Online information about mammography screening in Italy from 2014 to 2021.

BACKGROUND: Many studies have reported that the information women receive about the risk-to-benefit ratio of breast cancer screening is still scarce and biased toward benefit. In a study we conducted in 2014, we analysed online documents about breast cancer screening that were addressed to the general female public. In the present study, we used the same methodology to verify if the information provided to women was improved. METHODS: We evaluated documents addressed to the general female public and posted on the Internet by the Italian national and regional public health services. False-positive and false-negative screening results, biopsy-proven false-positive results, interval cancer, overdiagnosis, radiation exposure, and decrease in risk of mortality were analysed. In addition, quantitative data were searched. RESULTS: In 2021, the most frequently reported information was reduction in breast cancer mortality (58.2%). The most frequently reported risk was a false-positive mammogram (42.5%). Similar frequency rates were reported for interval cancer, false-negative result, and radiation exposure (35.8%, 31.3%, and 28.3%, respectively). Overdiagnosis and biopsy-proven false-positive result were the less reported risks (20.1% and 10.4%). Thirteen documents provided quantitative data about reduction of mortality risk (16.7%), and only 19 provided quantitative data about risks or harms (8.4%). Almost all organisations sent letters of invitation to women (92.5%) and provided screening free of charge (92.5%). The most recommended was biennial screening for women aged between 50 and 69 years (48.5%). Compared with the information in 2014, that in 2021 showed some improvements. The most marked improvements were in the numbers of reports on overdiagnosis, which increased from 8.0 to 20.1%, and biopsy-proven false-positive result, which increased from 1.4 to 10.4%. Regarding the benefits of breast cancer screening, reduced mortality risk became increasingly reported from 2014 (34.5%) to 2021 (58.2%). Conversely, quantitative data remained scarce in 2021. CONCLUSIONS: Moderate improvements in information were observed from 2014 to 2021. However, the information on breast cancer screening in documents intended for women published on Italian websites remain scarce.

Evaluation of Patients' Perception of Safety in an Italian Hospital Using the PMOS-30 Questionnaire.

BACKGROUND: In our study, an Italian version of the PMOS-30 questionnaire was used to evaluate its feasibility and to improve health care quality in an Italian hospital. METHODS: A cross-sectional study was conducted with 435 inpatients at a hospital in the Campania Region of Southern Italy using the PMOS-30 questionnaire and two other questions to assess patient feedback about the overall perception of safety. RESULTS: The item "I was always treated with dignity and respect" showed the greatest percentage of agreement (agree/strongly agree = 89.2%; mean = 4.24). The least agreement was associated with the four "Staff Roles and Responsibilities" items (agree/strongly agree ranged from 31.5 to 40.0%; weighted mean = 2.84). All other 25 items had over 55.0% agreement, with 19 items over 70%. Moreover, 94.5% of the patients considered the safety of the ward sufficient/good/very good, and 92.8% did not notice situations that could cause harm to patients. CONCLUSION: Patient perception of safety was found to be satisfactory. The results were presented to the hospital decision makers for suggesting appropriate interventions. Our experience showed that the use of the PMOS-30 questionnaire may improve safety and health care quality in hospital settings through patient feedback.

Patient Satisfaction and Food Waste in Obstetrics And Gynaecology Wards.

INTRODUCTION: Patient satisfaction is an indicator of healthcare quality, and expectation is an important determinant. A component of patient satisfaction is the quality of foodservice. An indicator of this quality is the food wasted by hospitalised patients. In the present study, we investigated patient satisfaction regarding food and foodservice, the expectation on food quality and the amount of food wasted in two obstetrics and gynaecology wards in Northern and Southern Italy. PATIENTS AND METHODS: A questionnaire, including sociodemographic data, rate of food waste, expectations of food quality and characteristics of food and foodservice, was administrated to 550 inpatients in obstetrics and gynaecology wards (275 for each hospital). Univariate analysis was performed to describe the results, and multivariate analysis was carried out to control for sociodemographic data. RESULTS: Northern patients were more satisfied with the quality of food (54.2% vs 36.0%) and foodservice (54.5% vs 38.2%) than southern patients. Northern patients had more positive expectations about the quality of food (69.5% vs 31.6%), whereas southern patients stated that they had no expectations. Southern patients gave more importance to mealtime (72.7% vs 26.2%), and many of them brought food from home to the hospital (30.2% vs 2.2%) through relatives who came to visit them. Southern patients discarded about 41.7% of food served, whereas northern patients discarded only about 15.3%. DISCUSSION: Food waste is a worldwide problem due to its economic, social and environmental effects. Especially in hospitals, food waste could have a negative impact on the overall patient satisfaction.

Measuring Health Literacy in Southern Italy: A cross-sectional study.

INTRODUCTION: Health Literacy (HL) is an important determinant of individual health. Limited HL is an increasing problem affecting the general population. This study aims to assess the level of HL in patients attending outpatient medical facilities in general medicine located in Naples and Caserta and investigate the association of HL with health behaviours and health status. MATERIALS AND METHODS: The study involved patients attending outpatient medical facilities in general medicine. The questionnaire had four sections-the sociodemographic information, the 16-items version of the European Health Literacy Survey questionnaire, the general self-efficacy scale (GSE) and the health status scale (EQ-VAS). Univariate and multivariate analyses were performed to investigate the sociodemographic determinants of HL. The Pearson correlation coefficients were determined to compare HL with health behaviours (GSE) and health status (EQ-VAS). RESULTS: The study showed that 61.6% of 503 patients had a low level of HL. After the multivariate analysis, HL was found to be higher among patients with higher education level and general self-efficacy score ≥30. There were no differences in HL between the age groups and people with or without chronic diseases. HL was stronger correlated with GSE than with EQ-VAS (0.53 vs 0.27). CONCLUSION: This is the first study on HL for Southern Italy. It showed a low level of HL. As the sample was not representative of the reference population, we cannot derive a corresponding conclusion for the general population of Southern Italy. Therefore, more data in Italy are needed to plan actions for improving HL.

Breastfeeding with and without the WHO/UNICEF baby-friendly hospital initiative: A cross-sectional survey.

The World Health Organization and United Nations Children's Fund's Baby-Friendly Hospital Initiative is aimed at the global promotion, protection and support of breastfeeding. In this study, we compared breastfeeding-related information received, knowledge and behaviours among postpartum women in Baby-Friendly Hospital Initiative accredited and non-accredited hospitals. We selected 10 hospitals: 9 non-accredited hospitals in the Campania region in southern Italy and one accredited hospital in the Piedmont region in northern Italy. In total, 786 women (580 (73.8%) in Campania and 206 (26.2%) in Piedmont) in the hospitals' maternity wards completed a questionnaire comprising 5 sections within 24 to 72hours after giving birth. The questionnaire investigated breastfeeding activities in the days immediately following childbirth, as well as the information provided by health personnel, knowledge about breastfeeding before and during hospitalisation, and participation in antenatal classes. To evaluate the comparison between the 2 regions, we performed at first a bivariate analysis and then a multinomial and a multivariate logistic regression. Compared with Piedmont, in Campania hospitals there was a rate of breastfeeding of 44.3% vs 89.3%, a skin-to-skin contact between mother and child of 74.5% vs 90.7% and first milk feed within 2hours of 15.0% vs 87.2%. The Campania group had fewer problems with child latching. The Campania group reported receiving less information about breastfeeding in general compared with the Piedmont group. In general, both groups showed good basic knowledge about different aspects of breastfeeding. In both regions, about 90% reported that the information received during the antenatal classes simplified the breastfeeding experience. Our study confirms the importance of systematic promotion of breastfeeding and subsequent delivery of adequate support to maternity departments, in accordance with international guidelines.

Patient Evaluation of Food Waste in Three Hospitals in Southern Italy.

In recent years, food waste has received great attention and is now considered the cause of many negative effects, including health, economic, social and environmental issues. A cross-sectional study was conducted among a sample of 762 inpatients at three hospitals of Campania region in Italy. The purpose of this study was to evaluate the amount of food waste occurring in these hospitals using a structured questionnaire and asking inpatients about the average percentage of food they had disposed of in the previous three days. The overall food wasted amounted to 41.6%. The main plates, first (pasta or rice), second plate (meat or fish), resulted in similar amounts of waste (38.5% and 39.7%, respectively). The side plate (vegetable or potatoes), however, generated the greatest amount of waste (55.0%); 40.7% of patients totally discarded this part of their meals. The type of food wastage among the three hospitals reflected similar patient behaviours, with the amount of food wasted never falling below 30%. Females tended to waste more food than males (59.1% vs. 38.2%; p = 0.000). Other variables were correlated with less food waste, such as having a good opinion of the food's quality (RR = 1.91; 95% C.I. = 1.68-2.17) and satisfaction with the foodservice in general (RR = 1.86; 95% C.I. = 1.64-2.10). Poor quality, different eating habits and the feeling of satiety were the main reasons patients gave for food waste. Our study suggests that the most promising way to reduce food waste in hospitals is to improve the quality of meals and to establish an individual, simplified and flexible meal reservation process based on specific needs and preferences.

The Discrimination Against, Health Status and Wellness of People Who Use Drugs in Italian Services: A Survey.

Background and Objectives: The aims of this study are to: describe the sociodemographic characteristics and typology of drug addiction among people who use drugs that attend the Servizio per le Dipendenze (SerD), and evaluate the competence and ability of these rehabilitation services to improve their health status and wellness. Materials and Methods: A cross-sectional study was conducted from January to July 2017. Patients attending two selected SerD facilities in the city of Naples, Italy were interviewed with a questionnaire gathering information on sociodemographic data, characteristics of drug addiction, characteristics of enrolment at the SerD, self-reported health status and wellness, and reports of the discrimination suffered. Results: Among the 451 people interviewed, 72.3% had started taking drugs by the age of 20, and half of them have used drugs within the last year. 54.5% of responders attended SerD for more than 10 years, and the two main reasons for attendance were to get help and to get methadone. 79.4% were declared to have a good/very good/excellent health status at the time of interviewing. 53.7% reported suffering from discrimination. Conclusions: Based on our study, discrimination is higher in participants who attended SerD for more than one year, who were formerly in prison, or who were current drug users.

Does written informed consent adequately inform surgical patients? A cross sectional study.

BACKGROUND: Informed consent (IC) is an essential step in helping patients be aware of consequences of their treatment decisions. With surgery, it is vitally important for patients to understand the risks and benefits of the procedure and decide accordingly. We explored whether a written IC form was provided to patients; whether they read and signed it; whether they communicated orally with the physician; whether these communications influenced patient decisions. METHODS: Adult postsurgical patients in nine general hospitals of Italy's Campania Region were interviewed via a structured questionnaire between the second and seventh day after the surgery at the end of the first surgical follow up visit. Physicians who were independent from the surgical team administered the questionnaire. RESULTS: The written IC form was given to 84.5% of those interviewed. All recipients of the form signed it, either personally or through a delegate; however, 13.9% did not know/remember having done so; 51.8% said that they read it thoroughly. Of those who reported to have read it, 90.9% judged it to be clear. Of those receiving the written consent form, 52.0% had gotten it the day before the surgery at the earliest 41.1% received it some hours or immediately before the procedure. The written IC form was explained to 65.6% of the patients, and 93.9% of them received further oral information that deemed understandable. Most attention was given to the diagnosis and the type of surgical procedure, which was communicated respectively to 92.8 and 88.2% of the patients. Almost one in two patients believed that the information provided some emotional relief, while 23.2% experienced increased anxiety. Younger patients (age ≤ 60) and patients with higher levels of education were more likely to read the written IC form. CONCLUSIONS: The written IC form is not sufficient in assuring patients and making them fully aware of choices they made for their health; pre-operative information that was delivered orally better served the patients' needs. To improve the quality of communication we suggest enhancing physicians' communication skills and for them to use structured conversation to ensure that individuals are completely informed before undergoing their procedures.

Too much medicine? Scientific and ethical issues from a comparison between two conflicting paradigms.

BACKGROUND: The role of medicine in society appears to be focused on two views, which may be summarized as follows: "Doing more means doing better" (paradigm A) and "Doing more does not mean doing better" (paradigm B). MAIN BODY: I compared paradigms A and B both in terms of a single clinical condition and in the general context of a medical system. For a single clinical condition, I analyzed breast cancer screening. There are at least seven interconnected issues that influence the conflict between paradigms A and B in the debate on breast cancer screening: disconnection between research and practice; scarcity of information given to women; how "political correctness" can influence the choice of a health policy; professional interests; doubts about effectiveness; incommensurability between harms and benefits; and the difficulty in making dichotomous decisions with discrete variables. As a general approach to medicine, the main representative of paradigm A is systems medicine. As representatives of paradigm B, I identified the following approaches or movements: choosing wisely; watchful waiting; the Too Much Medicine campaign; slow medicine; complaints against overdiagnosis; and quaternary prevention. I showed that both as a single condition and as a general approach to medicine, the comparison was entirely reducible to a harm-benefit analysis; moreover, in both cases, the two paradigms are in many respects incommensurable. This transfers the debate to the ethical level; consequently, scientists and the public have equal rights and competence to debate on this subject. Moreover, systems medicine has many ethical problems that could limit its spread. CONCLUSION: I made some hypotheses about scenarios for the future of medicine. I particularly focused on whether systems medicine would become increasingly accessible and widespread in the population or whether it would be downsized because its promises have not been maintained or ethical problems will become unsustainable.

Lying to patients with dementia: Attitudes versus behaviours in nurses.

BACKGROUND: Using lies, in dementia care, reveals a common practice far beyond the diagnosis and prognosis, extending to the entire care process. OBJECTIVES: In this article, we report results about the attitude and the behaviour of nurses towards the use of lies to patients with dementia. RESEARCH DESIGN: An epidemiological cross-sectional study was conducted between September 2016 and February 2017 in 12 elderly residential facilities and in the geriatric, psychiatric and neurological wards of six specialised hospitals of Italy's Campania Region. PARTICIPANTS: In all, 106 nurses compiled an attitude questionnaire (A) where the main question was 'Do you think it is ethically acceptable to use lies to patients with dementia?', instead 106 nurses compiled a behaviour questionnaire (B), where the main question was 'Have you ever used lies to patients with dementia?' ETHICAL CONSIDERATIONS: Using lies in dementia care, although topic ethically still controversial, reveals a common practice far beyond the diagnosis and prognosis, extending to the entire care process. FINDINGS: Only a small percentage of the interviewed nurses stated that they never used lies/that it is never acceptable to use lies (behaviour 10.4% and attitude 12.3%; p = 0.66). The situation in which nurses were more oriented to use lies was 'to prevent or reduce aggressive behaviors'. Indeed, only the 6.7% in the attitude group and 3.8% in the behaviour group were against using lies. On the contrary, the case in which the nurses were less oriented to use lies was 'to avoid wasting time giving explanations', in this situation were against using lies the 51.0% of the behaviour group and the 44.6% of the attitude group. CONCLUSION: Our results, according to other studies, support the hypothesis of a low propensity of nurses to ethical reflection about use of lies. In our country, the implementation of guidelines about a correct use of lie in the relationship between health operators and patients would be desirable.

Online information about risks and benefits of screening mammography in 10 European countries: An observational Web sites analysis.

Most publications about breast cancer do not provide accurate and comprehensive information, giving few or no data about risk/benefit ratios. We conducted a comparative study among 10 European countries about health information on breast cancer screening, assessing the first 10 Web sites addressing the general public that appeared following an Internet search.With the help of medical residents involved in the EuroNet MRPH Association, we analyzed the first 30 results of an Internet search in 10 European countries to determine the first 10 sites that offered screening mammography. We searched for the following information: source of information, general information on mammography and breast cancer screening, potential harms and risks (false positives, false positives after biopsy, false negatives, interval cancer, overdiagnosis, lead-time bias, and radiation exposure), and potential benefits (reduced mortality and increased survival).The United Kingdom provided the most information: 39 of all 70 possible identified risks (56%) were reported on its sites. Five nations presented over 35% of the possible information (United Kingdom, Spain, France, Ireland, and Italy); the others were under 30% (Portugal, Poland, Slovenia, Netherlands, and Croatia). Regarding the benefits, sites offering the most complete information were those in France (95%) and Poland (90%).Our results suggest that, despite consensus in the scientific community about providing better information to citizens, further efforts are needed to improve information about breast cancer screening. That conclusion also applies to countries showing better results. We believe that there should be greater coordination in this regard throughout Europe.

A standardized antenatal class reduces the rate of cesarean section in southern Italy: A retrospective cohort study.

Italy, along with Poland and Hungary, has the highest cesarean section rate (35.7%) in Europe. Among Italian regions, Campania has the highest rate of cesarean section (58.4%).We developed a standardized antenatal class to evaluate whether women who attend this class during pregnancy have a lower cesarean section rate. This antenatal class was developed according to the indication of the Italian Ministry of Health and the World Health Organization. We selected a cohort of women who participated in this antenatal class and a cohort of women who did not participate. We collected information on the mode of delivery, and other characteristics, of these women from certificate of birth assistance form available in 2 hospitals where the women gave birth.Among women who participated in the antenatal class, there were more Italians, the women were more educated, more women were employed and there were more primiparas compared with those who did not participate. Non-participants of antenatal class showed a higher rate of cesarean section than those who participated (56.2% vs 23.1%; relative risk [RR] = 2.43; 95% confidence interval [CI] 1.95-3.03; P < .0001), as well as after adjustment for other variables. This difference was stronger in 1 hospital (RR = 2.88; 95% CI 2.13-3.89; P < .0001) than in the other hospital (RR = 1.86; 95% CI 1.36-2.55; P < .0001).Our standardized antenatal class, which was performed in an area with a high rate of cesarean section, significantly reduced this rate, and this was still significant after adjustment for potential confounders.

Pollen concentrations and prevalence of asthma and allergic rhinitis in Italy: Evidence from the GEIRD study.

BACKGROUND: Pollen exposure has acute adverse effects on sensitized individuals. Information on the prevalence of respiratory diseases in areas with different pollen concentrations is scanty. AIM: We performed an ecologic analysis to assess whether the prevalence of allergic rhinitis and asthma in young adults varied across areas with different pollen concentrations in Italy. METHODS: A questionnaire on respiratory diseases was delivered to random samples of 20-44year-old subjects from six centers in 2005-2010. Data on the daily air concentrations of 7 major allergologic pollens (Poaceae, Urticaceae, Oleaceae, Cupressaceae, Coryloideae, Betula and Ambrosia) were collected for 2007-2008. Center-specific pollen exposure indicators were calculated, including the average number of days per year with pollens above the low or high concentration thresholds defined by the Italian Association of Aerobiology. Associations between pollen exposure and disease prevalence, adjusted for potential confounders, were estimated using logistic regression models with center as a random-intercept. RESULTS: Overall, 8834 subjects (56.8%) filled in the questionnaire. Allergic rhinitis was significantly less frequent in the centers with longer periods with high concentrations of at least one (OR per 10days=0.989, 95%CI: 0.979-0.999) or at least two pollens (OR=0.974, 95%CI: 0.951-0.998); associations with the number of days with at least one (OR=0.988, 95%CI: 0.972-1.004) or at least two (OR=0.985, 95%CI: 0.970-1.001) pollens above the low thresholds were borderline significant. Asthma prevalence was not associated with pollen concentrations. CONCLUSIONS: Our study does not support that the prevalence of allergic rhinitis and asthma is greater in centers with higher pollen concentrations. It is not clear whether the observed ecologic associations hold at the individual level.

Can antenatal classes reduce the rate of cesarean section in southern Italy?

BACKGROUND: Among European Countries, Italy has the highest rate of cesarean section (36.8%), and in the Campania region this rate reaches 60.0%. QUESTION: We conducted a retrospective cohort study to evaluate whether participation in antenatal classes during pregnancy reduces the rate of cesarean delivery in southern Italy. METHODS: We selected three local health authorities, with the lowest, the highest, and an intermediate rate of cesarean delivery. The study included 1893 mothers who brought their children for vaccination and were interviewed about their participation in antenatal classes and their obstetric history. FINDINGS: The main causes of cesarean section given in the interview were clinical indications (61.0%), previous cesarean section (31.0%) and woman's request (8.0%). When we excluded emergency cesarean delivery, we found a moderate association between participation in antenatal classes and cesarean section reduction (relative risk=1.27; 95% CI=1.08-1.49; in percentage values from 49.3% to 38.8%). Private hospitals and the two local health authorities with higher baseline rates of cesarean section showed an enhanced reduction of these rates. CONCLUSION: Our paper shows moderate efficacy of antenatal classes, which reduced the occurrence of cesarean section by about 10%. However, the cesarean section rate remained high. As it is possible that different classes have a different level of efficacy, a further study on a standardized model of an antenatal classes is in progress, to assess its efficacy in term of cesarean section reduction, with the purpose of its widespread implementation to the whole region.

Scarce information about breast cancer screening: An Italian websites analysis.

Although the public should have complete and correct information about risk/benefit ratio of breast cancer screening, public knowledge appears generally scarce and oriented to overestimate benefits, with little awareness of possible disadvantages of the screening.We evaluated any document specifically addressed to the general female public and posted on internet by Italian public health services. The presence of false positive, false positive after biopsy, false negative, interval cancer, overdiagnosis, lead-time bias, exposure to irradiation, and mortality reduction was analyzed.Of the 255 websites consulted, 136 (53.3%) had sites addressed to the female public. The most commonly reported information points were the false-positive (30.8% of sites) and radiation exposure (29.4%) rates. Only 11 documents mentioned overdiagnosis, 2 mentioned risk of false positive with biopsy, and only 1 mentioned lead-time bias. Moreover, only 15 sites (11.0%) reported quantitative data for any risk variables.Most documents about breast cancer screening published on the web for the female public contained little or no information about risk/benefit ratio and were biased in favor of screening.

Limitations of Western Medicine and Models of Integration Between Medical Systems.

This article analyzes two major limitations of Western medicine: maturity and incompleteness. From this viewpoint, Western medicine is considered an incomplete system for the explanation of living matter. Therefore, through appropriate integration with other medical systems, in particular nonconventional approaches, its knowledge base and interpretations may be widened. This article presents possible models of integration of Western medicine with homeopathy, the latter being viewed as representative of all complementary and alternative medicine. To compare the two, a medical system was classified into three levels through which it is possible to distinguish between different medical systems: epistemological (first level), theoretical (second level), and operational (third level). These levels are based on the characterization of any medical system according to, respectively, a reference paradigm, a theory on the functioning of living matter, and clinical practice. The three levels are consistent and closely consequential in the sense that from epistemology derives theory, and from theory derives clinical practice. Within operational integration, four models were identified: contemporary, alternative, sequential, and opportunistic. Theoretical integration involves an explanation of living systems covering simultaneously the molecular and physical mechanisms of functioning living matter. Epistemological integration provides a more thorough and comprehensive explanation of the epistemic concepts of indeterminism, holism, and vitalism to complement the reductionist approach of Western medicine; concepts much discussed by Western medicine while lacking the epistemologic basis for their emplacement. Epistemologic integration could be reached with or without a true paradigm shift and, in the latter, through a model of fusion or subsumption.

Socioeconomic inequalities in smoking habits are still increasing in Italy.

BACKGROUND: Socioeconomic inequalities in smoking habits have stabilized in many Western countries. This study aimed at evaluating whether socioeconomic disparities in smoking habits are still enlarging in Italy and at comparing the impact of education and occupation. METHODS: In the frame of the GEIRD study (Gene Environment Interactions in Respiratory Diseases) 10,494 subjects, randomly selected from the general population aged 20-44 years in seven Italian centres, answered a screening questionnaire between 2007 and 2010 (response percentage = 57.2%). In four centres a repeated cross-sectional survey was performed: smoking prevalence recorded in GEIRD was compared with prevalence recorded between 1998 and 2000 in the Italian Study of Asthma in Young Adults (ISAYA). RESULTS: Current smoking was twice as prevalent in people with a primary/secondary school certificate (40-43%) compared with people with an academic degree (20%), and among unemployed and workmen (39%) compared with managers and clerks (20-22%). In multivariable analysis smoking habits were more affected by education level than by occupation. From the first to the second survey the prevalence of ever smokers markedly decreased among housewives, managers, businessmen and free-lancers, while ever smoking became even more common among unemployed (time-occupation interaction: p = 0.047). At variance, the increasing trend in smoking cessation was not modified by occupation. CONCLUSION: Smoking prevalence has declined in Italy during the last decade among the higher socioeconomic classes, but not among the lower. This enlarging socioeconomic inequality mainly reflects a different trend in smoking initiation.

Complexity and indeterminism of evidence-based public health: an analytical framework.

Improving the evidence in public health is an important goal for the health promotion community. With better evidence, health professionals can make better decisions to achieve effectiveness in their interventions. The relative failure of such evidence in public health is well-known, and it is due to several factors. Briefly, from an epistemological point of view, it is not easy to develop evidence-based public health because public health interventions are highly complex and indeterminate. This paper proposes an analytical explanation of the complexity and indeterminacy of public health interventions in terms of 12 points. Public health interventions are considered as a causal chain constituted by three elements (intervention, risk factor, and disease) and two levels of evaluation (risk factor and disease). Public health interventions thus differ from clinical interventions, which comprise two causal elements and one level of evaluation. From the two levels of evaluation, we suggest a classification of evidence into four typologies: evidence of both relations; evidence of the second (disease) but not of the first (risk factor) relation; evidence of the first but not of the second relation; and no evidence of either relation. In addition, a grading of indeterminacy of public health interventions is introduced. This theoretical point of view could be useful for public health professionals to better define and classify the public health interventions before acting.

The informed consent in Southern Italy does not adequately inform parents about infant vaccination.

BACKGROUND: Vaccination centres in the Campania Region, southern Italy, vaccinate children with a hexavalent vaccine that contains the mandatory vaccines diphtheria, tetanus, poliomyelitis, and viral Hepatitis B. This vaccine also includes two non-mandatory vaccines, pertussis and Haemophilus influenzae type B. Information about these optional vaccines should be communicated to the parents, and informed consent should be obtained from parents before vaccination. We explored whether informed consent was delivered to the parents, whether they signed the consent form, and whether they read and acquired the information about the vaccination that their child would receive. METHODS: Childhood immunisations are provided at specific public health vaccination centres, "Unità Operative Materno-infantili's" (UOMIs). We selected four UOMI from the Campania Region where we interviewed 1039 parents bringing their children for the 1st, 2nd, or 3rd doses of hexavalent vaccine. The consent forms were collected from the four vaccination centres and were analysed with respect to clarity and completeness. RESULTS: Most of the respondents (89.5%) were mothers between 20 and 39 years of age (80.4% vs 59.6% of the fathers), they were married (87.2% vs 93.5% of the fathers), and only one-half of them were employed (50.2% vs 92.6% of the fathers). The informed consent form was received from 58.1% of the parents and signed by 52.8%, but read by 35.0% of them. Only 1.5% of parents knew which vaccines were mandatory, and 25.0% of them believed that the entire hexavalent vaccine was mandatory. When we asked the parents which non-mandatory vaccinations were administered to their children, only 0.5% indicated the Haemophilus influenzae type B and none indicated the pertussis vaccine. Thirty-six per cent of the parents replied that their child had not received any non-mandatory vaccines. No parents were informed by the operators that their children would receive non-mandatory vaccines. CONCLUSION: In our study, consent procedures did not allow parents to acquire correct information about vaccine options for their children. Furthermore, not one health care provider informed parents that their child was receiving non-mandatory vaccines. The informed consent process and the individual health care providers did not properly inform parents about the vaccines administered to their children.