The Italian Behavioral Risk Factor Surveillance System

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The Italian Behavioral Risk Factor Surveillance
System PASSI(Progressi delle Aziende Sanitarie
per la Salute in Italia)www.epicentro.iss.it/pass
i

• Pirous Fateh-Moghadam
• for the PASSI Coordinating Group
• National Centre for Epidemiology, Surveillance
  and Health Promotion

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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

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Example
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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

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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

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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

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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)

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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
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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

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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

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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

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A short glimpse into the results
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Respect of the smoking ban in public places LHU,
Trentino 2008 (n715)

• 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

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Respect of the smoking ban in public
placesPooled data 2008 (n37.560)

• 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

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BMI, Overweight and obese Pooled data - 2008
(n37.560)
BMI gt25
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Seat belt and helmet use
Seat belt use back seat () Pool PASSI 2008
Seat belt use - front seat () Pool PASSI 2008
Helmet use () Pool PASSI 2008
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Pap-smear during the last 3 years ()Women
25-64 (PASSI 2008)
75 (n. 15.531) Range 48 Sardegna - 91 Valle
dAosta
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Pap test negli ultimi 3 anni per Regione
()donne 25-64enni (PASSI 2008)
Pool PASSI 75 (n. 15.531) Range 48 Sardegna -
91 Valle dAosta
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Pap test negli ultimi 3 anni per Azienda
()donne 25-64enni (PASSI 2008)
86 (n. 1.549) Range 79 Piacenza - 91 Reggio
Emilia
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Pap smear organized screening programmes vs.
spontaneous screening (PASSI 2008)
Regions with organized screening
Regions without organized screening
82 respects the recommended time limit
69 respects the recommended time limit
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Trends over time FOBT in Emilia-Romagna
Soglia di desiderabilità

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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

- - - Cases of H1N1 per 1.000
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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)

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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

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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 Masters degree in Epidemiology and
  Surveillance (in cooperation with Tor Vergata
  University, Rome)
• 3) Ongoing annual training programmes on
  national, regional and local level

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PASSI on the Internet
The web site offers news, documentation and other
services for the network and the public health
community (forums, material for training
activities, etc.)
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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 RegionsLHU by coordinating group
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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 dArgento (repeated survey)
• Elderly people (65)

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The PASSI Coordinating Group at national level

• Centro nazionale di epidemiologia, sorveglianza e
  promozione della salute (CNESPS), Istituto
  Superiore di Sanità, Roma
• Sandro BALDISSERA, Nancy BINKIN, Barbara DE MEI,
  Gabriele FONTANA,
• Valentina MINARDI, Alberto PERRA, Valentina
  POSSENTI, 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
• Paolo DARGENIO, Stefania VASSELLI
• Dipartimento di prevenzione, ASL Caserta 2
• Angelo DARGENZIO

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Extra slides
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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
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A national system, a local implementation
All 21 Italian Regions agreed to participate
PASSI is focused on Italys 180 Local Health
Units (LHU)