Trends in Net Survival from Vulvar Squamous Cell Carcinoma in Italy (1990-2015).

(1) Objective: In many Western countries, survival from vulvar squamous cell carcinoma (VSCC) has been stagnating for decades or has increased insufficiently from a clinical perspective. In Italy, previous studies on cancer survival have not taken vulvar cancer into consideration or have pooled patients with vulvar and vaginal cancer. To bridge this knowledge gap, we report the trend in survival from vulvar cancer between 1990 and 2015. (2) Methods: Thirty-eight local cancer registries covering 49% of the national female population contributed the records of 6274 patients. Study endpoints included 1- and 2-year net survival (NS) calculated using the Pohar-Perme estimator and 5-year NS conditional on having survived two years (5|2-year CNS). The significance of survival trends was assessed with the Wald test on the coefficient of the period of diagnosis, entered as a continuous regressor in a Poisson regression model. (3) Results: The median patient age was stable at 76 years. One-year NS decreased from 83.9% in 1990-2001 to 81.9% in 2009-2015 and 2-year NS from 72.2% to 70.5%. Five|2-year CNS increased from 85.7% to 86.7%. These trends were not significant. In the age stratum 70-79 years, a weakly significant decrease in 2-year NS from 71.4% to 65.7% occurred. Multivariate analysis adjusting for age group at diagnosis and geographic area showed an excess risk of death at 5|2-years, of borderline significance, in 2003-2015 versus 1990-2002. (4) Conclusions: One- and 2-year NS and 5|2-year CNS showed no improvements. Current strategies for VSCC control need to be revised both in Italy and at the global level.

Treatment patterns among patients with malignant pleural mesothelioma: An Italian, population-based nationwide study.

BACKGROUND: Malignant pleural mesothelioma (MPM) is a rare cancer with a poor prognosis. Centralization of rare cancer in dedicated centers is recommended to ensure expertise, multidisciplinarity and access to innovation. In Italy, expert centers for MPM have not been identified in all regions. We aimed to describe the treatment patterns among MPM patients across different Italian regions and to identify factors associated with the treatment patterns across the regions. METHODS: We performed an observational study on a random sample of 2026 MPM patients diagnosed in 2003-2008. We included 26 population-based registries covering 70% of the Italian population. To identify factors associated with treatment patterns, across the different regions, we fitted a multinomial logistic regression model adjusted by age, sex, stage, histology and hospital with thoracic surgical department. RESULTS: MPM patients mostly received chemotherapy alone (41%) or no cancer-directed therapy (36%) especially the older patients. The first course of treatment for MPM patients differed across regions. Patients from Piedmont, Liguria and Campania were more likely to receive no cancer-directed therapy; those living in Tuscany and Sicily were more likely to get surgery; patients from Marche and Lazio were more likely to receive chemotherapy. These differences were not explained by age, sex, stage, histology and availability of a thoracic surgery department. CONCLUSIONS: There is limited expertise available and lack of a network able to maximize the expertise available may contribute to explaining the results of our study. Our findings support the need to ensure the appropriate care of all MPM patients in reorganizing the health care services. KEY POINTS: Significant findings of the study: MPM patients mostly received chemotherapy alone or no cancer-directed therapy especially the older patients. The first course of treatment for MPM patients differed across Italian regions. WHAT THIS STUDY ADDS: Differences in MPM clinical management are not explained by the age, stage, histology nor by the availability of a thoracic surgery department. Limited expertise for MPM contribute to explaining the unequal access to appropriate care for MPM patients in Italy.

Incidence trends of vulvar squamous cell carcinoma in Italy from 1990 to 2015.

OBJECTIVE: The incidence of vulvar squamous cell carcinoma has increased for decades in most Western countries - a trend virtually restricted to women aged <50 or 60 years. In southern Europe, conversely, the trends have been insufficiently studied. This article reports a study from Italy. METHOD: Thirty-eight local cancer registries, currently covering 15,274,070 women, equivalent to 49.2% of the Italian national female population, participated. Invasive cancers registered between 1990 and 2015 with an International Classification of Diseases for Oncology, 3rd revision, topography code C51 and morphology codes compatible with vulvar squamous cell carcinoma (n = 6294) were eligible. Incidence trends were analysed using joinpoint regression models, with calculation of the estimated annual percent change (EAPC), and age-period-cohort models. RESULTS: Total incidence showed a regular and significant decreasing trend (EAPC, -0.96; 95% confidence interval (CI), -1.43 to -0.48). This was entirely accounted for by women aged ≥60 years (EAPC, -1.34; 95% CI, -1.86 to -0.81). For younger women, the EAPC between 1990 and 2012 was 1.20 (95% CI, 0.34 to 2.06) with a non-significant acceleration thereafter. This pattern did not vary substantially in a sensitivity analysis for the effect of geographic area and duration of the registry. The age-period-cohort analysis revealed a risk decrease in cohorts born between 1905 and 1940 and a new increase in cohorts born since 1945. CONCLUSIONS: The decreasing trend observed among older women and the resulting decrease in total rate are at variance with reports from most Western countries. Age-period-cohort analysis confirmed a decreasing trend for earliest birth cohorts and an opposite one for recent ones.

Sense of Coherence in Nurses: A Systematic Review.

Background: Nurses experience high levels of distress due to the nature of their work and workplaces; Antonovsky's salutogenic theory shows that individual and work-related factors can influence human health. The aim of this paper is to analyze the possible correlations with different work-related and individual variables, which influence or are influenced by Sense of Coherence (SOC) and verify the possible use of SOC scales to prevent negative health determinants in workplaces. Methods: Electronic databases were searched with selected studies compared for sample, sample size, study design and basic results. Cross-sectional studies were reviewed for correlations between individual physical and mental health, distress, burnout, job satisfaction and SOC, with intervention studies used to assess the possible impact of training on nurses' SOC. Results: The review found several correlations between SOC and different work-related variables; but also with several individual characteristics. Conclusion: The review found that SOC was predictor of depressive state, burnout, job dissatisfaction among female nurses; therefore, SOC could be a health promoting resource.

Knowledge and beliefs on vaccines among a sample of Italian pregnant women: results from the NAVIDAD study.

BACKGROUND: Vaccine hesitancy is an emerging phenomenon in European countries and leads to decreasing trends in infant vaccine coverage. The aim of this study was to analyze the level of confidence and correct awareness about immunizations, which are crucial for the success of vaccination programmes. METHODS: As part of the NAVIDAD multicentre study, we examined vaccination confidence and complacency among a sample of 1820 pregnant women from 14 Italian cities. The questionnaire assessed the interviewee's knowledge, beliefs and misconceptions, as well as their socioeconomic status, information sources about vaccines and confidence in the Italian National Healthcare Service. RESULTS: Only 9% of women completely believed to the efficacy, necessity and safety of vaccinations. Almost 20% of them had misconceptions on most of the themes. There was a significant difference in the level of knowledge considering educational level: women with a high educational level have less probability of obtaining a low knowledge score (odds ratio (OR) 0.43 [95% confidence interval (CI) 0.34-0.54]). The level of knowledge was also influenced by the sources of information: women who received information from their general practitioner (GP) and from institutional websites had a significantly lower chance of having misconceptions (OR 0.74 [95% CI 0.58-0.96]; OR 0.59 [95% CI 0.46-0.74]). Finally, the results underlined the influence of trust in healthcare professional information on the likelihood of having misconceptions (OR 0.49 [95% CI 0.27-0.89]). CONCLUSIONS: The data suggest the efficacy of GPs and institutional websites as a source of information to contrast misconceptions and underline the importance of confidence in the healthcare system to increase complacency and confidence in vaccines.

Intensive tobacco cultivations, a possible public health risk?

The cultivation of tobacco has serious consequences for the environment: it impoverishes the soil by assimilating its nutrients, it involves an intensive use of highly polluting pesticides, it perturbs the ecosystem through deforestation, and it releases nicotine into the environment, which is toxic for humans. Italy is the first producer of raw tobacco in Europe and the Valtiberina area is among the most profitable. The first cultivations can be reconducted to the period around 1400. The objective of this experimental work is to verify the sustainability of tobacco cultivation near other crops using nicotine as an indicator. The nicotine on medicinal and wild plants adjacent to tobacco crops has been analyzed, assessing whether it is present or not and which is the concentration. To measure the nicotine present with ultra-high-performance liquid chromatography (UHPLC), LC/MS (liquid chromatography-mass spectrometry) method was used with LOQ (quantification limit) of 0.005 mg/kg. A total of 300 lots of aromatic herbs were sampled, and nicotine was detected in 82.3% of the samples in 2015 and 62.9% in 2016. Furthermore, in 2015, 121 samples of wild material were analyzed, of which 88.4% showed traces of nicotine. These first results indicate a possible potential threat for the population health. This shows that the tobacco cultivation should not be in close proximity to other plantation destined for nutrition, neither for man and nor animals. The elevated impact of nicotine on the ecosystem has negative consequences not only for the economy but it is also a potential public health threat.

Delphi consensus on the monitoring tools of main individual risk factors for chronic diseases by the company doctor. / Ricerca di consenso Delphi sugli strumenti per il monitoraggio da parte del medico competente dei principali fattori di rischio individuali per malattie croniche.

BACKGROUND: Data on individual risk factors for chronic diseases (smoking, physical activity, body mass) are collected by company physicians in heterogeneous ways. This makes comparisons, researches and evaluations difficult. OBJECTIVES: The aim of the study was to find a consensus on evaluation tools for chronic diseases risk factors and for health promotion programs in workplaces that could be performed by company physicians during their clinical activity. METHODS: A first set of tools, proposed by a working group of occupational physicians in Bergamo, was submitted through the Delphi technique to a national expert panel of 22 persons including recognized national experts in specific fields and occupational physicians skilled in health promotion. RESULTS: In three Delphi rounds, the panel selected a set of tools to monitor the main individual risk factors for chronic diseases (smoking, alcohol, physical activity, nutrition, stress and mental health) as well as general data related to the worker and his job. CONCLUSIONS: The use of these specific tools, collected in a homogeneous format, should be recommended to all Italian company physicians, in particular those who work in WHP-programs, in order to allow analysis, comparison and evaluation of health promotion programs effectiveness at a national level.

Human papillomavirus and gastrointestinal cancer: A review.

Human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide. Exposure to HPV is very common, and an estimated 65%-100% of sexually active adults are exposed to HPV in their lifetime. The majority of HPV infections are asymptomatic, but there is a 10% chance that individuals will develop a persistent infection and have an increased risk of developing a carcinoma. The International Agency for Research on Cancer has found that the following cancer sites have a strong causal relationship with HPV: cervix uteri, penis, vulva, vagina, anus and oropharynx, including the base of the tongue and the tonsils. However, studies of the aetiological role of HPV in colorectal and esophageal malignancies have conflicting results. The aim of this review was to organize recent evidence and issues about the association between HPV infection and gastrointestinal tumours with a focus on esophageal, colorectal and anal cancers. The ultimate goal was to highlight possible implications for prognosis and prevention.

Seasonal Variation in Skin Cancer Diagnosis.

PURPOSE: Seasonality of skin cancer is well known, and it is influenced by a number of variables, such as exposure and personal characteristics, but also health service factors. We investigated the variations in the diagnosis melanoma skin cancer (MSC) and non-melanoma skin cancer (NMSC) during the year. METHODS: We analyzed incident cases recorded in the Umbria Regional Cancer registry from 1994 to 2010 (1745 cases of MSC, 50% females, and 15,992 NMSC, 41% females). The Walter-Elwood test was used to assess seasonal effects. Relative risks were analyzed using negative binomial regression and splines. RESULTS: Seasonality of MSC and NMSC was similar. Incidence peaks were observed in weeks 8, 24, and 43 (February, July, and October) and troughs in weeks 16, 32, 52, and 1 (August and December). Both NMSC and MSC cancers showed most elevated risks in autumn. A seasonal effect was present for trunk (p < 0.001) and absent for face cancers (p = 0.3). CONCLUSION: The observed pattern of diagnoses presumably depends on health service factors (e.g., organization of melanoma days, reduced access to care in August and during Christmas holidays) and personal factors (e.g., unclothing in the summer and delays in seeking care). High incidence rates in autumn could also in part depend on a late cancer progression effect of UV exposure. More efforts should be placed in order to guarantee uniform access to care through the year.

Cancer burden trends in Umbria region using a joinpoint regression.

INTRODUCTION: The analysis of the epidemiological data on cancer is an important tool to control and evaluate the outcomes of primary and secondary prevention, the effectiveness of health care and, in general, all cancer control activities. MATERIALS AND METHODS: The aim of the this paper is to analyze the cancer mortality in the Umbria region from 1978 to 2009 and incidence from 1994-2008. Sex and site-specific trends for standardized rates were analyzed by "joinpoint regression", using the surveillance epidemiology and end results (SEER) software. RESULTS: Applying the jointpoint analyses by sex and cancer site, to incidence spanning from 1994 to 2008 and mortality from 1978 to 2009 for all sites, both in males and females, a significant joinpoint for mortality was found; moreover the trend shape was similar and the joinpoint years were very close. In males standardized rate significantly increased up to 1989 by 1.23% per year and significantly decreased thereafter by -1.31%; among females the mortality rate increased in average of 0.78% (not significant) per year till 1988 and afterward significantly decreased by -0.92% per year. Incidence rate showed different trends among sexes. In males was practically constant over the period studied (not significant increase 0.14% per year), in females significantly increased by 1.49% per year up to 2001 and afterward slowly decreased (-0.71% n.s. estimated annual percent change - EAPC). CONCLUSIONS: For all sites combined trends for mortality decreased since late '80s, both in males and females; such behaviour is in line with national and European Union data. This work shows that, even compared to health systems that invest more resources, the Umbria public health system achieved good health outcomes.

Epidemiologic surveillance of mesothelioma in Umbria.

BACKGROUND: Malignant mesothelioma (MM) is becoming a prominent health issue due to its low survival and for its increasing incidence in various countries. The objectives of this study were to evaluate epidemiological characteristics and trends of MM in the Umbrian Region for the period 2003-2013. METHODS: All cases of MM reported to Umbrian Population Cancer Registry between 2003 and 2013. Incidence Annual Standardized Rates (ASRs) were analyzed for all histological types of MM. Estimated Annual Percent Change (APC) and joinpoint regression analysis were used to out light the time trend of MM. Geographical distribution of the relative risk for each municipality was calculated by Standardized Incidence Ratios SIRs. RESULTS: 191 (156 males) MM cases were recorded in Umbrian residents in the period 2003-2013. Pleural mesothelioma affected 92.1% of the total. Gender ratio M/F was 5.9:1. ASRs for MM was 3.2 among men and 0.6 among women. Joinpoint analysis showed a decrease in females APC -8.4 (95% IC -33.7-26.6) and an increase in males APC 5.8 (95% IC -0.9-13.0). An occupational exposure was identified in 43.7% of females and in 90.7% of males. CONCLUSIONS: The protracted cancer latency and the continued asbestos existence as environmental contaminant in existing buildings, as well as a carcinogenic risk for the workers involved in removing operations of material containing asbestos justifies the investment in a specific surveillance system. Also important would be to implement a national risk communication strategy addressed to the general population, environment surveillance of the high risk areas and guarantee that all workers involved that even may deal with asbestos are always fully equipped and trained, not only for their individual risk but also for the potential risk of non correct disposal.

[Assessment of the impact over one year of a workplace health promotion programme in the province of Bergamo]. / Stima dell's effecto ad un anno di un programma di promozione della salute nei luoghi di lavoro in provincia di Bergamo.

OBJECTIVES: To estimate short-term effects of integrated health promotion in the workplace within the framework of the Bergamo WHP (Workplace Health Promotion) network, which involves 94 companies and about 21,000 workers. METHODS: A controlled non-randomized, before-after evaluation was carried out. Data were collected through anonymous questionnaires before (t0) and after participation in a 12-month health promotion programme (t1). The "control" group consisted of workers of companies participating in the programme who had not yet undertaken any interventions in the theme areas covered by the assessment. RESULTS: In the workers participating in the programme, positive early effects (after 12 months) were related to intake of food providing protection (fruit and vegetables) and increased rates of smoking cessation. The effects were more evident in males and in white collars. The physical activity and alcohol consumption trends went in the desired direction and with more effects than in the non-participating group, but without statistical significance. In the short term, no evident changes in events of road injury risk or in the quality of personal relationships were seen, probably due to the small size of the sample involved in these study areas. CONCLUSIONS: The results, although within the methodological limitations of the study, showed that after 12 months there was a reduction in some important risk factors for chronic diseases in workers participating in the programme, particularly for fruit and vegetable intake and smoking cessation. It will be important to monitor the effects of the programme on other risk factors in the medium and long term, and also the impact of employment status and gender so as to adjust the programme interventions accordingly. Cooperation with occupational/authorized physicians with use of their data collected from health surveillance, together with a limited set of general risk factor indicators, would be a desirable development for further studies.

Knowledge about tuberculosis among undergraduate health care students in 15 Italian universities: a cross-sectional study.

BACKGROUND: The Italian Study Group on Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health conducted a multicentre survey aiming to evaluate undergraduate health care students' knowledge of tuberculosis and tuberculosis control measures in Italy. METHODS: In October 2012-June 2013, a sample of medical and nursing students from 15 Italian universities were enrolled on a voluntary basis and asked to complete an anonymous questionnaire investigating both general knowledge of tuberculosis (aetiology, clinical presentation, outcome, screening methods) and personal experiences and practices related to tuberculosis prevention. Data were analysed through multivariable regression using Stata software. RESULTS: The sample consisted of 2,220 students in nursing (72.6%) and medicine (27.4%) courses. Our findings clearly showed that medical students had a better knowledge of tuberculosis than did nursing students.Although the vast majority of the sample (up to 95%) answered questions about tuberculosis aetiology correctly, only 60% of the students gave the correct responses regarding clinical aspects and vaccine details. Overall, 66.9% of the students had been screened for tuberculosis, but less than 20% of those with a negative result on the tuberculin skin test were vaccinated. Multivariable regression analysis showed that age and type of study programme (nursing vs. medical course) were determinants of answering the questions correctly. CONCLUSIONS: Although our data showed sufficient knowledge on tuberculosis, this survey underlines the considerable need for improvement in knowledge about the disease, especially among nursing students. In light of the scientific recommendations concerning tuberculosis knowledge among students, progress of current health care curricula aimed to develop students' skills in this field is needed.

The worksite as an asset for promoting health in Europe. Final results of the MoveEurope campaign.

Non-communicable diseases are a leading cause of morbidity worldwide and are predicted to increase in the next years. In 2008, 36.1 million people died from conditions such as heart disease, strokes, chronic lung diseases, cancers and diabetes (1). According to the WHO, 63% of the deaths, 77% of the loss of Healthy Life Years and 75% of health expenses in Europe are caused by cardiovascular diseases, cancer, chronic respiratory illnesses and mental health problems. All of these diseases have in common is the presence of modifiable risk factors (such as tobacco smoke, low consumption of fruit and vegetables, excessive intake of fats). Acting on these factors would lead to a reduction in the incidence of the aforementioned diseases. According to several studies conducted in the USA, Canada and Europe, the workplace seems an ideal place for implementing successful preventive strategies for the improvement of lifestyles. In 2006, the European Network for Workplace Health Promotion launched the Move Europe campaign to promote a healthy lifestyle at work, with the financial support of the European Commission. This campaign set new quality standards in behaviour-related workplace health promotion (WHP) and identified and documented good practices. Another aim of the campaign was to promote the benefits of implementing WHP, particularly focusing on four fields of life-style related WHP: physical activity, smoking prevention, nutrition and mental health. In two years, 65,215 contacts have been recorded in dedicated websites, of which 9,761 in Italy. A total of 2,548 enterprises in Europe asked to be certified and 125 events (such as seminars, workshops, conferences)were held.

Effect of healthcare on mortality: trends in avoidable mortality in Umbria, Italy, 1994-2009.

OBJECTIVE: Avoidable mortality trends over the period 1994-2009 were calculated to evaluate health intervention by the health system of Umbria, a region of central Italy. MATERIALS AND METHODS: Mortality data were supplied by the regional causes of death registry. Rates were standardized to the 2001 census Italian population. Joinpoint regression was used to analyze the trends. RESULTS: Overall avoidable mortality rates decreased significantly both in males (-3.9% per year) and in females (-3.6% per year). Mortality rates from ischemic heart and cerebrovascular disease about halved in the study period in both sexes. Avoidable mortality increased slightly only for a few causes (e.g. lung cancer in females). CONCLUSION: The overall trend of avoidable mortality indicates that the regional health/ preventive system is performing well.

[A health promotion program aimed at employees and restaurant operators: results of the European FOOD project]. / Programma di promozione della salute rivolto a lavoratori e addetti ai servizi di ristorazione. Risultati progetto Europeo FOOD.

Public health is facing a major challenge: the fight against overweight and obesity. Many projects have been developed and implemented all over the world. FOOD is one of the most important European programs to promote a healthy lifestyle and a balanced diet in the workplace. The program aims to improve the nutritional quality of the food offered in restaurants and to facilitate consumer choice by educating and informing employers and their employees. Different channels, tools and countries have been involved in this program which took place over the course of two years and is ongoing due to the high value of the applied methodology.

Incidence of multiple primary cancers following respiratory tract cancer in Umbria, Italy.

UNLABELLED: Improvements in cancer survival and life expectancy have placed a focus on long-term risks following a primary cancer, including that of developing other primary malignancies. The purpose of this study was to evaluate the risk, in patients with respiratory tract cancers, of developing a second primary malignancy. METHODS: Standardized incidence ratios (SIR) of observed to expected cases were calculated for residents of Umbria diagnosed with laryngeal and lung cancer between 1994 and 2008. Significance and 95% confidence intervals were determined assuming a Poisson distribution. RESULTS: In total, 189 and 340 cases of second primary cancers were observed respectively among laryngeal and lung cancer patients. Male laryngeal cancer patients were found to have a significantly increased risk of lung cancer (SIR=4.10), non-melanoma skin cancer (SIR=2.10), bladder cancer (SIR=2.25) and pancreatic cancer (SIR=3.85). In females, a significantly increased risk was observed only when all sites combined were considered. Male lung cancer patients were found to have a significantly increased risk for laryngeal cancer (SIR=4.36), esophageal cancer (SIR=3.97), kidney cancer (SIR=3.40), multiple myeloma and malignant plasma cell neoplasm (SIR=2.97), bladder cancer (SIR=2.20) and non-melanoma skin cancer (SIR=1.55). In females, the risk of developing a second cancer was higher but was not significant for non-melanoma skin cancers, colon and breast cancer. CONCLUSIONS: Study results show an excess risk of other primary malignancies in respiratory tract cancer patients, particularly males. This may be due to shared risk factors, genetic susceptibility, effect of first cancer treatments and increased diagnostic surveillance.

Tobacco use prevalence, knowledge and attitudes among Italian hospital healthcare professionals.

BACKGROUND: Healthcare professionals play a key role in tobacco use prevention because they are considered as model by patients. This multicenter study was aimed to evaluate smoking prevalence, knowledge and attitudes towards tobacco among Italian hospital professionals. METHODS: A cross-sectional study was carried out using a questionnaire administered to healthcare professionals in seven Italian hospitals, to investigate personal and occupational data, knowledge, attitudes, job setting, clinical activities, smoking habits and pattern for current smokers. Potential predictors of current smoking habits were evaluated using multiple logistic regressions. RESULTS: Sample population was comprised of 1082 health professionals (51.4% females; mean age was 37.3 years: 25.3% were nurses, 24.5% medical doctors, 17.1% students and 33.1% other healthcare workers). Smoking prevalence was 44%. Among responders, 67.7% considered healthcare professional as a model for citizens, 90.5% declared to see colleagues smoking cigarettes inside the hospital (47.4% in the dependents' toilets, 33.4% in the department kitchens and 4.7% in the patient room). Multivariate analysis showed that healthcare professionals working in Naples had a higher risk to be smokers in comparison to Rome [odds ratio (OR) = 2.29; 95% confidence interval (CI) 1.40-3.73]. Compared to medical doctors, post-graduate students (OR = 3.42; 95% CI: 1.81-6.44), nurses (OR = 2.48; 95% CI 1.51-4.08), nursing students (OR = 1.91; 95% CI 1.08-3.38) and auxiliary personnel (OR = 2.72; 95% CI 1.51-4.88), showed a higher likelihood of smoking. CONCLUSIONS: Among Italian hospital personnel there is a paradoxically large prevalence of smokers, higher than in the general population. Interventions aimed for the development of an adequate culture of health promotion, among these professionals, are urgently needed.

[Evaluation of a distance training course on workplace health promotion]. / La sperimentazione di un corso FAD sulla WHP per i professionisti a sostegno delle piccole e medie imprese.

Specialists qualified in workplace health promotion are very few. Results of a pilot distance training course which took place in 2008 show that the course was useful at the individual and organizational level and had a relatively low cost.