Appendices 1 4

1
Appendices 1- 4
Vengono qui illustrati programmi di ricerca ed
intervento in HP, nonché attività organizzative
correlate alla HP, che hanno uno scopo puramente
esemplificativo, mirano cioè a far comprendere le
applicazioni pratiche dei concetti esposti nelle
lezioni.
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Appendix 1
3

• Borgo Stefania, MD
• Lucio Sibilia, MD
• International Society of Doctors for the
  Environment Scientific Office
• Center for Research in Psychotherapy

4

• SUMMARY
• Background. Daily habits impinge on the
  environment in ways that ultimately may affect
  our health and safety also, hazards for health
  at individual and population level stemming from
  environmental pollution are function of exposure,
  that is of daily behaviours. Physicians have a
  strong influence on their patients' habits, both
  as models and by their advice or credit.

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• Aims. The present survey aimed at identifying
  doctors' ecologically relevant behaviours, in
  order to better understand their educational
  impact on their patients. A second aim was to
  raise doctors' awareness on ecological problems.

6

• Method. The program "Doctor for the Environment"
  was launched with the aid of the Int. Soc. of
  Doctors for the Environment (ISDE),Italian
  Section, UNESCO and WHO, by mailing to 20.000
  Italian general practitioners a leaflet inviting
  to choose 7 among 20 different statements in a
  provided list, each expressing an ecologically
  relevant health advice or behavior. Their answers
  will be printed on a poster, suitable for an
  office wall.

7

• Results. 3.5 of the sample answered, and all
  responders received the poster. Their answers
  revealed an ecological awareness as regards the
  possible toxic effects of drugs, the importance
  of prevention, contact with and respect for
  nature, and the cessation of cigarette smoking.
  Little attention was paid to the ecological
  qualities of the clinical setting, or to
  transport by train, bike or on foot.

8

• Comments. This feasibility study has shown that
  there is room for improvement in the ecological
  behaviours of physicians.

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The Project
Promoters International Society of Doctors for
the Environment (ISDE) - Italian Chapter,
UNESCO, WHO, Italian College of
Physicians Method I.Survey on a large sample of
Italian family doctors about ecological
attitudes and behaviours II. DELIVERY of POSTERS
containing the individually chosen statements
related to ecologically relevant habits III.
Follow up (2 years) on the outcomes of the
campaign.
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• Materials
• Poster
• List of statements to be transferred, as a
  personal choice, to the poster.
• Letter - with information/application form.

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Expected outcomes 1) EDUCATION Increased
interest towards environmental problems by
doctors and their patients, and promotion of
ecologically-friendly behaivours Physicians as
"models" for their patients and social change
agents   Recruitment of medical doctors for
preventive medicine programs and initiatives on
environmental health 2) RESEARCH Information on
doctor's environmental attitudes and life style
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• LIST OF STATEMENTS ON ECOLOGICALLY RELEVANT
  BEHAVIOURS
• (select from the list below)
• I do not smoke and I can help you to stop
  smoking.
• I use my car only when absolutely necessary. Why
  don't you do the same?
• I often eat fruit and vegetables, particularly
  when they are in season. Take care of your
  nutrition.
• I discard separately materials which can be
  recycled. Bring your expired drugs to the
  pharmacy or here.
• I drink moderately. Let's talk about it.
• I do not prescribe useless drugs, as they can be
  harmful.
• I save energy in my consulting room.
• I use disposable products as little as possible.
  Do not pollute the planet.
• I use unbleached paper. Let's use ecological
  paper.
• I can help you to prevent diseases. Please ask
  for information.

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• I enquire about your work as it can be connected
  with your symptoms.
• I do not smoke indoors. Respect air people
  breathe.
• My consulting room is cleaned with ecological
  products. Respect water it is a source of life.
• In my free time I walk in low polluted places.
  Let your lungs breathe.
• I exercise in a park. Do not jog in town or along
  busy roads.
• I teach my sons to respect nature it is a life
  insurance.
• I travel by train, by bicycle or on foot. Let's
  cut stress and pollution.
• My consulting room is not overheated in winter or
  exceedingly cooled in summer. Take care of your
  health and save environmental resources.
• My consulting room is ecological because natural
  and non polluting materials have been used.
• I do not smoke in front of my patients. For
  certain diseases it is necessary to stop smoking.

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• An example of poster

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General note Family doctors were chosen because
of their role in the Italian National Health
Service, which serves in principle the whole
population, and because they have preventive
responsibilities apart from the ordinary health
care.
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Prevention
Individual
Population
Promotion
19
Appendix 2
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Children Environmental Health

• An Italian priority within an international
  perspective

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Why Children?

• The future of mankind
• Representative of the vulnerable groups in the
  population
• Health for children is health for all.

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1999
23
2002
24
Components of healthy environments for children
25
Transition of childrens environmental health
risk with economic status
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National Conference (ISDE) on the Polluted
Child (Arezzo 5-6 June 1998) National Campaign
on Childrens Environmental Health
28
The 1st International Conference on Children's
Health and the Environment held in Amsterdam
11-13 August 1998. On this occasion the
International Network on Children's Health,
Environment and Safety - INCHES was constituted
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June 2000 Costitution of the Italian Network for
Childrens Health and Environment (RISBA)
workgroup of National Institutions and NGOs
already engaged in environmental health,
connected to the International Network Children's
Health Environment and Safety (INCHES)
30
RISBA participates in the EU funded project
Policy Interpretation Network on Children's
Health and Environment (PINCHE). The PINCHE
project is designed to provide decision makers,
environmental health professionals, and other
stakeholders with information relevant for health
policy
31
Childrens Health and Environment a Review of
Evidence (WHO, UE and European Environmental
Agency EEA) Book translated in Italian The 2003
World Health Day (7 April) which WHO dedicated to
children Environment and Health The
international Budapest Conference on The Future
of Our Children (June 2004).
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Appendix 3
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The patient and the urban environment

• by
• Feligetti Antonella, Martella Anna, Santangeli
  Marilena, Lucio Sibilia
• Center for Research in Psychotherapy, Piazza O.
  Marucchi, 5 - 00162 Roma (I)
•  Study performed within the research program
  "Environment and Health" of the International
  Society of Doctors for the Environment (ISDE)

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Method - I General Goals   The present study is
part of a larger survey which had the following
goals   1. To evaluate the distribution - among
the outpatients of general practitioners - of
perceptions of environmental pollution and
decay. 2. To assess the knowledge of ecological
problems in this population. 3. To survey the
distribution both of self-protective behaviors
from health risks of environmental origin and of
behaviors self-exposing to risk. 4. To survey
the distribution of behaviors of environmental
impact (recycling, saving power, water, etc.). 5.
To assess the expectations of efficacy of public
pressure on politicians and of changes in social
behaviors. 6. To survey the distribution of
perception of causal links (attributions) of
disease conditions with environmental
pollution. 7. To stimulate physicians to get
involved in health-related environmental
problems.

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Method - II   The questionnaire  
Likert-type questionnaire filled anonimously
108 multiple choice questions, divided into
3 different sections each pertaining to
A) Perception of environment (air, water, food,
noise) and ecologically relevant behaviors B)
Perceived relationship between pollution and
diseases (attributions) C) Self-protective
behaviors and potential for self-commitment for
protection of the environment. The
questionnaire included a socio-anagrafic form
(age, sex, marital status, living alone, area,
activity, educational level).It was filled in
the waiting rooms of primary care physicians.

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Behaviours and Beliefs
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Attitudes and Behaviours Towards Ecological Risk
50
Stress-coping model of exposure to environmental
pollution
Borgo S. Sibilia L. (2000) "Subjective and
objective assessment of pollution". UMWELT
PSYCHOLOGIE, 4, 2, 26-42 (sic.).
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References
Borgo S. Sibilia L. "Attitudes and behaviours
towards ecological risk in the urban environment"
Proceedings of MAB-UNESCO Symposium on
PERCEPTION AND EVALUATION OF THE QUALITY OF URBAN
ENVIRONMENT TOWARD INTEGRATED APPROACHES IN THE
EUROPEAN CONTEXT, (pp.143-154). Rome, 28-30 Nov.
1991.
Borgo S. Sibilia L. (2000) "Subjective and
objective assessment of pollution". UMWELT
PSYCHOLOGIE, 4, 2, 26-42.
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Appendix 4
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The XIII Conference of the European Health
Psychology SocietyPsychology and the Renaissance
of HealthFirenze, 1-3 October 1999
  Stress Management in School Teachers personal
and/or worksite change?     Borgo S. Sibilia
L.   Istituto di Terapia Medica Sistematica,
Università degli Studi di Roma "La Sapienza"
Centro per la Ricerca in Psicoterapia - Piazza O.
Marucchi n.5 - 00162 Roma in cooperation
withProvveditorato agli Studi di Roma e
Provincia - Roma (Schools Directorate of Rome
and Province)
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Background - I
  School teachers as a professional group are
exposed to high risk of developing stress-related
conditions and burn-out, for a number of reasons
Pupils' misbehaviour, specially from low
income areas Time/resource difficulties
(organizational changes) Unfulfilled
professional recognition needs, and Poor
relationships with peers, administration or
parents.
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Background I cont
Such occupational stress has been shown so far
to produce low job satisfaction, rise in
absenteism age-related decreases in performance
efficiency increase in blood pressure as
compared to other occupations higher rates of
severe psychological distress use of ineffective
or counterproductive teaching strategies.
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Background - II
It is then legitimate to assume that the morale,
the quality of life of teachers - apart from the
quality of teaching - should benefit from a
stress management program. Acceptance, perceived
benefits and true effectiveness of such an
intervention has not been properly evaluated so
far. Intervention should be best implemented in
the worksite, both for practical reasons, and for
addressing context-dependent sources of
stresses. Intervention implemented with
cognitive-social learning methods should be best
accepted than other approaches, given the
teachers' professional conceptual framework.
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general research design
  1. Feasibility study (current
study) 2. Screening for A. stress
symptoms/problems, and B. working stressors of
teachers 3. Intervention studya) Information b)
Stress management groups c) Psychotherapic
info./referral d) Working groups at local level
for organisational change
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AIMS of STUDY 1
This study aimed at assessing the feasibility
and the effectiveness of a cognitive-behavioural
intervention program aimed at reducing
psychosocial stress and preventing burn-out in
school teachers. The program was devised to
pursue this goal 1. by teaching and fostering
individual self-management skills, 2. by
increasing the cooperative climate of the school,
and 3. by targeting awareness of
context-dependent stress factors.
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Subjects
50 school teachers were selected by the
Administration of several Schools of the County
of Rome to participate, among those who had the
responsibility of health education. A few others
voluntarily joined. Final participants were 65
(22 MALES, 78 FEMALES), of average age 47
years, with 20 years of teaching.
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Assessment
 The assessment was performed twice at the
beginning of first encounter and at the end of
the last. The battery comprised two
questionnaires "Stress Symptoms" Questionnaire
(SSQ) stress-related somatic symtoms
complaints. A scale prepared ad hoc , by
translating and adapting a questionnare by L.H.
Miller, composed of 69 Likert-type items. It
includes 7 subscales 1. Muscolar and joint
complaints 2. Parasympathetic symptoms 3. Orthosym
pathetic symptoms 4. Emotional problems 5. Cogniti
ve dysfunctions 6. Endocrine symptoms
7. Immunological disorders
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Assessment cont
Automatic Thoughts Questionnaire (ATQ) freq.
of anxious and depressive self-thoughts.
Self-administered questionaire by S. Hollon P.
Kendall (translated by L.Sibilia), composed of 30
Likert-type items (5 steps).
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Method - I

• The program was implemented in 6 x 5 hour
  workshops in one of the Schools, every second
  week, for a total professional time (including
  assessment) of 30 hours, from Nov.'98 to Jan.'99.
• Each workshop, ran during the afternoon, was
  composed of two units, each comprising a lecture
  and practical training.
• The group was divided into 2 parallel sub-groups
  to better allow for individual participation.
  Each group followed the same program and was lead
  by one of the Authors.
• Basic notions about psychosocial stress were
  initially provided.
• Reciprocal interviewing techniques were taught
  and practised to foster a cohesive group climate
  (v. Sheldon Rose).

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Method - II

• Techniques used were emotional and cognitive
  self-monitoring and muscular relaxation, the
  latter implemented in the school gym.
• Self-monitoring was given as homework and then
  verified.
• Basic information about dysfunctional beliefs and
  imagery was provided, together with practice with
  examples from the participants.
• A group work was carried out for identifying
  occupational stress factors in the worksite, and
  for constructing an assessment instrument
  reflecting the participants' experience, in a
  co-operative climate.
• A final discussion was guided in order to
  strengthen the motivation to use the learned
  techniques, and to assess the chances of (and
  build-up the motivation for) changing the
  identified organisational factors.

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Results - Summary
Effectiveness compared to baseline, final
measures showed a significant marked reduction in
the frequency of anxious-depressive thinking (ATQ
scores), and a more pronounced reduction in
stress-related somatic symptoms (SSQ scores).
Participants' evaluation the program was rated
as satisfactory in many respects, e.g., useful
for monitoring and managing stress at a personal
level (albeit its introductory nature, and its
duration which was considered insufficient by
many).
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Note It was not possible to use a control group
for organisational reasons, but it is likely that
the seasonal differences between the baseline
period (early November) and the moment of the
final assessment (late January) have exerted a
contrasting influence towards the effects of the
program. In fact, teachers' activity was
unanimously appraised as more stressful and
hectic in the latter period.
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COMMENTS
We have provided evidence that a
cognitive-behavioural stress management program
for school teachers, implemented in the worksite,
is feasible, well accepted, and efficient in the
short term, to reduce stress-related problems.
The program was also cost-effective as 65
subjects could attend the workshops, using in
total 60 hrs of professional time. Particular
care seems to be necessary to secure from the
School administration an organisational
committment to allow full attendance by
participants.
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COMMENTS cont
Further studies would be necessary to1- confirm
these findings, also in the long term, 2 -
assess its effectiveness in a) improving the
quality of teaching, b) reducing the teachers'
risk of burn-out in the long run, c)
reducing the context-dependent sources of
occupational stress.