1. 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

2. 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

3. Emilia-Romagna LHU of Bologna Example:

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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 questionnaire 114 questions, many administered to specific subpopulations (e.g. cancer screening) or categories (e.g. present smokers)

10. 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

11. 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 rate12% Refusal rate 9% Not found 3%

12. A short glimpse into the results

13. 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

14. Respect of the smoking ban in public places Pooled 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

15. BMI, Overweight and obese Pooled data - 2008 (n=37.560) BMI >25

16. 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

17. Pap-smear during the last 3 years (%) Women 25-64 (PASSI 2008) 75% (n. 15.531) Range: 48% Sardegna - 91% Valle dAosta

18. Pool PASSI 75% (n. 15.531) Range: 48% Sardegna - 91% Valle dAosta Pap test negli ultimi 3 anni per Regione (%) donne 25-64enni (PASSI 2008)

19. Pap test negli ultimi 3 anni per Azienda (%) donne 25-64enni (PASSI 2008) 86% (n. 1.549) Range: 79% Piacenza - 91% Reggio Emilia

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

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

22. 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

23. 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)

24. 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…

25. 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

26. 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 site 15 issues already published PASSI on the Internet

27. 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

28. 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+)

29. 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 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 Zadigroma Eva BENELLI, Stefano MENNA The PASSI Coordinating Group at national level

30. Extra slides

31. 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

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