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Background: Since the use of medicines is strongly correlated to population health needs, higher drug consumption is expected in socio-economical deprived areas. However, no systematic study investigated the relationship between medications use in the treatment of chronic diseases and the socioeconomic position of patients. The purpose of the study is to provide a description, both at national level and with geographical detail, of the use of medicines, in terms of consumption, adherence and persistence, for the treatment of major chronic diseases in groups of population with different level of socioeconomic position. Methods: A cross-sectional study design was used to define the "prevalent" users during 2018. A longitudinal cohort study design was performed for each chronic disease in new drug users, in 2018 and the following year. A retrospective population-based study, considering all adult Italian residents (i.e. around 50.7 million people aged ≥ 18 years). Different medications were used as a proxy for underlying chronic diseases: hypertension, dyslipidemia, osteoporosis, diabetes and chronic obstructive pulmonary disease. Only "chronic" patients who had at least 2 prescriptions within the same subgroup of drugs or specific medications during the year were selected for the analysis. A multidimensional measures of socio-economic position, declined in a national deprivation index at the municipality level, was used to identify and estimate the relationship with drug use indicators. The medicine consumption rate for each pharmacological category was estimated for prevalent users while adherence and persistence to pharmacologic therapy at 12 months were evaluated for new users. Results: The results highlighted how the socioeconomic deprivation is strongly correlated with the use of medicines: after adjustment by deprivation index, the drug consumption rates decreased, mainly in the most disadvantaged areas, where consumption levels are on average higher than in other areas. On the other hand, the adherence and persistence indicators did not show the same trend. Conclusions: This study showed that drug consumption is influenced by the level of deprivation consistently with the distribution of diseases. For this reason, the main levers on which it is necessary to act to reduce disparities in health status are mainly related to prevention. Moreover, it is worth pointing out that the use of a municipal deprivation indicator necessarily generates an ecological bias, however, the experience of the present study, which for the first-time deals with the complex and delicate issue of equity in Italian pharmaceutical assistance, sets the stage for new insights that could overcome the limits. [ABSTRACT FROM AUTHOR]

Country of origin might affect vaccine uptake in children born to immigrants. We aimed to evaluate differences in childhood vaccination coverage (VC) and timeliness by macro-area of origin of foreign mothers residing in Italy. Multicentre retrospective birth cohorts. We analysed data of 23,287 children born in 2009–2014 to foreign women in the cities of Rome, Turin and Treviso. We retrieved data through record-linkage of the population, vaccination and birth registries. We estimated VCs at different ages for vaccines against tetanus, measles and meningococcal group-C, using the Kaplan–Meier method. Factors associated with vaccine uptake were evaluated using multilevel Poisson models. Estimates of VC at any age and for all antigens were significantly lower in children born to women from Asia and higher in children born to women from Africa, as compared to other macro-areas. Similar differences by area of origin were observed for timeliness; independently of mother's sociodemographic characteristics and neonatal outcomes, the probability of delay vaccination after 2 years of age for each antigen was highest in children born to women from Asia. The risk of missed vaccination for all antigens was significantly higher in children born to younger and unemployed women. Factors related to area of origin (e.g., cultural habits, language skills) are likely to affect parents' decision to vaccinate their children. These factors, as well as sociodemographic characteristics, should be adequately investigated and addressed to increase vaccine uptake in foreign children, especially those born to Asian women. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVE: To evaluate the independent and mutual effects of neighbourhood deprivation and of individual socioeconomic conditions on mortality and to assess the trends over the past 30 years and the residual neighbourhood heterogeneity. DESIGN: General and cause specific mortality was analysed as a function of time period, highest educational level achieved, housing conditions, and neighbourhood deprivation, using multilevel Poisson models stratified by gender and age class. SETTING: The study was conducted in Turin, a city in north west Italy with nearly one million inhabitants and consisting of 23 neighbourhoods. PARTICIPANTS: The study population included three cohorts of persons aged 15 years or older, recorded in the censuses of 1971, 1981, and 1991 and followed up for 10 years after each census. MAIN RESULTS: Individual and contextual socioeconomic conditions showed an independent and significant impact on mortality, both among men and women, with significantly higher risks for coronary heart and respiratory diseases among people, aged less than 65 years, residing in deprived neighbourhoods (9% and 15% excess for coronary heart diseases, 20% and 24% for respiratory diseases, respectively for men and women living in deprived neighbourhoods compared with rich). The decreasing time trend in general mortality was less pronounced among men with lower education and poorer housing conditions, compared with their more advantaged counterparts; the same was found in less educated women aged less than 65 years. CONCLUSIONS: These results and further developments in the evaluation of impact and mechanisms of other contextual effects can provide information for both health and non-health oriented urban policies. [ABSTRACT FROM AUTHOR]

Italy is a destination country for a growing international migration, accounting for 8.4% of the total population. The COVID-19 pandemic has increased the difficulties in accessing healthcare services among immigrants, and barriers due to linguistic and cultural differences had a significant impact during the pandemic. This paper presents the methodology used in the project 'Epidemiological surveillance and control of COVID-19 in metropolitan urban areas for the containment of SARS-CoV-2 circulation in the immigrant population in Italy', carried out with the technical and financial support of the Italian Ministry of Health. This methodology is aimed to identify and select statements available in the literature, transferable to the Italian context, on the topic of interventions deemed useful in reducing the impact of the COVID-19 pandemic on the foreign population in urban/metropolitan settings.In February 2022, a systematic search was conducted in databases such as Medline, Embase, and Web of Science, as well as on national and international websites (WHO, Italian Institute of Health, and CDC), and on 'RecMap' (included in the 'COVID19 Recommendations' website) to identify guidelines containing recommendations on the management and prevention of COVID-19 among immigrants. The selected recommendations were divided into intervention areas (infection control, vaccination, screening, planning and monitoring, healthcare systems). In the first phase, a group of researchers independently assessed the inclusion of recommendations through three rounds of consensus. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess the quality of the included guidelines. In the second phase, an external group of experts independently evaluated the relevance of the included recommendations using a Likert scale. The document is the result of a collaborative work based on evidence from the literature available until that time. The adaptation and adoption of recommendations already formulated by other international organizations on the topic of preparedness and response to the COVID-19 pandemic, evaluated through a consensus process with experts, can be a valid method aimed at producing documents to inform and guide those involved in the care of immigrants in Italy, as well as promoting inclusive forms of prevention in emergency contexts.

Objectives: to describe indicators, data sources, and levels of geographical stratification used within the framework of the CCM project "Epidemiological Surveillance and Control of COVID-19 in Metropolitan Urban Areas and for the containment of SARS-CoV-2 circulation in the immigrant population in Italy"., Design: population-based observational study based on data from the Integrated Covid-19 Surveillance System and the archive of hospital discharge records., Setting and Participants: interregional collaborative project. Resident population in 5 Italian Regions (Piedmont, Emilia-Romagna, Tuscany, Lazio, and Sicily)., Main Outcomes Measures: crude and age-standardized rates of diagnostic test utilization and positivity, hospitalization (in any department and in intensive care unit), and mortality in COVID-19 cases., Results: starting from the set of 11 indicators from the Italian National Institute for Health, Migration and Poverty (INMP) project "Epidemiology of SARS-CoV-2 Infection (COVID-19) and Use of Health Services in the Immigrant Population and Vulnerable Population Groups in Italy", the five most effective indicators for CCM purposes were identified. The INMP project highlighted higher rates of test access and positivity among Italians compared to foreigners, higher standardized hospitalization rates among foreigners, and higher standardized mortality rates among Italians, with geographical and temporal heterogeneity. The intersection between the DEGURBA (degree of urbanisation) classification and altimetric zones defined five levels of territorial stratification characterized by decreasing population density. Approximately 81% of the population involved in the CCM project resided in the first two levels; 43% of Italians lived in areas with intermediate population density in hilly or plain areas, while 48% of foreigners were concentrated in densely populated areas., Conclusions: sharing the collaborative approach and a research methodology already tested, integrated with the analysis of disaggregated indicators by morphological, functional, and administrative characteristics of the residential territory, allowed for assessing differences in the impact of the pandemic between Italians and foreigners residing in more or less densely populated areas.

Background: according to the literature, socially disadvantaged strata of the population, including immigrants, have been more vulnerable to the risk of SARS-CoV-2 infection due to greater exposure and less opportunity to protect themselves, and to COVID-19 complications due to metabolic and clinical risk factors as well as to healthcare access barriers. Two Italian projects - coordinated by the Italian National Institute for Health, Migration and Poverty and the Italian National Centre for Disease Prevention and Control - set up an epidemiological surveillance to monitor the temporal trends of the SARS-CoV-2 pandemic in five Italian regions using validated indicators., Objectives: to identify differences between Italians and immigrants in terms of the epidemic evolution and its health consequences, and to investigate possible differences by urbanisation degree and region of residence., Design: cross sectional study., Setting and Participants: resident population in five Italian regions: Piedmont, Emilia-Romagna, Tuscany, Lazio, and Sicily., Main Outcomes Measures: frequencies of positive tests, routine hospitalisations, and deaths related to COVID-19 were collected, with respect to the period between 22.02.2020 and 31.01.2021. Data were aggregated by week, region, degree of urbanisation, gender, age (5-year classes), and citizenship (Italian/foreigner). Crude and standardised rates of the outcomes considered were calculated, stratified by gender, citizenship, region, and aggregated by pandemic macro-period., Results: the study population counts approximately about 23 million residents as of 01.01.2020 (9.4% immigrants). During the period of interest, 1,542,458 cases of infection were recorded, whereas hospitalisations amounted to 175,979, and deaths to 44,867. Lower crude rates of hospitalisations and deaths were observed among immigrants compared to Italians. The age-standardised hospitalisation rates, on the other hand, showed an opposite trend and were significantly higher among immigrants, due to the excess observed in urban areas, especially in periods of epidemic peak, both for males (weekly mean standardised rate: 34.6 per 1,000 of foreign residents vs 24.3 of Italians over the period October 2020-January 2021) and females (23.2 vs 15.1 over the period February-April 2021). These differences seem to be more pronounced in the central regions and tend to disappear for residents in scarcely populated areas. Standardised mortality rates were higher among immigrants, both men and women, from October 2020 and more markedly in February-April 2021 among men., Conclusions: the impact of COVID-19 was stronger among immigrants in relation to hospitalisation, especially during epidemic peak periods and in some regions. The difference in the impact on mortality was smaller. There is some heterogeneity among regions and urban areas that is worth considering in the planning of interventions and integration policies.

Background: the COVID-19 pandemic had important effects on people's health and socioeconomic conditions. Health surveillance systems fail to provide an adequate epidemiological profile of the pandemic in the recently immigrated population. In Piedmont and Emilia-Romagna Region (Northern Italy), a study was conducted in the public and private structures dedicated to the reception of migrants,Objectives: to evaluate the impact of the epidemic on the migrant population assisted in local reception centres., Design: quantitative analysis based on data collected in reception centres; qualitative analysis which, through 10 focus groups and 35 interviews with operators and migrants, investigated the consequences of the pandemic, their mechanisms, and their explanations., Setting and Participants: users and operators of reception services for migrants in the cities of Turin (Piedmont) and Bologna (Emilia-Romagna)., Main Outcomes Measures: quantitative analysis: access to services, prevalence of diseases, prevalence of test positivity; qualitative analysis: spread of the virus, organization of services, perceived critical issues and needs, solutions adopted, information received, perceived impact on health, perceived impact on social determinants., Results: a varied picture emerges. The few data available do not show a greater incidence and severity of the virus compared to the Italian population, despite strong elements of risk linked to precarious living and working conditions being reported. Reception services have implemented more flexible organizational methods, with effective prevention measures. The interruption of care pathways has led to the flare-up of previous pathologies, but getting in touch with services for the pandemic control has also allowed diagnosis and management of unknown diseases. Uncertainty, fear, social withdrawal, and crisis of the migratory project have increased mental disorders., Conclusions: in this scenario, close collaboration between public and third sector structures has proved fundamental and must be strengthened to overcome access barriers and make services more inclusive and equitable. It is also necessary to develop information systems capable of monitoring the health needs of this 'invisible' population.

Background: The COVID-19 pandemic has had, and still has, a profound impact on national health systems, altering trajectories of care and exacerbating existing inequalities in health. Postponement of surgeries and cancellation of elective surgical procedures have been reported worldwide. In Italy, the lock-down measures following the COVID-19 pandemic caused cancellations of surgical procedures and important backlogs; little is known about potential social inequalities in the recovery process that occurred during the post-lockdown period. This study aims at evaluating whether all population social strata benefited equally from the surgical volumes' recovery in four large Italian regions., Methods: This multicentre cohort study covers a population of approximately 11 million people. To assess if social inequalities exist in the recovery of eight indicators of elective and oncological surgery, we estimated Risk Ratios (RR) through Poisson models, comparing the incidence proportions of events recorded during COVID-19 (2020-21) with those in pre-pandemic years (2018-19) for each pandemic period and educational level., Results: Compared to 2018-19, volumes of elective surgery showed a U-shape with the most significant drops during the second wave or the vaccination phase. The recovery was socially unequal. At the end of 2021, incidence proportions among highly educated people generally exceeded the expected ones; RRs were 1.31 (95%CI 1.21-1.42), 1.24 (95%CI 1.17-1.23), 1.17 (95%CI 1.08-1.26) for knee and hip replacement and prostatic surgery, respectively. Among low educated patients, RR remained always < 1. Oncological surgery indicators showed a similar social gradient. Whereas volumes were preserved among the highly educated, the low educated were still lagging behind at the end of 2021., Conclusions: Surgical procedures generally returned to pre-pandemic levels but the low educated experienced the slowest recovery. An equity-oriented appraisal of trends in healthcare provision should be included in pandemic preparedness plans, to ensure that social inequalities are promptly recognised and tackled., (© 2024. The Author(s).)

The term Headache Disorders (HD) refers to a number of nervous system pathologies characterised by recurrent headaches. Despite the serious impact HD have on the health system, society, and the economy, these are an underestimated, underdiagnosed, and, hence, undertreated phenomenon. Triptans are the first-line therapy for the acute treatment of moderate to severe migraine but their utilization is still inadequate, perhaps also because in Italy no triptan can be bought without a medical prescription. In this article, the data from a 2016-2017 study has been further analysed with the aim of evaluating any associations between the use of triptans and the other series of variables identified in the questionnaire. This further analysis has been connected to the role that community pharmacies could play on this issue. The questionnaire was administered to 4,424 pharmacy users by 610 purposely trained pharmacists working in 514 pharmacies. The survey was carried out in 19 of the 20 Italian regions. The data shows that only 25% of patients suffering from HDs are prescribed triptans. Older patients, those with definite migraines, and those with a chronic disorder resort more frequently to this class of pharmaceuticals, as do those patients in care at a specialist headache centre. The multivariable analysis also confirmed these results. Our study, which performed a direct detection, in real life, on patients requesting pharmacological treatment for a migraine headache, therefore confirmed the need to investigate the reasons behind the low use and prescription of triptans in the Italian population. Moreover, any future studies should take advantage of community pharmacies, plan actions that would allow a series of evaluations over time of the requirements of migraineurs, and establish a process to put these patients under the care of the pharmacy to ensure adherence to therapy., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Baratta et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: The health condition of immigrants traditionally follows a transition from a low disease occurrence to the epidemiological profile of the deprived groups in the host country. In the Europe, studies examining differences in biochemical and clinical outcomes among immigrants and natives are lacking. We examined differences in cardiovascular risk factors between first-generation immigrants and Italians, and how migration pattern variables could affect health outcomes., Material and Methods: We included participants between 20 and 69 years recruited from a Health Surveillance Program of the Veneto Region. Blood pressure (BP), total cholesterol (TC) and LDL cholesterol levels were measured. Immigrant status was defined by being born in a high migratory pressure country (HMPC) and subdivided by geographical macro-areas. We used generalized linear regression models to investigate differences between these outcomes among immigrants compared to native-born, adjusting for age, sex, education, BMI, alcohol consumption, smoking status, food consumption, salt consumption in the BP analysis and the laboratory in charge for cholesterol analysis. Within immigrant subjects, the results were stratified by variables of the migration pattern: age at immigration and length of residence in Italy., Results: Thirty seven thousand three hundred and eighty subjects were included in the analysis, 8.6% were born in an HMPC. Heterogeneous results were seen by the macro-areas of origin and sex, with male immigrants from CE Europe (β = 8.77 mg/dl) and Asia (β = 6.56 mg/dl) showing higher levels of TC than native-born, while female immigrants from Northern Africa showed lower levels of TC (β = -8.64 mg/dl). BP levels were generally lower among immigrants. Immigrants residing in Italy for more than 20 years had lower levels of TC (β = -2.9 mg/dl) than native-born. In contrast, immigrants who arrived <20 years ago or arrived older than 18 years had higher levels of TC. This trend was confirmed for CE Europeans and was inverted for Northern Africans., Conclusions: The large heterogeneity in the results depending on sex and macro-area of origin indicates the need for targeted intervention in each specific immigrant group. The results confirm that acculturation leads to a convergence toward the epidemiological profile of the host population that depends on the starting condition of the immigrant group., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Dalla Zuanna, Batzella, Pitter, Russo, Spadea and Canova.)

Objectives: to analyze the difference of the SARS-CoV-2 infection impact between Italian and foreigner subjects, evaluating the trend of infections and access to diagnostic tests (molecular or antigenic swabs for the detection of SARS- CoV-2) in the two different populations, inducing the detection of new positive cases in the population., Design: retrospective population study for the period February 2020-June 2021., Setting and Participants: Italian and foreign resident population on 1st January of the years 2020 and 2021 in the Regions participating to the project: Piedmont, Lombardy, Veneto, Emilia-Romagna (Northern Italy), Tuscany, Lazio (Central Italy), and Sicily (Southern Italy)., Main Outcome Measures: in the two populations, for every week and aggregated by macropandemic period were calculated: • the test rate (people tested on the population); • the swab positivity rate (positive subjects on those who are tested); • the new positives (positive subjects on study population); • the percentage of foreigners among the new positive cases. The ratio of the value of the indicators in the foreign and Italian populations (with 95% confidence interval) was calculated to evaluate the association between nationality (Italian vs not Italian) and outcome. The analyses were conducted at the regional level and at pool level., Results: the trend of new positives by nationality (Italian vs not Italian) has a similar tendency in the different pandemic waves. However, the incidence of new positives during pandemic waves among foreigners is lower than in Italians, while it tends to increase during intermediate periods. Except for the summer periods, foreigners are less tested than Italians, but the percentage of new positives out of the total of new ones tested is higher among foreigners compared to Italians. The relative weight of new positives among foreigners tends to increase in periods with the greatest risk of inflow of SARS-CoV-2 for foreigners., Conclusions: the epidemic trends in the two populations are similar, although foreigners tend to show lower incidence values, probably in part because they are tested less frequently. Furthermore, in foreigners compared to Italians, there is a greater risk of contracting SARS-CoV-2 infection, especially in periods of relaxation of containment Coronavirus measures, reopening of national borders, production and commercial activities.

Objectives: to quantify the variability of COVID-19 mortality from the beginning of the pandemic to mid-July 2021, in relation to the immigrant status and by Region and period., Design: observational incidence study., Setting and Participants: the study population consists of the residents at the beginning of 2020 in seven Regions (Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany, Lazio, Sicily) aged <=74 years., Main Outcome Measures: absolute frequency of deaths occurred in subjects who tested positive for SARS-CoV-2, crude and standardized rates (standard: Italian population at the beginning of 2020), and mortality rates ratios (obtained using Poisson models), by immigrant status and stratified by gender, Region of residence, and period. The study period was divided into 5 subperiods: 22.02.2020-25.05.2020, 26.05.2020-02.10.2020, 03.10.2020-26.02.2021, 27.02.2021-16.07.2021., Results: the study includes more than one half of the Italian population and most of the immigrants residing in the country, who are younger than Italians and experienced fewer COVID-19 deaths. Deaths among those who tested positive varied greatly between Regions and periods; standardized rates showed considerable increases over time among immigrants. In terms of rate ratios, there were excesses among immigrant males in the third period (MRR: 1.46; 95%CI 1.30-1.65) and in the fourth period (MRR: 1.55; 95%CI 1, 34-1.81). Among immigrant females, there is an indication of lower risk in the third period (MRR: 0.79; 95%CI 0.65-0.97) and of greater risk in the fourth period (MRR: 1. 46; 95%CI 1.21-1.77). Finally, the effect is modified by the Region of residence, both in the third and in the fourth period for males and only in the fourth period for females., Conclusions: the risk of premature mortality due to COVID-19 is linked to immigrant status and with an intensity that varies by gender, Region, and period. More accessible tools for prevention, diagnosis and early healthcare can support immigrant communities in managing the risk factors linked to the spread of infections and, in particular, counteract their evolution into more severe disease outcomes.

Objectives: to describe differences in the incidence of SARS-CoV-2 infections between Italians and foreigners residing in seven Italian Regions during the different phases of the pandemic and by gender., Design: retrospective observational study., Setting and Participants: all confirmed SARS-CoV-2 infections from 02.02. 2020 to 16.07.2021 in the seven Regions under study were included. Italian resident population calculated by the National Institute of Statistics as of 01.01.2020 was used to calculate the rates. The considered period is divided into 5 sub-periods (phases)., Main Outcome Measures: number of confirmed SARS-CoV-2 infections in the five phases of the pandemic and crude rates by citizenship (Italian vs foreign). Distribution of infections by age group and by week. Crude and age-adjusted incidence rates ratios (IRR) were calculated, by Region, gender, and phase of the pandemic., Results: an epidemic curve delay was observed in foreigners in the first phase of the epidemic, in particular in the northern Regions, the most affected in that phase. The first phase of the epidemic was characterized by a greater proportion of cases occurred in people aged over 60 years than the other phases, both in Italians and in foreigners. The incidence among foreigners is higher during the summer of 2020 (intermediate period: June-September 2020) and during the last period (May-July 2021) in all Regions. The overall figure shows a lower incidence among foreigners than Italians, except for males in Tuscany., Conclusions: the lower incidence rates among foreigners should be interpreted with caution as the available data suggest that it is at least partly attributable to less access to diagnostic tests. Regional differences found in the study deserve further research together with the effect of gender and country of origin.

Objectives: to describe trends of overall and intensive care hospitalization for COVID-19 since the beginning of the pandemic in Italy until June 2021, and to compare the results between foreign and Italian population., Design: retrospective observational study., Setting and Participants: hospital discharges of 28 million people living in Lombardy, Piedmont, Emilia-Romagna (Northern Italy), Toscana and Lazio (Central Italy) occurred between 22.02.2020 and 02.07.2021 in the hospitals located in each considered Region., Main Outcome Measures: two weekly outcomes were examined: 1. the overall number of COVID-19 hospitalizations; 2. the number of COVID-19 hospitalizations in intensive care units., Results: a higher COVID-19 overall and intensive care unit hospitalization was found among the foreign population compared to Italians. The association emerged only after the adjustment for age, and it was consistent among all Regions, though less marked in Lombardy. The association varied across epidemic phases., Conclusions: the issue of vulnerability of migrants to the risk of severe COVID-19 calls for a diversity-sensitive approach in prevention. The specific country of origin and the prevalence of preventable co-morbidities that are often underestimated in the migrant populations, and related to COVID-19 complications, should be taken into consideration in future analyses.

Objectives: to examine the differences in SARS-CoV-2 infection and hospitalization rates among migrant populations in Veneto Region (Northern Italy), according to the geographic area of origin., Setting and Participants: all residents in Veneto Region aged <65 years were included in the analyses. All subjects infected by SARS-CoV-2 and hospitalized for COVID-19 were identified by means of the regional biosurveillance system., Main Outcome Measures: age- and gender-specific infection and hospitalization rates were stratified by geographic area of origin and were estimated using the number of incident cases over the resident population in Veneto on 01.01.2021. Incidence rate ratios (IRR) for infection and hospitalization rates were estimated using a Poisson model, adjusted for age and gender, among migrants compared to Italians., Results: compared to Italians, SARS-CoV-2 infection rates were significantly higher among migrants from Central and South America and Central and South Asia, lower among those from North Africa and High-Income Countries (HIC), and were approximately halved for those coming from Other Asian Countries (mainly represented by China). Hospitalization rates were significantly higher for all migrant populations when compared to Italians, with the exception of those coming from HIC. Neither age nor gender seemed to modify the association of the geographic area of origin with SARS-CoV-2 infection and hospitalization rates. IRR for SARS-CoV-2 infection of migrants compared to Italians showed how migrants from Other Asian Countries had the lowest infection rates (-53%), followed by people from HIC (-25%), North Africa (-21%), and Eastern Europe (-10%). Higher infection rates were present for Central and South America and Central and South Asia (+17% and +10, respectively). Hospitalization rates were especially high among migrants from Central and South Asia, Africa, and Central and South America, ranging from 1.84 to 3.14 times those observed for Italians., Conclusions: a significant heterogeneity in SARS-CoV-2 infection and hospitalization rates of migrant populations from different geographic areas of origin were observed. The significantly lower incidence rate ratio for infections, compared to that observed for hospitalizations, is suggestive of a possible under-diagnosis of SARS-CoV-2 infection among migrant populations. Public health efforts should be targeted at increasing support among migrants to contrast the spread of the pandemic by potentiating vaccination campaigns, contact tracing, and COVID-19 diagnostic tests.

Objectives: to describe the epidemiology of SARS-CoV-2 infection in relation with the use of nasal swabs in the immigrant population in Italy, using data from the COVID-19 national surveillance system and to verify if a difference is present comparing natives and immigrant., Design: descriptive study based on longitudinal health-administrative data., Setting and Participants: general population of six Italian Regions (Piedmont, Lombardy, Veneto, Emilia-Romagna, Tuscany, Lazio) covering about 55% of the resident population and 72% of foreigners' population., Main Outcome Measures: regional rates of access to at least a nasal swab, separately by country of origin., Results: across all the periods, a lower rate in the foreigners' group was observed, with the only exception of the period May-June 2021. Considering separately High Migratory Pressure Countries (HMPCs) and Highly Developed Countries (HDCs), a higher proportion of nasal swabs performed in people coming from HDC with respect to HMPCs and natives was noticed. This observation is consistent in males and females., Conclusions: during the first wave of the pandemic, Italians have had a higher proportion of nasal swabs compared to migrants across all Regions. This difference disappeared in the following periods, probably due to a major availability of diagnostic tests.

Introduction: The health status and health care needs of immigrant populations must be assessed. The aim of this study was to evaluate barriers to accessing primary care and the appropriateness of health care among resident immigrants in Italy, using indicators regarding maternal health, avoidable hospitalization, and emergency care., Methods: Cross-sectional study using some indicators of the National Monitoring System of Health Status and Healthcare of the Immigrant Population (MSHIP), coordinated by the National Institute for Health, Migration and Poverty (INMP), calculated on perinatal care, hospital discharge, and emergency department databases for the years 2016-2017 in nine Italian regions (Piedmont, Trento, Bolzano, Emilia-Romagna, Tuscany, Umbria, Latium, Basilicata, Sicily). The analyses were conducted comparing immigrant and Italian residents., Results: Compared to Italian women, immigrant women had fewer than five gynecological examinations (8.5 vs. 16.3%), fewer first examinations after the 12th week of gestational age (3.8 vs. 12.5%), and fewer than two ultrasounds (1.0 vs. 3.8%). Compared to Italians, immigrants had higher standardized rates (× 1,000 residents) of avoidable hospitalizations (males: 2.1 vs. 1.4; females: 0.9 vs. 0.7) and of access to emergency departments for non-urgent conditions (males: 62.0 vs. 32.7; females: 52.9 vs. 31.4)., Conclusions: In Italy, there appear to be major issues regarding accessing services and care for the immigrant population. Policies aimed at improving socioeconomic conditions and promoting integration can promote healthy lifestyles and appropriate access to health care, counteracting the emergence of health inequities in the immigrant population., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Di Napoli, Ventura, Spadea, Giorgi Rossi, Bartolini, Battisti, Cacciani, Caranci, Cernigliaro, De Giorgi, Fanolla, Lazzeretti, Mininni, Mirisola and Petrelli.)

Earlier in 2020, seven Italian regions, which cover 62% of the Italian population, set up the Mimico-19 network to monitor the side effects of the restrictive measures against Covid-19 on volumes and quality of care. To this aim, we retrospectively analysed hospital discharges data, computing twelve indicators of volume and performance in three clinical areas: cardiology, oncology, and orthopaedics. Weekly indicators for the period January-July 2020 were compared with the corresponding average for 2018-2019; comparisons were performed within 3 sub-periods: pre-lockdown, lockdown, and post-lockdown. The weekly trend of hospitalisations for ST-segment elevation myocardial infarction (STEMI) showed a 40% reduction, but the proportion of STEMI patients with a primary PTCA did not significantly change from previous years. Malignant neoplasms surgery volumes differed substantially by site, with a limited reduction for lung cancer (< 20%) and greater declines (30-40%) for breast and prostate cancers. The percentage of timely surgery for femoral neck in the elderly remained constantly higher than the previous 2 years whereas hip and knee replacements fell dramatically. Hospitalisations have generally decreased, but the capacity of a timely and effective response in time-dependent pathways of care was not jeopardized throughout the period. General trends did not show important differences across regions, regardless of the different burden of Covid-19. Preventive and primary care services should adopt a pro-active approach, moving towards the identification of at-risk conditions that were neglected during the pandemic and timely addressing patients to the secondary care system., (© 2021. The Author(s).)

Introduction: Type 2 diabetes is an important public health issue, yet adherence to drugs and regular clinical follow-up is still suboptimal. This study aims to evaluate a community pharmacy programme for monitoring and enhancing adherence to prescribed pharmacological therapies and recommended examinations among patients with confirmed diabetes., Methods: The intervention was conducted in different Italian areas between April 2017 and January 2018. All adult patients who entered a pharmacy with a personal prescription for any antidiabetic drug and agreed to participate, were interviewed. Those found to be non-adherent received counselling from the pharmacists. All patients were invited for a follow-up interview after 3 months., Results: Overall, 930 patients were enrolled and completed the baseline interview. We found low rates of non-adherence, ranging from 8% to 13% for prescribed pharmacological therapies, and 11-29% for the recommended clinical examinations. Non-adherence to oral therapies was higher among younger and recently diagnosed patients; that to clinical examinations was higher in men, those with an intermediate duration of diabetes and less educated patients. Large geographical differences persisted after the adjustment for individual factors. Only 306 patients (32.9%) returned for the follow-up interview, most of whom were already adherent at baseline., Conclusions: Poor adherence to drugs or clinical examinations is not easy to identify in the usual operating setting of community pharmacies. Furthermore, the majority of patients did not return for follow-up, making it impossible to evaluate the efficacy of the pharmacists' counselling. It might be more effective to plan interventions addressed to specific subgroups of patients or areas., Competing Interests: The authors have declared that no competing interests exist.

Background: Heart failure (HF) represents a severe public health burden. In Europe, differences in hospitalizations for HF have been found between immigrants and native individuals, with inconsistent results. Immigrants face many barriers in their access to health services, and their needs may be poorly met. We aimed to compare the rates of avoidable hospitalization for HF among immigrants and native individuals in Italy., Methods: All 18- to 64-year-old residents of Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome between January 1, 2001 and December 31, 2013 were included in this multicenter open-cohort study. Immigrants from high migratory pressure countries (divided by area of origin) were compared with Italian citizens. Age-, sex-, and calendar year-adjusted hospitalization rate ratios and the 95% CIs of avoidable hospitalization for HF by citizenship were estimated using negative binomial regression models. The hospitalization rate ratios were summarized using a random effects meta-analysis. Additionally, we tested the contribution of socioeconomic status to these disparities., Results: Of the 4 470 702 subjects included, 15.8% were immigrants from high migratory pressure countries. Overall, immigrants showed a nonsignificant increased risk of avoidable hospitalization for HF (hospitalization rate ratio, 1.26 [95% CI, 0.97-1.68]). Risks were higher for immigrants from Sub-Saharan Africa and for males from Northern Africa and Central-Eastern Europe than for their Italian citizen counterparts. Risks were attenuated adjusting for socioeconomic status, although they remained consistent with nonadjusted results., Conclusions: Adult immigrants from different geographic macroareas had higher risks of avoidable hospitalization for HF than Italian citizens. Possible explanations might be higher risk factors among immigrants and reduced access to primary health care services.

Background: 'Scuola sicura' (SS) programme aims to monitor the rate of COVID-19 and to contain its spread within the school population through early case isolation., Objectives: to describe the initial process and outcome evaluation results., Design: descriptive study of an experimental screening testing programme in children in Piedmont Region (Northern Italy) in the period January-March 2021. The data used came from the COVID-19 platform and the Local Health Units, the archives of birth certificates (CedAP), and hospital discharge files (SDO)., Setting and Participants: the screening programme targeted second and third grade students in first level secondary schools. Participants were subdivided into four groups; one group each week underwent screening, yielding one test per student per month., Main Outcome Measures: it was calculated: 1. number of positive cases detected vs total number of students tested in the SS programme; 2. number of positive cases detected outside the SS program vs. total number of students in the target population. The number of quarantines due to SS and no-SS case identification were detected. To investigate the spread of COVID-19 in households, the mother-child pairs were identified through record linkage between the CedAP and SDO archives, and positive mothers were identified., Results: sixty-nine percent of schools and 19.5% of the students participated in the programme. SS detected 114 positives cases for SARS-CoV-2. On 08.03.2021, the target classes started distance learning: 69 of the 114 positive students were identified before that date, leading to the activation of 67 quarantine measures. Only for 61 out of 69 of those students (88%) was possible to identify the mother; 46 mothers had performed a swab test after the positivity of their child with a positive result in 11 cases. Asymptomatic cases identified at screening during in-class learning period accounted for 26.5% of the total number of cases occurred in the participating classes., Conclusions: this is one of the few studies (and the first in Italy) to describe the functioning and predictive capacity of school screening testing for SARS-CoV-2 in a real-world situation. The findings provide data-driven suggestions for government agencies when planning large-scale school screening testing programmes.

Objectives: to compare the educational gradient in mortality between Italians and immigrants and to assess the hypothesis of status inconsistency in the immigrant population, evaluating the relationship between educational qualification and occupational class., Design: multicentre longitudinal study., Setting and Participants: subjects aged 30-64 years, resident in Turin, Bologna, Modena, or Reggio Emilia who took part in the 2011 Census and followed up until 31.12.2018., Main Outcome Measures: all-cause mortality by educational qualification and occupational class was compared between Italians and immigrants from High Migratory Pressure countries; analyses were carried out using mortality rate ratios (MRR) and relative index of inequality (RII), applying Poisson models, adjusted for city, calendar period, age, and macroareas of origin, stratified by gender., Results: occupational class among immigrants is evenly distributed across educational qualifications. Compared with Italians, immigrant men and women had a weaker and non-significant inverse educational gradient in mortality, which did not change substantially after the adjustment for occupational class., Conclusions: the results support the status inconsistency hypothesis, which may be partly responsible for the observed flattening of the educational gradients. The macroarea of origin appears to be a key determinant of mortality inequalities. Therefore, the use of educational qualification in exploring health inequalities among immigrants should be always complemented with other indicators of socioeconomic position and migratory history.

Objectives: to evaluate the impact on prenatal/perinatal care and pregnancy outcomes of the main social determinants (education, professional status and citizenship), with the aim of identifying the areas of care and the subgroups of women who are most at risk as priority targets of interventions for the reduction of inequalities; to evaluate the impact of the pregnancy Agenda on the appropriateness of care., Design: cross-sectional observational study., Settings and Participants: the childbirth assistance certificates (CedAP) related to childbirths occurred in the Piedmont region in the years 2010-2018 were analysed., Main Outcomes Measures: for each indicator of prenatal and perinatal care, multiple Poisson regression models were performed to estimate the prevalence ratios for the social determinants, adjusted for maternal age, parity, year of birth, and area of residence/maternity ward., Results: the observed deliveries were 274,086 and the newborns were 278,473, with a 25% reduction over time. Among pregnant women, there has been an increase in schooling, a reduction in employed women, and a stabilization of the percentage of immigrant women from countries with strong migratory pressure. Foreigners and inactive women show greater risks of poor prenatal care and less adherence to screening; education has greater impact on pregnancy outcomes. The trend towards greater adherence to the guidelines appears to be related to the introduction of the pregnancy Agenda, in turn associated with a greater use of public health services., Conclusions: social inequalities persist in prenatal/perinatal care and pregnancy outcomes. The results of this study support the hypothesis that offering quality and low-threshold services, such as family health centres, could be a first effective measure to tackle inequalities.

In Italy, few multicentre population-based studies on pregnancy outcomes are available. Therefore, we established a network of population-based birth cohorts in the cities of Turin, Reggio Emilia, Modena, Bologna, and Rome (northern and central Italy), to study the role of socioeconomic factors and air pollution exposure on term low birthweight, preterm births and the prevalence of small for gestational age. In this article, we will report the full methodology of the study and the first descriptive results. We linked 2007-2013 delivery certificates with municipal registry data and hospital records, and selected singleton livebirths from women who lived in the cities for the entire pregnancy, resulting in 211,853 births (63% from Rome, 21% from Turin and the remaining 16% from the three cities in Emilia-Romagna Region). We have observed that the association between socioeconomic characteristics and air pollution exposure varies by city and pollutant, suggesting a possible effect modification of both the city and the socioeconomic position on the impact of air pollution on pregnancy outcomes. This is the largest Italian population-based birth cohort, not distorted by selection mechanisms, which has also the advantage of being sustainable over time and easily transferable to other areas. Results from the ongoing multivariable analyses will provide more insight on the relative impact of different strands of risk factors and on their interaction, as well as on the modifying effect of the contextual characteristics. Useful recommendations for strategies to prevent adverse pregnancy outcomes may eventually derive from this study.

Background and Aims: Given the paucity of symptoms in the early stages of type 2 diabetes, its diagnosis is often made when complications have already arisen. Although systematic population-based screening is not recommended, there is room to experience new strategies for improving early diagnosis of the disease in high risk subjects. We report the results of an opportunistic screening for diabetes, implemented in the setting of community pharmacies., Methods and Results: To identify people at high risk to develop diabetes, pharmacists were trained to administer FINDRISC questionnaire to overweight, diabetes-free customers aged 45 or more. Each interviewee was followed for 365 days, searching in the administrative database whether he/she had a glycaemic or HbA1c test, or a diabetologists consultation, and to detect any new diagnosis of diabetes defined by either a prescription of any anti-hyperglycaemic drug, or the enrolment in the register of patients, or a hospital discharge with a diagnosis of diabetes. Out of 5977 interviewees, 53% were at risk of developing diabetes. An elevated FINDRISC score was associated with higher age, lower education, and living alone. Excluding the number of cases expected, based on the incidence rate of diabetes in the population, 51 new cases were identified, one every 117 interviews. FINDRISC score, being a male and living alone were significantly associated with the diagnosis., Conclusions: The implementation of a community pharmacy-based screening programme can contribute to reduce the burden of the disease, particularly focusing on people at higher risk, such as the elderly and the socially vulnerable., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Describing and monitoring socioeconomic inequalities in health are the prerequisite for planning equity policies. In Italy, some cities have integrated personal information from the municipal registries with Census data and with data from healthcare information systems to set up Longitudinal Metropolitan Studies (LMS). Under the coordination of the Italian National Institute for Health, Migration, and Poverty (NIHMP), six cities in the LMS network have contributed to the present monograph: Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome. MORTALITY RESULTS. Significant socioeconomic differences by level of education were seen in all the participating centres. People who live alone or in single-parent households are more likely to die, as are those living in a substandard dwelling. Immigrants resident in the six cities included in the study showed lower all-cause mortality than Italians (males: MRR 0.83; 95%CI 0.78-0.90 - females: MRR 0.70; 95%CI 0.64-0.77). Sub-Saharan Africans experienced a significant higher mortality than Italians (males: MRR 1.33; 95%CI 1.12-1.59 - females: MMR 1.69; 95%CI 1.31-2.17). Immigrants had a neonatal and post-neonatal mortality risk about 1.5 times higher than Italians (neonatal: OR 1.71; 95%CI 1.22-2.39 - post-neonatal: OR 1.63; 95%CI 1.03-2.57). A difference between Italians and immigrants was also observed for mortality in children aged 1-4 years, though less marked (OR 1.24; 95%CI 0.73-2.11). Excesses concerned particularly immigrants from North Africa and from sub-Saharan Africa as well as those residing in Italy for >5 years. HOSPITALISATION RESULTS. Hospitalisation rates are lower for immigrants than for Italians, except when due to infectious diseases, blood disorders, and, among women, for reasons linked to pregnancy and childbirth. Avoidable hospitalisation rates of adults from low migratory pressure Countries are lower than or equal to those of Italians. On the contrary, adults from low migratory pressure Countries show higher avoidable hospitalisation rates compared to Italians in every cohort, with the exception of Rome (RR 0.81; 95%CI 0.78-0.85), with RR ranging from 1.08 (95%CI 0.96-1.22) in Venice to 1.64 (95%CI 1.47-1.83) in Modena., Conclusions: Maternal and child health is the most critical area of health for immigrant population. Considering the importance that the issue of health equity has taken on in the political agenda, the data presented in this volume are a great asset, particularly in light of the long recession and the social crisis that have impacted the Country.

Background: Compared to hosting populations, immigrants are usually considered more vulnerable to communicable diseases, many of which are vaccine-preventable. This study aims to estimate vaccination coverage (VC) and timeliness in children born to women from high migratory pressure countries (HMPC) and to evaluate factors affecting differences with children born to Italian women or women from advanced development countries (ITA + ADC)., Methods: We retrospectively analysed data of children born in 2009-2014 and resident in areas served by three local health units in the cities of Rome (n = 40,284), Turin (n = 49,600), and Treviso (n = 20,080). Data were retrieved through record-linkage of the population, vaccination, and birth registries. We used the Kaplan-Meier method to estimate VCs at different ages for the 3rd dose of vaccine against tetanus and the 1st dose of vaccines against measles and meningococcal group C. Factors affecting differences in VCs by citizenship were evaluated using log-binomial models., Results: In Rome, VCs at 2 years of age were consistently higher in children born to ITA + ADC women than in children born to HMPC women, while differences in VCs by citizenship varied according to antigen and birth-cohort in Turin and Treviso, respectively. Where differences were observed, these were only partially explained by the mother's socio-demographic characteristics, level of utilisation of health-services during pregnancy, and maternal, perinatal, and neonatal outcomes. Finally, we observed a reduction of VCs in recent birth cohorts (2012-14 vs. 2009-11), especially in children born to ITA + ADC women., Conclusions: Differences in VCs by citizenship were not homogeneous and varied according to geographical context, antigen, and birth-cohort. These differences are likely to be also affected by informal barriers (e.g., linguistic and cultural barriers), which should be addressed in implementing strategies to increase vaccine uptake in foreign children. Moreover, our results suggest that effective strategies to promote vaccinations in the autochthonous population are also needed., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: to evaluate the association between short term maternal exposure to high temperature and air pollution on preterm births (PBs), which represent the first cause of perinatal mortality and morbidity in developed Countries, and to identify maternal risk factors enhancing individual susceptibility., Design: time series. SETTING E PARTICIPANTS: all singleton live-births occurred in six Italian cities between 1st April and 31st October of each year in the period 2001-2010 were identified through the Certificate of Delivery Care Registry (CedAP)., Main Outcome Measures: births occurred between 22nd and 36th week of gestation were defined as preterm births. Daily values were obtained for maximum apparent temperature (MAT), PM10, NO2, and O3. Exposures-preterm births association was estimated using a generalized additive model (GAM) with a Poisson distribution. Exposure and city-specific lag structure were computed using a non-linear distributed lag model (DLNM)., Results: 121,797 newborns were enrolled, 6,135 (5.0%) of which were PBs. For MAT, a linear relationship was observed for Turin (Piedmont Region, Northern Italy), Trieste (Friuli Venezia Giulia Region, Northern Italy), Rome (Lazio Region, Central Italy), and Palermo (Sicily Region, Southern Italy), while non-linear relationship was found for Bologna (Emilia-Romagna Region, Northern Italy) and Venice (Veneto Region, Northern Italy). The relative risks (RR) for MAT, computed comparing the 90th vs. the 75th percentile, vary from 1.02 (95%CI 0.95-1.09; lag 0-2) in Palermo to 1.94 (95%CI 1.32-2.85; lag 0-3) in Venice. For pollutants, a significant effect for 10 µg/m3 (IQR) increase of PM10 in Rome (RR: 1.07; 95%CI 1.02-1.12; lag 12-22) and for 16 µg/m3 (IQR) increase of O3 in Palermo (RR: 1.29; 95%CI 1.03-1.62; lag 2-9) was detected. In Rome, a significant effect modification by age and education level of the MAT-PB relationship and by education level and clinical conditions of PM10-PB was found., Conclusions: results showed a clear positive association between MAT and the risk of NP and a lower and variable effect of pollutants. It is important and necessary to limit the impact of these risk factors on the probability of NP with appropriate prevention programmes.

Headache disorders are considered the second leading cause of years lived with disability worldwide, and 90% of people have a headache episode at least once a year, thus representing a relevant public health priority. As the pharmacist is often the first and only point of reference for people complaining of headache, we carried out a survey in a nationwide sample of Italian pharmacies, in order to describe the distribution of migraine or non-migraine type headaches and medicines overuse among people entering pharmacies seeking for self-medication; and to evaluate the association, in particular of migraine, with socio-demographic and clinical characteristics, and with the pathway of care followed by the patients. A 14-item questionnaire, including socio-demographic and clinical factors, was administered by trained pharmacists to subjects who entered a pharmacy requesting self-medication for a headache attack. The ID Migraine™ Screener was used to classify headache sufferers in four classes. From June 2016 to January 2017, 4424 people have been interviewed. The prevalence of definite migraines was 40%, significantly higher among women and less educated people. About half of all headache sufferers and a third of migraineurs do not consider their condition as a disease and are not cared by any doctor. Among people seeking self-medication in pharmacies for acute headache attacks, the rate of definite or probable migraine is high, and a large percentage of them is not correctly diagnosed and treated. The pharmacy can be a valuable observatory for the study of headaches, and the first important step to improve the quality of care delivered to these patients., Competing Interests: The authors have declared that no competing interests exist.

Background: The LIFE MED HISS project aims at setting up a surveillance system on the long term effects of air pollution on health, using data from National Health Interview Surveys and other currently available sources of information in most European countries. Few studies assessed the long term effect of air pollution on hospital admissions in European cohorts., Objective: The objective of this paper is to estimate the long term effect of fine particulate matter (PM2.5) and nitrogen dioxide (NO 2 ) on first-ever (incident) cause-specific hospitalizations in Italy., Methods: We used data from the Italian Longitudinal Study (ILS), a cohort study based on the 1999-2000 National Health Interview Survey (NHIS), followed up for hospitalization (2001-2008) at individual level. The survey contains information on crucial potential confounders: occupational/educational/marital status, body mass index (BMI), smoking habit and physical activity. Annual mean exposure to PM2.5 and NO 2 was assigned starting from simulated gridded data at spatial resolution of 4 × 4 km 2 firstly integrated with data from monitoring stations and then up-scaled at municipality level. Statistical analyses were conducted using Cox proportional hazard models with robust variance estimator., Results: For each cause of hospitalization we estimated the hazard ratios (HRs) adjusted for confounders with 95% Confidence Interval (CI) related to a 10 μg/m 3 increase in pollutants. For PM2.5 and NO 2 , respectively, we found positive associations for circulatory system diseases [1.05(1.03-1.06); 1.05(1.03-1.07)], myocardial infarction [1.15(1.12-1.18); 1.15(1.12-1.18)], lung cancer [1.18(1.10-1.26); 1.20(1.12-1.28)], kidney cancer [1.24(1.11-1.29); 1.20(1.07-1.33)], all cancers (but lung) [1.06(1.04-1.08); 1.06(1.04-1.08)] and Low Respiratory Tract Infections (LRTI) [1.07 (1.04-1.11); 1.05 (1.02-1.08)]., Discussion: Our results add new evidence on the effects of air pollution on first-ever (incident) hospitalizations, both in urban and rural areas. We demonstrated the feasibility of a low-cost monitoring system based on available data., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Recent studies suggest that inequalities in premature mortality have continued to rise over the last decade in most European countries, but not in southern European countries., Methods: In this study, we assess long-term trends (1971-2011) in absolute and relative educational inequalities in all-cause and cause-specific mortality in the Turin Longitudinal Study (Turin, Italy), a record-linkage study including all individuals resident in Turin in the 1971, 1981, 1991 and 2001 censuses, and aged 30-99 years (more than 2 million people). We examined mortality for all causes, cardiovascular disease (CVD), all cancers and specific cancers (lung, breast), as well as smoking and alcohol-related mortality., Results: Overall mortality substantially decreased in all educational groups over the study period, although cancer rates only slightly declined. Absolute inequalities decreased for both genders (SII=962/694 in men/women in 1972-1976 and SII=531/259 in 2007-2011, p<0.01). Among men, absolute inequalities for CVD and alcohol-related causes declined (p<0.05), while remaining stable for other causes of death. Among women, declines in absolute inequalities were observed for CVD, smoking and alcohol-related causes and lung cancer (p<0.05). Relative inequalities in all-cause mortality remained stable for men and decreased for women (RII=1.92/2.03 in men/women in 1972-1976 and RII=2.15/1.32 in 2007-2011). Among men, relative inequalities increased for smoking-related causes, while among women they decreased for all cancers, CVD, smoking-related causes and lung cancer (p<0.05)., Conclusions: Absolute inequalities in mortality strongly declined over the study period in both genders. Relative educational inequalities in mortality were generally stable among men; while they tended to narrow among women. In general, this study supports the hypothesis that educational inequalities in mortality have decreased in southern European countries., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

North-western Italy has a long history of domestic influx, however little is known on how migrant mortality compares to mortality at the local level. While geographic mortality gradients may play a role, conceptualizations developed for international migration may also be relevant. Using this theoretical framework, the study investigated immigrant-native differentials in the north-western city of Turin through a 34-year follow-up that was facilitated by the Turin Longitudinal Study. The study population comprised inhabitants of age 30-74 years at the 1971 census. Survival trajectories were modelled through the Gompertz distribution and were examined for nativity status, birthplace, length of stay and age at arrival (the last two variables were combined). All estimates were adjusted for socio-economic factors. Overall, the risk of dying for internal migrants was lower, compared to locals, and consistent with geographic gradients. However, this pattern hid significant differences mediated by both age at arrival and length of stay. The advantage appeared to be exclusive to young and adult migrants, despite differentials narrowing over time. Immigrants who arrived after age 44 suffered instead a progressively greater excess risk, compared to natives, as residence increased. The dissipation of the health advantage found in internal migrants, along with poor health outcomes amongst people older at arrival, raises concern about immigrants from developing countries who need to endure a more demanding journey and adjustment to the new environment. The study indicated, through lengthy longitudinal data, that immigrant-native differentials were best explained by the stratified variable 'length of stay by age at arrival' and this should inform future studies., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

This paper provides a synthesis on socioeconomic inequalities in cancer incidence, mortality and survival across countries and within countries, with particular focus on the Italian context; the paper also describes the underlying mechanisms documented for cancer incidence, and reports some remarks on policies to tackle inequalities.From a worldwide perspective, the burden of cancer appears to be particularly increasing in developing countries, where many cancers with a poor prognosis (liver, stomach and oesophagus) are much more common than in richer countries. As in the case of incidence and mortality, also in cancer survival we observe a great variability across countries. Different studies have suggested a possible impact of health care on the social gradients in cancer survival, even in countries with a National Health System providing equitable access to care.In developed countries, there is increasing awareness of social inequalities as an important public health issue; as a consequence, there is a variety of strategies and policies being implemented throughout Europe. However, recent reviews emphasize that present knowledge on effectiveness of policies and interventions on health inequalities is not sufficient to offer a robust and evidence-based guide to the choice and design of interventions, and that more evaluation studies are needed.The large disparities in health that we can measure within and between countries represent a challenge to the world; social health inequalities are avoidable, and their reduction therefore represents an achievable goal and an ethical imperative., (© 2011 Merletti et al; licensee BioMed Central Ltd.)

Objective: the study is aimed at developing a nationwide deprivation index at municipality and census block level, based on the 2001 Census data, and meeting epidemiological needs., Setting and Participants: The study uses data drawn from the 2001 General Census of Population and Housing. From the 280 variables defined at census block level (352,605 census tracts with average number of inhabitants 169, standard deviation 225; and average area 0.6 km², sd 2.4 km²) five traits that operationally combine to represent the multidimensionality of the social and material deprivation concept have been selected; these are: low level of education, unemployment, non-home ownership, one parent family and overcrowding. The index is calculated by summing standardized indicators and it is also available as categorical by quintiles of population. The same procedure is applied to aggregate frequency data at municipality level. The correlation between mortality and deprivation has been evaluated using 2000-2004 general mortality., Results: considering national data, a strong north-south gradient in deprivation was observed. The municipality deprivation index 2001 is highly correlated to the index likewise calculated on the basis of the previous 1991 Census (r=0.91). General mortality was positively correlated to the index (in particular in population up to 64 years and in larger size municipalities)., Conclusion: the pattern described by the deprivation index was coherent with what is already known about geographic distribution of poverty and its impact on mortality. Such outcome bears out the index use for epidemiological purposes.

Objective: To determine the magnitude of social inequalities in cancer incidence according to different socioeconomic indicators and to assess the independent role of each indicator., Methods: Data from the Turin Longitudinal Study and the Piedmont Cancer Registry (1985-1999) were used to analyse the relationship of cancer incidence with three dimensions of individual socioeconomic position (education, occupation, and material living conditions) and with an area-based deprivation index. Multivariate Poisson regression models were used to estimate both relative risks and relative indexes of inequality (RIIs)., Results: Results showed an independent role of all the socioeconomic indicators. The overall gradients of inequalities, expressed by the RIIs for total cancer incidence, varied from 9 to 26% among men; among women, we estimated a 22% protection at the bottom of the educational hierarchy, and a 12% gradient for decreasing ease of living conditions. For most cancer sites, socioeconomic position in early adult life was as important as later socioeconomic position, while the area-based deprivation index played only an additional role., Conclusions: Different socioeconomic indicators pinpoint to a series of specific risk factors that are related to specific phases of the life course. Individual level data, rather than ecological data, is preferred to accurately monitor social inequalities in cancer risk.

Objective: To review the scientific evidence on the effectiveness of interventions to promote attendance to breast and cervical cancer screening among lower socioeconomic groups., Methods: We performed a computerized literature search looking for relevant papers published between 1997 and 2006. Papers were classified into three groups based on the type of intervention evaluated: (1) implementation of organized population screening programs; (2) different strategies of enhancing attendance within an organized program; (3) local interventions in disadvantaged populations., Results: The available evidence supports the hypothesis that while organized population screening programs are successful in increasing overall participation rates, they may not per se substantially reduce social inequalities. Some strategies were consistently found to enhance access to screening among lower socioeconomic groups, including cost-reducing interventions (e.g. offering free tests and eliminating geographical barriers), a greater involvement of primary-care physicians and individually tailored pro-active communication that addresses barriers to screening., Conclusions: Evidence from studies suggests that the attendance of deprived women to cancer screening can be improved with organized screening programs tailored to their needs. The same may apply to the prevention of adverse outcomes of other health conditions, such as hypertension, hypercholesterolemia, and diabetes., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: A relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC) as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage., Methods: From the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome), we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma) among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block) income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles) and hospitalization rates (RR, 95% CI) separately for the selected conditions controlling for age, gender and city of residence., Results: Overall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people., Conclusions: The socioeconomic gradient in ACSC hospitalization rates confirms the gap in health status between social groups in our country. Insufficient or ineffective primary care is suggested as a plausible additional factor aggravating inequality. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalizations among poor people.

The objective of this study was to investigate the relationship between cancer incidence and socioeconomic status, and to examine the temporal trends in social inequalities in cancer risk. Educational differentials in the incidence of cancer (25 sites) among adult residents of Turin (Italy) were examined using data from the Turin Longitudinal Study and the Piedmont Cancer Registry. The relationship between cancer incidence and educational level was evaluated over three 5-year periods between 1985 and 1999 using Poisson models. An estimated 17% of malignancies among men in the low-educational group were attributable to education, whereas women with a low educational level were slightly protected. Less-educated men had higher risks of upper aero-digestive tract, stomach, lung, liver, rectal, bladder, central nervous system and ill-defined cancers, and lower risks of melanoma, kidney and prostate cancers. Women with lower educational levels were at higher risk of stomach, liver and cervical cancers, whereas they were less likely to be diagnosed with melanoma, ovarian and breast cancers. For most sites, the educational gradient in risk did not vary substantially over time. The educational inequalities in cancer incidence observed in this cohort appear similar in magnitude and direction to socioeconomic inequalities found in other Western countries; for some cancer sites results partly differ from the results of other studies, and require further investigation. A thorough understanding of the relative burden of well-documented causes of social inequalities in cancer risk is essential to address preventive measures and to direct future research on unexplained social differences.

Objective: In countries with universal health coverage, socioeconomic status is not expected to influence access to effective treatment and its prognosis. We tested whether socioeconomic status affects the rates of elective total hip replacement and whether it plays a role in early and late outcomes., Design: Multicity population-based longitudinal study., Setting and Participants: From Hospital Registries of four Italian cities (Rome, Milan, Turin, and Bologna), we identified 6140 residents aged 65+ years undergoing elective total hip replacement in 1997-2000., Main Outcome Measures: An area-based (census block) income index was used for each individual. Poisson regression yielded rate ratios (RR) of population occurrence by income level. Logistic regression estimated odds ratios (OR) of selected outcomes within 90 days. Cox proportional hazard models evaluated effects of income on rates of revision of total hip replacement and mortality up to 31 December 2004. Analyses were adjusted for age, gender, city of residence, and coexisting medical conditions., Results: Low-income people were less likely than high-income counterparts to undergo total hip replacement [RR = 0.87, 95% confidence interval (CI) 0.81-0.95]; the effect was stronger among those aged 75+ years (RR = 0.76, 95% CI = 0.66-0.86). Low income was associated with higher risk of acute adverse medical events (P trend = 0.05) and of general infections and decubitus ulcer (P trend = 0.02) within 90 days. The effects were even higher among those aged 75+ years. No effects were found either for orthopaedic complications within 90 days or for revision and mortality., Conclusions: Total hip replacement is underutilized among elderly deprived individuals. Disadvantaged patients seem more vulnerable to acute adverse medical events after surgery. The evidence of unmet need and poor prognosis of low social class people has important implications for health care policy.

Background: The indicators of healthy life expectancy measure differences in health among various population subgroups more sensitively than do indicators of mortality., Objectives: The aim of the study was to analyze some of the above indicators to evaluate the differences among occupational categories in Turin., Methods: Mortality tables by occupation were calculated on Turin residents, aged 18-64 years in 1991, using the Turin Longitudinal Study which combines personal, census, and health information for the residents of the city. Longitudinal assessments of health expectancy were obtained by means of record-linkage with the Cancer Registry, the Diabetes Registry, and hospital discharge records. In addition, prevalence estimates of good health, disability, and chronic illness, obtained from ISTAT (Central Statistics Institute) investigations in 1999-2000 were combined with mortality data using Sullivan's algorithm., Results: Among men there was a systematic disadvantage in almost all indicators of health expectancy for some manual occupations, while jobs requiring more qualifications were more advantaged. The health profile for women was more controversial, with an overall disadvantage among women who were professional consultants, although this group showed substantial variability: the legal professions had the lowest life and health expectancies, with approximately 3 years of life less than the health professions, which were among the most advantaged., Discussion: The various indicators gave results which were at times conflicting, especially because the information obtained from the available sources had major limitations. The development of indicators needs to aim for greater homogeneity between mortality and health data to ensure maximum comparability.

Background: People in a lower social position have a higher prevalence of unhealthy behaviour, more difficult access to healthcare, and lower compliance with drug treatment; as a consequence, social differences in mortality are likely to be higher in people with diabetes compared with the non-diabetic population. We compared diabetics with non-diabetics in terms of mortality and social differences in mortality., Methods: In all, 31 264 residents in Turin (northern Italy), who were > or =20 years old, registered in the local diabetes register between 1991 and 1999. They were followed up from recruitment to December 1999, and their cause-specific mortality by educational level was analysed. This was compared with that of the local non-diabetic population. Diabetes was classified as type 1 (< or =35 years at diagnosis) or type 2 (>35 years)., Results: For type 1 diabetes, the all-cause standardized mortality ratio (SMR) was 197.6 (95% CI:155.7, 247.4) in men and 336.0 (95% CI:259.3, 428.2) in women; for type 2 diabetes, the all-cause SMR was 142.8 (95% CI:138, 147.6) in men and 143.4 (95% CI:138.5, 148.5) in women. Whereas social differences in mortality were evident among non-diabetic men and women for all causes of death considered, no significant differences were found among diabetic women. Mortality was slightly increased among less educated diabetic men, particularly for neoplasms, although this gradient was less steep than that among non-diabetics., Conclusions: These results suggest that the regular clinical follow-up and health education provided by the local network of diabetic centres might play an important role in confronting the adverse effects of diabetes and in reducing social differences in health.

Socioeconomic inequality and its impact on health is a growing concern in the European public health debate. In many countries, the issue is moving away from description towards the identification of the determinants of inequalities and the development of policies explicitly aimed at reducing inequalities in health. In Italy, ten years after the publication of the first report on inequalities in health, this topic is seldom present on the agenda of public policy makers. The purpose of this report is to update the Italian profile of social variation in health and health care in order to stimulate the debate on ways to tackle inequalities in health that are preventable. In the first section of this book, the threefold objective is to describe the principal mechanisms involved in the generation of social inequalities in health (Introduction); to report Italian data on the distribution and magnitude of this phenomenon in the last decade; and to evaluate policies and interventions in both the social (chapter 1.9, Section I) and the health sector (chapter 2.3, Section I), which are potentially useful to reduce health inequalities. It is intended for anyone who is in a position to contribute t o decision-making that will benefit the health of communities. For this reason, chapters are organized by specific determinants of inequalities on which interentions may have an impact. The methodological approach in the second section focuses on the best methods to monitor social inequalities including recommendations on social indicators, sources of information and study models, based on European guidelines revised for the Italian situation. According to data from national and local studies, mortality increases linearly with social disadvantage for a wide range of indicators at both the individual (education, social class, income, quality of housing) and the geographical level (deprivation indexes computed at different levels of aggregation). This positive correlation is evident for both sexes, with the steepest gradient observed among adults of working age, although differences persist also among the elderly. The causes of death found to be most highly correlated with social inequality, and largely responsible for the increasing inequality over the last decade, are those associated with addiction and exclusion (drug, alcohol and violence related deaths), with smoking (lung cancer) and with safety in the workplace and on the roads (accidents). Similar gradients and trends have been observed with different outcomes, such as self-reported morbidity, disability and cancer incidence (chapter 1.1, Section I). Reproductive outcomes confiirm this picture: compared to women belonging to the upper classes, those women in low conditions experience more spontaneous abortions and their children suffer from higher infant mortality and low birth weight. This is a critical issue since poor infant health, particularly for metabolic and respiratory pathologies, affects health in adult life. There is now substantive evidence showing that also socioeconomic circumstances at birth or during adolescence may have a strong impact on adult health (chapter 1.2, Section I). Differences in harmful lifestyles, such as smoking, heavy drinking, drug use, unhealthy diet, obesity and physical inactivity, have a similar effect. The only exception is smoking among women, which is positively correlated with socioeconomic status; however, since women in the upper classes have a greater tendency to quit smoking, the gradient will soon be reversed (chapter 1.7, Section I). On the other hand, most of these behaviours do not follow from free and conscious individual choice; they are a form of adaptation to chronic stress originating in the work-place (chapter 1.4, Section I), or to particularly unfavourable events and conditions, such as unemployment (chapter 1.5, Section I) or lack of family and social support (chapter 1.6, Section I). Poor socioeconomic circumstances are the threshold of absolute poverty and may lead to social exclusion, a condition with a heavy impact on health, which in Italy includes marginal groups of the native population and broader classes of immigrants (chapter 1.3, Section I). Finally, there is recent and consistent evidence on the existence of a "contextual" effect on health, as opposed to the "compositional" effect given solely by the aggregation of individual processes. According to this hypothesis, characteristics of the infrastructure, and the physical and socioeconomic environment of an area would have an impact on individual health independent from the cultural and economic resources personally available to people living in that area (chapter 1.8, Section I). With respect to the health care system, various studies are in agreement in demonstrating that poor and less educated people have inadequate access both to primary prevention and early diagnosis (chapter 2.1, Section I), and to early and appropriate care (chapter 2.2, Section I). They also experience higher rates of hospitalization, particularly in emergencies and with advanced levels of severity.

The geographic distribution of health status across Italian regions shows a North-South gradient, with better conditions in the North for both males and females. Using data from the 2000 National Health Interview Survey, the authors first analyze the geographic variation in subjective health and presence of chronic conditions, with specific attention to the effects of individual and area-based socioeconomic conditions and their heterogeneity across regions. The results suggest the North-South gradient in health is mainly affected, at least for subjective health, by the different composition of macro-areas with respect to individual education, and is slightly influenced by contextual circumstances. Moreover, being less educated results in poorer health in some regions (mainly South and Isles) than in others (mainly Northeast). The authors next analyze the circumstances affecting the presence of more disadvantaged people in the South, to highlight features of the Southern context that might exacerbate social inequalities in health and features of Northern areas that might allay them. Indicators of inequalities, welfare, labor, and power resources were analyzed. The results confirm the disadvantage of the South in terms of social, economic, and cultural features, mainly revealing the compositional effects found in the first part of the study. However, the contextual predictive value of income inequalities, quality of care, and social cohesion can have a supplementary effect on health outcomes of disadvantaged persons.

Background: The hepatitis B virus (HBV) vaccination was introduced in Italy in 1991 as compulsory among newborns and among 11-year-old children., Methods: We conducted a retrospective study to evaluate the HBV immunization coverage of the two target populations by the public health services in the Lazio region and to analyze factors associated with starting and completing HBV immunization in the initial period of the campaign. We used data registered in the public health services of 7/51 Health Districts. As a proxy indicator of services' performance we used the "expected immunization period," that is, the 6-month period in which each child should have been started on immunization, according to the calendar., Results: HBV vaccine coverage rates were 63% in the younger cohort and 50% in the older one. The results of univariate and multivariate regression analysis showed that starting HBV immunization was associated with being newborn (crude OR = 3.30; 95%CI 2.17-2.44), with living in a small city (crude OR = 6.81; 95%CI 6.12-7.58), and with being assigned to the second (crude OR = 1.77; 95%CI 1.65-1.90) or to the third 6-month period of the expected immunization period (crude OR = 2.58; 95%CI 2.42-2.76). The probability of completing HBV immunization was higher among children who had had the first dose "age-appropriately" or with "acceptable delay" and among those living in small cities. It was lower among children in the second or the third 6-month period. Size of urban area of residence was associated with both outcomes: the city of Rome showed the lowest probabilities of starting and completing HBV immunization, while the small cities showed the highest ones., Conclusions: The performance of public health services was the most important determinant of recourse to public health services for vaccinations; it varied according to size of urban area; in towns organization difficulties contributed to the delay of starting vaccination, for at least a year. The expected immunization period was a good proxy indicator of services' performance. The timing of the first dose was the strongest predictor of completing vaccination also at the beginning of the campaign., (Copyright 2001 American Health Foundation and Academic Press.)

A population survey was conducted to assess the duration of anti-HBs levels > 10 IU/l in vaccinees living in Lazio Region (Italy) 5 years after the introduction (15 June 1991) of compulsory vaccination of new-borns and 11-year-old children. A random sample of 1192 (533 children born in 1991--92 and 659 adolescents born in 1979--81) was selected. In 92.9% of children and 94.1% of adolescents anti-HBs titres were protective (> or = 10 IU/l). These subjects with protective titres were divided into three categories: low responders (anti-HBs titres = 10--500 IU/l), medium responders (anti-HBs titres = 501--2000 IU/l) and high responders (anti-HBs titres > 2000 IU/l). Factors associated with the level of response were analysed, using a multiple politomic logistic regression analysis. Greater age at first dose (11--12 years) was associated with higher titres (OR = 2.1, 95% CI = 1.4--3.2 for medium responders and OR = 3.0, 95% CI = 1.9--4.8 for high responders). Simultaneous administration of DT vaccine was associated with lower titres (OR = 0.4, 95% CI = 0.2-0.8 for medium responders and OR = 0.3, 95% CI = 0.1--0.7 for high responders).

Although the interest for equity is growing, scanty attention has been reserved so far in Italy to health care inequalities. The relation between hospitalization and socioeconomic position in Rome has been studied by evaluating overall heterogeneity and differences in access to effective non-discretionary treatments or at high degree of generic or specific inappropriateness. An area-based socioeconomic index was assigned to 86.4% out of 554.168 discharges of Rome residents identified during 1997 through the hospital information system. The analysis was performed by comparing standardized hospitalization rates across socioeconomic groups through linear trends and risk ratios. A significant inverse relation of overall hospitalization with socioeconomic position was observed for both acute admissions (+44% for most deprived males) and day hospital (+25%). No difference was found in use of effective treatments such as admissions in coronary care units for acute myocardical infarction or surgery for hip fractures. The inverse relation between socioeconomic position and acute hospitalization blunted in day hospital for inguinal hernia repair and actually reversed for cataract removal among females. The hospitalization risk for minor skin diseases, an ambulatory care sensitive condition, resulted inversely associated to socioeconomic position. An excess of hospitalization was also observed for poorest females undergoing appendectomy. Results indicate that observed heterogeneity between socioeconomic groups does not depend only on different health needs but also on an unequal utilization of services: although disadvantaged groups have equal access to treatments of non-discretionary effectiveness, they hardly use innovative services and are more vulnerable in receiving unnecessary treatments.

The study objectives were to determine the effects of a large-scale school-based HIV prevention campaign, in terms of both positive and negative effects of each single message, and to identify sub-populations more at risk. Forty-six schools, randomly sampled from all schools in the Lazio region, were randomized to either an intervention or a control group. The study population consisted of 3866 students. Questionnaires on AIDS-related knowledge and risk perceptions were administered to students before and after the intervention. Odds ratios were calculated to represent the extent to which the intervention was associated with an improvement (OR+), and the extent to which it prevented a worsening (OR-). Overall, the intervention was successful in communicating important messages, such as the impossibility of transmitting HIV through social contacts (OR+ all significantly > 1 and OR- always< 1), the meaning of 'seropositivity' (OR+: 1.28, 95% CI: 0.99-1.64; OR-: 0.73, 95% CI: 0.58 0.91), and the lack of a resolutive cure for AIDS (OR+: 1.61, 95% CI: 1.10-2.36; OR-: 0.76, 95% CI: 0.57-1.02). The worst results were observed in vocational and art schools, where OR + > 1 were observed for only three questions and OR- values usually exceeded 1. This study highlights the necessity of remodelling the intervention, indicating which messages need to be modified. The low impact of educational programmes among students of vocational and art schools makes them a population more at risk, that should be considered as a priority target population for interventions.