Disuguaglianze

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.

Status In-Process

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.

METHODS: Grey and peer-reviewed literature, published after 1983, was reviewed from Europe and the USA.

RESULTS: Available data provide consistent indications that waste facilities are often disproportionally more located in areas with more deprived residents, or from ethnical minorities. This applies to waste incinerators, landfills, hazardous waste sites, legal and illegal. In studies considering health effects (mainly from Europe), risks are estimated with standardization for SES. Such standardization almost always decreases risk estimates for several cancers and reproductive outcomes. However, effect modification is not investigated in these studies.

CONCLUSIONS: The patterns of association between waste-related environmental pressures and SES suggest that some of the observed inequalities in exposure and health represent a case of environmental injustice as they are the result of social processes and may be prevented, at least partly. Disentangling the possible health effects remains difficult, due to limitations in the methodology. It seems important to investigate if disadvantaged people are more vulnerable, i.e. risks differ in different social groups living in the same area. Notwithstanding these open questions, public health officers and decision makers should identify waste management policies to minimize their potential health impacts and their unequal distribution.

Status In-Process

OBJECTIVES: We evaluated the association between PM(10) concentration and out-of-hospital coronary deaths in eight Italian cities during 1997-2004.
METHODS: 16 989 subjects aged >35 years who died out-of-hospital from coronary causes were studied and hospital admissions in the previous 2 years identified. We studied the effect of the mean of current and previous day PM(10) values (lag 0-1). A city-specific case-crossover analysis was applied using a time-stratified approach considering as confounders weather, holidays, influenza epidemics, and summer decrease in population. The pooled percentage increase (95% CI) in mortality per 10 microg/m(3) increase in PM(10) was estimated.
RESULTS: A statistically significant increase in out-of-hospital coronary deaths was related to a 10 microg/m(3) increase in PM(10): 1.46% (95% CI 0.50 to 2.43). Although no statistically significant effect modification by age was found, the effect was stronger among subjects aged >65 years (1.60%, 0.59 to 2.63), particularly those aged 65-74 (3.01%, 0.74 to 5.34). People in the lowest socio-economic category (3.34%, 1.28 to 5.45) had a stronger effect than those in the highest category. No clear effect modification was seen for gender, season or any specific comorbidity. An indication of negative effect modification was seen for previous admission for cardiac dysrhythmias. Subjects without hospital admissions in the previous 2 years were slightly more affected by PM(10) effects (1.91%, 0.28 to 3.47) than those with at least one previous hospital admission (1.44%, 0.09 to 2.82).
CONCLUSIONS: Our results show that short term exposure to PM(10) is associated with coronary mortality especially among the elderly and socio-economically disadvantaged. No clear effect modification by previous hospitalisations was detected except for cardiac dysrhythmias, possibly due to protective treatment.

BACKGROUND: The incidence of invasive cervical cancer in HIV-positive women is higher than in the general population. There is evidence that HIV-positive women do not participate sufficiently in cervical cancer screening in Italy, where cervical cancer is more than 10-fold higher in women with AIDS than in the general population. The aim of the present study was to evaluate the history of Pap-smear in HIV-positive women in Italy in recent years. We also examined the sociodemographic, clinical, and organizational factors associated with adherence to cervical cancer screening.

METHODS: A cross-sectional study was conducted between July 2006 and June 2007 in Emilia-Romagna region (Northern Italy). All HIV-positive women who received a follow-up visit in one of the 10 regional infectivology units were invited to participate. History of Pap-smear, including abnormal smears and subsequent treatment, was investigated through a self-administered anonymous questionnaire. The association between lack of Pap-smear in the year preceding the interview and selected characteristics was assessed by means of odds ratios (OR) and 95% confidence intervals adjusted for study centre and age.

RESULTS: A total of 1,002 HIV-positive women were interviewed. Nine percent reported no history of Pap-smear, and 39% had no Pap-smear in the year prior to the date of questionnaire (last year). The lack of Pap-smear in the last year was significantly associated with age <35 years (OR = 1.4, compared to age > or =45 years), lower education level (OR = 1.3), first HIV-positive test in the last 2 years (OR = 1.4), and CD4 count <200 cells/microl (OR = 1.6). Conversely, when women were advised by a gynecologist rather than other health workers to undergo screening, it significantly increased adherence. Non-significantly higher proportions of lack of Pap-smear in the last year were found in women born in Central-Eastern Europe (OR = 1.8) and Africa (OR = 1.3). No difference in history of Pap-smear emerged by mode of HIV-acquisition or AIDS status.Three hundred five (34%) women reported a previous abnormal Pap-smear, and of the 178 (58%) referred for treatment, 97% complied.

CONCLUSIONS: In recent years the self-reported history of Pap-smear in HIV-positive women, in some public clinics in Italy, is higher than previously reported, but further efforts are required to make sure cervical cancer screening is accessible to all HIV-positive women.

PURPOSE: To update the information on age at menarche in the Italian population and to verify the influence of genetic, nutritional, and socioeconomic factors on menarcheal age. Recent studies suggest that the magnitude of the secular trend toward an earlier age at menarche is slackening in industrialized countries.

METHODS: This multicenter study was conducted on a large, population-based sample of Italian high school girls (n = 3,783), using a self-administered questionnaire. The questionnaire was used to gather information on the girls, including demography, anthropometry, menarcheal date, regularity of menses, behavioral habits, and physical activity. The questionnaire was also used to gather information on parents, including demography and mothers' and sisters' menarcheal ages. The median age at menarche and its 95% confidence interval were estimated by means of Kaplan-Meier survival analysis. To identify the independent predictive factors of age at menarche, multivariate mixed-effects models were applied.

RESULTS: The median age at menarche of the subjects was 12.4 years (95% confidence interval: 12.34-12.46). The girls had their first menses approximately one-quarter of a year (median-0.13) earlier than did their mothers (p < .0001). Among all variables, parents' birth area, body mass index, family size, and the mother's menarcheal age were significantly and independently associated with age at menarche.

CONCLUSIONS: This study confirmed the reduction in the trend toward earlier menarche in Italy. The results also confirmed that genetic and nutritional factors are strong markers for early menarche. Currently, socioeconomic factors do not seem to play as significant a role as in the past.

This paper focuses on the differences in regional expenditure on health care in the attempt to verify how equitable is the pattern of health care supply across the Italian regions and whether disparities are related to the existing socioeconomic imbalances, especially in terms of the North-South divide. The analysis has been carried out according to an egalitarian view of equity. For several categories of health services simple concentration measures and an horizontal inequity index have been derived to quantify the degree of inequity due to the discrepancy between the actual regional expenditure and a "just" amount implied by need indicators. Findings are that richer areas spend more than the "fair" amount on hospital and residential care as well as on the overall health care system, whereas inequity favouring poorer areas occurs in the delivery of pharmacological and secondary care.

The paper investigated differences in the use of hospital care, out-patient care and pharmaceutical care in Piemonte, a region of northern Italy with 4,000,000 inhabitants, taking into account factors of need and supply, for capitation purposes. The study used a geographical design, with the municipalities as statistical units, and was based on integrated data from health and health service information systems, the population census and on the geographical distances among municipalities. Hierarchical regression models were fitted with the utilisation of services as the outcome variable and a set of direct and indirect factors of need and supply indicators as covariates. Higher health service consumption rates were observed for the most disadvantaged employment categories, in addition to the elderly. Distance from hospital was inversely correlated with the hospitalisation rate. A formula for determining capitation can be developed using age and indirect factors of need as weights.

The aim of this study is to investigate to what extent occupational exposures may explain socioeconomic inequalities in lung cancer incidence after adjusting for smoking and dietary factors. Analyses were based on a subsample of the European Prospective Investigation into Cancer and Nutrition (EPIC study), a prospective cohort. The analyses included 703 incident lung cancer cases among men in Denmark, the United Kingdom, Germany, Italy, Spain and Greece. The socioeconomic position was measured using the highest level of education. The estimates of relative indices of inequality (RII) were computed with Cox regression models. We first adjusted for smoking (with detailed information on duration and quantity) and dietary factors (fruits and vegetables consumption) and then for occupational exposures. The exposure to three carcinogens [asbestos, heavy metals and polycyclic aromatic hydrocarbons (PAH)] was analyzed. The occupational exposures explained 14% of the socioeconomic inequalities remaining after adjustment for smoking and fruits and vegetables consumption. The inequalities remained nevertheless statistically significant. The RII decreased from 1.87 (95% CI: 1.36-2.56) to 1.75 (1.27-2.41). The decrease was more pronounced when adjusting for asbestos than for heavy metals or PAH. Analyses by birth cohort suggested an effect of occupational exposures among older men, while due to small number of endpoints, no conclusion could be drawn about the role of occupational exposures in educational inequalities among younger men. Our study revealed that the impact of occupational exposures on socioeconomic inequalities in cancer incidence, rarely studied until now, exists while of modest magnitude.

Status In-Process

RESULTS: In multiple linear regression models, adjusted for age, education, place of birth and residence, and total energy intake, there was no significant association between the period of interview and MDS in both sexes. Subjects aged 55-64 years, those with high education, and those born in central and southern Italy showed the highest adherence to the Mediterranean diet in both sexes.

CONCLUSIONS: In this population, adherence to the Mediterranean diet showed no significant change over the last 15 years.

Status In-Process

METHODS: Comparable data on systemically administered antibiotics and socioeconomic determinants in 17 European countries were available between 2000 and 2005. We estimated an ad hoc econometric model by means of a hybrid log-log functional form and random effects generalised least squares regressions. Lagged values and the instrumental variable method were applied to address endogeneity of bacterial resistance and infections. Bacterial resistance was measured by the rate of penicillin non-susceptible Streptococcus pneumoniae isolates (PNSP) and methicillin-resistant Staphylococcus aureus (MRSA).

RESULTS: The population income, demographic structure, density of general practitioners and their remuneration method appeared to be significant determinants of antibiotic consumption. Although countries with higher levels of bacterial resistance exhibited significantly higher levels of per capita antibiotic use, ceteris paribus, the responsiveness of antibiotic use to changes in bacterial resistance was relatively low (0.09-0.18).

CONCLUSIONS: The study confirms that socioeconomic factors should be taken into account while explaining differences in outpatient antibiotic use across countries. The impact of supply-side factors and incentives attached to payment schemes for physicians need to be considered in government interventions to reduce inequalities and improve effectiveness in antibiotic utilisation.

Status In-Process

METHODS: Residents of Rome in October 2001 were selected. Individual and area-based SEP indices were available. GIS was used to obtain traffic indicators at residential addresses: distance from HTR (> = 10,000 vehicles/day), length of HTR, average daily traffic count, and traffic density within 150 meters of home. Hospitalisations in the 5-year period before enrolment were used to characterise health status. Logistic and linear regression analyses estimated the association between traffic exposure and socio-demographic characteristics.

RESULTS: We selected 1,898,898 subjects with complete SEP information and GIS traffic indicators. A total of 320,913 individuals (17%) lived within 50 meters of an HTR, and 14% lived between 50 and 100 meters. These proportions were higher among 75+ year-old subjects. Overall, all traffic indicators were directly associated with SEP, with people living in high or medium SEP areas or with a university degree more likely to be exposed to traffic than people living in low SEP areas or with a low level of education. However, an effect modification by area of residence within the city was seen and the association between traffic and SEP was reversed in the city centre.

CONCLUSIONS: A large section of the population is exposed to traffic in Rome. Elderly people and those living in areas of high and medium SEP tend to be more exposed. These findings are related to the historical stratification of the population within the city according to age and socioeconomic status.

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In-Process

METHODS: Data are derived from a 2005-6 World Health Organization collaborative study, to establish the relationships between different types of club and a range of health outcomes (self-perceived health, wellbeing and symptoms) and health-related behaviours (smoking, drinking). Multi-level logistic regression was used to assess the independent effects of club participation by controlling for gender and socioeconomic position. Data were compared across six countries.

RESULTS: All the considered outcomes, both in terms of perceived health and wellbeing and health behaviours were associated with participation in formal associations. The associations are in the expected direction (participation corresponding to better health) except for some particular association types.

CONCLUSIONS: Participation in formal associations seems supportive for good health and health behaviours in adolescence, and should be promoted in this age group.

Status In-Process