The Italian Behavioral Risk Factor
Surveillance System – PASSI
(Progressi delle Aziende Sanitarie per la Salute in Italia)
www.epicentro.iss.it/passi
Pirous Fateh-Moghadam
for the PASSI Coordinating Group
National Centre for Epidemiology, Surveillance and Health Promotion
Background
•57 million inhabitants
•21 regions
•Universal health care and
preventive services
– Local Health Units (LHU)
 1 unit per 300,000 residents
(100,000 – 1,000,000)
– Regional health authorities
 Interpretation/adaptation of
national guidelines (national
health plans)
Example:
Emilia-Romagna
LHU of Bologna
Data collection, analyses
and dissemination of
results are based on
LHU level (and on
regional level as well)
A system able to:
– Collect useful and representative data on
health behaviors at LHU level
– Provide timely feedback  planning and
evaluation of programs/interventions
– Facilitate comparisons between LHU/regions 
identify best practices
– Permit comparisons with international data
– Last but not least:
• Promote the professional development of local and
regional staff
• Increase the use of epidemiological data at local level
PASSI (Progressi delle Aziende
Sanitarie per la Salute in Italia)
• 2005 and 2006:
– Two pilot cross-sectional studies testing
materials and methods for the future
implementation of a surveillance system
– Knowledge shared by CDC/BRFSS and other
international experts was very useful in setting
up the system
• In 2006 the MoH funded the National
Centre for Epidemiology, Surveillance and
Health Promotion (CNESPS) to develop
ongoing surveillance of behavioral risk
factors and preventive measures included
in the National Prevention Plan
Method
• Since 2007 ongoing (monthly) data collection
in each participating LHU:
– telephone interviews of at least 275
persons/year/LHU
– Interviewers: LHU personnel using a standardized
questionnaire (questions adapted from BRFSS, Cindi,
Steps, ISTAT  comparisons)
• Participants selected from LHU population
registers using stratified random sampling
• Inclusion criteria: age 18-69, residence in
catchment area, availability of telephone
number (mobile or land-line, obtained through
various sources)
The questionnaire
114 questions, many
administered to specific
subpopulations (e.g. cancer
screening) or categories
(e.g. present smokers)
Topics included: priorities of
the National Health Plan
• quality of life
• smoking habits
• physical activity
• diet
• alcohol consumption
• driving behavior
• cardiovascular risk factors
• cancer screening
• vaccinations
• mental health
• domestic accidents
• socio-demographic aspects
Not only behaviours…
• Public health interventions
– Screening programmes
– Counselling by general practitioners
– Optional modules on:
• Police interventions for drunk drivers
• Evaluation of special health promotions programmes
implemented at regional level (“Genitori più”)
• Diabetes
• Work place safety
• H1N1 Influenza
• Importance of social determinants of health:
– All risk factors/compliance with public health programmes
are broken down by
• Income
• Education
Data collection (2007-2009)
• 21/21 Regions have begun data collection since
April 2007, though not all at the same time
• Health personnel involved and trained: ~ 1.000
• Complete interviews: ~ 96,000
– 21,996 in 2007
– 37,560 in 2008
– 36,016 in 2009 (preliminary)
• 2009:
– Response rate:
– Substitution rate
• Refusal rate
• Not found
88%
12%
9%
3%
A short glimpse into the
results:
Respect of the smoking ban in public places
LHU, Trentino 2009 (n=736)
• Italian smoking ban:
– Went into effect in jan/2005
– Covers all enclosed public
places
100
79
80
60
40
15
20
5
1
0
Alw ays
respected
Alm ost Som etim es
Never
alw ays
respected respected
respected
• In Trentino the
compliance with the law
is very good. 94% of the
interviewed people
reported that the ban is
always or almost always
respected
Respect of the smoking ban in public places
Pooled data – 2009 (n=36.016)
• Compliance in Trentino
is higher compared to
the pooled data
(respect always/almost
always: 86%)
• The respect of the law
decreases going from
north to south
Trends over time
Smokers (%)
• the ongoing (monthly)
data collection offers
the possibility to
compare annual
prevalences…
Passi – Trentino – 2007-2009
35
30
25
20
25,5
24,7
1
2
3
2007
2008
2009
25,1
%
15
10
5
Monthly distribution of percentages of smokers age 18-69
Piemonte 2007-09 (%)
0
• … and to perform
time series
analyses as well
Pap smear within the last 3 years per region (%)
women age 25-64 (PASSI 2008)
valle d’ ao sta
bo lzano
FVG
ER
veneto
to scana
piemo nte
umbria
trento
liguria
lo mbardia
lazio
marche
po o l
mo lise
abruzzo
sicilia
basilicata
campania
puglia
sardegna
%
0Pool PASSI
20
40
75%
(n.6015.531)80
Range: 48% Sardegna - 91% Valle d’Aosta
100
Pap smear within the last 3 years per local health
unit (%) - women age 25-64 (PASSI 2008)
%
100
80
60
40
20
0
Re
Ce
Fe
__ Copertura Desiderabile 80%
….. Copertura Accettabile 65%
Ra
ER
Mo
Rn Bo+Im Fo
86%
Pr
Pc
(n. 1.549)
Range: 79% Piacenza - 91% Reggio Emilia
- - - Cases of H1N1 per 1.000
Emergency module on H1N1
•
Think it is likely
to have flu cases
in family
•
Is worried about
H1N1
•
Limits his/her
activities in daly
life because of
H1N1
•
Willing to get
vaccinated
Data use
• Health profiles and prioritization
processes
• Intervention planning and evaluation
– National and regional prevention plan
– Local intervention planning
• Dissemination of results (reports & fact
sheets on specific issues, scientific
articles)
Sustainability
• National and regional public health
authorities are embedding surveillance
issues in the main Italian frameworks
on prevention of chronic diseases
– National and Regional Prevention Plans
– Gaining Health
• Since Passi does not use call centers
the motivation of the interviewers and
supervisers is paramount
– Economic benefits (only in some regions)
– Passi as a means of professional growth…
Integration of data on
behavioural risk factors
• OKkio (repeated survey)
– Overweight, obesity and physical activity of
school-children (elementary school)
• HBSC (repeated survey)
– Adolescence
• PASSI (ongoing monitoring)
– Adults (18-69)
• PASSI d’Argento (repeated survey)
– Elderly people (65+)
The PASSI Coordinating Group at national level
Centro nazionale di epidemiologia, sorveglianza e promozione della salute (CNESPS), Istituto Superiore di Sanità,
Roma
Sandro BALDISSERA, Paolo D’ARGENIO, Barbara DE MEI, Gigi FERRANTE, Valentina MINARDI, Alberto PERRA,
Valentina POSSENTI, Elisa QUARCHIONI, Stefania SALMASO
Dipartimento di sanità pubblica, Azienda USL di Cesena
Nicoletta BERTOZZI
Dipartimento di Statistica, Università degli studi Ca’ Foscari, Venezia
Stefano CAMPOSTRINI
Dipartimento di sanità pubblica, AUSL Modena
Giuliano CARROZZI
Direzione generale della prevenzione sanitaria, Dipartimento prevenzione e comunicazione, Ministero della salute,
Roma
Stefania VASSELLI
Dipartimento di prevenzione, ASL Caserta 2
Angelo D’ARGENZIO
Direzione promozione della salute, Azienda provinciale per i servizi sanitari, Trento
Pirous FATEH–MOGHADAM
Ufficio di statistica, Istituto superiore di sanità, Roma
Giada MINELLI
Dipartimento prevenzione AUSL Roma C
Massimo O. TRINITO
Zadig
Eva BENELLI, Stefano MENNA
Extra slides
Data on health behaviours
• Collected by National Institute of
Statistics (ISTAT) with several
limitations:
–
–
–
–
quinquennial surveys
national and regional level
delay in dissemination of data
items included not always useful for public
health planning and evaluation
 lack of data on health behaviour at LHU
level, where many health interventions
are planned and (sometimes) evaluated
Gaining Health
86% of deaths and 77% of the disease burden in the WHO
European Region are caused by non-communicable diseases
Gaining Health is the European strategy to tackle the most
important behavioral risk factors linked to this group of disorders
Guadagnare Salute
In 2007 the Italian Ministry of Health
(MoH) approved the programme
“Guadagnare Salute”, designed to
improve the quality of life and well-being
of people through health promotion
A national system, a local implementation
All 21 Italian Regions
agreed to participate
Emilia-Romagna
PASSI is focused on
Italy’s 180+ Local
Health Units (LHU)
LHU of Bologna
The technological infrastructure of PASSI:
an innovative system using free and open-source software
• e-Passi: a web-based infrastructure to collect, centralize
and analyze data
• Because of technological heterogeneity among local
health units and variable technical capacities among
users, the infrastructure must be flexible, user-friendly,
and independent of local hardware and software
installations
• A smart client application that uses a readily-available
internet browser for:
– stand-alone functions for data entry and real-time record
saving (XML format) on interviewers’ computers
– interview tracking (assignment, current status)
– CATI-like data entry
– automatic and secure (SSL) upload of completed
interviews
Source: Paolo Brunetti, Gabriele Dallago, Steno Fontanari, Stefano Menegon
BMI, Overweight and obese
Pooled data - 2008 (n=37.560)
BMI >25
70
55
60
50
40
32
%
30
20
10
10
3
0
Underw eight
Norm al
w eight
Overw eight
Obese
Seat belt and helmet use
Seat belt use - front seat (%)
Pool PASSI 2008
Seat belt use – back
seat (%)
Pool PASSI 2008
Helmet use (%)
Pool PASSI 2008
Pap-smear during the last 3 years (%)
Women 25-64 (PASSI 2008)
Valori %
84 - 91
80 - 84
66 - 80
48 - 66
No dati
75%
(n. 15.531)
Range: 48% Sardegna - 91% Valle d’Aosta
Pap smear: organized screening
programmes vs. spontaneous screening
(PASSI 2008)
Regions with organized
screening
within the last 12
months
Regions without
organized screening
45%
1-3 years ago
37%
within the last 12
months
1-3 years ago
more than 3 years ago
9%
more than 3 years ago
Never
9%
Never
0
10
20
82%
30
40
50
respects the recommended time limit
42%
27%
12%
19%
0
10
20
69%
30
40
50
respects the recommended time limit
Trends over time:
FOBT in Emilia-Romagna
80
Soglia di desiderabilità
60
54
Soglia di accettabilità
48
40
28
20
5
0
Passi 2005
%
Passi 2006
Passi 2007
Passi 2008 - I
semestre
Training plan
•
Promoting the professional development of local and
regional staff is one of the main objectives of the project
• Training activities:
1) short courses for the start-up of the system
– stepwise process involving regional and local coordinators
and interviewers
– completed in all Regions
2) two year cycle of courses and supervised activities on
surveillance systems, communication, and public health
interventions leading to a Master’s degree in
Epidemiology and Surveillance (in cooperation with Tor
Vergata University, Rome)
3) Ongoing annual training programmes on national, regional
and local level
PASSI on the Internet
The web site offers news, documentation and other services
for the network and the public health community (forums,
material for training activities, etc.)
www.epicentro.iss.it/passi
PASSI-one: a monthly newsletter for the
surveillance network, in electronic format,
freely downloadable from the web site
15 issues already published
Under construction
• Data analyses (2009) on
regional and local level:
– Epi-info programme codes
– Blue-print of reports
• Release of dataset 2007-2009
 possibility of subgroup and
trend analyses
• Development of web-site for
interactive data interrogation
• More scientific pubblications on
international journals
Delivered to
Regions&LHU by
coordinating group