1. Migration patterns
For some years the industrialised countries of the Mediterranean area have been affected by constant migratory flows of people who, driven by precarious living conditions in their countries of origin embark on often risky journeys in the hope of obtaining conditions of greater well-being and freedom. Italy has changed from a country of emigration into a preferred migratory destination and has been forced to address the problems that arise from permanent, temporary and seasonal immigration.
According to the official data of the Ministry of Internal Affairs, the number of foreigners legally residing in Italy as of December 31, 2001 was 1.362,630 - equal to approximately 2.8% of the Italian population, while estimates of the presence of illegal or clandestine immigrants range from 15 to 30% of immigrants as a whole. The most numerous immigrant communities are those originally coming from: Morocco (158,000). Albania (144,000). Rumania (75.000), the Philippines (64.000). China (56.000) and Tunisia (46,000).
2. Epidemiological developments
This migratory phenomenon has given rise to a series of political, economic, social, sanitary and health problems. With regard to health care, although a gradual administrative decentralisation is taking place in this field, immigration will remain under state control.
However, official data for evaluating the health of the immigrant population are not available since Italy does not yet have a national epidemiological observatory. The sources of information on the types and characteristics of diseases suffered by immigrants are there- fore the case histories of public and voluntary structures that provide psychosocial health assistance to immigrants throughout the country.
Available data show that, generally speaking, immigrants are in good health at the time they leave their own countries but their health deteriorates during both the journey and their star in Italy. The diseases most frequently suffered by immigrants in Italy are the non-infectious ones developed in the host country, typical of the hardship in which most immigrants are forced to live. The National AIDS Register of the Istituto Superiore di Sanità shows a significant increase in the proportion of cases of AIDS reported among immigrants: from 1.7% in 1993/94 to 8.9% in 2001/02. The majority of cases concerned persons from Africa. South America and Eastern Europe.
Although Law 40/98 regulates health care to foreigners residing in Italy, whether legally or illegally, it often happens that foreigners, especially illegal residents, do not make use of the services of the National Health System. Fear of contact with public structures and a lack of correct information about HIV/AIDS (particularly about the test) mean that immigrants are reluctant to undergo the clinical examinations aimed at timely diagnosis and adequate. well-monitored pharmacological treatments, with the result of late diagnosis. Indeed. far many immigrants there is only a small lapse of time between their first test for HIV antibodies and the diagnosis of AIDS, if the events are not actually simultaneous.
Therefore, steps must be taken to improve the quality of services of prevention, care and treatment for foreign populations and strategies need to be adopted far promoting a transcultural form of medicine, willing to recognise cultural diversity. An adequate, concrete response to the health needs of foreigners must necessarily entail an examination of their needs and an analysis of demand, plus a reorganisation of services based on the specific requirements of the target group, planning new strategies and approaches characterised by flexible services, technical and relational training of personnel, a multidisciplinary approach (teamwork) and an integrated collaboration between public services, NGOs and voluntary associations (network activities).
2.1 New diagnoses of HIV in the post-HAART era. Comparison of Italian and foreign populations
Many recent studies show that Black and Latino persons are more likely to receive late HIV diagnosis, late adequate treatment and late support. Recent advances in HIV treatment underscore the need to increase the early knowledge of HIV serostatus. In Italy, access to heath services, HIV testing and treatment are free of charge. Over the last few years, the number of immigrants attending the outpatient clinic for HIV / AIDS of the Istituto Nazionale per le Malattie Infettive L. Spallanzani in Rome, one of the largest centres far the diagnosis and treatment of HIV in Italy, was seen to grow. We set out to describe the epidemiological and clinical characteristics of persons newly diagnosed with HIV and to compare these characteristics for the Italian and foreign populations (persons from non-EU countries).
The study included all adults attending the outpatient clinic and diagnosed as HIV positive between January 1997 and December 200l. A total of 463 HIV positive persons 358 Italians and 105 immigrants - were observed. Forty percent of the immigrants were Africans, 40% were Latinos from Central or South America and 20% were from Eastern Europe or North Africa. Over the years there has been an increase in the number of HIV diagnoses observed, while the proportion of immigrants among those diagnosed has also grown (from 8% in 1997 to 36% in 2001).
The immigrants were less likely to have had a previous negative HIV test result; they were more likely to test as a result of antenatal screening. Sixty-four percent of immigrants compared to 43% of Italians contracted HIV through heterosexual intercourse, while 2% compared to 10% reported intravenous drug use.
Our data show that, during the HAART (Highly Active Antiretroviral Therapy) era, immigrants accounted for an increasing proportion of the new diagnoses of HIV. There were signifìcant differences in epidemiological characteristics between the populations studied. More than 40% of the persons with a new diagnosis of HIV had the disease in a relatively advanced stage. No differences emerged between immigrants and Italians with regard to the clinical stage. This can be explained by the fact that we did not consider the patients in this report, but only patients seeking HIV testing at an outpatient clinic: it is possible that they may have had greater access to appropriate services or a greater aware - ness of their status. Strategies to give foreigners the opportunities, information and motivation necessary far being tested must be improved.
3. Legislative policy: recent modifications and additions
On the subject of immigration, the political criteria set by the legislature in force have been characterised by the fìrm intention to stress legality within the democratic system. In pursuit of this objective, the government's programme has aimed at giving all foreigners residing in Italy a well-defìned legal status by implementing legislative measures designed to legalise illicit work, to set clear-cut and severe rules as regards the expulsion of clandestine immigrants and foreigners guilty of serious crimes, to tie residence permits to the length of job contracts, to strengthen official administrative structures and to make administrative and criminal sanctions harsher. At the same rime the parliament also passed legislative measures designed to:
-favour all humanitarian organisations engaged in the promotion of social development activities;
-make it possible to facilitate and revise bilateral cooperation and aid programmes far non-humanitarian initiatives in favour of non-EU member countries that collaborate in the prevention of flows of illegal migration. These countries also participate in the fight against criminal organisations engaged in clandestine immigration, trafficking in human beings, exploitation of prostitution and drugs and arms traffic. They carry out law enforcement activities to prevent the return of foreign citizens who have been expelled.
For a comprehensive view of the aforementioned regulations, reference must be made to Legislative Decree no. 286 of July 25, 1998, with the force of law, containing the Consolidated Act of the measures regarding immigration and the regulations governing the status of foreigners, with the result that practically all the legislation currently in force on the subject is consolidated in a single text. In the case of applicants far refugee status, article 1 of Law no. 39 of February 28,1990 remains in force, though it has been extensively modified and supplemented by the recently passed Law no. 189 of July 30, 2002 (known as the 'Bossi-Fini-Giovanardi Law'). The most significant innovations introduced in Legislative Decree no. 286 of July 25, 1998 by the aforementioned Law 189/02 can be summed up as follows: November 30th of the preceding year was fixed as the deadline far setting quotas of foreign immigrants to be accepted in Italy; entry visas may be refused far reasons of security without giving the reasons; criminal punishment may be inflicted if an application far an emigration visa made to the diplomatic delegation or consulate in the country of origin is accompanied by false statements; photographs and fingerprints are to be taken of foreigners applying far residence permits; residence permits far work are only to be issued if a contract of residence far a permanent job has already been signed; the duration of the residence permit is to be limited to the duration of the employment contract; severe penalties are to be inflicted on persons who falsify entry visas or other deeds or documents regarding residence in the country; the employer must guarantee lodging; the employer must make a formal commitment to pay the immigrant's repatriation costs; the period of residence required far obtaining a residence card is increased from five to six years. The measures against clandestine immigration contain more severe administrative and criminal penalties than previously. Specifically, adequate measures are contemplated far expulsion, escort to the border by the police; in addition, expulsion orders are to be adopted as an alternative punishment to imprisonment.
The immigrant's right of defence is confirmed, although it is not clearly defined in specific cases. The services designed to provide access to employment, provided far under the previous regulations, are replaced by the so-called 'pre-emption right' granted to potential immigrants who attend professional training courses in their countries of origin under programmes financed by the Italian government.
As regards applicants far refugee status, a clear legislative reference is now contained in the abovementioned Law no. 189 of July 30, 2002. In short: a temporary residence permit is issued which is valid until the necessary background investigation far the granting of refugee status is completed; the administrative procedures far handling the application are simplified; the system of protection and safeguard far applicants far asylum and refugees is guaranteed. All the abovementioned provisions, as well as those issued under Legislative Decree no. 195 of September 9, 2002, which contains urgent provisions regarding the legalisation of illicit work by 'non-EU immigrants' and was converted with amendments into Law no. 222 of October 9, 2002, will be supplemented by implementation regulations and government provisions.
3.1 Health policies and immigration: the impact of the new law on immigration
The Bossi-Fini-Giovanardi Law, carne into force on September 10, 2002: It met with heat-ed reactions. The government's attempt to make the measure less drastic by permitting, the regularisation first of family assistants and then of illegal workers (Legislative Decree no. 195 of September 9,2002) did not succeed in softening the tone of the discussion.
The presence of immigrants in Italy is a great occasion and opportunity: not so much in economic and job-related terms - though this is certainly the case - but in the light of cultural and social considerations and, as a result, organisational consequences as well. Immigrants bring with them a kaleidoscope of cultures; they have varied expectations and a different perception of their bodies, health and illness; and they belong to a variety of social situations with different legal statuses. This has led to a closer examination and a questioning not only about these developments, but also about our own attitude and approach as health workers, the way the services are organised and the relationship that each of us manages to establish with others, be they Italians or foreigners. This process necessarily involves a reciprocal adjustment to one another's cultures. It involves forms of integration that enrich a society and an organisation petrified by too much affluence and by budgets frequently designed far a culture of desires, appearances and virtual worlds rather than far essential needs and a standard of living that takes into account human relations and the feeling of belonging to a community. No law or regulation can determine this process, but it can certainly acknowledge and attempt to regulate this phenomenon in terms of integration and respect even by establishing severe rules, provided that they are justified by manifest conditions that everyone, both Italians and foreigners, must observe.
Limiting the reflection on the new law to topics related to health care, we cite the re- marks contained in the final document of the 7th Consensus Conference on Immigration held in Erice, Sicily in May 2002, an event where approximately 250 health operators working in the public or private social services and in voluntary associations carne from all over Italy to exchange ideas and examine the available scientific data on the health of immigrants and on health policies. The final resolution of the Consensus states: 'the fact that the residence permit is tied to employment casts foreigners in a utilitarian light, reducing them to nothing more than a work force, with the risk of exposing them to blackmail and harmful exploitation by employers (in fact, being fired would have far more serious consequences than simply losing a job); it also makes it impossible far workers to make durable plans. Furthermore, by creating obstacles to legalisation (in particular the "abolition" of sponsorships) it encourages illegal situations, which have been found to represent a significant risk factor far health. The restrictive criteria far family reunification impede the formulation of long-term projects and the emotional stability of the immigrants, with resulting damage to their psychological and physical well-being.
The adoption of a simplified procedure far asylum, combined with the abolition of funding far the National Asylum Programme - resulting in a sudden cessation of assistance far asylum seekers and refugees, many of whom find themselves without housing or even the most elementary assistance - will produce (and is already producing) significant dam - age to the health of these persons, who are the weakest among the immigrants'.
Starting from the very first days of implementation, we have noticed an effect that gives serious cause for concern. Many health service operators believe that the health regulations guaranteeing access to service both to legal immigrants and, even more importantly, to clandestine immigrants have been abrogated and so they refuse to provide assistance. Nonetheless, everyone holding a long-term residence permit must be registered with the National Health Service, while illicit and clandestine immigrants are guaranteed essential, emergency, preventive and permanent care and it is forbidden to report them to the police if they are hospitalised or cared for. In confirmation of this, some regional governments more or less promptly issued comments/memorandums confirming not only that the right of immigrants to health care remained unchanged, but that foreigners in the course of regularising their situation (those who had submitted a request to bring their 'illegal' jobs onto the legal labour market) had obtained the right to register with the National Health Service.
The new law on immigration has increased the cultural gap, the fears, suspicions and reciprocal prejudices existing between Italians and foreigners; at a time when the provisions of the national legislation regarding health care for foreigners should be put into effect at the local level through initiatives that could make the system truly accessible.
4. Campaigns for the prevention of HIV/AIDS for mobile populations
As part of the prevention campaigns organised by the Ministry of Health during the period 2001-2002, the Ministry has gone on with the distribution of materials designed for the migrant populations and produced in the course of the 6th Informational-Educational Campaign on AIDS. In 2002 the procedure for a call for tenders to select the agency to handle the information campaign for 2003/2004 was completed. The programme chosen includes the production of multilingual brochures, along with multilingual posters on public transport vehicles and a varied sports programme that has recently attracted a good deal of interest from young foreigners living in Italy.
5. Research and training activities of the Italian NFP (2001/02)
5.1 Research activities of the Italian NFP
During the period 2001/02, the Italian National Focal Point (NFP) - coordinated by the Istituto Superiore di Sanità (National Institute of Health), which has experts belonging to public structures, NGOs and voluntary associations - proposed and implemented two projects in Italy.
The first is the project 'Creation of a national network of the non-governmental psychosocial health structures that work with immigrant populations suffering from problems related to HIV infection or sexually transmitted diseases (STDs)'. The general objective of this study, coordinated by the Istituto di Ricovero e Cura a carattere Scientifico L. Spallanzani, is to provide an updated overview of the actual situation in Italy with regard to NGOs and voluntary associations that work with mobile populations and AIDS/STDs.
This is being done in order to favour collaboration among the different services while facilitating access by foreign citizens to the structures in question.
The second is the project' Arianna - a pilot study for the creation of a multi-centre training network for linguistic-cultural operators and mediators, to be utilised in initiatives of information and prevention of HIV infection and sexually transmitted diseases targeted to groups of immigrants at risk of exclusion from psychosocial health services: clandestine and illegal immigrants, foreign prostitutes and drug addicts'. The objective of the study, coordinated by the Istituto di Ricovero e Cura a carattere Scientifico San Gallicano, is to provide specific training to linguistic-cultural mediators and to operators working in psychosocial health centres accessible to foreign users.
5.2 A training experience proposed by the Italian NFP
Among the many actions designed to safeguard the health of migrant populations, the Italian National Health Plan far 2002-2004 stresses the need for initiatives that facilitate access to services and make them easier to use, including providing specific information that takes the cultural diversity of the target group into account. In October of 2002, the Istituto Superiore di Sanità organised a 'Training course designed far psychosocial health operators in order to achieve an integrated multi-professional approach to the health of immigrants'. The training process was designed far the staff of the National Health System, of NGOs and of voluntary associations. It was designed to stimulate, through an analysis of the current situation, reflection on the need to pursue a transcultural health approach aimed at recognising the 'diversity' of others and making the most of their human and cultural heritage. The course tried to improve teamwork and network activities, so as to increase the effectiveness and quality of the services supplied to foreign citizens. The subjects dealt with included:
- the epidemiological situation of HIV among migrant populations;
- particularly high-risk infectious pathologies among immigrants;
- health policies and legislative aspects regarding mobile populations;
- communication and relational aspects within a transcultural framework.
6. Availability of services and access to medical treatment: past experiences of public structures, NGOs and voluntary associations belonging to the Italian NFP (2001/02)
6.1 Telephone counselling on HIV/AIDS within a transcultural framework
Between November 29, 1995 and December 31, 2002 the Telefono Verde AIDS (TVA) of the Istituto Superiore di Sanità received a total of 1.682 calls from foreign users: 493 (29.3%) from citizens of the Americas; 484 (28.8%) from citizens of African countries; 262 (15.6%) from citizens of non-EU countries; 253 (15.0%) from citizens of the European Union; 174 (10.3%) from citizens of Asian countries and 4 (0.2%) from citizens of the countries of Oceania. In the case of 12 users (0.7%), it was not possible to identify their origin.
The groups of users were:
- persons who had heterosexual intercourse and were not drug addicts: 1,041 (61.8%)
- subjects who did not engage in risky behaviour: 341 (20.3%)
- HIV-positive persons: 151 (9.0%)
- homosexuals or bisexuals: 111 (6.6%)
- drug addicts: 15 (0.9%)
- persons who had received blood transfusions: 6 (0.4%)
- not indicated: 17 (1.0%)
Most questions concerned information on the test. Among the other topics discussed were modes of transmission, psychosocial topics, misinformation, prevention, symptoms, and therapies and research. The telephone proves to be a particularly useful tool in the prevention of HIV / AIDS, not only due to the rapid access offered but also because its anonymity facilitates discussion of the illness and helps overcome the uneasiness felt with topics regarding the sexual sphere.
In replying to the questions asked by the callers, the counsellors of the TVA must keep in mind a series of psychological, social and cultural factors that have a great influence on the outcome of the informative message, making the counselling process highly complex.
This is particularly true in the case of foreign citizens who, in addition to the language difference, have different socio-anthropological and religious customs. Therefore the TVA not only represents a rapid and economical instrument for supplying' personalised' scientific information, but also a privileged observatory for evaluating the information needs of the general public and for planning more effective prevention actions.
6.2 The San Gallicano Institute Department of Preventive Medicine for Migration, Tourism and Tropical Dermatology
The services of the San Gallicano Institute in Rome are aimed at clandestine and illegal immigrants, Gipsy people, refugees and asylum seekers, immigrant and Italian transsexuals and homeless people, among other groups. Since 1996, San Gallicano Department of Preventive Medicine for Migration, Tourism and Tropical Dermatology has availed itself of the help of linguistic-cultural mediators. Over the last few years the City Council of Rome has given significant encouragement to a policy of health promotion 'without exc1usion', through projects coordinated by its Health Promotion Policies Department. This Department has engaged in a number of social promotion activities aimed at supporting disadvantaged homeless people with health problems, in collaboration with a medical institution that can offer scientific reliability and cultural awareness from its experience in the field. In July 1999 an agreement was made between the City Council of Rome, the Health Promotion Policies Department and the San Gallicano Institute for the purpose of developing social and health services for homeless and resident people and immigrant and Gipsy groups in Rome. This has resulted, among other things, in the use of linguistic - cultural mediators specially trained for work with the homeless, and to experimentation with a social administration service that offers referrals and establishes connections between the homeless who seek aid from the San Gallicano Institute, the public structures and the social private centres operating in the field.
6.3 Access of immigrants to the AIDS Operational Unit of the Local Health Care RM/E, Rome
The law of 1998 finally extended access to health care to immigrants without residence permits. As a result, this population was able to deal with its health needs in those cases where the legislation was applied. With the passing of the law, the AIDS Operational Unit of the Local Health Care RM/E (Rome/District E), for years one of the landmarks for the local immigrant community in terms of HIV prevention, became a centre of standard health care for immigrants too. Patients attending the outpatient unit are not only people who wish to be tested because they have been exposed to the risk of AIDS, but also groups of immigrants with health problems under way. When the requirements are met, immigrants are issued an identification card and a health care number, and are offered basic health care with a medical examination, prescription of treatment for the diseases found and prescription for more examinations by a specialist.
Everyone is informed of the possibility of being tested for HIV free of charge, with preand post-test counselling. A number of observations can be made on the basis of the experience of past years. A large part of immigrants who have attended the service suffer from diseases that have long been neglected or have become chronic. The offer of the test was quickly accepted by nearly all the patients, who expressed their satisfaction with being able to overcome their lack of information, up to that point, on the procedures for carrying out the test, as well as their embarrassment over asking about it. During the counselling, most patients expressed significant concern, primarily with regard to the potential risks faced by spouses from whom they were separated for lengthy periods. The counselling has proved to be a useful personalised intervention that provides an opportunity far reflection on HIV infection, the risks and the adoption of safer behaviours. In addition, it gives the psychologist working at the clinic an important chance to learn about patients' uneasiness, problems and psychological symptoms. The patient learns that there is a psychologist who can be contacted in times of need. Contacts with patients often uncovers psychological problems that have long been neglected. The experience of the AIDS Operational Unit, though limited, together with the follow-up studies carried out in Rome District E, show the efficacy both of testing and counselling in promoting safer behaviours. Nevertheless, the actions need to be adjusted to reflect factors, such as language, culture, religion, sexuality and cognitive and behavioural problems, that influence the quality of communication and the therapeutic relationship.
6.4 Activities of the Committee far the Rights of Prostitutes
As in previous years, the majority of the women engaged in prostitution are foreigners, primarily coming from Nigeria, followed by those coming from Eastern Europe and Latin America. Recently, Chinese women have been found working in a number of large cities. There has been a significant drop in the number of Albanian women, while the number of women from Rumania has increased. The newly arrived women know very little about STDs. A Help Line against violence was established in 2002 (a DAFNE VIP project of the European Commission) and a survey on the telephone calls received reporting instances of violence was carried out. Apart from serious cases of attacks and robberies, a significant amount of violence emerged by clients who abuse the women, preventing the use of condoms.
The law on immigration (Law 40/98) was amended and is now much more restrictive and penalising for non-EU foreigners who wish to enter Italy. The effects of this law on people who practise prostitution are extremely serious, given that many of them have not only entered Italy clandestinely but have already been subject to expulsion orders and either disobeyed the measures or returned illegally for a second time; other prostitutes are forced by those who exploit them to carry false papers. All these circumstances result in immediate arrest and imprisonment. Persons caught by the police far the first time arte either immediately escorted to the border and expelled or placed in special centres that differ only slightly from jails. Every day a large number of women are caught during police round-ups. As a result of the repressive measures, there is less prostitution on the street but a rise in prostitution in homes.
The law on immigration made no changes in art. 18 regarding the fight against the trafficking of persons for the purpose of sexual exploitation, but the repressive practices make it almost impossible for the women involved to be informed of their rights and succeed in requesting aid in entering social programmes. Nevertheless, more than fifty projects have been started up in Italy to support the victims of such trafficking. Given the slow pace of the Italian court system, at the moment it is not possible to obtain figures on how many traffickers have been sentenced, though there can be no doubt that charges have been brought against many. In the past, 10 billion lire (5 million euros) were allocated each year in support of the law against trafficking in persons. At present there are plans to reduce this expenditure by 50% , a cut that will prevent many social and prevention projects from going on.
The 'clean streets' campaign recently launched by the government, though designed to meet the requests of citizens for a greater security, has not addressed the trafficking of persons, as shown by the fact that no funds have been allocated far these victims.
Though the law upholds the right to medical care and preventive treatment far infectious diseases far illegal immigrants as well, there is the risk that the new law will make it increasingly difficult far persons who practise prostitution to gain access to health services. At present, the women are hesitant to access health services or centres far immigrants because they obviously fear the potential consequeces; in addition, the operators fìnd it increasingly difficult to arrange far the health services to provide care and treatment. During the last two years the national campaigns on AIDS prevention have not taken into account the target group of prostitutes and their clients. The government has proposed that a new law be passed on prostitution, calling far obligatory medical examinations far prostitutes.
6.S Activities of the Lila CEDIUS (Human Rights and Public Health Centre) during 2002 in the field of Immigration.
Lila CEDIUS (Human Rights and Public Health Centre) is a non-profit organisation based in Milan. In the course of 2002, its activities in the immigrant health sector were mainly carried out as part of a research project co-financed by the Istituto Superiore di Sanità. This project focused on primary and secondary prevention, as well as on treatment of HIV and STDs among immigrant patients. The objective was to evaluate the ethnic-cultural, psychological. linguistic and religious difficulties faced by health personnel, foreign users and cultural mediators, in order to draw up communication strategies designed to optimise the quality of the services already accessible in the sample cities. This objective was to be achieved by creating and trying out a working protocol designed to overcome the difficulties that hinder proper communication between health personnel and immigrant patients.
Many studies have been carried out in order to understand the problems of immigrants, and ad hoc training programmes have been implemented far immigrant communities and cultural mediators, but nothing has been done to learn about the obstacles encountered by physicians while interacting with immigrant patients and providing assistance. treatment and information. A point highlighted by an initial analysis of both groups involved in the research (users and operators) is the difficulty in communicating and the misunderstandings caused by language. which are seen as the single greatest obstacle to obtaining access to health structures. Next come problems related to bureaucracy: from the perspective of the users, these consist of difficulties in gaining access to structures, in not knowing the procedures to follow, the documents to be submitted or which structures to go to (for example. they may go to the emergency room for services that are not urgent and are therefore turned away). As far as the operators are concerned, the greatest difficulties are caused by a lack of information / training on the legislation regulating immigration and on the approach to immigrant users, since the cultural approach is not a subject included in any type of official training provided to physicians or nurses. The operators themselves say that they would like to receive more information and take part in training courses. They stress the importance of having information material to distribute to immigrants so as to favour better access.
A more in-depth, comparative analysis of the data demonstrates that behind the apparent language barrier there are further difficulties due to the lack of a shared conceptual framework: it is the operators themselves who, though they initially state that cultural differences are of little importance, go on to express the need far the presence of cultural mediators, not merely far the purpose of translation but as a liaison between the two cultures.
The working group that met to discuss and plan possible communication strategies aimed at optimising health services identified three possible approaches to be developed by the structures responsible for treatment. The first is introducing ECM (Permanent Medicine Education) courses, within those already started, organised by the local health units and coordinated both by persons working in these same structures as well as by others from the private social sector, regarding the topics of legislation, health care and interpersonal relations. The second approach is permanent updating on regional enforcements and memoranda. The third approach is the distribution and publication of existing ministerial guides in different languages.
7. Conclusions
The long-term experience acquired by the individual members of the Italian NFP in activities involving health care' and treatment for foreign users has made it possible, in the course of the last year, to carry out two research projects (see 5.1), as well as a training course for operators engaged in services meant for foreign citizens (see 5.2). The shared objective of these initiatives was to identify conditions that can favour easier access and more effective use of the psychosocial health services, considering that the existence of public or voluntary services and the right to access (guaranteed by the laws in force) do not always guarantee the basic levels of assistance for vulnerable persons, such as immigrants.
The National Health Plan for 2002-2004, as part of a series of initiatives designed to safeguard the health of migrant populations, among other things emphasises the need for projects that facilitate access to the services and that improve their utilisation. What is more, as has been observed for some time now, the multifaceted nature of migratory activity in Italy, in terms of ethnic and language make-up, age and the various goals of migrants, calls for the identification of easy-to-use access points able to overcome the rigidity of deadlines and procedures. In addition, there is the need to train people who can be recognised by foreign citizens as resources meant to favour a matching of the immigrants' need for health with the services offered. At the same time, psychosocial health operators must have access to training courses on the elements of law, medicine and interpersonal relations that come into play during interaction with foreign users.
Accessibility to the psychosocial health structures, meaning the possibility far the user to benefit from the necessary service on a timely basis, represents the top priority far those working to promote the health of the migrant population. The end goal is to ensure the highest possible levels of service.
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9. List of members of the Italian NFP
Dr Laura CAMONI
Telefono Verde AIDS
IstitUto Superiore di Sanità
Dr Anna COLUCCI
Telefono Verde AIDS
IstitUto Superiore di Sanità
Mrs Pia COVRE
Comitato per i Diritti Civili delle Prostitute
Mrs Anna D'AGOSTINI
Telefono Verde AIDS
Istituto Superiore di Sanità
Dr A. Rosa FRATI
Ministero della Salute
Dr Pietro GALLO
Telefono Verde AIDS
Istituto Superiore di Sanità
Dr Salvatore GERAO
Area Sanitaria CARITAS Diocesana di Roma
Dr Anna Maria LUZI
Coordinatrice NFP Telefono Verde AIDS
Istituto Superiore di Sanità
Dr Rodolfo MAYER
Università ' La Sapienza' di Roma
Dr Nicola PETROSILLO
II Div. Mal. Infettive INMI L. Spallanzani IRCCS di Roma
Dr Giovanni REZZA Reparto AIDS e MST Lab, Epidemiol. Biostat.
Istituto Superiore di Sanità
Dr Enrica ROSA
Istituto Superiore di Sanità
Dr Angela SPINELLI
Reparto Indagini campionarie di popolazione Lab. di Epidem. e Biostat.
Istituto Superiore di Sanità
Dr Laura SPIZZICHINO
Unità Operativa AIDS ASL RM E
Dr Rudi VALLI
Telefono Verde AIDS
Istituto Superiore di Sanità
Dr Stefano VOLPICELLI LILA
Centro Studi di Milano
We thank the following persons for their precious contribution to this report:
Nicoletta Orchi (Istituto di Ricovero e Cura a carattere scientifico L. Spallanzani. Roma) Claudia Sala (Centro per i Diritti Umani e la Salute Pubblica -Lila CEDIUS, Milano) Luigi Toma (Istituto di Ricovero e Cura a Carattere Scientifico Santa Maria e San Gallicano, Roma).
Thanks also to Francesca Meduri (Laboratorio Epidemiologia Biostatatistica. Istituto Superiore di Sanità, Roma) for her precious administrative contribution.
