Azzurra Massimi

Policy and planning of prevention in Italy: Results from an appraisal of prevention plans developed by Regions for the period 2010–2012

Health policies on disease prevention differ widely between countries. Studies suggest that different countries have much to learn from each other and that significant health gains could be achieved if all countries followed best practice. This paper describes the policy development and planning process relating to prevention activities in Italy, through a critical appraisal of Regional Prevention Plans (RPPs) drafted for the period 2010-2012. The analysis was performed using a specific evaluation tool developed by a Scientific Committee appointed by the Italian Ministry of Health. We appraised nineteen RPPs, comprising a total of 702 projects, most of them in the areas of universal prevention (62.9%) and prevention in high risk groups (27.0%). Italian Regions established prevention activities using an innovative combination of population and high-risk individuals approaches. However, some issues, such as the need to reduce health inequalities, were poorly addressed. The technical drafting of RPPs required some improvement; e.g. the evidence of the effectiveness and cost-effectiveness of the health interventions proposed was seldom reported. There were significant geographical differences across the Regions in the appraisal of RPPs. Our research suggests that continuous assessment of the planning process of prevention may become a very useful tool for monitoring, and ultimately strengthening, public health capacity in the field of prevention. Further research is needed to analyze determinants of regional variation.

The negative effect of financial constraints on planning prevention activities: some evidence from the Italian experience.

This study was aimed to assess the association between regional financial deficits and Recovery Plans and the quality of the 702 projects developed by the Italian Regions within the National Prevention Plan 2010–13. Multivariate analyses showed significant associations between Recovery Plans and low quality of projects, possibly due to weak regional public health capacities. Regions with Recovery Plans are likely to focus mainly on short-term issues with a high impact on health care costs, leaving few resources available for prevention. A different approach to financial deficit focused on long-term strategies, including those for health promotion and disease prevention, is needed.

Are community-based nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis

The expansion of primary care and community-based service delivery systems is intended to meet emerging needs, reduce the costs of hospital-based ambulatory care and prevent avoidable hospital use by the provision of more appropriate care. Great emphasis has been placed on the role of self-management in the complex process of care of patient with long-term conditions. Several studies have determined that nurses, among the health professionals, are more recommended to promote health and deliver preventive programs within the primary care context. The aim of this systematic review and meta-analysis is to assess the efficacy of the nurse-led self-management support versus usual care evaluating patient outcomes in chronic care community programs. Systematic review was carried out in MEDLINE, CINAHL, Scopus and Web of Science including RCTs of nurse-led self-management support interventions performed to improve observer reported outcomes (OROs) and patients reported outcomes (PROs), with any method of communication exchange or education in a community setting on patients >18 years of age with a diagnosis of chronic diseases or multi-morbidity. Of the 7,279 papers initially retrieved, 29 met the inclusion criteria. Meta-analyses on systolic (SBP) and diastolic (DBP) blood pressure reduction (10 studies—3,881 patients) and HbA1c reduction (7 studies—2,669 patients) were carried-out. The pooled MD were: SBP -3.04 (95% CI -5.01—-1.06), DBP -1.42 (95% CI -1.42—-0.49) and HbA1c -0.15 (95% CI -0.32–0.01) in favor of the experimental groups. Meta-analyses of subgroups showed, among others, a statistically significant effect if the interventions were delivered to patients with diabetes (SBP) or CVD (DBP), if the nurses were specifically trained, if the studies had a sample size higher than 200 patients and if the allocation concealment was not clearly defined. Effects on other OROs and PROs as well as quality of life remain inconclusive.

The need to improve implementation and use of lifestyle surveillance systems for planning prevention activities: an analysis of the Italian Regions.

OBJECTIVES To describe the level of use of lifestyle surveillance systems in Italy and to identify predictors of their use by the Italian Regions for planning and monitoring purposes. STUDY DESIGN Data were extracted from the 19 Regional Prevention Plans (RPPs) and the health promotion and prevention projects included in them developed by the Italian Regions within the National Prevention Plan 2010-2013. METHODS The 19 RPPs and the 702 projects were appraised using a tool specifically developed for the purpose. Multiple logistic regression was performed to identify predictors of use of surveillance systems in the 359 projects that could use them. RESULTS The analysis of regional epidemiological contexts does not always rely upon surveillance system data and there were too few projects aimed at the maintenance and the development of these systems. Moreover, fewer than half of projects that could have used surveillance systems for planning and evaluation procedures actually did so, despite the potential value of these data. There was a statistically significant association between Regional Health Care Expenditure (RHCE) and the use of surveillance system data for planning and/or evaluation of the projects (OR 7.81, 95% CI 2.86-21.29). CONCLUSIONS Use of surveillance systems for regional prevention planning in Italy is not optimal due to late implementation, presence of different data collecting systems and RGDP inequalities. There is a pressing need for full implementation of surveillance systems to allow better definition of the priorities and objectives of public health interventions.

Correction: Patient experience and utility of genetic information: a cross-sectional study among patients tested for cancer susceptibility and thrombophilia

We evaluated whether genetic tests with evidence of clinical and personal utility (i.e. APC and BRCA1/2 tests) are associated with higher satisfaction and a more positive perception of care experience than those with undefined utility (i.e. tests for thrombophilia). A cross-sectional survey was performed through telephone interviews to patients tested for deleterious variants in APC or BRCA1/2 genes, or for inherited thrombophilia (FV Leiden and/or FIIG20210A) during a 5-year period (2008–2012). Three aspects of patient experience were assessed: effective communication through pre- and post-test genetic counselling; collaboration between caregivers on the management of patient care; and impact of genetic testing on quality of life. Overall 237 patients had telephone interviews. Multivariate logistic regression analyses showed that patients tested for APC or BRCA1/2 variants were more likely to be satisfied with both pre- and post-test counselling than those tested for inherited thrombophilia (APC vs. thrombophilia, p = 0.039 and 0.005; BRCA1/2 vs. thrombophilia, p = 0.030 and <0.001). Patients tested for APC were more likely to report an improvement in quality of life than those for thrombophilia (OR = 2.97, 95%CI 1.14, 7.72; p = 0.025). A positive association was observed between patients who underwent BRCA1/2 testing, and self-perceived improvement in quality of life (OR = 1.41, 95%CI 0.74, 2.69; p = 0.294). Tests of undefined clinical and personal utility are associated with a lower degree of patient satisfaction with genetic counselling and no clear opinions on changes in quality of life compared with those with well-defined utility.

Familial Hypercholesterolemia: A Systematic Review of Guidelines on Genetic Testing and Patient Management

Background Familial hypercholesterolemia (FH) is an autosomal-dominant hereditary disorder of lipid metabolism that causes lifelong exposure to increased LDL levels resulting in premature coronary heart disease and, if untreated, death. Recent studies have shown its prevalence to be higher than previously considered, which has important implications for the mortality and morbidity of associated cardiovascular disease (CVD). Several clinical tools are used worldwide to help physicians diagnose FH, but nevertheless most patients remain undetected. This systematic review of guidelines aims to assess the role of genetic testing in the screening, diagnosis, and management of patients affected by heterozygous or homozygous FH and to identify related health-care pathways. Methods We performed a systematic review of the literature; inclusion criteria were English or Italian guidelines focusing on genetic testing. The guidelines were included and evaluated for their content and development process using the Appraisal of Guidelines for Research and Evaluation II instrument. Results Ten guidelines were considered eligible, and all were judged to be of good quality, with slight differences among them. The most common indications for performing genetic tests were high levels of cholesterol, or physical findings consistent with lipid disorder, in the subject or in the family history. Subsequent screening of family members was indicated when a mutation had been identified in the index patient. Regarding patient management, the various guidelines agreed that intensive treatment with lipid-lowering medications should begin as quickly as possible and that lifestyle modifications should be an integral part of the therapy. Conclusion Since the early detection of affected patients is beneficial for effective prevention of CVD, genetic testing is particularly useful for identifying family members via cascade screening and for distinguishing between heterozygous and homozygous individuals, the latter of which require more extreme therapeutic intervention.

Are knowledge and skills acquired during the Master Degree in Nursing actually put into practice? A pilot study in Italy

Background. Literature on the evaluation of the Master’s Degree in Nursing is scarce. The objective of this pilot study was to test a questionnaire aimed at monitoring the activities of nurses after receiving the Master’s degree. Methods. An electronic questionnaire was administered to 36 graduates who obtained the Master’s degree during the academic year 2010/2011. Results. Almost 80% of the participants judged their level of improvement in knowledge and skills during the course to have been satisfactory, but the level of implementation of these competencies at work was quite low. Conclusion. Competencies acquired during the Master’s degree course are not always put into practice.

Maternal Smoking and Socio-Demographic Characteristics in Correlation with Low Birth Weight: A Turin (Piedmont) Study

Abstract Introduction. 15 to 25% of women smoke during pregnancy. Scientific evidence suggests that exposure to smoking causes decreased birth weight. The aim of this study was to assess the correlation between smoking during pregnancy, maternal sociodemographic characteristics, and low birth weight. Methods. Data were derived from 1572 questionnaires administered to each woman that gave birth at the Gynecology Teaching Hospital “S. Anna” in Turin (Italy) during the period from 2008 to 2010. Multiple logistic analysis was used to evaluate the association between socio-demographic characteristics and birth weight; the stepwise approach with a “backward elimination” procedure was followed, and the goodness of fit of the model was estimated using the Hosmer-Lemeshow test. Results. The univariate analysis revealed that smoking cigarettes (17%), having a lower educational level (13%), and female sex of the infant (13%) seem to be risk factors, as they increase the risk of having a low birth weight child. Logistic regression analysis showed that gestational age and maternal smoking are the statistically associated variables. Conclusions. The results confirmed that birth weight increases proportionally with the length of the gestational age and that maternal smoking and the child’s sex (female) increase the risk of having a lower birth weight. Logistic regression demonstrated that the association between maternal smoking and low birth weight shows an increased risk for the whole population (OR=2.85), for male (OR=3.45) and for female newborns (OR=2.44) Izvleček Uvod. Med nosečnostjo kadi 15 % do 25 % žensk. Znanstveni dokazi kažejo, da izpostavljenost kajenju povzroča nižjo porodno težo. Cilj te študije je oceniti povezavo med kajenjem med nosečnostjo, socialnodemografskimi značilnostmi matere in nizko porodno težo. Metode. Podatki so bili pridobljeni iz 1572 vprašalnikov, ki so jih izpolnile vse ženske, ki so v obdobju od leta 2008 do leta 2010 rodile v učni bolnišnici za ginekologijo »S. Anna« v Torinu (Italija). Za oceno povezave med socialno-demografskimi značilnostmi in porodno težo je bila uporabljena multipla logistična analiza; sledil je postopni pristop z »vzvratnim izločanjem« in ocena ustreznosti modela s pomočjo Hosmer- Lemeshowega testa. Rezultati. Univariatna analiza je razkrila, da kajenje cigaret (17 %), nižja stopnja izobrazbe (13 %) in ženski spol dojenčka (13 %) predstavljajo dejavnik tveganja, saj povečujejo tveganje, da bo imel otrok nizko porodno težo. Analiza z logistično regresijo je pokazala, da sta gestacijska starost in kajenje matere statistično povezani spremenljivki. Zaključki. Rezultati potrjujejo, da se porodna teža povečuje sorazmerno z gestacijsko starostjo ter da kajenje matere in spol otroka (ženski) povečujeta tveganje za nižjo porodno težo ob rojstvu. Logistična regresija dokazuje, da povezava med kajenjem matere in nizko porodno težo pomeni povečano tveganje za celotno populacijo (RO = 2,85), tako za novorojenčke moškega (RO = 3,45) kot tudi ženskega spola (RO = 2,44)

Quality and relevance of master degree education for the professional development of nurses and midwives

BACKGROUND Advanced education in nursing is essential to provide safe, high quality and efficient health services in line with population needs. However, there is an almost complete lack of studies on how nurses view the usefulness of post-graduate education for their current employment and for professional advancement. OBJECTIVES To evaluate how nurse graduates view the quality, relevance and applicability of the knowledge and skills acquired during the Master of Science in Nursing (MSN) degree. DESIGN Multicentre cross-sectional study. METHODS A multicenter cross-sectional study was carried out through an online questionnaire mailed (July 2014-June 2015) to 560 nurses who obtained the MSN degree from 23 Italian universities in the academic year 2010-2011. DISCUSSION A total of 426 nurses completed the survey (response rate 76.1%), 80% of whom believed they had acquired knowledge and skills useful in their professional life after graduation. A multiple logistic regression model highlighted the characteristics of nurse graduates who judged the masters course relevant for their present role. In brief, they are expert nurses (OR=3.41, 95% CI=1.54-7.54) who achieved professional growth after the course (OR=5.25, 95% CI=2.67-10.33) and who judged the course very good or excellent (OR=2.16, 95% CI=1.04-4.52). Only 8% of the respondents achieved a full professional growth after the course. CONCLUSION In Italy, MSN courses are able to provide a high level of skills and competencies. However, given the low rate of professional growth after the course, specific policies should increase the employment rates of new masters graduate nurses.

Childhood vaccinations. Validation of a tool for measuring knowledge, attitudes and vaccine hesitancy in pregnant women.

Background. The objective of this pilot study was to test a questionnaire aimed at assessing knowledge of and attitudes towards vaccination, as well as intention to vaccinate, among pregnant women. Methods. The questionnaire was self-administered by 49 pregnant women attending antenatal classes at three Family Centers in Rome. Results. Poor knowledge of vaccinations, inadequate attention from healthcare professionals, recurrent consultation of unreliable sources of information, and misconceptions about the side effects of vaccines, all contribute to vaccine hesitancy. Where appropriate, questionnaire sections were shown to be internally consistent. Conclusion. The questionnaire proved reliable and is suitable for further studies.