The Italian Behavioral Risk Factor Surveillance System – PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia) Pirous.

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 – 1,000,000)

– Stewardship: interpretation of national guidelines (national health plans) by regional health authorities

Emilia-Romagna

LHU of Bologna

Example:

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 (sometimes) evaluated

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 experts was very useful in setting up the system

• In 2006 the MoH 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

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

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 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

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

The questionnaire114 questions, many administered to specific subpopulations (e.g. cancer screening) or categories (e.g. present smokers)

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• H1N1 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: 88%– Substitution rate 12%

• Refusal rate 9%• Not found 3%

A short glimpse into the results

Respect of the smoking ban in public places LHU, Trentino 2008 (n=715)

• Italian smoking ban:– Went into effect in jan/2005– Covers all enclosed public

places

• In Trentino the compliance with the law is very good. 96% of the interviewed people reported that the ban is always or almost always respected

82

143 1

0

20

40

60

80

100

Alwaysrespected

Almostalways

respected

Sometimesrespected

Neverrespected

Respect of the smoking ban in public placesPooled data – 2008 (n=37.560)

• Compliance in Trentino is higher compared to the pooled data (respect always/almost always: 87%)

• The respect of the law decreases going from north to south

BMI, Overweight and obese Pooled data - 2008 (n=37.560)

3

55

32

10

0

10

20

30

40

50

60

70

Underweight Normalweight

Overweight Obese

%

BMI >25

Seat belt and helmet useSeat belt use – back

seat (%)Pool PASSI 2008

Seat belt use - front seat (%) Pool PASSI 2008

Helmet use (%) Pool PASSI 2008

Pap-smear during the last 3 years (%)Women 25-64 (PASSI 2008)

84 - 9180 - 8466 - 8048 - 66No dati

Valori %

75% (n. 15.531)Range: 48% Sardegna - 91% Valle d’Aosta

0 20 40 60 80 100

sardegnapuglia

campaniabasilicata

siciliaabruzzomolise

poolmarche

laziolombardia

liguriatrento

umbriapiemontetoscanaveneto

ERFVG

bolzanovalle d’aosta

% Pool PASSI 75% (n. 15.531)Range: 48% Sardegna - 91% Valle d’Aosta

Pap test negli ultimi 3 anni per Regione (%)donne 25-64enni (PASSI 2008)

_ _ Copertura Desiderabile 80%

….. Copertura Accettabile 65%

0

20

40

60

80

100

Re Ce Fe Ra ER Mo Rn Bo+Im Fo Pr Pc

%

Pap test negli ultimi 3 anni per Azienda (%)donne 25-64enni (PASSI 2008)

86% (n. 1.549)Range: 79% Piacenza - 91% Reggio Emilia

Pap smear: organized screening programmes vs. spontaneous screening

(PASSI 2008)

9%

9%

37%

45%

0 10 20 30 40 50

Never

more than 3 years ago

1-3 years ago

within the last 12months

82% respects the recommended time limit

69% respects the recommended time limit

Regions with organized screening

19%

12%

27%

42%

0 10 20 30 40 50

Never

more than 3 years ago

1-3 years ago

within the last 12months

Regions without organized screening

Trends over time: FOBT in Emilia-Romagna

%

5

28

4854

0

20

40

60

80

Passi 2005 Passi 2006 Passi 2007 Passi 2008 - Isemestre

Soglia di accettabilità

Soglia di desiderabilità

Emergency module on H1N1

• Think it is likely

to have flu cases

in family

• Is worried about

H1N1

• Limits his/her

activities in daly

life because of

H1N1

• Willing to get

vaccinated

- -

- C

ase

s of

H1

N1

per

1.0

00

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)

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…

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

The web site offers news, documentation and other services for the network and the public health community (forums, material for training activities, etc.) www.epicentro.iss.it/passi

PASSI-one: a monthly newsletter for the surveillance network, in electronic format, freely downloadable from the web site15 issues already published

PASSI on the Internet

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

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+)

Centro nazionale di epidemiologia, sorveglianza e promozione della salute (CNESPS), Istituto Superiore di Sanità, RomaSandro BALDISSERA, Nancy BINKIN, Barbara DE MEI, Gabriele FONTANA,Valentina MINARDI, Alberto PERRA, Valentina POSSENTI, Stefania SALMASO

Dipartimento di sanità pubblica, Azienda USL di CesenaNicoletta BERTOZZI

Dipartimento di Statistica, Università degli studi Ca’ Foscari, VeneziaStefano CAMPOSTRINI

Dipartimento di sanità pubblica, AUSL ModenaGiuliano CARROZZI

Direzione generale della prevenzione sanitaria, Dipartimento prevenzione e comunicazione, Ministero della salute, RomaPaolo D’ARGENIO, Stefania VASSELLI

Dipartimento di prevenzione, ASL Caserta 2Angelo D’ARGENZIO

Direzione promozione della salute, Azienda provinciale per i servizi sanitari, TrentoPirous FATEH–MOGHADAM

Ufficio di statistica, Istituto superiore di sanità, RomaGiada MINELLI

Dipartimento prevenzione AUSL Roma CMassimo O. TRINITO

ZadigromaEva BENELLI, Stefano MENNA

The PASSI Coordinating Group at national level

Extra slides

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 (MoH) approved the programme “Guadagnare Salute”, designed to improve the quality of life and well-being of people through health promotion

All 21 Italian Regions agreed to participate

A national system, a local implementation

Emilia-Romagna PASSI is focused on Italy’s 180+ Local Health Units (LHU)

LHU of Bologna