units (LHU) § 1 unit per 300, 000 residents (100, 000 – 1, 000) – Regional health authorities § Interpretation/adaptation of national guidelines (national health plans)

Example: Emilia-Romagna LHU of Bologna Data collection, analyses and dissemination of results are based on LHU level (and on regional level as well)

A system able to: – Collect useful and representative data on health behaviors at LHU level – Provide timely feedback planning and evaluation of programs/interventions – Facilitate comparisons between LHU/regions identify best practices – Permit comparisons with international data – Last but not least: • Promote the professional development of local and regional staff • Increase the use of epidemiological data at local level

PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia) • 2005 and 2006: – Two pilot cross-sectional studies testing materials and methods for the future implementation of a surveillance system – Knowledge shared by CDC/BRFSS and other international experts was very useful in setting up the system • In 2006 the Mo. H funded the National Centre for Epidemiology, Surveillance and Health Promotion (CNESPS) to develop ongoing surveillance of behavioral risk factors and preventive measures included in the National Prevention Plan

Method • Since 2007 ongoing (monthly) data collection in each participating LHU: – telephone interviews of at least 275 persons/year/LHU – Interviewers: LHU personnel using a standardized questionnaire (questions adapted from BRFSS, Cindi, Steps, ISTAT comparisons) • Participants selected from LHU population registers using stratified random sampling • Inclusion criteria: age 18 -69, residence in catchment area, availability of telephone number (mobile or land-line, obtained through various sources)

The questionnaire 114 questions, many administered to specific subpopulations (e. g. cancer screening) or categories (e. g. present smokers) Topics included: priorities of the National Health Plan • quality of life • smoking habits • physical activity • diet • alcohol consumption • driving behavior • cardiovascular risk factors • cancer screening • vaccinations • mental health • domestic accidents • socio-demographic aspects

Not only behaviours… • Public health interventions – Screening programmes – Counselling by general practitioners – Optional modules on: • Police interventions for drunk drivers • Evaluation of special health promotions programmes implemented at regional level (“Genitori più”) • Diabetes • Work place safety • H 1 N 1 Influenza • Importance of social determinants of health: – All risk factors/compliance with public health programmes are broken down by • Income • Education

Data collection (2007 -2009) • 21/21 Regions have begun data collection since April 2007, though not all at the same time • Health personnel involved and trained: ~ 1. 000 • Complete interviews: ~ 96, 000 – 21, 996 in 2007 – 37, 560 in 2008 – 36, 016 in 2009 (preliminary) • 2009: – Response rate: – Substitution rate • Refusal rate • Not found 88% 12% 9% 3%

A short glimpse into the results:

Respect of the smoking ban in public places LHU, Trentino 2009 (n=736) • Italian smoking ban: – Went into effect in jan/2005 – Covers all enclosed public places • In Trentino the compliance with the law is very good. 94% of the interviewed people reported that the ban is always or almost always respected

Respect of the smoking ban in public places Pooled data – 2009 (n=36. 016) • Compliance in Trentino is higher compared to the pooled data (respect always/almost always: 86%) • The respect of the law decreases going from north to south

Trends over time Smokers (%) • the ongoing (monthly) data collection offers the possibility to compare annual prevalences… Passi – Trentino – 2007 -2009 Monthly distribution of percentages of smokers age 18 -69 Piemonte 2007 -09 (%) 2007 2008 2009 • … and to perform time series analyses as well

Pap smear within the last 3 years per region (%) women age 25 -64 (PASSI 2008) Pool PASSI 75% (n. 15. 531) Range: 48% Sardegna - 91% Valle d’Aosta

Pap smear within the last 3 years per local health unit (%) - women age 25 -64 (PASSI 2008) 86% (n. 1. 549) Range: 79% Piacenza - 91% Reggio Emilia

- - - Cases of H 1 N 1 per 1. 000 Emergency module on H 1 N 1 • Think it is likely to have flu cases in family • Is worried about H 1 N 1 • Limits his/her activities in daly life because of H 1 N 1 • Willing to get vaccinated

Data use • Health profiles and prioritization processes • Intervention planning and evaluation – National and regional prevention plan – Local intervention planning • Dissemination of results (reports & fact sheets on specific issues, scientific articles)

Sustainability • National and regional public health authorities are embedding surveillance issues in the main Italian frameworks on prevention of chronic diseases – National and Regional Prevention Plans – Gaining Health • Since Passi does not use call centers the motivation of the interviewers and supervisers is paramount – Economic benefits (only in some regions) – Passi as a means of professional growth…

Integration of data on behavioural risk factors • OKkio (repeated survey) – Overweight, obesity and physical activity of school-children (elementary school) • HBSC (repeated survey) – Adolescence • PASSI (ongoing monitoring) – Adults (18 -69) • PASSI d’Argento (repeated survey) – Elderly people (65+)

The PASSI Coordinating Group at national level Centro nazionale di epidemiologia, sorveglianza e promozione della salute (CNESPS), Istituto Superiore di Sanità, Roma Sandro BALDISSERA, Paolo D’ARGENIO, Barbara DE MEI, Gigi FERRANTE, Valentina MINARDI, Alberto PERRA, Valentina POSSENTI, Elisa QUARCHIONI, Stefania SALMASO Dipartimento di sanità pubblica, Azienda USL di Cesena Nicoletta BERTOZZI Dipartimento di Statistica, Università degli studi Ca’ Foscari, Venezia Stefano CAMPOSTRINI Dipartimento di sanità pubblica, AUSL Modena Giuliano CARROZZI Direzione generale della prevenzione sanitaria, Dipartimento prevenzione e comunicazione, Ministero della salute, Roma Stefania VASSELLI Dipartimento di prevenzione, ASL Caserta 2 Angelo D’ARGENZIO Direzione promozione della salute, Azienda provinciale per i servizi sanitari, Trento Pirous FATEH–MOGHADAM Ufficio di statistica, Istituto superiore di sanità, Roma Giada MINELLI Dipartimento prevenzione AUSL Roma C Massimo O. TRINITO Zadig Eva BENELLI, Stefano MENNA

Extra slides

Data on health behaviours • Collected by National Institute of Statistics (ISTAT) with several limitations: – – quinquennial surveys national and regional level delay in dissemination of data items included not always useful for public health planning and evaluation lack of data on health behaviour at LHU level, where many health interventions are planned and

Gaining Health 86% of deaths and 77% of the disease burden in the WHO European Region are caused by non-communicable diseases Gaining Health is the European strategy to tackle the most important behavioral risk factors linked to this group of disorders Guadagnare Salute In 2007 the Italian Ministry of Health (Mo. H) approved the programme “Guadagnare Salute”, designed to improve the quality of life and well-being of people through health promotion

A national system, a local implementation All 21 Italian Regions agreed to participate Emilia-Romagna PASSI is focused on Italy’s 180+ Local Health Units (LHU) LHU of Bologna

The technological infrastructure of PASSI: an innovative system using free and open-source software • e-Passi: a web-based infrastructure to collect, centralize and analyze data • Because of technological heterogeneity among local health units and variable technical capacities among users, the infrastructure must be flexible, user-friendly, and independent of local hardware and software installations • A smart client application that uses a readily-available internet browser for: – stand-alone functions for data entry and real-time record saving (XML format) on interviewers’ computers – interview tracking (assignment, current status) – CATI-like data entry – automatic and secure (SSL) upload of completed interviews Source: Paolo Brunetti, Gabriele Dallago, Steno Fontanari, Stefano Menegon

BMI, Overweight and obese Pooled data - 2008 (n=37. 560) BMI >25

Seat belt and helmet use Seat belt use - front seat (%) Pool PASSI 2008 Seat belt use – back seat (%) Pool PASSI 2008 Helmet use (%) Pool PASSI 2008

Pap-smear during the last 3 years (%) Women 25 -64 (PASSI 2008) 75% (n. 15. 531) Range: 48% Sardegna - 91% Valle d’Aosta

Pap smear: organized screening programmes vs. spontaneous screening (PASSI 2008) Regions with organized screening 82% respects the recommended time limit Regions without organized screening 69% respects the recommended time limit

Trends over time: FOBT in Emilia-Romagna Soglia di desiderabilità Soglia di accettabilità %

Training plan • Promoting the professional development of local and regional staff is one of the main objectives of the project • Training activities: 1) short courses for the start-up of the system – stepwise process involving regional and local coordinators and interviewers – completed in all Regions 2) two year cycle of courses and supervised activities on surveillance systems, communication, and public health interventions leading to a Master’s degree in Epidemiology and Surveillance (in cooperation with Tor Vergata University, Rome) 3) Ongoing annual training programmes on national, regional and local level

PASSI on the Internet The web site offers news, documentation and other services for the network and the public health community (forums, www. epicentro. iss. it/passi material for training activities, etc. ) PASSI-one: a monthly newsletter for the surveillance network, in electronic format, freely downloadable from the web site 15 issues already published

Under construction • Data analyses (2009) on regional and local level: – Epi-info programme codes – Blue-print of reports • Release of dataset 2007 -2009 possibility of subgroup and trend analyses • Development of web-site for interactive data interrogation • More scientific pubblications on international journals Delivered to Regions&LHU by coordinating group