Volume 4

Electrostimulation: Therapeutic Support In Contemporary Aesthetic Speech Therapy


Submission Date: 2022-12-06
Review Date: 2022-12-08
Pubblication Date: 2022-12-09


Electrostimulation can be considered a technological innovation of great help in improving muscle conditions in several areas or specialties such as Neurology, Orthopedics, Physiotherapy, Dermatology and also in Speech Therapy. Facial Aesthetics is one of the areas of activity of speech therapists specialized in Orofacial Motricity, an area of activity that introduced the electrostimulation technique in the therapeutic program, a contemporary proposal as a therapeutic support to accelerate and optimize results. With the aim of softening wrinkles, this technique can prevent and/or treat the stigmas of aging (Lepri, 2020)

Through aesthetic speech therapy, we speech therapists expand our professional area, maintaining the same field of action, that is, a therapeutic process that develops in all its fullness based on the area of Orofacial Motricity. Thus, the speech therapist is able to modify, restore and promote orofacial harmonization, as it acts directly on the functional and muscular aspects of orofacial structures, acting directly on some of the causes and consequences of facial changes resulting from the aging process (Lepri, 2020).

The electrostimulation technique in Aesthetic Speech Therapy is considered an innovation that offers the therapist new intervention possibilities to promote orofacial harmonization, restoring the characteristics of rejuvenation in a direct and effective way. Considered as a therapeutic support technique, it favors prevention and aesthetic balance whenever associated with functional balance. This technique works from the inside out in a controlled manner, generating deep muscle contractions, promoting a “lifting” effect, stimulates metabolism, increases vascularization, oxygenation and soft tissue trophism, in addition to enabling the restoration of volume and also muscle tone, and considerable improvement in the texture and vitality of the skin (Souza et.al 2007).      

Electrotherapeutic currents indicated in Aesthetic Speech Therapy

FES (Functional Electrical Stimulation), a pulsed electrical current and its modulations capable of stimulating the motor nerve and obtaining functional muscle contraction as a result ( Bohórquez et.al. , 2013) which aims to generate a functional movement from the artificial muscle contraction whether in intraoral or extraoral modalities. The FES stimulation mode, in addition to improving the metabolic and functional condition of the muscles, also favors muscle strength and endurance, especially in the lower middle third of the face, SMAS and facial retaining ligaments. When applied for aesthetic purposes, it can combat facial flaccidity, a result of multiple factors, including muscle atrophy. The electrostimulation technique must be associated with orofacial exercises and functional reprogramming (chewing, swallowing, breathing), an important condition to optimize and maintain the results obtained (Lepri, 2020).

KOTZ, current developed in Russia in the 1970s, introduced in Canada and the United States by the Russian scientist Yadou M. Kotz. Indicated mainly for cases of flaccidity and circulatory disorders, its correct use can improve tissue and muscle condition, effect lymphatic drainage and increase cellular oxygenation (Pereira, 1999). The discomfort factor, the perception of electric current, is sometimes a limiting factor for using the technique. The Kotz current has in its characteristics a carrier of medium frequency, this condition favors the delivery of the electric charge that causes less sensorial discomfort and makes possible the applicability of the intensity parameter with high dose in an efficient way allowing vigorous muscular contractions ( Ward et al, 2006 ).Kotz current would therefore be an effective alternative to replacing the FES mode of electrical stimulation, especially in cases of those patients with muscle and tissue flaccidity (gravitational wrinkles) with a lowered sensory threshold.

TENS, Trasncutaneous Electrical Nerve Stimulation, it is a low-frequency electrostimulation modality that selectively stimulates large-diameter tactile fibers without activating smaller-diameter nociceptive fibers, promoting pain relief and thus generating functional gains (Chiarello et al., 2005). The explanation for the analgesic effect is that this current promotes the release of endorphins, which are endogenous analgesics released whenever the body feels pain. The applicability of the TENS mode in speech therapy may be related to the analgesia effect, which is why this current is used with excellent results, for example, in the control of painful symptoms in temporomandibular joint disorders (Fernandes et al., 2006). However, TENS can also be used in Aesthetic Speech Therapy in order to enhance the effect of muscle relaxation and the release of tension in soft tissues, a condition that favors the smoothing of expression wrinkles.

MESN, ( Microcurrente Electrical Neuromuscular Stimulation), they act directly on the stimulation at the cellular level of micro structures producing micro stimulation and neuro stimulation. It is a general bioelectric current in the range of microamperes, as it is able to allow a more efficient transport of ions, which in turn increases cellular metabolism and energy of muscle fibers (Jyothis, 2005). According to Soriano et. al 2002, some physiological effects favor an improvement in the aesthetic condition of the face such as; optimization of metabolism, increase in adenosine triphosphate and collagen production, increase in the lymphatic drainage effect of intracellular ionic exchanges and mobilization of liquids from the lymphatic and blood circulations.


There is no single procedure capable of reversing all the changes resulting from the facial aging process. In a therapeutic process, it is necessary to combine techniques for the different structural planes of the face. Speech therapy with a focus on facial aesthetics supported by the technique of intra and extra oral electrostimulation has been shown to be effective in redefining facial contours and smoothing expression wrinkles.


  1. Bohórquez, I.J.R.; Souza, M.N.; Pino, A.V. (2013) Influência de parâmetrosda estimulação elétrica funcional na contração concêntrica do quadrícepes. Revista Brasileira de Engenharia Biomédica, vol. 29, n.2, p. 153 – 165.
  2. Fernandes, G. Ferreira,A., Gonçalves, D. et al., (2006) TENS uma modalidade de tratamento para a dormuculo esqueléticocrônico da face. Revista de odontologia da UNESP, v. 35, n.especial.
  3. Jyothis, A.B.R. ( 2005) Arndt- Schutz Law: a scientific evidence. Homeopathy Times, v.2, n. 11.
  4. Lepri, Juliana R. (2020). Eletroestimulação na Fonoaudiologia Estética.Ed. Pró-Fono, ISBN: impresso 978-65-87564-00-5; SP/Brasil.
  5. Pereira, F. N. (1999) Eletroterapia sem mistérios. Rio de Janeiro ed. Robson Achimé.
  6. Souza, S.L.G.; BraganholoL. P.; Avila A.C.M. et al. (2007) Recursos fisioterapêuticos utilizados no tratamento do envelhecimento facial. São Paulo: Revista Fafibeon line, n.3.
  7. Soriano, M.C.D.; Perez, S.C.; Bakués, M.I.C. (2002) Eletroestética profissional aplicada: teoria e prática para autilizaçãode correntes na estética. Saint Quirze dell Valles: sorisa.
  8. Ward, A.; Oliver, W. G.; Buccella, D. (2006) Wrist rxtensor torque production and discomfort asociated whith low frequency and burst- modulated kolohertz-frequency currents. Physical Theraphy, v.86, n.10, p.1360-1367.

Evaluating the quality of the relationship between health workers and patients/caregivers during the Covid-19 pandemic: a review

Article Navigation

Submission Date: 2022-10-31
Review Date: 2022-11-15
Pubblication Date: 2022-11-17



The SARS-Covid 19 pandemic has produced a change in the relationship between health professional and patient and between doctors and family members. Restrictions to avoid the spread of the virus encouraged the use of electronic communication in interactions and the use of face masks in hand-to-hand contact, reducing the possibility of communication.
Communication has changed, losing important non-verbal components and partly body language. This change risked impoverishing the relationship between doctor/nurse and patient/family, as the role of non-verbal communication is vital in healthcare (Diamare et al., 2021). Indeed, facial expressions, gestures, eye contact, posture and tone of voice 'speak' with great intensity, becoming an important tool for healthcare professionals in understanding symptoms.
To this end, it was decided to implement a health and business psychology survey to analyze any emerging needs and to improve the quality of the relationship in the healthcare facilities participating in the survey. Therefore, questionnaires were administered to healthcare professionals and patients/caregivers in order to investigate how they interact and their different points of view on similar issues.


In healthcare, quality in the care field was first discussed immediately after the end of the Second World War with W. E. Deming, an expert in business organization, who began to spread the criteria of organizational quality aimed at the continuous improvement of resources based on his experiences during the reconstruction of the American military and technological potential (Colucci A., F. Ferretti, R. Cioffi, 2009).

Avedis Donabedian, a founding physician of the study of healthcare quality, defines Quality as: “doing only what’s useful (theoretical effectiveness), in the best way (practical effectiveness) with the least cost (efficiency), to those (accessibility), and only to those, who really need it (appropriateness), having the care done by those who are competent to do it (competence), obtaining the results deemed best (satisfaction)” (Donabedian A., 1988).

In 1997, healthcare satisfaction was considered the most important predictor of the overall satisfaction in hospitals and is still one of the outcome indicators of the quality and efficiency in healthcare systems (Merkouris A, Papathanassoglou EDE, Lemonidou C., 2004).

In the study and evaluation of quality of care, it’s fundamental to include the relationship and bonding with the patients which is, according to the literature, the most perceived aspect in the care process.

However, the safety regulations imposed by the Covid-19 pandemic, especially with the use of the face masks, have taken away mimic elements of non-verbal communication from the relationship between health workers and patients/caregivers. These aforementioned elements are fundamental to establish a good doctor-patient alliance from the very beginning. Because of these changes, the relationship has inevitably changed, leading to the need of developing new skills regarding the quality of verbal and non-verbal communication in the care process: for instance, the ability to create patient trust, the ability to treat the patient with care, empathy and sensitivity (Egman S.,et al. 2011), which can guarantee an experience similar to that in the pre-pandemic condition.

Customer Satisfaction questionnaires, a tool used in almost all companies and not only the ones related to healthcare, allow one to have real feedback on the service offered, to identify problems and to show the quality of the services offered (Perucca R, 2001). Because of that, surveys on perceived quality are increasingly common in organizations that pay attention to the individual. (Tanese A., Negro G., Gramigna A, 2003).

Regarding the technical quality of care, the fundamental requirements are the appropriateness of the service provided and the skills with which the appropriate care is delivered, without neglecting the necessary balance between the risk/benefit assessment and ethical issues. While doctors and nurses would like to achieve technical excellence, patients seem to be more involved in accessibility and performance.

Then, Customer Satisfaction can represent a strategic lever to improve the service offered starting from the relationship between the health professional and the user, especially because healthcare personnel’s competence is expressed through the quality of the care. The focus must be on the patient as a whole, identifying their needs through a holistic approach (Egman S.,et al.,2011).

The SARS-Covid 19 pandemic has produced a change in the relationship between health professional and patient and between doctors and family members. Restrictions to avoid the spread of the virus encouraged the use of electronic communication in interactions and the use of face masks in hand-to-hand contact, reducing the possibility of communication.

Communication has changed, losing important non-verbal components and partly body language. This change risked impoverishing the relationship between doctor/nurse and patient/family, as the role of non-verbal communication is vital in healthcare (Diamare et al., 2021). Indeed, facial expressions, gestures, eye contact, posture and tone of voice ‘speak’ with great intensity, becoming an important tool for healthcare professionals in understanding symptoms.

To this end, it was decided to implement a health and business psychology survey to analyze any emerging needs and to improve the quality of the relationship in the healthcare facilities participating in the survey. Therefore, questionnaires were administered to healthcare professionals and patients/caregivers in order to investigate how they interact and their different points of view on similar issues.

Service objectives

In Public Local Health Service ‘A.S.L. Napoli 1 Centro’ a team of psychologists from the ‘U.O.C. Quality and Humanization’  (http://www.aslnapoli1centro.it/it/eventi/-/asset_publisher/LVl9/content/u-o-c-qualita-e-umanizzazione;jsessionid=D6A7778E6626841DFBE355BF817C5C6A?redirect=http%3A%2F%2Fwww.aslnapoli1centro.it%2Fit%2Feventi%3Bjsessionid%3DD6A7778E6626841DFBE355BF817C5C6A%3Fp_p_id%3D101_INSTANCE_LVl9%26p_p_lifecycle%3D0%26p_p_state%3Dnormal%26p_p_mode%3Dview%26p_p_col_id%3Dcolumn-2%26p_p_col_count%3D1), in partnership with the Primary Care Department, implemented a pathway to assess the quality of the relationship between health workers and patients/caregivers, and to research the services provided by the healthcare facilities during the period of the Covid-19 pandemic, in order to structure interventions aimed at reducing the discomforts expressed by internal/external users.

In addition, the questionnaires were administered exclusively online, exploring the still-very-young area of healthcare digitalization.


The aim of this study is to explore the different views of operators and patients/caregivers on the care provided and especially the operator/patient relationship during the period of the COVID-19 pandemic.

In particular, the aim was to develop a method for more in-depth future research into possible changes in non-verbal communication during pandemic emergencies following the use of personal protective equipment (PPE).

Target group

The questionnaires were addressed to operators in districts and hospital wards involved in the COVID-19 emergency, reaching a total of 62 operators in 30 days.

The mirror interview was previously addressed to caregivers and patients from the same catchment area.

Methods And Materials

The study was carried out through an online interview aimed at exploring, from the point of view of the healthcare operators, the perceived quality of healthcare and the relationship with patients/caregivers, especially regarding the degree of attention and participation in care, the quality of information and empathy.

In line with the current aims of healthcare digitization, the questionnaires administration was proposed exclusively online through a QR CODE, considering that questionnaires could not be handed on paper due to the ongoing pandemic.

This online protocol, illustrated by the posters displayed in the healthcare facilities, was supported by moments of unstructured sharing spaces, making the respondents participate in quality improvement processes through the evaluation of their degree of satisfaction. Despite the lack of digital literacy, there have been some responses and participation regardless.

The questionnaire was created and developed using the Microsoft Forms platform, which allows the creation and sharing of surveys. Thanks to this platform, it has been possible to create a QR code to fill in the questionnaire directly from smartphones. Health workers and users/caregivers accessed the questionnaire by framing the QR code inside the posters placed in the local healthcare facilities. This allowed the user to fill in the questionnaire faster and with certainty of data registration while respecting their privacy, since it was completely anonymous.


The qualitative analysis presented here is based on data emerged from a thematic comparison between the answers of the questionnaire addressed to users (reported in the previously published study “Humanisation of the health worker-user relationship and improvement of the quality of services” (Diamare et al. 2021)), with those of the questionnaire presented in this paper, adapted to be administered to health workers.

  1. On the first item “How carefully and effectively do you think you participated in the care of your patients?” 57% of the respondents report that they participated very carefully and 15% “not at all”. Only 28% report having “moderately” participated. The majority is therefore satisfied with the job done with their patients, despite the difficulties and limitations due to the SARS-Covid 19 pandemic.
Tab. 1
  • In response to the question: “Do you believe that you provided clear and adequate information about the patient’s state of health and treatment during the period of hospitalization?” a large proportion of healthcare professionals claim to have provided the patient with clear and adequate information about the patient’s state of health and treatment in all facilities: 44% felt that they were very satisfied, 10% “not at all” satisfied with the clarity and 41% “moderately” satisfied.
Tab. 2
  • Concerning the question “Do you think that being “empathetic” is important for a doctor/health worker in relation to his patients?” all respondents considered empathy to be a pivotal factor in their profession. Specifically to the question “If yes, what level of empathy (from 1 “not at all” to 5 “plenty”) do you feel has been achieved in the relationship with your patients with whom you have had contact during the pandemic?” the practitioners find a good level of empathy with their patients. In fact, the majority of healthcare workers consider that a high level of empathy was achieved in their relationship with their patients, as can be seen from the graph in Tab. 3.
Tab. 3

At the same time, patients/caregivers in the majority of cases perceive this relationship as positive, even though a small percentage (10% “extremely” and 3.3% “moderately”) report a low level of empathy with caregivers (Diamare S. et al., 2021)

  • The question “Do you consider eye contact to be important in patient care during the pandemic period?” shows that almost all of the practitioners interviewed considered eye contact with patients to be important.
Tab. 4

Only a small percentage does not attach the same importance (7% “moderately”, 3% “a little”) to eye contact.

Also for 86.6% of patients/caregivers the eyes are an important means of communication.

  • Concerning the question “During the treatment period, how much were you able to emotionally support your patients/caregivers despite the limitations imposed by COVID-19?” more than half of the caregivers believe that they “moderately” (54%), “very much” (30%) or “extremely” (5%) offered their emotional closeness. However, there is a small percentage (11%) who feel that they have not been able to give their support, as can be seen from the percentages in the following graph (Tab. 5).
Tab. 5

At the same time, as shown in the previous Pilot Study, most of the patients/caregivers interviewed felt supported by the caregivers (“very much” 26.7% and “extremely” 53.3%).

  • When asked “How much do you think that your state of mind influences your relationship with patients?” there is a certain heterogeneity in the thinking of the health workers (Tab. 6): 7% of the interviewed health workers state that their state of mind does not influence their relationship with the patient at all and 25% that it influences it “a little”; whereas 26% think that their state of mind is “moderately” influential on the patient, 31% that it influences them “very much” and 11% “extremely”.
Tab. 6
  • From the question “How well did you feel understood by your patients/caregivers with regard to the difficulties you faced in dealing with the Covid-19 pandemic?
Tab. 7

As the percentages below and the graph (Tab. 7) show, only 17% felt “very much” and 8% “extremely” understood by their patients/caregivers.

44% of the respondents felt “moderately” understood by their patients.

But the 31% who felt “a little” understood gives us an indication of an emerging critical issue, on which corrective actions need to be articulated.


Analyzing the results relating to the Health Care Workers’ perception of the quality of their communication and relationship with their patients, it is possible to note that, despite the difficulties and restrictions imposed by the pandemic emergency, the workers believe that they managed to take care of their patients carefully and effectively, and that they provided clear and exhaustive information, both on their state of health and on the methods of care. Bearing in mind the impact of the pandemic and the difficult situation that many patients faced, emotional support from healthcare professionals is of paramount importance in dealing with this difficult time. In fact, one must not only consider the physical damage, but also the emotional impact that an illness has on the subject’s inner world; therefore, good communication between health workers and patients/caregivers offers a containment of suffering and emotional distress.

In line with what has been said so far, from the analysis of the answers it emerges that the healthcare personnel considers empathy as an essential tool of the work, strongly supported by the gaze that represents a vehicle of immediate understanding of the other. In this regard, an interesting point to be adequately investigated with further scientific studies is to understand whether the gaze assumes a greater weight in interpersonal relationships.

All health professions assume the role of ‘communicator and translator’ not only of information but also of feelings. But it is interesting to note that some practitioners believe that their state of mind does not have too much relevance on the relationship with the patient/caregiver.

An even minimal measure of the interviewed users would have wished for more empathy in the relationship. Therefore, what needs to be further investigated is the patient’s and caregiver’s view of the degree of understanding, closeness and empathy they feel they have received from the healthcare personnel, in order to have more elements available on the importance of the caregivers’ state of mind  in the relationship.

Not all workers, on the other hand, perceived understanding from patients and their caregivers with regard to the practical and emotional difficulties caused by the emergency, despite the fact that they, on the other hand, felt they had offered support and understanding to them. During the pandemic period, healthcare workers carried out their work in exceptionally difficult conditions, and understanding the emotional state of those working in healthcare facilities became a fundamental step in dealing with states of emergency while avoiding the risk of unwarranted aggression.

However, it is possible to infer from both of the assessments examined the strong spirit of adaptation that health workers and patients/caregivers demonstrated during the health emergency. There’s a certain congruence of the opinions of patients/caregivers and carers concerning the quality of the relationship, which represented perhaps one of the most important resources in the difficulties management.

These results were fundamental for the implementation of online communities of salutogenesis addressed both to practitioners and patients/caregivers such as the “Virtual Wellness Lounges” and of contents developed in the training courses “Health Advocacy and Psycho-body Empowerment” and in programmes aimed at conscious digitalisation such as “Enterprise 2.0 for Quality Improvement“.

In emergency situations, communicative exchange is essential because the feeling of participation increases resilience. Therefore, paths of humanisation and improved communication are also a priority in order to improve the quality of care in times of crisis in order to get closer to each other and to respond appropriately also to the submerged needs of the users.

The way of communicating with the patient/caregiver does not only depend on the scientific and technical level, but also on his/her ability to empathically ‘enter’ into contact with the patient and his/her body expressions. Mimicry is undoubtedly a useful tool, since it arouses in the interlocutor a feeling of “similarity”, and this opens up good communication channels.

An important aspect, in the social context in which the questionnaire was administered, is to allow a reflection on perceived sadness and distress, as a “natural” reaction to an extraordinary event that has affected both patients/caregivers and operators and that, therefore, needs to be welcomed by specialized personnel trained in humanisation processes. That is to say, we are not only emphasizing the importance of ‘clinically treating’ people affected by overt reactive syndromes, but of taking care of a silent distress that runs through us, makes us unhappy and harms the wellbeing of the individual and of the community.


Analyzing the results it was found that, despite the important communication restrictions and the lack of contact, the quality of the caregiver-patient relationship is perceived positively in most cases. An interesting understanding was also established on the caregivers’ side regarding the difficulties encountered by healthcare workers during the COVID-19 pandemic in the management of patients and their families.

It can be said, in the end, that the health emergency, while amplifying negative emotions, generated deep trust in health personnel.

Regarding the aspects that could be further investigated by means of Customer Satisfaction surveys in healthcare, it’s interesting to introduce elements to assess the effectiveness of communication and relations: indicators of empathy, non-verbal communication, attention to the patients and caregivers’ state of mind, and to increase the resources allocated to such projects.


Bellocchio Olimpia (P.O. Ospedale del Mare), Scognamiglio Mariarca (P.O. Loreto Nuovo), Mario Sabatino (D.S. 25), Alberta Mariniello (P.O. Pellegrini) for the dissemination of questionnaires.


  1. Al-Dogether AH.,2000. Inpatients satisfaction with nursing services at king kha-lid university hospital. Riyadh, Saudi arabia. J Fam Community Med.;7(3):37–45.
  2. App, B., McIntosh, D. N., Reed, C. L., & Hertenstein, M. J. (2011). «Nonverbal channel use in communication of emotion: How may depend on why.» in Emotion, 11(3), 603-617
  3. Bellavia M, Tomasello G, Damiani P, Damiani F, Geraci A, Accardo F, et al., 2012. Towards An Improvement of Hospital Services and Streamlining of Health Care Costs: The DRG Analysis in Italy. Iran J Public Health. 31;41(7):1–6.
  4. Colucci A., F. Ferretti,R. Cioffi.,2009. Cenni teorici sul concetto di qualità percepita in sanità. Giornale Italiano di Medicina del Lavoro ed Ergonomia.Pavia:PI-ME;;31(3):34-41.
  5. Crisp-Centro di ricerca intrauniversitario per i servizi di pubblica utilità, 2011. Manuale del Sistema di Valutazione della Performance degli Ospedali Lombardi. [online]. Università degli studi di Milano Bicocca.
  6. Diamare S. (2017), «I “Salotti del Ben Essere”: spazio di promozione della salute per caregivers di pazienti con problemi di salute mentale» in La Salute Umana, Editore Perugia.
  7. S. Diamare,  G. Cinquegrana, E. D’Anna, A. Glorioso, L. La Pignola,  A. Liuzzi, R. Valente, S. Verde, W. Longanella, M. Corvino (2021), Umanizzazione del rapporto operatore sanitario-utente e miglioramento della qualità dei servizi, La Salute Umana, n. 283
  8. Diamare S. (2019), «Un metodo di Embodied Education in Riabilitazione: approcci di valutazione partecipata e di empowerment psicocorporeo», in Journal of Advanced Health Care.
  9. Donabedian A., 1988. The Quality of Care: How Can It Be Assessed?. JAMA.260(12): 1743-8.
  10. Egman S., Giammona S., Ziino Colanino M., Cappello G., Lombardo R., Marchese F.,2011. L’Infermiere Nel Processo Della Qualità. [online]. Nurse Science.;(19):1-10
  11. Garista P., Pocetta C., (2005),  «Lavorare sui “casi” per lo sviluppo di conoscenze e il miglioramento di qualità in promozione della salute.», in Educazione sanitaria e promozione della salute.
  12. Merkouris, A., Papathanassoglou, ED, & Lemonidou, C. (2004). Valutazione della soddisfazione del paziente per l’assistenza infermieristica: approccio quantitativo o qualitativo?. Rivista internazionale di studi infermieristici , 41 (4), 355-367.
  13. Perucca R., 2001. Consumers with options. Service excellence models help to ensure that patients get the quality care they expect. Nursing Manage-ment.;32(9):20–24
  14. Tanese A., Negro G., Gramigna A.,2003. La customer satisfaction nelle amministrazioni pubbliche. 2a Edizione. Roma: Rubbettino Editore.

Geopolitical Security Of University Staff In Teaching / Research Activities Abroad



Vanacore Giuseppe1, Niola Giovanni2, Ruotolo Fabrizio3

1Head of the Prevention and Protection Office at the Federico II University of Naples
2Prevention and Protection Service Officer at the First Prevention and Protection Office - Federico II University of Naples
3Prevention Technician Prevention Technician c / o ASL Napoli 1 Centro - Supervisory Inspector


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


This report aims to address the problem of occupational safety for people, whether structured or not, belonging to universities, engaged in scientific, research or study activities in the context of scenarios exposed to possible geopolitical risks.

The term geopolitics refers to the science that analyzes the relationships between geographical factors and political choices, which are constantly evolving due to new world structures, emerging problems affecting different areas of the world, dynamics capable of redesigning geopolitical realities by creating imbalances and instability.

Globalization, although it has reduced physical distances, has not been able to neutralize the cultural, ethnic, religious and political divisions that require a continuous process of assessment and monitoring of the risks to which travelers may be exposed so: plan activities; schedule an immediate return; identify trusted people of reference and support once you reach the foreign location; communicating in advance one’s movements and having a knowledge of the cultural and anthropological factors of the social fabric of the host country become factors that, inevitably, must be taken into account in order to avoid unexpected consequences,

At the same time, international scientific research, which represents one of the key factors for the growth and development of society in the medium-long term, by virtue of its potential ability to provide innovation through technological application, has now assumed a leading role for the activity of researchers; the frequent exchanges of scholars of different nationalities make it possible to pursue collaborative projects that determine growth in the scientific and technological fields. More generally, international exchanges are an opportunity for intercultural, social and linguistic learning that determine, for our country, a more competitive and attractive presence at the international level of all Italian research and higher education institutions as a qualified contribution to construction. of the EU and non-EU scientific and technological space

In light of the news reports of the disappearance of Erasmus students and researchers engaged in research activities abroad, the need has emerged to combine the growth of international exchanges with that of preparing suitable security measures for personnel who carry out research or studies. in foreign locations

Therefore, knowledge of geopolitical risks is essential for the purposes of the correct assessment of the factors that may influence the “safety” of researchers whether they belong to employees or students, doctoral students, etc. .. The preventive analysis of these factors allows, with a sufficient degree of approximation, to give an assessment of the different levels of risk.

Methodology And Materials

The topic is addressed in the light of the obligation provided for by art. 28 of Legislative Decree 81/08 which requires the employer to assess all risks to the health and safety of workers. If the assessment of the risks ordinarily attributable to one’s activities is taken for granted, the assessment of those dependent on the danger deriving from socio-political, health and economic scenarios is not taken for granted, although they can cause accidents, even lethal ones, and the onset of serious professional diseases

Therefore, a procedure has been drawn up which, starting from the elaboration of a regulation governing the management of the safety of workers engaged in research activities in contexts where the incidence of specific geopolitical factors is found, leads to a methodology that allows first identify the factors that can affect the psycho-physical integrity of staff abroad. The procedure, in addition to focusing on the owners and with delegated functions, defines the steps from the preliminary monitoring phase of these factors to the administration of a specific questionnaire upon return from abroad. In the preliminary phase of risk assessment, all the information and training tools offered by new technologies and by governmental, international and non-governmental institutions will be used

To this end, the Italian Government offers travelers numerous travel support and assistance tools in relation to the health situation, the presence of embassies and consulates, information on public order, crime, terrorism and mobility. This information is integrated with that from international and non-governmental organizations that provide information of various kinds, from health and humanitarian to those on political and financial stability. In addition, the Farnesina offers a specific collaboration service dedicated to Universities and Research Centers, which have a greater vocation for internationalization, with the support of the skills and experience gained by the Crisis Unit.

Therefore, taking into account the importance of the preliminary monitoring of geopolitical risks and the variability of cognitive sources, the preparation of a correct procedural procedure will allow for an assessment of the risks that can capture the actual and concrete criticalities of the host country.

The idea of ​​adopting a regulation also goes to remedy a gap found in the monitoring process of geopolitical risks that concerns the subject “responsible for the purposes of Legislative Decree 81/08”, since, for this problem there is no exact discipline starting from the identification of the subject, in the university system, required to supervise the assessment of the related risks and the possible adoption of corrective and precautionary measures. This criticality is largely dependent on the freedom of research and teaching recognized to teachers, which allows for ample autonomy and independence in planning activities abroad.

Therefore, following an analysis of the current administrative-accounting authorization processes adopted in the Fridericiano University for missions abroad, which generally end with an authorization for expenditure, a geopolitical risk monitoring procedure was added.

The procedure requires that the teacher promoting the activity abroad or the university tutor, who supports the student in the related activity, in producing the request for a foreign mission / trip to obtain the authorization for expenditure, completes the preliminary risk monitoring form in which in addition to their personal and career data indicates:

  • Place of the mission / trip
  • The type of accommodation of the stay
  • Length of stay
  • Purpose of the activity
  • Possible frequency with which the same location is chosen
  • Level of cultural linguistic knowledge of the country / locality

Subsequently, the Employer, or his / her delegate, with the support of the RSPP together with the Tutor / supervisor will evaluate this form by making a preliminary estimate of the risks including contextual factors (social / economic crises, conflicts, crime, sanitary conditions, etc. ) and subjective factors (knowledge of the country, traveler’s health suitability, estimate of the risks at the host facility, degree of linguistic-cultural knowledge of the country of destination, etc.) reporting in form B the preliminary indications on the estimated risk level

This first monitoring of potential geopolitical risks will end with a final opinion from the Director of the Department in which he can indicate any precautions that the applicant for the mission will have to take before and / or during the mission abroad (form C).

Considering that the preferred countries for the aforementioned missions / trips are often identified as they are already recipients of other missions due to the presence of cultural and scientific collaboration agreements with European and non-European universities, in order to allow the establishment of a database containing the ” feed back ”of travelers upon their return, a specific questionnaire was drawn up to be administered upon return from the mission with a request for information on the main risk factors found in the country visited (form D). These elements will constitute a database that will allow both to validate the results of the preliminary risk monitoring and to integrate the information already acquired from institutional and non-institutional sources with that coming from the direct experience of the researchers concerned. The procedure thus set up will allow, when fully operational, to obtain an updated mapping of the risks present in a specific area.

Everything is accompanied by a short “traveler’s manual” in which information is provided on the common behaviors to observe for those who intend to spend a period of study abroad. It was divided into three chapters (territorial and logistical risk, cultural and language differences, crime and social order) and a final part.

Results And Discussion

In the wake of the protest movements born in 2016 following the murder of Giulio Regeni, an Italian doctoral student, some universities have promoted information and training initiatives to identify the most suitable measures for the protection of students / doctoral students / postdocs / researchers / professors who have to go to work in areas at geopolitical risk. Risk communication and the fight against disinformation were the objectives of our working group. Therefore, starting from an analysis of the data of the missions carried out in the last 5 years by staff belonging to a Department of Humanities of the Federico II, we have found that over the years there has been a progressive increase in international exchanges by the staff of the ‘University which also involved the non-employed, precarious and fixed-term one. However, this trend had a turnaround in 2020 due to the Covid19 pandemic. We also found that the share of missions carried out outside the EU was significant, which, in relation to the geopolitical and health context, were indicated as places with greater geopolitical risk. Therefore, we simulated a geopolitical risk assessment by adopting the designed procedure, finding the effectiveness of the proposed methodology in identifying potential risk areas.

Tab. 1

These data will allow us to protect workers abroad by providing them with information on the most suitable preventive measures and to the limit to advise against the mission. The results of the geopolitical risk assessment procedure, collected in this way, will integrate the DVR pursuant to art. 28 of Legislative Decree 81/08.


  1. POINT SAFE. (2017) How to improve the safety of those who work in areas at geopolitical risk. Available in: https://www.puntosicuro.it/view-pdf/come-migliorare-la-sicurezza-di-chi-lavora-in-zone-a-rischio-geopolitico-AR-17493
  2. Sclip. G., 2017, Accessible security The occupational safety of researchers in areas at geopolitical risk What is the norm between intelligence and terrorism? Available in: Geopolitical_Risk.pdf (units.it)
  3. Ministry of Foreign Affairs and International Cooperation, Available at: https://www.esteri.it/mae/it/, http://www.viaggiaresicuri.it
  4. Organization for Safety and Health in Europe. Available in: https://www.osce.org/it
  5. World Health Organization. Available at: https://www.who.int
  6. United Nations Regional Information Center. Available in: https://unric.org/it
  7. Sace Group Cdp for the support of Italian companies in the global market. Available in: https://www.sace.it
  8. National Geographic. Available at: https://www.nationalgeographic.com
  9. Around the World, SC Infectious and Tropical Diseases. Available in: http://www.ilgirodelmondo.it

Effectiveness Of Workplace Health Promotion In Protecting Against COVID Risk



Tobia Loreta1, Provvidenti Luca1, Mancinelli Vittorio1, Guerrini Luca1, Fiasca Fabiana1, Fabiani Leila1

1Dept. of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


The emergence of the COVID-19 pandemic has had health, social and psychological impacts on workers worldwide (1, 2,3). The Italian National Institute for Insurance against Labour Accidents (INAIL) has developed a classification system for companies (4) at high, medium and low Covid risk based on exposure probability, proximity index and aggregation factor.  Exposure measures the probability to be in contact with potential sources of infection during work activities (e.g., health sector, hazardous waste management, research laboratories). Proximity measures the intrinsic features of work activity that cannot guarantee an adequate social distancing (e.g., specific tasks such as in assembly lines) for part or for most of the working time. Aggregation measures work activities that may determine contacts with people other than workmates (e.g., restaurants, retail, entertainment, hospitality, education).

Educational activities have been classified as medium-low risk of transmitting Sars-CoV-2.

Every company had to implement a safety and prevention protocol against Covid-19 in the workplace. The document is based on the shared protocol of April 2020, as amended and supplemented on 6 April 2021, agreed by the employers’ associations and the trade unions for the regulation of measures to contrast and contain the spread of the Covid-19 virus in workplaces (5). In line with such enhanced measures, the University of L’Aquila established a COVID Committee composed of the Employer, the Health and Safety Officer, the Workers’ Health and Safety Representatives, and the occupational health physicians. Various countermeasures were implemented to mitigate the risk of spreading the virus, such as transitioning to virtual instruction, remote working, reduced capacity within the offices and the laboratories at any one time, social distancing, use of face masks, hygienic measures, access controls, contact tracing of possible contacts of confirmed cases of COVID, and monitoring of the mandatory quarantine requirements set forth by the health authority.

In relation to the University’s health promotion programme that has been in place for 5 years, this study aimed at investigating the relationship between the COVID-19 preventive measures and the occupational risk perception and the adoption of more protective health behaviours to mitigate the spread of SARS-COV-2.

Methods and materials

The University Health Care System managed health surveillance with proactive attitude serving as a reference point (also through a helpline) for the identification of persons at risk (contact-tracing), for the recommendation of molecular swab tests, for monitoring the mandatory quarantine and/or isolation requirements, for advising the arrangement of occupational health appointments before returning to work from sick leave, and for the management of vulnerable subjects through a remote work or remote education order.

The survey was conducted from July 2020 to January 2021, as part of the University’s worksite Health Promotion programme, called “Ateneo in salute” (i.e., good health and well-being in the University) that has been in place for five years. The voluntary based programme aims at raising awareness among workers on health promotion measures to prevent the risk of metabolic, cardiovascular diseases (Cuore project – Italian National Health Institute), and of other chronic conditions.

The programme involved the collection of data related to the medical history and lifestyle practices of the respondents, a medical examination along with health counselling and follow-up visits, free access to blood and urine tests to detect any metabolic and blood lipids diseases, electrocardiogram, and promotion of adherence to screening and vaccination campaigns. The collected data were added to a database that was subsequently complemented with the survey questionnaire on COVID-19 risk perception.

The survey used an online questionnaire (Microsoft Form) that was sent through email by the University Health Care System to all the univaq.it domain users.

The questionnaire was designed to collect data on specific medical conditions in relation to Covid-19: symptoms, any history of previous positive molecular nasopharyngeal test or antigen test, any mandatory quarantine or isolation measures. It assessed the pandemic-related risk perception with responses based on a 1-10 scale, with 10 being the highest perceived risk, the individual preventive measures such as hand hygiene, the use of PPE, and of social distancing behaviours. Moreover, the questionnaire aimed to assess the willingness to accept a COVID-19 vaccine if made available.

The merging of the database of Ateneo in Salute with the responses to the questionnaire has generated a complete dataset of 314 records concerning the university employees, including lecturers and technical/administrative staff (137 M and 177 F) divided by age group and role, as reported in Tables 1 and 2.

Age groupNumber of employeesEmployees in %
<=30 years227
30 > x <= 40 years4714,9
40 > x <= 50 years6320
50 > x <= 60 years11536,6
>60 years4915,7
Tab 1 – division by age group of the employees who took part in the study

Indirectly employed personnel (Residents, PhD Students, Interns)59
Technical/administrative staff131
Tab 2 – division by role of the employees who took part in the study

The statistical analysis examined the frequency measures, the measures of central tendency and the measures of association between the variables. The multivariate logistic regression model was used to determine the association between the variables. The significance associated to the measures was assessed using the Student’s t-test, the Chi-square test, the Fisher exact test, and the Wilcoxon test.

Based on the mean score (7.11±2.26) assigned to the perceived risk for COVID-19 infection, the sample was stratified in two groups: medium low score (1-7) vs high score (8-10). The discrete and nominal variables were expressed as absolute and percentage frequencies, and the difference between the two groups was assessed using the Chi-square test or the Fisher exact test, as appropriate. The continuous variables were reported as mean values to determine the standard deviation, the difference between the two groups was assessed using the independent samples t-test. Where statistical significance was reported, the variables were included into a multivariate logistic regression model to detect the independent factors associated to a higher COVID-19 risk perception. A backward-stepwise selection was performed determined by AIC (Akaike Information Criterion) to select the best multivariate model. The statistical analysis was carried out using STATA/IC statistical software package version 15.1. The chosen level of significance was <0.05.

Results and discussion

Among the 314 respondents, 31% reported undergoing a molecular/PCR test and 49% undergoing an antigen test (Table 3). These percentages are to be correlated to the intensive engagement interventions by the University Health Care System to spread awareness regarding the COVID risk factors among the university employees.

No workplace COVID-19 clusters were detected among the university employees.

Tab. 3 – Comparison of the COVID-19 prevention measures
* χ2 test
**Fisher’s exact test

Participants assessed their perceived COVID-19 infection risk on a scale from 1 to 10 (mean 7.11±2.26).

Average age is higher in the group that reported a greater perceived risk for COVID-19 (52.05±10.98 vs 46.73±11.26, p<0.001). The respondents who showed a high-risk perception also reported undergoing antibody tests (96.86% vs 90.97%, p=0.029) and implementing protective health behaviours and using PPE more frequently than the respondents who reported a medium-low perceived risk for COVID-19 infection (93.08% vs 83.87%, p=0.010). 

The perceived risk for COVID-19 infection increases with age (OR 1.04, IC 95% 1.02 – 1.06, p=0.001) and decreases where a family history of diabetes was reported (OR 0.53, IC 95% 0.28 – 0.99, p=0.049). The respondents who reported a higher perceived risk (8-10) have a personal medical history of cancer (8.23% vs 3.36%, p=0.069), hypertension (16.03% vs 9.40%, p=0.083), or were prescribed at least one drug for the treatment of a chronic condition (37.34% vs 29.53%, p=0.147). The respondents who had a lower perceived risk (1-7) reported a regular alcohol consumption (36.91% vs 26.75%, p=0.056). 

Thus, chronological age results to be a statistically significant factor associated with a higher perceived risk for COVID-19 infection and a greater health concern. Concern and implementation of protective behaviours increase with age. This association reflects the correlation spread by scientific studies and the mass media among the negative effects of the Sars-Cov-2 and age. (6,7,8).

Thus, age and cardiovascular and oncological conditions affect risk perception and the perceived health risks associated with worse prognosis (9). 

The correlation between alcohol consumption and the low-risk perception is interesting. We do not know whether alcohol has a calming effect that reduces risk perception or whether the consumption was related to an initial greater risk perception.

Among the participants in the study, the individual sensitive attitudes leading to greater adherence to prevention and awareness campaigns did not imply different perceived risks for Covid-19 infection. Instead, there is a statistically significant relationship between health promoting and Covid risk perception. In line with the requirements of Italian Legislative Decree No. 81/08, workplace health promotion is an effective tool for raising awareness about health in general and about the Sars Cov 2 risk. In order to assess the effectiveness of the health promotion measures, a comparison with other Italian universities would be useful.


  1. WHO, 2020a. https://www.who.int/emergencies/diseases/novel-coronavirus-2019 .
  2. L. Dietz, H.F. Patrick, C. David, F. Mark, J.A. Eisen, V.D.W. Kevin, 2019 novel coronavirus (COVID-19) pandemic: built environment considerations to reduce transmission, M. Systems. 5 (2020), e00245–20. https://doi.org/10.1128/mSystems.00245-20.
  3. W. Tan, X. Zhao, X. Ma, A novel coronavirus genome identified in a cluster of pneumonia cases—Wuhan, China 2019–2020, China CDC Weekly 2 (2020) 61–62, https:// doi.org/10.46234/ccdcw2020.017.
  4. Documento tecnico sulla possibile rimodulazione delle misure di contenimento del contagio da SARS-CoV-2 nei luoghi di lavoro e strategie di Prevenzione Aprile 2020 ISBN 978-88-7484-911-5; Sergio Iavicoli, Fabio Boccuni, Giuliana Buresti, Diana Gagliardi, Benedetta Persechino, Bruna Maria Rondinone, Antonio Valenti; www. Inail.it
  5. Protocollo condiviso di aggiornamento delle misure per il contrasto e il contenimento della diffusione del virus SARS-CoV-2/COVID-19 negli ambienti di lavoro- Accordo sindacale
  6. M. Cristina Polidori, Helmut Sies, Luigi Ferrucci, Thomas Benzing COVID-19 mortality as a fingerprint of biological age Ageing Research Reviews 67 2021 101308.
  7. Abbatecola, A.M., Antonelli-Incalzi, R., 2020. COVID-19 spiraling of frailty in older italian patients. J. Nutr. Health Aging. https://doi.org/10.1007/s12603-020-1357- 1359.
  8. Akbar A.N, Gilrov D W 2020 Aging immunity may esacerbate Covid 2019 Science 369 (6501) 256-257.
  9. Yangyang Chen  , Jiahao Feng  , An Chen  , Jae Eun Lee  , Longtian .Risk perception of COVID-19: A comparative analysis of China and South Korea. International Journal of Disaster Risk Reduction 61 2021 (102373).

Work-Related Stress And Covid 19 Pandemic Stress



Ruotolo Fabrizio1, Fusco Antonio2, Vanacore Giuseppe3, Niola Giovanni4

1Tecnico della Prevenzione - ASL Napoli 1 Centro - Ispettore Vigilanza
2Capo Ufficio Sorveglianza Sanitaria e Gestione Documentale - Università degli Studi di Napoli Federico II
3Capo Ufficio Primo Ufficio Prevenzione e Protezione - Università degli Studi di Napoli Federico II
4Addetto al Servizio Prevenzione e Protezione - Primo Ufficio Prevenzione e Protezione - Università degli Studi di Napoli Federico II


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


Since the 1990s, the world of work in Italy has undergone a process of organizational and economic transformation. The changes, underestimating the impact on the well-being of workers, have generated significant discomfort, not exclusively of a material nature, for larger sectors of the working population. Consequently, we found ourselves directly facing the consequences of this discomfort characterized, on the one hand, by forms of work organization pathology and, on the other, by adverse effects on the psycho-physical health of individuals.

The current emergency situation caused by the Covid 19 pandemic represents a stressor both for the organization of work and for the psycho-physical health of individual workers. Pandemic stress is, in fact, a completely new condition, which is leading to an unconventional state of stress, consequent on the one hand to the strong concern of the contagion, on the other to the new working methods also determined by technological progress (eg work. remotely or home working, smart working, teleworking). The activity of the smartworker, in fact, is characterized by different and generally greater responsibilities since remote work or home working is frequently an activity with objectives, often in the absence of the support deriving from belonging to a work group, as is normally the case. occurs in face-to-face activities.

The proposed method of assessing the work-related stress risk, with particular attention to what can be related to the Covid 19 factor, will be even more relevant for the purposes of post-pandemic management, in consideration of the uncertainty that may concern the socio-economic implications in the near future. economic and health care.

Methodology And Materials

The processing of the work was conducted in accordance with Article 28 paragraph 1, Legislative Decree 9 April 2008 no. 81 which provides, in the global context of risk assessment, also that of work-related stress risk, according to the contents of the specific European Agreement of 8 October 2004. Specifically, the work has set out to proceed with a revision of the method prepared for the assessment and management of work-related stress risk, as indicated by the 2010 and 2017 Inail Guidelines.

The procedure for conducting the assessment and management of work-related stress risk is divided into the phases referred to below.

  • Communicative and informative actions: it consists in communicating the employer’s will to proceed with the evaluation, clarifying that the essential element for conducting the evaluation is the participation of all workers, or their representatives, and of the figures of the Company’s Prevention and Protection . Equally essential is identifying the work-related stress risk factors present in the work cycle, potentially capable of causing damage to biopsychic homeostasis.
  • Documentary and objective analysis of work organization: corresponds to the verification phase of all the documentation available in the company being evaluated and the actual situations (company organization chart, work environments, health data, human and instrumental resources management, legal data , Risk Assessment Document, periodic meeting reports).
  • Subjectivity analysis: this involves identifying the homogeneous groups, or workers, to whom the survey checklists are to be administered.
  • Risk assessment: operational phase in which the checklists are administered on which, once collected, the data is evaluated and any further investigations are carried out. From what emerged in this evaluation phase derives the need, or not, to prepare a plan of interventions and corrective actions, and / or any specific training program, and / or also the need to proceed to investigations on identifiable cases individuals and / or collectives through the collaborative support of specialist figures.
  • Monitoring and control: Provides for the indication of the timing of monitoring and control of interventions and corrective actions, as well as the indication of the timing of risk re-evaluation in the presence of organizational changes.

Operationally, the assessment of the work-related stress risk is divided into two phases, as shown below.

  • Phase 1: is conducted by the figures of the Company Prevention and Protection with the consultative participation of the RLS, and reaches the evaluation by administering to the identified homogeneous groups of check-lists built on the dimensions “Sentinel Events, Work Content and Work Context” , taking into consideration the Covid 19 factor. The checklists administered consist of a series of analysis indicators and for each of these three choice situations are identified (optimal, alert, alarm), each with a respective score. In addition, a specific column “NOTES” is included in the check-lists, in which the reasons and rationale for the chosen situation are reported.

Phase 1 is broken down into two sub-phases, listed below.

  • Phase 1a: In this phase, the preliminary assessment is carried out and the check-lists are administered to the homogeneous groups identified. If the overall result of the evaluation is estimated at medium-low, the results of each indicator evaluated are analyzed considering the organizational complexity, the company size and the homogeneous group, with indication of control and monitoring measures.
  • Phase 1b: If the result of the overall assessment and of the individual indicators is estimated to be medium-high, we proceed to the in-depth analysis by analyzing the reasons given for the chosen situations and the ordinary risk elements emerged in the activities (in presence and in home working and smartworking). From this stage, through the administration of specific checklists elaborated according to the emerged risks, collective and individual interviews and focus-groups, proposals for corrective and improvement measures are developed and, where possible, a training program that can have an effective impact on the prevention of any critical issues that have emerged. To conduct this phase, the evaluators can request the support of a special commission, made up of specialist figures (for example psychologists, psychotherapists) and can also decide on the transition to Phase 2.
  • Phase 2: this phase is the exclusive responsibility of the commission which carries out an assessment of individual and / or collective identified cases of high risk, with subsequent identification and implementation of targeted collective and individual psycho-social analysis interventions.

Each identified homogeneous group is given a series of Check-lists on the three assessment areas, consisting of event indicators as shown below:

  • Sentinel Events Area
    • Business Indicators Checklist
  • Job Content Area
    • Check-list of Work Environment Indicators and work equipmentChecklist Indicators Task planningCheck-list Indicators Workloads and work rates
    • Check-list of Working Time Indicators
  • Context Area of ​​Work
    • Check-list Indicators Function and Organizational Culture
    • Checklist Indicators Role within the organization
    • Career Evolution Indicators Checklist
    • Check-list of Decision-Making Autonomy Indicators – Work Control
    • Check-list Indicators Interpersonal relationships at work
    • Covid 19 Employment Indicators Checklist
    • Check-list of Home Work Interface Indicators – Work / Life balance

From the sum of the scores obtained in the three areas examined, the overall risk level is obtained, which is compared with the numerical and descriptive strings for interpreting the risk, as shown below.

  • LOW RISK 25%: The analysis of the indicators does not highlight any particular organizational conditions that can determine the presence of work-related stress, it is advisable to monitor the organization every two years (Phase 1 a).
  • MEDIUM RISK 50%: The analysis of the indicators highlights organizational conditions that can determine the presence of work-related stress. For each condition identified, targeted improvement actions must be adopted. It is advisable to implement a prevention policy and actively involve the competent doctor and the person in charge (Phase 1 b). Monitor the indicators every year.
  • HIGH RISK + 50%: The analysis of the indicators highlights organizational conditions that indicate the presence of work-related stress. An assessment of the workers’ perception of stress must be carried out by involving the competent doctor or other specialized figures (Phase 2). Monitoring of stress conditions and the effectiveness of improvement actions after 6 months.

In addition, the results of the checklists of the three assessment areas identify the level of risk in each area as well as that of each individual indicator, allowing to define, for the specific assessment area or for the specific indicator, a control plan and monitoring and specific corrective and / or improvement actions.

Results And Discussions

With the pandemic, workers have had to redefine their lifestyles and adapt to work differently due to adapt to agile ways of working. This new modality configures a sort of hybrid work for which no guidelines have been defined regarding the aspects that characterize it. This lack is also found in the checklist provided by the INAIL guidelines proposed for the assessment of work-related stress risk.

In fact, the new working methods can highlight critical issues in the “Work Content” area, specifically, in the “Work Environment and Work Equipment” dimension since the workers of the same work context, even of the same group, no longer share the same same work environment. The “Working Hours” dimension could also be different from that of home working, being potentially influenced by the hyperconnection event. It is clear that the stress assessment must take into consideration the risks related to the issue of staying at work (and therefore connected and available) beyond one’s working hours, together with those of worker-technology interaction, a potential factor of techno-stress. ().

In the “Work Context” area, the “interpersonal relationships at work” dimension could be reviewed, which could be revised with the addition of indicators that investigate any changes in the quality of relationships with colleagues / superiors and / or if the the climate of trust previously created has had variations and / or, again, whether the new methods of communication dictated by the pandemic are effective. The “decision-making autonomy-control of work” dimension could be integrated with indicators that assess the quality of work independently and the perceived degree of isolation.

Even in the “Sentinel Events” area it is conceivable that the analysis of these objective data, whose evaluation is expected every three years, will be modified if the work activity is mainly done from home. In fact, it is conceivable that a series of indicators such as “sick leave”, “percentage of absences from work and holidays not taken”, “proceedings and disciplinary sanctions” should be eliminated.

For what has been highlighted, it is necessary to ask whether it is still conceivable to use a single checklist, as provided by the INAIL guidelines, for all types of work and whether the focus should be organized only on homogeneous groups and not on individual workers. In light of this, the assessment methodology proposed through this work seeks to help Employers to be able to carry out an assessment of the work-related stress risk that takes into account the changes deriving from the pandemic, on the one hand to adapt it to the type of work activity, on the other hand to refine the analytical interventions on homogeneous processing groups, up to the single worker in Phase 1b.


  1. European agreement on stress at work of 8 October 2004. (Agreement signed by CES – European trade union; UNICE – “European confindustria”; UEAPME – “European association of crafts and SMEs; CEEP -” European association of publicly owned and general economic).
  2. Interconfederal agreement for the transposition of the European framework agreement on work-related stress concluded on 8 October 2004. 9 June 2008 https://www.inail.it/cs/internet/docs/stress-lavoro-ordo-interconfederale.pdf ? section = activities
  3. Approval of the information necessary for assessing the risk of work-related stress referred to in Article 28, paragraph 1 bis, of Legislative Decree 81 of 9 April 2008, and subsequent amendments. Circ. November 18, 2010 – Ministry of Labor and Social Policies – Directorate General for the Protection of Working Conditions Ministry of Labor – Circular 18/11/2010. Approval of the information necessary for assessing the risk of work-related stress referred to in Article 28, paragraph 1-bis of Legislative Decree 81/08 and subsequent amendments
  4. Inail 2011. Assessment and management of work-related stress risk <https: // www.inail.it/cs/internet/attiv/ricerca-e-tecnologia/area-salute-sul-lavoro/rischi-psicosociali-e-tutela – vulnerable-workers / work-related-stress-risk.html>
  5. Inail 2017. The methodology for the assessment and management of work-related stress risk – Manual for use by companies in implementation of Legislative Decree 81/08 and subsequent amendments. <https://www.inail.it/cs/internet/docs/alg-pubbl-la-metodologia-per-la-valutation-e-gestione.html>
  6. Shared protocol regulating measures to combat and contain the spread of the Covid 19 virus in the workplace of 14.03.2020, as integrated on 24.04.2020 and subsequent amendments.
  7. Di Tecco, C. INAIL (2020) – Considerations and research experience on the management of work-related stress risk in relation to the Covid 19 emergency.
  8. Shared protocol for updating the measures to combat and contain the spread of the SARS-CoV-2 / COVID-19 virus in the workplace of 6.04.2021

The Importance And / Or The Need For Environmental Assessments For Environments At Risk During The Pandemic: Types Of Reliefs, Changes In The Use Of Environments Starting With The Risk



Prete Mario1, De Rosa Annalisa2, Basile Maria Rosaria2, Speranza Antonella2, Izzo Luigi2, Finizio Rosaria2

1Degree in Techniques of prevention in the environment and in the workplace), professional consultant at UOC PREVENTION AND PROTECTION ASL NA2 NORD


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


Sanitary emergency

The Covid-19 emergency and the need to cope with it have led to a profound restructuring – in a very short time – of the Italian hospital system, entire departments or sectors, in fact, have been reconverted with total reorganization.

This radical change, therefore, inevitably marked major changes in the methodology of carrying out environmental monitoring as well as on the methods of endorsing decisions regarding the conversion of hospitalization environments.

What previously appeared to be standardized actions, have been subjected to a radical revolution in order to also preserve the health of the company’s Prevention Technicians, who, on the front line and in full pandemic, have never stopped accessing in hospitals and especially in the new Covid-19 wards to ensure continuity in monitoring the company prevention and protection system, thus avoiding exposing health workers, who are committed to coping with the significant workload, to further risks.


Planning and management of environmental monitoring

The planning of the planned monitoring and checks was carried out, as a practice, taking into account the frequency and the last control date, or in conjunction with any structural and / or equipment change.

At present, the main parameters monitored in each hospital are:

Monitoring of anesthetic gases

It allows you to check the concentration of anesthetic gases (nitrous oxide and halogenates) during surgery, in order to assess the exposure of healthcare workers, the efficiency of the air handling unit and the correct functioning of the system and devices for anesthesia as they are subject to progressive deterioration of the pneumatic seals;

Circular no. 5/89 of the Ministry of Health. (a) TLV-Ceiling

Microclimatic monitoring

It allows you to check the correct functioning of the controlled contamination ventilation and conditioning system, in order to ensure the correct air changes and the “thermal comfort” of the health workers who work within the operating room;

Presidential Decree n. 37/97, ​​D.G.R. Campania 7301/2001 and Microclimate Guidelines, ventilation and lighting in the workplace (I.S.P.E.S.L. 2006); Guidelines for the definition of safety and hygiene standards in the workplace (I.S.P.E.S.L. 2009) and UNI EN ISO 7730: 2006.

Particle monitoring

It allows you to check the correct functioning of the controlled contamination ventilation and conditioning system, in order to ensure the retention of particulate matter, a potential carrier of microorganisms present in the environment, depending on the ISO class of each individual operating room.

ISPESL 2009 Guidelines

Microbiological monitoring

It allows to check the level of contamination by microorganisms on surfaces and in the air and therefore to evaluate the effectiveness of the sanitization / disinfection protocols adopted, the effectiveness of the air handling unit, compliance with the behavioral procedures by the staff .

UNI EN 13098: 2002; UNI EN ISO 14698: 2004

Chemical Monitoring and Antiblastic Drugs – UMACA

It allows you to check, on the basis of actual use, the methods and quantities used, the level of contamination of chemical agents, paying particular attention to the presence of carcinogens and mutagens.

The checks are carried out on surfaces (floors, handles, work tools), monitoring the presence of tracer drugs such as:

  1. coordination compounds of platinum
  2. 5-Fluorouracil
  3. Cyclophosphamide

Technical Standards of Oncological Galenics (SIFO 2016), Legislative Decree 81/08 and subsequent amendments Title IX chapter I

Legionella Pneumophila monitoring

This monitoring allows to prevent colonization and bacterial multiplication in water distribution, heating and air conditioning systems and reduce the risk of Legionella pneumophila pneumonia in hospitalized people and hospital staff.

Guidelines for the prevention and control of legionellosis

Activities undertaken

The Prevention and Protection Unit of the Napoli 2 Nord ASL, in the face of the radical and necessary change in monitoring due to the Covid-19 emergency, immediately undertook training and training campaigns for personnel dedicated to the activities.

Dressing and undressing, disinfection and sanitization of instrumentation and rescheduling of monitoring times are just some of the initiatives implemented by the U.O.C:

  • The main training and training activity regarding dressing and undressing was carried out through the dissemination of demonstration videos in compliance with the anti-contagion measures provided for by the Prime Minister’s Decree;
  • For the disinfection and sanitization of monitoring equipment (microclimatic station, particle counter, anesthetic gas monitor, sas, bubbler for peracetic acid, sound level meter, accelerometer), the UOC has set up filter areas dedicated to the sanitization of the equipment through the use of the Micro-Defender system.
  • This technique, through aerosolization interventions, allows a highly effective preventive action against all pathogenic microorganisms;
  • Finally, thanks to a great coordination work between UOC and the staff of each single hospital unit, it was necessary to reshape the monitoring times in compliance with the routine activities carried out by the health personnel, thus avoiding interference between the various activities carried out and drastically reducing the contamination risk.


All the above activities were made possible thanks to teamwork and great participation and collaboration on the part of both the Prevention and Protection Unit and the health personnel of the environments being sampled. This meticulous work has ensured that all the personnel dedicated to it have never found any positivity in the course of their work and that all the hospitals in the area have continued to receive support in the field of prevention and protection.

In fact, in full emergency, approximately 360 monitoring of all possible environmental pollutants were guaranteed even in the covid-19 wards, also paying close attention to sensitive departments such as hemodynamics, operating rooms and dialysis.


  1. D.lgs 81/08 e s.m.i ;
  2. D.G.R. Campania 7301/2001 Circolare n. 5/89 del Ministero della Sanità. (a) TLV-Ceiling;
  3. D.P.R. n. 37/97;
  4. Linee Guida Microclima, aerazione e illuminazione nei luoghi di lavoro (I.S.P.E.S.L. 2006);
  5. Linee Guida per la definizione degli standard di Sicurezza e di Igiene del lavoro nel reparto operatorio (I.S.P.E.S.L. 2009);
  6. UNI EN ISO 7730:2006;
  7. UNI EN 13098:2002;
  8. UNI EN ISO 14698:2004;
  9. Standard Tecnici di Galenica Oncologica (SIFO 2016);
  10. Linee Guida per la prevenzione e il controllo della legionellosi

The digitization of construction sites



Piccolo Carmine1, Modestino Raffaella1, Solimene Gianni2

1Inail Uot Avellino
2Centro per la Formazione e Sicurezza in Edilizia della Provincia di Avellino


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


BIM, acronym for Building Information Modeling, is a method of approach to the planning, construction and management of a building that is gaining ground in the world in recent years.

The highly innovative element of the methodology is the possibility to allow the various professional figures involved in the project to collaborate in the creation of the virtual model of the work, each contributing, on the basis of their skills and responsibilities, with the information that concern.

Collaboration, accessibility and interoperability are an important part of the application of this operational methodology. BIM allows to identify in advance any critical issues and errors, and to intervene promptly already in the design phase.

Even if the digitization process has reached the construction sector with a certain delay compared to the other economic sectors, this phenomenon is now inevitable given the spread of digitization techniques that now affect every area of ​​life.

To understand the incidence of this phenomenon in the construction field, it makes no sense to think about the construction site as a generic entity, since there are large, medium, small and micro construction and infrastructure sites, but it is necessary to identify what are the structural invariants on which to reason in order to highlight the integration of information technology in the industry.

In the collective imagination it is easy to associate the digital construction site with places with high levels of automation and robotization, for the increasingly constant presence of SARP Systems (Sistema Aeromobile a Pilotaggio Remoto) for monitoring the progress of the work, sensors for the management of worker safety, smartphones that allow stakeholders to exchange and share information on the construction site. But the true heart of the fourth industrial revolution in the construction sector lies in the “invisible”, that is, in the synchronization of production and decision-making processes, in the ability to digitally manage flows, share the “data” to generate decision-making processes.

Consequently, even the simplest realities can point to high levels of digitization, accelerating a process that has had a slow evolution, perhaps also due to mistrust and cultural blocks typical of the building sector.

The management of the construction site has always been based on a mostly static and documentary approach, however it is evident that the construction site evolves and transforms according to the work to be carried out, leading to the onset of different risks and therefore different prevention measures and protection to be adopted.

Therefore, as regards the aspects of safety management on the construction site, tools that can respond to the dynamism of the activities that follow one another are particularly useful; this goal was achieved by BIM as it introduced another dimension: time. Using this methodology, it is possible to focus attention on particularly sensitive moments, analyze them and understand what the risk factors may be, even more easily evaluating the progress of the work in relation to the programming carried out.

It is possible to cite numerous examples of applications of the technologies for a more efficient management of safety on construction sites:

  • The use of high-precision sensors that measure the pollutants in the air, the noise level and other standard environmental parameters to provide data to artificial intelligence systems capable of offering efficient monitoring of environmental risk in the workplace.
  • The use of sensors and software to control access and monitor worker safety, automate the tracking processes of machines and materials, thus obtaining information automatically.
  • The digitization of information, web platforms and cloud storage that allow the operator on site, through the use of a tablet or smartphone, to quickly connect to the database with the necessary information.
  • The same training and information activity provided for D. Lgs 81/2008 can derive numerous benefits from the application of the Information Tecnology. In this case virtual reality can allow to overcome the limit of a theoretical training that does not contextualize the worker in the space designated for him in relation to his role and therefore to the risks actually present. Training using virtual reality is intended to help workers and technicians familiarize themselves with particularly dangerous areas and situations, since it is carried out within the same construction site where they will work later or for which they will be responsible as personnel for health and safety at work.

From these considerations it is natural to ask at what point is the digitization process of Italian shipyards. Numerous surveys conducted by major associations and organizations highlight the state of the art at national and international level through annual reports; in this work, on the other hand, we wanted to conduct a survey on the local situation, interviewing employers in the province of Avellino.

The legislation governing BIM

In the European scenario, the regulatory cornerstone for the introduction of Building Information Modeling is Directive 2014/24 /EU of the European Parliament and the Council. Introduced in 2014, the legislation obliges EU member states to promote and adapt to BIM for public works by 2016.

Pursuing a strategy aimed at “smart, sustainable and inclusive growth” of the public contracts sector, the Directive considers technology as a necessary tool to achieve this goal.

In Italy, this Directive was implemented with Legislative Decree 50 of 2016, Code of Public Contracts.

With the entry into force of the Code of Contracts and Public Procurement, the BIM methodology also becomes a determining evaluation parameter of the requirements.

The Ministerial Decree n.560 of 2017 (BIM Decree) subsequently sanctions the introduction and mandatory nature of BIM in the public procurement sector, defining the methods, introduction times, methods and specific electronic tools and extending their use to all phases of a work, from planning to management and verification.

Furthermore, a series of definitions are introduced, partly already contained in the Code of public contracts, partly unpublished; in particular, the concept of the data sharing environment is introduced to pursue the objectives of transparency, sharing and traceability. Using digital systems, an environment must be created where all data is produced, collected and shared.

These measures are accompanied by an intense standardization activity that plays an important role in defining the guidelines to be followed in the adoption of this methodology: the UNI 11337 standard.

UNI 11337 regulates the aspects related to the digital management of construction information processes. Specifically, it deals with models, documents and information objects for the development of digitized products and processes. Divided into ten parts each dedicated to specific aspects to be regulated, it is constantly evolving to follow the changes in the process.

The survey at the national level

In recent years, the phenomenon of the digitization of construction sites is a topic of great interest to the scientific community, as the introduction of the BIM methodology in the infrastructure sector has led to a very important cultural change.

To understand the opinion regarding BIM, at national level, it is interesting to analyze the 2020 ASSOBIM report, the association created to promote the dissemination of Building Information Modeling and support the activity of the entire BIM technological chain in Italy and the ” annual survey on the sector of Italian engineering companies, final balance 2020-budget 2021 “of the OICE (Associazione delle Organizzazioni di Ingegneria e Consulenza Tecnico Economica).

The starting point of the 2020 edition of the ASSOBIM BIM Report was the analysis of the degree of knowledge and use of Building Information Modeling and its potential among industry operators. The interviewed sample – largely made up of design firms (over 52% of the sample) and engineering companies (17.1%) – knows and uses the BIM methodology, while a further 40% know it but do not use it or makes partial use of it, and only a marginal number of operators (just over 10%) are unaware of it. The growth in knowledge, skills and use was matched by the data on the degree of awareness of the benefits deriving from the adoption of the BIM methodology in professional practice. Over 80% of the sample – 10% more than in 2019 – are convinced that the adoption of BIM is able to contribute strongly (up to a third less) to the reduction of the initial construction cost and costs relating to the entire life cycle of the building, as well as the reduction (up to 50% less) of the overall time for carrying out the work, from start to completion of the works.

The survey conducted by the OICE, on the other hand, shows that:

86.4% of companies declare that they have made investments in BIM (Building Information Modeling). Investments in BIM were mainly aimed at training (87.4%) and the purchase of software (76.4%).

31.3% of larger companies believe the usefulness of investments in BIM is high, while this percentage drops to 16.3% for smaller companies. At the same time, only 6.3% of larger companies consider the effectiveness of these investments insufficient, while the percentage rises to 20.7% for smaller companies.

Survey methodology in the province of Avellino

The survey on the Avellino area was carried out by integrating the study of the reference framework with the analysis of a questionnaire developed ad hoc to understand the approach to the digitization process of companies in the area.

The questionnaire

The questionnaire was developed in order to provide an overview both on the real integration of technologies and digital processes within construction companies and on the perception of employers towards innovative technologies.

 The questionnaire proposes a series of questions, a total of 18 questions, with multiple choice that provide control tools to assess the actual match between the perception of technologies and their effective integration into the company.

The questions can be grouped into five macro sections:

  • A. Understanding of the type of company, its size and its cultural approach to IT
  • B. Familiarity with new communication technologies and information sharing
  • C. Surveys on the state of use of the software in the company
  • D. Surveys on the status of worker safety management using IT techniques
  • E. Prospects for technological development in the company.


The results are presented below and divided according to the macro-sections identified in the questionnaire.

A. Understanding of the type of company, its size and its cultural approach to IT

The sample analyzed is made up of a total of 37 companies, mainly small businesses (only one company has a number of employees between 51 and 100).

The analysis of the level of availability for innovation and change aimed at understanding any mistrust and cultural blocks offers a very positive data: 57.67% of the interviewees described themselves as open to innovation while adopting a prudent approach, and declares an average age between 41 and 50 years, with some cases, 18.92%, with an age between 61-70 years.

B. Familiarity with new communication technologies and information sharing
Fig. 1 – Question 5 – how to communicate with employees
Fig. 2 – Question 6 – how to communicate with technicians

The second section of the questionnaire, after the initial questions regarding the classification of the sample, shows, Figures 1 and 2, that the primary form of communication with employees, but also with other safety figures, is contact telephone and instant messaging systems, while there is little inclination towards the issue of cloud computing and digital interoperability between the figures involved in the activity. Even the use of specific applications appears to have a very low response (only 4 companies).

C. Surveys on the state of use of the software in the company
Fig. 3 – Question 4 – digital medium used for site management
Fig. 4 – Question 7 – digitally managed activities
Fig. 5 – Question 9 – using BIM

The third section, Figures 3, 4 and 5, describes the type of software used in the management of the construction site to carry out digitized procedures and understand the level of knowledge of the territory of the BIM methodology. It is interesting to note that 3 companies have declared that they do not use any digital support for the registration of attendance and expenses, but use paper to keep track of the following information.

While it is not surprising that over 88% of the interviewees declare that they use software application for the  metric calculation, it is interesting to highlight that almost the 42% keep digital track of the deadlines related to the training of workers in the field of safety at work and 33% of the deadlines of periodic checks of machines and systems.

The data relating to BIM confirm a lack of knowledge and above all use of the BIM methodology; only 4 companies (approximately 12%) used the model in its entirety.

D. Surveys on the status of worker safety management using IT techniques
Fig. 6 – Question 8 – Cloud propensity
Fig. 7 – Question 10 – digitalized management of means of transport
Fig. 8 – Question 12 – use of augmented reality
Fig. 9 – Question 13 – use of 360 degree cameras and SAPR systems
Fig. 10 – Question 14 – use of sensors for environmental risk assessment
Fig. 11 – Question 15 – use of software for risk assessment

As regards the management of worker safety with the support of information technologies, the data obtained must be read, probably, taking into account the small working realities that characterize the area. Almost 50% of respondents say they are willing to invest in the use of the cloud once they have fully understood how it works and the advantages, Figure 6, while the 16,22% of the interviewees declare that no digital support is necessary for the type and size of their business; this information read taking into account the territory also motivates the scarce application of innovative systems of artificial intelligence and augmented reality such as sensors, SARP systems and more.

It is clear that the aspects managed most in digital form are those related to legal obligations, both as regards machines and people.

E. Prospects for technological development in the company
Fig. 12 – Question 16 – reasons for the use of digital tools
Fig. 13 – Question 17 – obstacles to the digitization of the business

The section on future prospects, however, is heartening; there is an awareness that digital technology can improve work activity according to 65% of respondents, Figure 12, and there is a statement of poor knowledge of the applicability of information technologies in the construction sector, 28.57%, Figure 13, given that it manages to motivate the slow process of digitization in the sector. However, the figure of 25.71%, representing the percentage of interviewees who declares “work culture and deep-rooted traditions” as the greatest impediment to the digitization process, a reason perhaps to be considered taking into account the average age of the employers.

As for the last answer, in which the interviewee was given the opportunity to express their opinion freely, unfortunately there were not many important observations; on the whole, all of them confirm the importance of technology as a tool for improving construction site management, while few focus on the validity of technological supports to improve worker safety. Specifically, an answer confirms the impression obtained by analyzing the data: “for safety it is more difficult, since the only attention is to keep the documents in order”.


The results of the survey conducted allow us to highlight the real problems that the digitalization process is generating in the construction sector in the province of Avellino. A sector fragmented by skills, little available to integrations and innovations.

The greatest limits perhaps derive from the type of companies operating in the construction sector: small businesses not motivated to invest in information technology to manage simple construction sites.

Another limit not to be overlooked is the lack of specific knowledge and therefore

the importance of the study carried out lies in the acquired awareness of the need to promote technological development in the construction sector and to disseminate the benefits deriving from the use of information technologies for the management of worker safety not only to comply with the provisions of the law but above all to disseminate an innovative safety culture.


  1. Ciribini (2019). Il cantiere digitale. Italy: Società Editrice Esculapio srl.
  2. Direttiva 2014/24/UE del Parlamento europeo e del Consiglio, del 26 febbraio 2014, sugli appalti pubblici e che abroga la direttiva 2004/18/CE Testo rilevante ai fini del SEE
  3. Decreto Ministeriale n.560 del 2017
  4. EU-OSHA – Agenzia Europea per la sicurezza e salute sul lavoro (2020). Digitalizzazione e sicurezza sul lavoro (SSL). EU-OSHA
  5. M. Garramone (2017).  Il BIM come strumento operativo per la progettazione della sicurezza in cantiere – un caso di studio. Disponibile in: https://aifos.org/home/associazione/concorso_tesi_laurea/tesi_laurea_2017/il_bim_come_strumento_operativo_per_la_progettazione_della_sicurezza_in_cantiere_un_caso_di_studio
  6. Oice (2021). Rilevazione annuale sul settore delle società italiane di ingegneria.
  7. Puma (2019). BIM: la gestione della sicurezza in cantiere. Disponibile in:https://www.ediltecnico.it/74827/bim-gestione-sicurezza-cantiere/
  8. V. Carena (2020). BIM Report 2020: da ASSOBIM la “fotografia” del BIM in Italia. Disponibile in: BIM Report 2020: da ASSOBIM la “fotografia” del BIM in Italia – BIM Portale

The Pandemic Prepares A Changing Job, A New Risk Assessment



Panico Giovanni1, Romano Anna2, Cangiano Antonia3, Albero Simona4

1Tecnico della Prevenzione nell’Ambiente e nei Luoghi di Lavoro, SIAN/SIP ASL NAPOLI 2 NORD ;
2Tecnico della Prevenzione nell’Ambiente e nei Luoghi di Lavoro, SIP ASL SALERNO
3Tecnico della Prevenzione nell’Ambiente e nei Luoghi di Lavoro, SPSAL ASL SALERNO;
4Infermiera Dipartimento di Prevenzione ASL SALERNO


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


The COVID-19 pandemic, which spread from the first months of 2020, although affecting a purely health aspect of people’s lives, has contributed to speeding up changes in the organization of work that have already been in place for years due to technological evolution , causing a strong acceleration towards other organizational types of work including smart working. When we talk about smart working we think of one of the consequences of the virus, such as surgical masks and social distancing, but in reality it is a new organizational structure based on giving people back flexibility and autonomy in the choice of spaces, times and the tools to be used in exchange for greater responsibility for achieving corporate objectives.

The state of the art

Smart working is defined as a subordinate employment relationship, characterized by the absence of time or space constraints and an organization by objectives, established through an agreement between employee and employer. It is a modality that helps the worker to reconcile the times of life and work and, at the same time, favor the growth of his productivity.

In 2019, in Italy, the percentage of people working from home was 4.8, among the lowest in Europe. Our country was far from the leading Sweden with a percentage of workers equal to 37.8%, but also from European countries such as France 23.1% and Spain 4.8%, or structurally similar such as Germany 12.3%. In April 2020, in full emergency, more than a third (37%) of EU workers appeared to have started working from home and Italy that started from the rear was one of the most participatory countries; smart working workers in March 2020 were over 6.6 million and it is expected that after the pandemic the number will stabilize at 5.3 million.

Advantages and disadvantages

Remote work, albeit over short periods of application, has shown enormous economic and social benefits at various levels.

For workers, this new work organization increases the opportunities for reconciliation in the life-work spheres especially for people with disabilities or with assistance responsibilities and it has been estimated that even a single day a week of remote working can save an average of 40 hours. per year of travel.

For the employer, the application of a well-structured smart working tool can lead to an increase in productivity equal to about 15% per worker, which amounts to 13.7 billion euros in benefits at national level as the workers feel more empowered with an improvement in performance and results and an increase in motivation and satisfaction with their work. Furthermore, by reorganizing the spaces, the company will be able to save on costs related to light, heating, air conditioning, cleaning and consumables to an extent directly proportional to the percentage of Smart working.

The environment would also seem to benefit in the long term with a hypothesized lowering of emissions equal to 135 kg of CO2 per year thanks to the reduction of travel and the redevelopment of extra-urban areas.

But on the other hand, in such a short time of “application” we can already find many disadvantages with repercussions also on the health of the workers: 

  • shifting of connection costs, equipment and adaptation of the premises to the workers to be used for work;
  • lengthening of the working day due to the lack of a clear boundary between work and home which can lead people to work too many hours without the right breaks (overworking), with the risk that they will not be able to return to “normal” ways of working. In fact, it is likely that workers who return to the workplace after a period of isolation have concerns that can cause stress and psychological distress.
  • fragmentation of the workforce and isolation from the organizational and social aspect of the worker as the links between workers can become less close, and the possibility of sharing and insertion into the corporate culture is less. Communication becomes ineffective and slower with difficulties in planning activities, defining priorities and updating workers in real time

Risk and prevention measures

The organizational model of smart working, with which we have been called to confront in this emergency situation, is a model to which the pandemic has only given an acceleration and with which the world of work has to deal with for the present and for the future, especially in relation to the new risk assessment and prevention strategies.

From the first considerations, a difficulty has already been found in the objective assessment of the structural risks to which the worker could be exposed as the employer cannot be aware of all the situations in which the agile worker decides to carry out the own business. In order to be able to manage this aspect without transferring the responsibility for the suitability of the workplace to the worker by means of self-certification in which he is obliged to certify the possession of requisites that he probably does not possess, it could be decided to “contract” the space / premises for the execution of the activity made in compliance with the health and safety aspects by the Employer with the supply of necessary equipment and furnishings and a periodic verification also through digital tools to verify the permanence of the requirements.

Alongside structural risks, however, psychosocial risks that are often treated as a secondary issue require even more attention in this organizational typology of work because it is difficult to objectively talk about issues related to the emotional sphere. Although smart working requires extensive use of digitization, this should not imply estrangement, the isolation of the agile worker who is particularly exposed to hyper-connection, overworking, technological dependence, absence of recovery times, isolation and unclear identification of boundaries between working and non-working spaces and times. These aspects are partially offset by the autonomy in time management. If we try to apply the work-related stress risk assessment according to the INAIL methodology to the organizational typology of smart working, the following can be assumed.

The preliminary stress assessment consists in the detection of objective and verifiable indicators belonging to three categories represented by sentinel events, context factors and content factors.

Sentinel events are alarm bells on dysfunctions and inconsistencies in the organization of work. Remote work would certainly reduce the values ​​relating to accident rates and absence due to illness.

In the content indicators, remote work could have a positive effect on the items relating to the work environment and equipment, working hours and shifts since they would fall within the new organizational autonomy of the worker as well as for the context aspects of work relating to the home-work interface and work / life balance. But some aspects relating to organizational function and culture, work control and interpersonal relationships would certainly have a negative evaluation.

There are no “concrete” prevention measures for psychosocial risks, but it becomes necessary for the employer to intervene with a rational organization of the work model adopted and to help make workers aware of and participate in this new organization of work. Once again the key tool is represented by communication / information and training on the new organizational structure aimed at indicating clearly and unambiguously the objectives to be achieved and the times to be able to do so, study and rational distribution of workloads and in order to avoid the isolation of workers periodic calls or videoconferences where the achievement of the objectives are monitored to contain the levels of stress and avoid the isolation of the worker by encouraging discussion.

Final considerations

 The remodeling of work observed during the health emergency has shifted attention to risks attributable to the psychosocial sphere; this is where the D.L. once again it is called to intervene to safeguard the state of health of workers understood by the WHO as a state of complete psychophysical well-being through a new organization of work that brings the production costs back to the DL and takes into account the need to create frequent moments of confrontation between workers to avoid isolation and encourage aggregation. The taking root of this new form of work will have obvious repercussions both in the workplace on the management of the activity and on the organization of spaces and in the living environments where the times and purposes of travel change in search of a new balance between life. and work-life balance work.


  1. Interregional Technical Coordination of Prevention in Workplaces. Assessment and management of work-related stress risk: operational guide; 2010
  2. “Guidelines for risk management in smart working mode” national council of engineers eng. G. Fede, ing. S. Bergagnin and the Temporary Telematic group “Smart working and solitary work”

Rethinking security in the days of Covid to discover non-technical skills



Misale Fiorenza

Università Roma Tre


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue

The emergence of the concept of risk dates back to the pre-modern era when the first maritime companies were established, this term was used in the insurance field to indicate the dangers that could be encountered during sea crossings; the concept of risk was traced exclusively to supernatural otherworldly forces and fatality.

Towards the end of the eighteenth century, the concept of probability is elaborated in mathematics and it is begun to realize that some events, until then ascribed to fate, actually occurred with a describable regularity, and were therefore predictable in this sense. [1]

Risk and danger are terms often used interchangeably, but these are two concepts which, despite having elements in common, diverge in meaning.[2]

While the term hazard (hazard) refers to a characteristic of the object or situation that can cause damage, the term risk adds to the concept of danger the probability of coming into contact with it and being affected by it.

The danger recalls the concepts of certainty and certainty, has an objective value and is strictly linked to the object to which it refers (if a substance is dangerous it remains so regardless of who uses it), the risk, on the other hand, also has a subjective value, it is the evaluation of the possibility of coming into contact with a danger and with the consequent damage.

Occupational risk is the assessment of the probability that the worker will come into contact with the hazard in proportion to the severity factor of the damage that the same worker could suffer.

The risk formula is R = p x G where with p we mean the probability and with G the severity of the outcome.

To know the risk and cope with it, it is first of all necessary to evaluate it, the adoption of suitable prevention and protection measures is the first activity that must be placed in chronological order to make the work activity safer.

Thinking about safety from a technical and technological point of view is certainly very important but it is not a sufficient condition, behind every accident we have an individual who makes decisions for which it is fundamental, in order to address the issue of health and safety in a integrated, also consider the man variable in its entirety. The perception of risk, understood as a cognitive process that guides people’s behavior, plays an important role in preventive strategies, focuses on the “human factor” in workplace safety, an element that more than any other contributes to injury determinism.

Human error cannot be radically eliminated but it is possible to identify and minimize it by promoting the spread of “Non – techical skills” which complementary to technical skills, can contribute to the activation of safe and effective performance.

“Non-technical skills are all those skills at a cognitive, behavioral and interpersonal level that are not specific to the expertise of a profession but which are equally important in the success of operational practices while maintaining the highest degree of safety”.[3]

The parameters of safety and work performance are related to non-technical skills that can be placed both at the individual level (decision-making skills, task orientation, situation awareness, stress management), and at the group level (skills of the group to coordinate, communicate and exercise effective and authoritative leadership).

One of the basic non-technical skills is situation awareness, which Endsley defines as the “perception of the elements of the environment present within a period of time and a certain space, the understanding of their meaning and the projection of their status in the immediate future “. The prerequisite is continuous monitoring of the environment.[4]

Loss of situational awareness has been recognized as the leading cause of aviation accidents particularly those involving highly automated aircraft.[5]

Endsley proposes a differentiation of situation awareness on the basis of three levels:

  1. Collection of information;
  2. Interpretation of the information;
  3. Anticipation of future states.

In the collection of information there may be thorns such as the unavailability of data or difficult to perceive, the failure in the analysis or observation of the data or a bad interpretation of the latter. In the second and third levels, there may be a lack, a lack or misuse of mental models, an overestimation in conditions of lack of information, or a loss of memory.

The perception of risk is to be understood as the ability to identify a source of danger as soon as possible. It is a personal process; we decide to face or avoid the risk situation in a subjective way.

This process conditions actions, behaviors, evaluations, choices about an entity or a potentially dangerous situation. The subjective perception of risk is not linear and is not directly proportional to the increase in the dangers; it is subject to influences and distortions and is linked to psychological, cultural and social aspects.[6]

Not always all aspects of a risky situation are perceived and this can lead to an overestimation or underestimation of the risk; there are some specific factors that regulate our perception and make certain things scare us more than others even if they are not really dangerous. Let’s see some of them:

  1. Control: we are less afraid of situations we think we can control, even natural disasters or climate change are scary to the extent that they become uncontrollable.
  2. Familiarity: we perceive the things that are most common to us as less risky (for example we are not afraid of stairs or hairdryers) even if they are the ones that cause the greatest number of accidents; family hazards are believed to be less likely.[7]
  3. Proximity: we perceive as more serious risks that concern us personally or that concern people or environments immediately close to us.
  4. Personalization: the description of a particular case is more frightening than the description of the danger in general (the photographs of the consequences of Chernobyl on children impress us much more than reading a newspaper article).
  5. The imagination: we underestimate the risks that appear less frightening to us (we are much more afraid of dying in a fire than dying of a heart attack).
  6. The catastrophic nature: we fear catastrophes, that is, events that strike on a large scale, take place quickly and are located in one point (for example, a massacre is more effective than murder).
  7. The calculation of risks and benefits: the greater the benefits we derive from a situation, the less importance we give to the related risks.
  8. Uncertainty: risks that are not visible, situations that we do not understand or of which we have no experience scare us more.[8]

Our decisions are often guided by assessments based on mental processes that we unwittingly adopt and which in psychology are described as heuristics, these “reasoning shortcuts” allow us to reach a conclusion quickly.

One of these shortcuts is the heuristic of consent or conformity to the majority (so everyone fan) which indicates that sort of attitude that pushes us to be influenced by others, this modality occurs more frequently if the topic is unfamiliar or if the possibility of processing information is low.[9]

In the context of conduct at risk, information on the behavior of others makes us take precautionary measures in a proportional way, if for example we learn that 12% of people use protective measures we will be less likely to use them, we will tend to use them against if they told me that 88% use them.[10]

Optimistic bias or unrealistic optimism (“it doesn’t happen to me”) is the belief that you are able to control a situation and consider yourself immune to harm. Our perception of risk is lower when we perform those activities we do on a daily basis such as driving or smoking. This phenomenon is known as the “illusion of control”.

The discrepancy between knowledge and behavior occurs when, even knowing that a certain behavior is risky, it is performed anyway, demonstrating that although knowledge is a fundamental prerequisite for implementing preventive behavior alone, it is not sufficient.

The results of a study of 32 coal miners in the Appalachian Mountains at high risk for noise induced hearing loss (NIHL), show that two categories of barriers (environmental and individual) prevent miners from using their hearing protectors. despite having high levels of knowledge and perception of negative consequences.[11]

A decisive role in the perception of risk is played by trust and communication, the media, for example, can trigger fears about non-existent or minor risks and hide or diminish real and serious risks.

The public debate that gave rise to the line of investigation known in psychology as “perception of risk” was that related to nuclear energy. It was immediately evident that there is no regularity between the degree of objective risk posed by a nuclear power plant and the subjective perception of the risk that people had.

It was icastic that it is a function of many factors other than the objective risk itself such as: degree of control, voluntariness of hiring, the severity of the consequences, the perceived benefits, the catastrophic nature of a potential accident, the risk for future generations, the immediacy effects, knowledge and others.

The perception of the degree of danger deriving from a substance, activity or behavior therefore does not depend only on the real, objective risk, but it undergoes a “transformation” as a function of numerous factors or reasoning strategies. Wrong choices in crisis situations, underestimating the severity of a danger, overestimating one’s ability to stem the consequences of a possible error, are just some of the reasoning procedures that can lead to an injury.


  • [1] Lemma, P., Percezione del rischio e modernità. Convegno nazionale “importanza di una comunicazione per lo sviluppo dei programmi vaccinali”. Comunicazione. Genova 21 ottobre 2004
  • [2] Orciano M., Salute e sicurezza sul lavoro. I rappresentanti dei lavoratori per la sicurezza nella Regione Marche, quaderni di ricerca CRISS n. 1, Milano 2015
  • [3] Prati G., Pietrantoni L., Rea A. “Competenze non tecniche e marcatori comportamentali nelle professioni a rischio.” Nuove tendenze della psicologia 4.3 (2006): 353-370
  • [4] https://www.puntosicuro.it/…/fattore-umano-sicurezza-sul-lavoro-AR-16109
  • [5] Di Nuovo S., La valutazione dell’attenzione dalla ricerca sperimentale ai contesti applicativi, Franco Angeli, Milano 2006, p.91
  • [6] Smelser N. J., Theory of collective behavior, the Macmillan Company, New York 1963
  • [7] Covello T., La percezione dei rischi tecnologici: un a rassegna della letteratura, in S. Sartori, T. Squillacioti, “RTI/Studi-Valsamb”, 13, 1984
  • [8] Morini S., Il rischio da Pascal a Fukushima, Bollati Boringhieri, Torino 2014, p. 41
  • [9] Maldonato M., Quando decidiamo. Siamo attori consapevoli o macchine biologiche?, Giunti, Firenze 2015
  • [10] Buunk, Bram P., Regina JJM EIJNDEN, and Frans W. Siero. “The Double‐Edged Sword of Providing Information About the Prevalence of Safer Sex.” Journal of Applied Social Psychology 32.4 (2002): 684-699
  • [11] Patel, Dhaval S., et al. “Understanding barriers to preventive health actions for occupational noise-induced hearing loss.” Journal of health communication 6.2 (2001): 155-168

Activities To Fight Covid 19 In The Departments Of Prevention Of The A.S.L. And Vaccination Obligation For Health Professionals Of The Campania Region



La Rocca Carmine1, La Padula Saverio2, Tozzi Arcangelo Saggese3, La Rocca Maurizio4

1graduating in Prevention Techniques of the Sacred Heart Catholic University and Trainee ASL Salerno
2MED / 50 Lecturer in Prevention Techniques of the Catholic Sacred Heart University and TPALL ASL Potenza
3Director of the Hygiene and Public Health Service of the Prevention Department of the Salerno ASL
4Director of Professional Teaching Activities of the CdL TPAL Univ. Fed. II ASL Salerno office and National Commissioner of the TPAL Register - FNO TSRM PSTRP


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


Re-Modulation Of Prevention Activities In The Public Health Departments Of Aa.Ss.Ll. In Times Of Covid-19

The situation resulting from the SARS-CoV-2 coronavirus pandemic has led to a reshaping of the ordinary activities of the Public Health Services of the Prevention Departments of the A.S.L./A.T.S. of the NHS, engaging the Technical Prevention staff, and the other health professions, also in the control activities of the containment measures of the SARS-CoV-2 contagion in the living and working environments, in contact tracing activities and subsequently to collaborate with the HUB centers for the vaccination activities of the entire population.

The main role played by the Prevention Technicians is certainly represented by the surveillance and control activities in the living and working environments, especially carried out in health and social health facilities, beauticians, tattoo artists, gyms, tourist accommodation facilities, on construction sites, in the sector.

agriculture, industry. etc., in order to also verify the adoption of measures to combat COVID-19 issued by the competent Authorities on the subject (Ministry of Health, Regions), first of all the measures provided for by the anti-COVID-19 protocols referred to in the Prime Ministerial Decree of 24 April 2020 and subsequent amendments; activities mainly carried out in collaboration with other police forces (Carabinieri of the NAS and NIL, Labor Inspectorate, Police Headquarters, Local Police, etc.).

These were immediately flanked by collaboration activities for contact tracing or contact tracing which involved various Prevention Technicians in the Public Health Services alongside doctors, nurses and other health professionals. It is an extremely useful activity to reduce and prevent the spread of the virus and a pandemic.

Finally, with the introduction of the anti Covid-19 vaccination campaign at the beginning of 2021, several Prevention Technicians in a moment of emergency have been used in the vaccination centres of the AA.SS.LL. for the various collaborative activities to be carried out with Doctors and other Healthcare Operators with the common goal of reaching herd immunity with 80% of the vaccinated population by October 2021.

Covid-19 Vaccination And Health Professionals

The health authorities and the scientific community, recognizing the vaccine as the tool par excellence in the fight against Covid-19, being known as pandemics in the past centuries have been eradicated through vaccination, immediately committed themselves strongly to this and on 27 December 2020 in Italy the distribution of the COVID-19 vaccine has begun.

With the Decree of 12 March 2021, the National Vaccine Plan for the execution of the vaccination campaign was adopted by the Ministry of Health, by the Extraordinary Commissioner for the emergency, ISS, AGENAS and AIFA, the aim of which is to achieve 500,000 administrations per day and coverage of at least 80% of the population by Sept – Oct 2021.

Difficulties in applying and understanding the provisions that have followed one another immediately emerged, not only among citizens, politicians and institutions, but also among health professionals, initially due to the fact that not in a few cases provision on the vaccination against covid-19 were changed, by the competent Authorities, subsequently the debate due to the obligation imposed by a law intensified.

On the basis of the scientific studies available, with respect to mortality from COVID-19, it was possible to certify that the age and the presence of pathologies represent the main variables, which dictated the order of priority for the vaccination campaign by dividing the population to be vaccinated in 5 categories, considering as a priority, regardless of age and pathological conditions, totr vaccinate health professions, school staff, police forces, residential socio-health communities, RSA, etc.

Obviously, among these categories, particular attention was paid to all health professions and health professionals who are at the forefront in the diagnosis, treatment and care of COVID-19 in public and private health and social health facilities, in pharmacies, parapharmacies and professional offices.

Covid-19 Vaccinations In The Salerno Asl And In The Campania Region For Health Professionals

From direct experience in the Salerno ASL, which has a population of 1,081,380 inhabitants over the entire province of Salerno, it was possible to verify that in the first ten days of August the vaccination centres of the Public Health and Hygiene Service had already subjected to complete vaccination about 700,000 people representing about 70% of the population, to this it must certainly be added a significant figure which is represented by the 70,000 people recovered from COVID-19 in the province of Salerno (about 7% of the population).

With regard to the entire territory of the Campania region, from an extrapolation of the data from the institutional site, starting from a total population of 5,801,700 inhabitants, the vaccinated people with complete cycle result in approximately 3,350,000, representing approximately 65%. of the regional population, to these it must be added the 438,000 people recovered from Covid-19 (about 7% of the population).

Therefore, in order to achieve the 80% target set by the Vaccination Plan or to achieve “herd immunity” at least 70%, it was necessary to intercept for the months of September and October at least another 15-20% of the population, that is about 1,000,000 people, primarily health professions who, to date, although obliged, have not yet undergone vaccination and obviously all the remaining school staff.

From an in-depth search on all the sites of the orders of the province of Salerno, the registered health professions are doctors and dentists (for about 7,700), veterinarians (about 700), pharmacists (about 2,300), biologists (about . 6,000), psychologists (about 1,000), nurses (about 9,000), midwives (about 400), technicians of medical radiology, rehabilitation and prevention (about 3,000), physicists and chemists (about 200), to these it must be added other Healthcare Professionals (eg Op. Socio Sanitari). Therefore it is estimated about 31,000 health professionals and other Op. Of health interest (about 3% of the population) in the province of Salerno and at least about 110,000 in the Campania region, but to date not everyone have undergone vaccination.

Assuming the numbers published on the website of the Presidency of the Council of Ministers for the Campania region (108,621), it is noted that the health personnel still not vaccinated stands at approximately 3,400 operators, of whom we do not yet know precisely in which health structures they provide their activities, as reconnaissance by general managers is underway, and it is not known whether the reason for the lack of vaccination is linked to individual and social behavioral determinants or simply linked to their health conditions.

Anti Covid-19 Vaccination Obligation

The mandatory nature of vaccines in Italy is not a new issue as it had already been addressed with the D.L. 73/2017 which had reintroduced the vaccination obligation for certain diseases, which was abolished at the end of the 1990s, provided for an administrative penalty for parents and the requirement of access for preschools.

Italy is the first nation to have imposed a COVID-19 vaccination obligation.

Legislative Decree 44/2021 which, albeit a temporary rule as it was limited in its operation to 31/12/2021 and limited to the specific health sector, is causing important repercussions on the employment relationship for those who do not intend to accept the obligation.

The co. 6 of the art. 4 of the aforementioned Legislative Decree in fact states that non-compliance with the vaccination obligation determines the suspension from the right to perform services or tasks that involve interpersonal contacts or involve the risk of spreading the infection from SARS-CoV-2, with the possibility for the employer to work of assigning the health worker to different tasks, even lower ones, and, if this is not possible, no salary is due for the period of suspension.

The legitimacy of art. 4 can only be assessed in application of the constitutional principles and in particular of art. 32 of the Constitution which states that “The Republic protects health as a fundamental right of the individual and the interest of the community”.

No one can be obliged to a specific health treatment except by law, which cannot in any case violate the limits imposed by respect for the human person.

Therefore, there is a dual interpretation of the rules, on the one hand it protects the citizen in his right to health and in his freedom to choose treatments, on the other it recognizes a public interest in health, which may entail the obligation for individuals to submit to treatments arranged only by law and within the limits imposed by respect for the human person.

Current Status Anti Covid-19 Vaccine Obligation

From the major newspapers it has been learned that in this last period (May-August 2021) various Healthcare Organizations of the NHS are moving towards the application of the provisions on the obligation of the anti Covid-19 vaccine for Healthcare Workers.

Obviously, many are those who, during the sanctioning procedure of warning to get vaccinated, show up at the vaccination centres for administration.

The procedures implemented by the Health Authorities are well defined, first the health professions are formally invited by the Public Health Departments to undergo the administration of the anti Sars-Cov-2 vaccine, indicating terms and methods, and only if they do not they show up for scheduled appointments, the immediate suspension provision is triggered until vaccination is completed and in any case no later than 31 December 2021.

The person concerned, the employer and the professional order to which they belong are immediately informed of the non-compliance with the vaccination obligation, at the same time communicating the suspension from the right to perform services or tasks that involve interpersonal contacts or involve, in any another form, the risk of spreading the infection from Sars-Cov-2, the Order, once it receives the communication from the ASL, must take note of the lack of vaccination and suspend the professional.

The Ministry of Health itself clarifies how to proceed in a letter of reply to Fnomceo of 17 June 2021, which asked for information on how to apply the law.

With regard to the suspension provision, only administrative appeal to the Regional Administrative Court is allowed within the terms of 60 days. from the date of notification and in this regard, there are a number of health workers in service at the NHS, the affiliated structures and private structures, who are resorting to the TAR against the cancellation of the sanctions provided for by the ASL to which they belong (suspensions, demotions, etc.).

From the latest government data issued in mid-August 2021, there are almost 37,000 Italian health care professionals who are not vaccinated so-called “No vax” and among the Regions with the most “no vax” Friuli Venezia Giulia and Emilia Romagna stand out with approximately 5,000 and 13,500 respectively 10% and 7.4% of unvaccinated workers and immediately after Puglia and Sicily which respectively count approximately 9,000 and 5,700 unvaccinated health workers.

From an in-depth publication of recent studies or surveys present on institutional sites with respect to the propensity for vaccination against Covid-19 by health professionals, no determination has yet been made, however three publications have been found to be relevant and very interesting from mention in the survey covered by this study.

A study was recently conducted to evaluate the attitude towards the COVID19 vaccine among Coronavirus patients hospitalized in a city in northern Italy and it emerged that more than half of the respondents in the selected cohort were hesitant or undecided about the vaccine (59.2%).

This result is in line with another survey recently conducted by AGENAS in collaboration with the Scuola Superiore Sant’Anna of Pisa which involved 12,322 residents of all Italian Regions and Autonomous Provinces. The survey revealed that 17.6% of those interviewed were unwilling to get vaccinated * 2. The other very interesting recent study, carried out by Agenas in collaboration with the Scuola Superiore Sant’Anna, is based on a survey conducted on the websites of the 21 Italian Regions and Local Health Authorities on the state of the art of online communication in this regard to the anti Covid-19 vaccination and it has emerged that receiving clear information on the COVID-19 vaccine can increase the propensity of Italian citizens to get vaccinated and how the internet represents one of the main sources of information on COVID-19 vaccination.

Objectives Of The Project

For the many contradictions and doubts on Legislative Decree no. 44/2021 about the compulsory vaccination against COVID-19 which is further causing discussion not only from the point of view of health, but above all for the ethical and legal implications that the precept entails, it was considered to consult a sample of the population of practitioners of the health professions and to administer a questionnaire in order to fully understand the main reasons that lead them to think that the obligation is wrong and that all this, by reaction, triggers even more fears and no-vax instincts or that the reasons are different and to be included in the investigation.

Based on the evidence resulting from the scientific studies specified in the introduction, the present study was aimed at observing the attitudes of the “health population” towards vaccination against COVID-19, at investigating the behavioral causes that may give rise to an implementation deficit in adherence to the vaccination campaign against COVID-19, at researching which sources of information on the virus drawn from health professions, to obtain immediate assessments of the attitudes and preferences of health professionals useful for defining more effectively decisions to be taken, by institutions, in particular the regional health services, in the face of difficult cases of “no vax”, while at the same time allowing to estimate the importance that health professionals attribute to the different characteristics of public interventions, for example making mandatory by law a vaccination in conditions of management of health emergencies with few precedent compared to other actions that could be more effective.

In this regard it should be remembered that social influences and individual behavioral determinants are to be taken into due consideration in this type of investigation, so much so that several studies show how social networks have an impact, both positively and negatively, on the behavior of people even about the decision to get vaccinated.

The survey on the propensity to vaccinate against covid-19 and on the information borne by health professions, compared to the studies already conducted on citizens, is of great interest, in addition to the fact that there is a legal obligation for them to undergo vaccination, above all because ethically speaking these health workers have important responsibilities as they perform services or tasks that involve interpersonal contacts or involve a risk of spreading the infection from Sars-Cov-2.


This project envisaged the administration of an online questionnaire to a sample of health professions in the Campania region. The survey questionnaire was developed following an accurate analysis of the relevant scientific literature, flanked by a benchmarking analysis of the most important surveys on the issues investigated.

The questionnaire, which saw the combined use of observational and experimental methodologies, is aimed at participants to express their degree of agreement with respect to a series of statements, on a scale whose extremes represent strong disagreement and strong agreement. In other observational questions, participants select one or more options from a predefined list of answers.

The questionnaire was administered through the “Google” platform and the link was sent electronically via e-mail to all the Presidents of the Orders of the Health Professions of the Campania region for appropriate dissemination and possible publication on its institutional website, also sent via the social channels to about 800 health professionals with direct knowledge of the authors of this research project and finally published on the institutional site of the Salerno ASL.

Membership took place voluntarily between June and September 2021 and the data collected, in full compliance with the rights and anonymity of the participants, are treated in accordance with EU Reg. No. 2016/679 (GDPR), of the Legislative Decree n. 196/2003 “Code regarding the protection of personal data”.

The research project, which explored issues of relevant topicality in the daily public debate between politics, experts and institutions at different levels, provided for the subdivision of the questionnaire to be administered into 3 Sections:

  • In a first section, the profile of the health professions subject of the survey was observed;
  • In the second section, the questionnaire measured the attitudes of health professions towards vaccination against COVID-19 and studied the relative importance of some factors in influencing the propensity to vaccinate against COVID-19;
  • In the third section, the survey investigated what are the issues related to vaccination against COVID-19 on which health professions also require more information and which communication channels are desired by them.

The survey involved 613 health workers, belonging to the various health professions recognized as such by the current legislation on the subject, which are specified below:

Surgeon, Dentist, Veterinarian, Pharmacist, Health Professions of the Nursing and Midwifery Area (CPS Nurse, CPS Pediatric Nurse; CPS Midwife), Health Professions of the Technical-Health Area (Health Technician of Medical Radiology, Health Technician of Medical Laboratory, Audiometrist Technician, Neurophysiopathology Technician, Orthopedic Technician, Audioprosthesis Technician, Cardiocirculatory Physiopathology Technician and Cardiovascular Perfusion, Dental Hygienist, Dietitian), Health Professions in the Rehabilitation Area (Podiatrist, Physiotherapist, Speech therapist, Orthopedic surgeon and Neuropedic Therapist) Developmental, Psychiatric Rehabilitation Technicians, Occupational Therapist, Professional Educator), Health Professions of the Prevention Area (Environmental and Workplace Prevention Technician, Health Assistant), Psychologist, Biologist, Physicist and Chemist.

Results And Discussion: The Profile Of The Healthcare Professional Subject Of The Survey

SECTION I identifies the profile of the professional, age (answers in graph 1), sex (answers in graph 2), the degree qualification that qualifies him for the profession and the type of professional activity exercised (answers in Table 1)

 Tab 1

In line with their natural placement, 84% of the health professionals interviewed carry out their activity with an employment relationship, 67% in activity at the NHS (ASL / AO) and 18% at accredited or affiliated health facilities. at the NHS (clinics, nursing homes, rehabilitation homes, nursing homes, etc.), a small part of health professionals (about 12%) are freelance professionals in private practices and the remaining 4% is represented by new graduates or in any case graduates of the health professions looking for their first job.

The population surveyed is represented for approximately 59% by female exhibitors and for the remaining 41% by men, distributed evenly and equally representative of all the age groups interviewed (20/29, 30/39, 40/49, 50/59, 60/70 and> 71);

of these professionals about 35% have a single-cycle master’s degree (doctors, veterinarians, pharmacists and others) or two-year master’s / specialist degrees, the other 65% have a three-year degree in the health professions or they are in possession of the equivalent qualification.

The last two questions of the first section investigate the health status of the health population under study.

QUESTION 5 – “Health status with respect to Sars-Cov-2 infection” (answers in graph 1):
  • He was infected with SARS-COV-2 but asymptomatic (2.5%);
  • He infected with SARS-COV-2 with mild or moderate symptoms without hospitalization (8.4%);
  • He became infected with SARS-COV-2 with severe symptoms with hospitalization (0.5%);
  • I have never received a confirmed SARS-COV2 diagnosis (88.7%).
Fig. 1
QUESTION 6 – “Temporal information with respect to Sars-Cov-2 infection” (answers to graph 2):
  • I have never received a confirmed diagnosis at SARS-COV2 88.9%);
  • Infected in the absence of vaccination or before vaccination (9.7%);
  • Infected between the first and second dose (0.9%);
  • Infected after vaccination against COVID-19 (0.5%);
Fig. 2

From these two responses, the significant data is that about 10% of the health offices to date have been infected with Sars Cov 2, of these about 73% with mild or moderate symptoms and without hospitalization, 23% asymptomatic, only 4% had severe symptoms and were hospitalized.

The other relevant data that results from calculations on infected operators subject to the survey, is that about 97% of them took the virus before the complete vaccination course, more precisely 89% before vaccination, 9% between the I and II dose; only 2% of the interviewees contracted the Sars-Cov-2 virus after vaccination.

Results And Discussion: Attitudes On Vaccination Against Covid-19

Section 2 illustrates the questions that investigate the attitudes of health professions towards vaccination against COVID-19 and for each question there are graphs with the results relating to the perceptions of the sample with respect to macro-themes: risks of the disease and vaccination, vaccines and pharmaceutical companies, propensity to vaccinate themselves and more.

11 questions in this section were asked to respondents on a five-point Likert scale, other questions presented as statements against which the respondent had to express his or her level of agreement.

SECTION 2 – QUESTION N. 7 – “Are you inclined to vaccinate against Covid-19 ? ” (answers in graph 3)
  • To be Against vaccination Covid-19 (2.9%);
  • Undecided (4.8%);
  • In favor (92.3%);
  • To be against all mandatory vaccinations.
Fig. 3
QUESTION N. 8 – “Do you receiv the anti covid-19 vaccination ? ” (answers in graph 4):
  • I took first and second doses (93%);
  • I only performed the 1st dose (4.5%);
  • I intend to get the COVID-19 vaccine as soon as possible (1.4%);
  • I have no intention of vaccinating myself (1.1%).
Fig. 4

From these two questions, the significant data to be noted is that about 3% are still opposed to this Covid-19 vaccination which could be the no vax of the interviewees and about 5% represent the undecided.

Obviously, almost 93% of Healthcare Workers are decidedly in favor and have undergone the vaccination, only 4.6% have done the 1st dose and are waiting for the 2nd one.

The other relevant fact is that among the 3% of the no vax against there is a 1.2% of health professionals who we can call them “irreducible” who are not at all willing to get vaccinated, compared to 1.4% who instead they declare that they would also intend to get vaccinated, it would remain to understand the reasons that led them to postpone, and we will see this in the following questions and in graph n. 7. Data of the Health Operators not yet subjected to vaccination which are in line with the national average of 3% as also recorded in the Campania region, as published by the Ministry at the date of this survey.

Question n. 9 – “How much do you think these statements related to the safety of the Covid-19 vaccine are in keeping with your view” (answers in graph 5): VERY AGREE – ENOUGH AGREE – LITTLE = ENOUGH DISAGREE – NOT AT ALL = TOTALLY DISAGREEING):

  • The risks associated with the COVID-19 disease are greater than the possible side effects of the vaccine;
  • The COVID-19 vaccine was developed quickly to make sure it is safe and effective;
  • Vaccination against Covid-19 is not needed if you follow safety procedures and protection systems accompanied by healthy lifestyles or natural remedies;
  • The COVID-19 vaccine is big business for pharmaceutical companies and cannot be trusted;
  • The COVID-19 vaccine is the quickest way to get back to normal;
Fig. 5
  • Vaccines are among the safest pharmaceutical products;
  • I do the covid-19 vaccine only to protect the people around me (patients, family members, etc.);
  • I believe in a strong risk-reducing effect of SARS-Cov-2 infection in fully vaccinated versus unvaccinated people;
  • I have the perception that this vaccination is not effective;
  • I noticed access problems (long waiting times or insufficient availability of vaccines);
  • I have no confidence in the institutions and in particular in the services offered by public health;

The majority of healthcare professionals, between 75% and 94% are convinced:

  • in a strong SARS-COV-2 risk reduction effect of vaccinated versus unvaccinated (for 94%), which is the strongest way to return to normal (for 93%), that the possible risks related to COVID-19 disease are greater than the side effects of the vaccine (for 92%) and that vaccination cannot be replaced by other means of prevention (for 80%);
  • moreover that vaccines are among the safest pharmaceutical products (for 83%) and that it is not a business for pharmaceutical companies (for 75%).

While the healthcare population is divided almost in half, between 46% and 53%, in arguing that:

  • the Covid-19 vaccine was developed too quickly to be sure it is safe and effective (for 46%) and that they only undergo administration to protect their family members or patients (for 53%).
  • On the other hand, only a minority of the Healthcare Professionals interviewed (between 1-2% and 5%):
  • has the perception that the anti covid-19 vaccine is not effective (about 2%);
  • less than 1% have no confidence in the institutions and in the offer of public health services, less than 2% have little confidence and only 5% have noted access problems and long waiting times at the NHS vaccination centres.
QUESTION N. 10 – “Do you think it is right to introduce legal obligations for vaccination against COVID-19” (see Legislative Decree no. 44/2021 converted into law) as already happened with the previous law 73/2017 which required vaccination for certain diseases” (reply in graph 6):
  • Definitely Yes (56.6%);
  • Yes, but I believe that this law on the obligation of the anti covid-19 vaccine is not an appropriate intervention, we should use other methodologies and individual and collective risk assessments to identify a more restricted and contained obligation on some categories of people and belonging to precise risk classes (26.9% + 0.4%);
  • Definitely No (3.5%);
  • No, because this law on the requirement of the anti covid-19 vaccine is not an appropriate intervention, other methodologies and risk assessments should be used … .. as above (3.8%);
  • I do not think it is right to introduce limitations for those who, even if they can, decide not to vaccinate against COVID-19 (6.5%);
  • No, I consider it a health dictatorship (2%).
Fig. 6

Significant data to be noted are that:

  • about 56% believe it is absolutely right to introduce a legal obligation;
  • a non-negligible fact is that about 27% of the interviewees answer “YES” but, from a legislative point of view, they believe it is right that more restricted risk classes could be identified to make the vaccine mandatory with a law, also on the basis of the evaluation of the risk on the part of the competent doctor of the work of the health facility where the activity of the health professional is exercised as required by Legislative Decree no. 81/2001 and subsequent amendments;
  • 6.5% do not believe it is right to make Covid-19 vaccination mandatory;
  • 2% consider it a health dictatorship, here comes out the “NO VAX” orientation of those who are not at all willing to get vaccinated, who do not believe that the Covid-19 vaccine is effective, in other words that part of the health workers who is opposed to Covid-19 vaccination (see in this regard also the results of questionnaires 8 and 9).
QUESTION N. 11 – “What is the main reason why you have decided to postpone the vaccination” (answer in graph 7):
  • Diseases / health conditions that did not allow vaccination (4%) + Pregnancy and Breastfeeding (1%) + Allergies (0.2%) + Waiting 90 days after covid-19 virus negativization (0.2%) + Already Positive (0.2%) + For pathologies (0.4%) + other similar options;
  • I was advised against joining the vaccination program by health professionals (0.5%);
  • Doubts related to the usefulness of vaccinations (2%) + little time for experimentation (0.2%) + strong doubts related to short and long-term side effects or side effects (0.4%), other similar ones;
  • None of the reasons, I do not fall into this case history (84.9%) + I have not postponed (4.5%);
Fig. 7

The significant health data to be noted is that of 9.9% of health workers who have postponed or who did not undergo vaccination, at the time of data collection from the interviewees, it is mainly due to their health status, specifically for:

  • 5.5% is due to diseases and pathologies or in any case health conditions that did not allow vaccination,
  • 1% of witch is due to pregnancy, 0.2% is due to breastfeeding, 0, 2% is due for side effects, therefore over 4% is for particular pathologies;
  • 1% is due to waiting 90 days after the virus is negative or because it is positive for Sars-cov-2 or due to the fact that with the serological assay it already had antibodies against Covid-19.

The fact remains that over 3% of the health workers interviewed have doubts related to the usefulness of vaccinations and other similar reasons to always be identified among the “no vax” of the interviewees.

SECTION 3 asks questions about vaccine knowledge, possible incentives to get vaccinated, and sources of information related to the COVID-19 vaccine.

One of the questions in this section was presented to respondents as statements about which the respondent had to express his or her level of agreement or disagreement and for some questions posed on a five-point Likert scale.

QUESTION N. 12 – “On a scale of 1 (poor) to 5 (excellent), how do you rate the level of your knowledge on vaccination against COVID-19” (answers in graph 8):
  • 5 (ottime);
  • 4 (buone);
  • 3 (sufficienti);
  • 2 (mediocre);
  • 1 (scarse);
 Fig. 8
QUESTION n. 13 – “Would correct information and greater insight into the risks of vaccination against Covid-19 in the short and long term give incentives to do it?” (graph 9):
  • Yes (55.4%);
  • Yes, because all the professionals give information only about the benefits of vaccination but not about the risks (24,7);
  • No (7.7%);
  • I don’t know (12.2%).
Fig. 9
QUESTION n. 14 – “Who did you get more information about COVID-19 from?” (answers in graph 10):
  • on the website of my Region / ASL Institutional sites (eg Ministry of Health, Istituto Superiore di Sanità, AIFA) for 53.6% + 0.4%;
  • Through specific television programmes with virologists, epidemiological experts and institutions (30.8% + 0.2% +);
  • on websites / forums that promote them (3.7%);
  • on sites / forums that advise against vaccinations (0.7%) and more;
  • Other (about 9%): scientific training / CME / scientific journals and specialized websites (5%) + from doctors and competent doctor where I work (2%) + from frontline work (2%) + from GPs (0 , 4%) and more.
Fig. 10
QUESTION N. 15 – “Have you found a discrepancy of opinions on the anti covid-19 vaccination from various health professionals and virological experts that you have consulted or listened to?” (graph 11):
  • Yes (68% + 0.8%);
  • No (19.7%);
  • I did not consult any “health professionals” (11.5%).
Fig. 11
QUESTION N. 16 – “Who would you like more information about COVID-19 from?” (answers in graph 12):
  • Vaccination services of the ASL (37%);
  • Family doctor (25%);
  • Other trusted doctors (virologists or other specialists) for 20.4%;
  • Associations or other specialized bodies also on the web (12.3%);
  • Internet (2.4%); Other (3.9%).
Fig. 12

From the results of the questions posed to the interviewees, it was found that 95% of health professionals declare that they have sufficient or good knowledge on the subject of vaccination against Covid-19, only 5% consider them scarce or mediocre;

  • 80% believe that they would in any case be more incentivized to vaccinate if they were correctly and better informed about the risks of vaccination against Covid-19 in the short and long term, at the same time they require more information from the Vaccination Centres, General Practitioners and by the Doctors in charge of the health facility where they work;
  • about 60% of the interviewees declare that the major sources of information were drawn on the internet from institutional sites (ministry, region, ASL, etc.) and other institutional sites for about 54%, from sites and forums that promote the campaign vaccine for about 4%,
  • for more than 31% through specific broadcasts with experts and institutions,
  • about 4% through CME scientific training and specialist scientific journals;
  • only a minority of 1% received information from general practitioners and / or PLS, 1% from the company competent doctor and 1% from doctors or health workers at their work in health facilities.

A minority of 1%, on the other hand, identified in the so-called “no vax”, drew information from sites and forums that advise against vaccination against covid-19.

Another critical element is a large majority of 70% of respondents who declare that they have found a discrepancy of opinions on the anti covid-19 vaccination by various health professionals and virological experts who have consulted or listened to on social networks, TV and more.


Once the data collection was completed, not only an evaluation of the results was carried out but an analysis of the readability of all the data with the aim of highlighting and providing ideas for improving the communication process and approach of health professionals with the topic covered by the present study because the interviewees, each for its particular health activity, are at the forefront of fighting this pandemic.

The results presented in this research may be useful for the Prevention Departments of the Health Authorities and Institutions to understand the propensity to vaccinate against covid-19 also of the health professions and to monitor their perception of the information and communication methods, in order to identify useful strategies to sensitize health professionals and others, in particular the hesitant people and no vax, to raise the level of trust in the vaccination campaign, in the institutions and in the role of experts.

In fact, from our data also for health professionals, the receipt of clear and correct information on the COVID-19 vaccine would increase their propensity, as already noted for Italian citizens by the existing literature * 3 and by the statements made by the European Center for Prevention and Disease Control (ECDC) * 4 which report how the access to reliable information and adequate communication increases people’s willingness to undergo vaccines of any kind and leads to significant results in promoting vaccine acceptance.

The doubt shown in this survey also by health professionals on the probable short and long-term side effects of covid-19 vaccination are by no means negligible, they represent about half of the interviewees, this mainly due to the confusion generated by media overexposure – in several contradictory occasions – of scientific experts and institutions in charge, although aware that the evidence on the efficacy and safety of vaccines authorized by the EMA and AIFA derives from controlled clinical studies and that the available knowledge on the benefit-risk profile of vaccines may gradually accumulate as the vaccination campaigns currently underway in the various countries continue.

Our data suggest that, avoiding unnecessary clashes on clinical aspects by experts in the field but even more by politics can only help to overcome the skepticism of the undecided and to make the few opposed “no vax” think better even among the health workers.

As far as knowledge and sources of information are concerned, even health professionals recognize the Internet and TV as the main information channels on COVID-19 vaccination, as well as assisting them in ECM training and reading scientific and specialized journals.

The latter data are also in line with the analysis conducted on the Italians by AGENAS in collaboration with the Scuola Superiore Sant’Anna, from which it emerged that 45.3% recognize the Internet as the second main channel of information on anti-vaccination COVID-19, after television and that in recent years an increasing number of citizens search for health information on the Internet (88%).

The Internet and the websites that populate it therefore represent a key channel for also informing health professionals on issues related to vaccination against COVID-19.

Just under half of the interviewees believe it is not right or at least inappropriate to introduce a legislative obligation for vaccination against covid-19 for healthcare workers (DL 44/2021).

Neglecting 2% of the probable no vax who consider it a health dictatorship, a good part believes it right that more restricted risk classes could be identified to make the vaccine mandatory, also re-evaluating the figure of the Competent Doctor as required by Legislative Decree no. 81/2001, so that there is an assessment of the risk of the health facility and of the particular activity carried out, avoiding to involve in the warning and suspension procedures provided for by paragraph 4 of art. 6 of the aforementioned DL, health workers with serious health problems or pregnant workers who do not allow them to join the anti covid-19 vaccination campaign.

Last but not least, we underline that 10% of the health workers interviewed were infected with the SARS-COV-2 virus and that only 2% became infected after complete vaccination, this in support of the many studies carried out so far on the population that lead us to understand the great efficacy of this anti covid-19 vaccination campaign.

The project therefore makes it possible to report a series of actions that policy makers and employers of public and private health structures could undertake to support good communication to their health professionals on COVID vaccination19.

In particular, the actions to be implemented in order to improve communication and the propensity to vaccinate against covid-19 for health professionals are:

  • Increasing communication and information on anti-covid-19 vaccination, including on short and long-term side effects, by providing an information desk in each ASL of the NHS within the prevention department and involving general practitioners in order to strengthen the information and sensitize their clients to the administration of the vaccine;
  • Containing, as far as possible, discrepancies of views of the scientific world on the issue of vaccination against covid-19 in the major media (TV, etc.), on the other hand avoiding them by the institutions, by providing for a regulation on communication to be kept aside institutions and politics to avoid confusion between health professionals and citizens;
  • organizing meetings and consultations with psychologists, epidemiologists, hygienists, occupational doctors, experts on vaccination against covid-19, in each ASL of the SSN for those health professionals who are against and “no vax”, in the same way also involving no vax citizens;
  • convocation by the Competent Doctors of all health care workers of the health facility with partial or unsuitable suitability / ability or who are pregnant in order to assess the compatibility with the administration of the anti covid-19 vaccine even before starting the warning procedures and suspensions put in place by general managers and other employers to implement the legislative obligation.


  1. Gerussi V, Peghin M, Palese A, et al. Vaccine Hesitancy among Italian Patients Recovered from COVID-19 Infection towards Influenza and Sars-Cov-2 Vaccination. Vaccines 2021; 9: 172. doi: 10.3390 / vaccines9020172
  2. Mantoan D, Nuti S, Cantarelli P, et al. The vaccine and vaccination against COVID-19: The propensity of the Italian population to join the vaccination campaign. 2021.
  3. Caserotti M, Girardi P, Rubaltelli E, et al. Associations of COVID-19 risk perception with vaccine hesitancy over time for Italian residents. Soc Sci Med 2021; 272. doi: 10.1016 / j.socscimed.2021.113688
  4. European Center for Disease Prevention and Control (ECDC). Catalog of interventions addressing vaccine hesitancy. 2017. https://ecdc.europa.eu/sites/portal/files/documents/Catalogue-interventions-vaccine-hesitancy.pdf
  5. Iavicoli S, Boccuni F, Buresti G, et al. Technical document on the possible remodeling of the containment measures of the SARS-CoV-2 contagion in the workplace and prevention strategies. Rome: INAIL April 2020. ISBN 978-88-7484-911-5
  6. Impact of COVID-19 vaccination on the risk of SARS-CoV-2 infection and subsequent hospitalization and death in Italy. ISS and Ministry of Health Working Group “Surveillance of COVID-19 vaccines. 11.05.2021
  7. Fabiani M, Onder G, Boros S, Spuri M, Minelli G, Mateo Urdiales A, Andrianou X, Riccardo F, Del Manso M, Petrone D, Palmieri L, Vescio MF, Bella A, Pezzotti P. The case fatality rate of SARS-CoV-2 infection at regional level and through

Work Safety In The Wind Energy Sector: State Of The Art, Problems And Future Perspectives



Grasso Salvatore1, Terzo Felice2

1Physicist, PhD, CEO at IVPC SERVICE Srl
2HSE at IVPC Service Srl


Pubblication Date: 2022-11
Printed on: Volume 4, Publications


The development of wind energy in Italy constitutes one of the cornerstones of the turning point towards the environmental sustainability that the new Ministry of Ecological Transition has decided as a condition, also thanks to the growing attention worldwide, public opinion and Institutions are placing in climate change and the now imperative need to reduce emissions into the atmosphere.

The workers of the sector are exposed to dangers that can cause death and serious injuries during all the phases of a wind farm project.

In particular, the most relevant activities for the assessment of health and safety risks are:

  • installation of the turbine;
  • installation of the cables;
  • commissioning of the turbine;
  • maintenance of the turbine;
  • dismantling of the wind farm.

Once operational, wind farms are unmanned structures where specialized technical personnel access only for the time strictly necessary to carry out maintenance and repairs.

A well-designed wind farm, built and subject to careful periodic maintenance, has an average lifetime of 20 years, during which some parts of the plant need to be repaired or replaced due to mechanical or electrical faults, due to wear of the components and operation in conditions of strong “stress” such as mechanical stress and frequent power variations linked to the stochastic nature of the anemometric resource.

The installation phase of a wind farm can last a few months, during which the technicians are engaged on average for 9-10 hours a day in the activities of pre-assembly of the components, erection of the wind turbine and electromechanical completion.

During operational activities, a typical team consists of two / three technicians who work in the turbine for a period of 7-8 hours per day, to carry out scheduled maintenance or repairs.

In both phases, the time that workers spend on the wind turbine takes up almost the entire working day, increasing the probability of exposure the an health and safety risk.

Moreover, the safety risks during the installation and maintenance of wind turbines are connected to the technological aspects of complex machinery and to the environmental and meteorological conditions the workers are exposed to.

The main risk factors in the wind sector are:

  • Ergonomics (Prolonged uncomfortable positions in tight spaces)
  • High physical load for the ascent to the turbine
  • Works carried out at height
  • Emergency Management and Evacuation from the Turbine
  • Hard-to-reach area in an emergency
  • Extreme weather conditions
  • Electrical risk

They can be classified into general and specific risks as per the table below

General risksSpecific risks
SlidingWork at height
Lifting and transport of loadsElectrical work
ErgonomicsWork in restricted spaces
Drugs and alcoholWork Abroad
Business travel/Working hoursWork in hot conditions
Tab. 1 – main risks in a wind farm

The assessment of these risks and the identification of appropriate prevention and protection measures are currently being studied and reviewed by various working groups, also in collaboration with the relevant Institutions, in order to adapt the production processes and make them increasingly safer. Among the most important results, in which we participated directly through ANEV, we like to mention the collaboration with INAIL which in 2019 issued the guidelines for the operation of wind farms, an important signal of regulatory compliance for an innovative and rapidly expanding professional sector in our Country.

Much remains to be done to improve the comfort and safety conditions of workers in the wind sector, especially in anticipation of a general phenomenon of aging of the technical staff who, having started their career in the mid-90s, are largely in the range between 50 and 60 years old.

To understand the problems and risks of this particular category of workers, and to have the necessary elements to identify the prevention and protection measures, it will be useful to recall in the following paragraph a brief description of the production processes inherent to the installation and maintenance of the wind farms.

How a wind farm is built and managed

The identification of a suitable site for the construction of a wind farm constitutes the first phase of this activity, and is carried out through a series of technical studies and feasibility analyzes, including:

  • Anemometric studies to evaluate the availability of the wind “resource”
  • Viability and suitability to construction site to evaluate the possibility of building on inaccessible sites and with complex road accesses
  • Analysis of the constraints on the area of interest and environmental impact assessment
  • Access to the connection point to the electricity grid
  • Availability of soils

Subsequently, we proceed to the elaboration of the layout and the geological surveys preparatory to the construction.

The photographic flow chart below schematically represents the evolution of these activities

Fig. 1 – development and design steps

Once the necessary permits have been obtained, the construction is started, where the civil works for the construction of the foundations, and the electromechanical works for the lifting and assembly of the wind turbines are clearly identifiable.

Fig. 2 – construction steps

Finally, after the wind plant has been commissioned, the O&M Companies carry out all the activities necessary to optimize the electrical production and keep the plants in a correct state of use and maintenance in order to minimize downtime for failure and extend the turbines lifetime, which in industrial models should be at least 20 years.

Fig. 3 – O&M steps

From this description, it can be deduced that the main activities that the wind energy technicians undertake on technologically complex machinery are those of lifting, installation and maintenance of wind turbines, and it is therefore on these phases that the professional risk analysis is focused and the constant search for solutions to improve working conditions.

Relevant aspects of health and safety risk for wind technicians

Wind energy is a relatively new industrial sector for which the legislator has never regulated in a detailed way and shaped the health and safety requirements applicable to that sector both from the point of view of machine safety requirements and as regards the characterization of specific training.

Fig. 4 – traditional metal workers and wind workers

The operators are mainly classified as “metal mechanics workers”, which is limiting as the machines they interact with (Wind turbines) have intrinsic characteristics and dangers that expose them to risks other than those of the generic engineering sector.

Evolving technology

We have gone from older wind turbine installations (although still in operation) to more complex wind turbines in terms of height and size.

Fig. 5 – 90s wind turbines and latest generation models
Small wind

Even small-sized wind turbines (despite their small size) present problems and criticalities due to reduced operator space for maneuver, lack of mechanical aids and some lack of anchoring points.

Fig. 6 – small wind turbine

A wind farm is generally located in places far from built-up areas, which can be reached with difficulty due to the lack of adequate roads and access is also conditioned by the occurrence of meteorological events; the lack of coverage of the telephone network and often of radio links can further aggravate the working condition.

Fig. 7 – installation site of a wind farm
Aging of staff

It should also be considered that in recent years the problems associated with the aging of personnel have been emerging also in relation to all the risks set out above since the companies operating in the sector, most of which have been established since the 1990s, will have to confront with a workforce that is no longer young and without a precise protocol to be adopted to address the problem.

Wind Sector Analysis

The fatal cases in the wind sector from 1970 to 2016 were 144: 87 victims were involved in the construction and management of turbines, while the other 57 cases involved people not directly employed in the production of wind energy.

In 2018 alone (INAIL data) there were 149 deaths in the agriculture sector. This is to say that, despite the wind sector has not yet been fully taken into consideration under the specific and peculiar regulatory and contractual aspects, it has, over the years, equipped itself with a management system made up of procedures, work instructions, voluntary training protocols, which has reduced intrinsic problems to a minimum, making residual some relevant risks such as work at height, electrical and mechanical. In fact, despite the high level of risk in the wind sector, the attention paid to safety by the companies in the sector allows the number of accidents to be far lower than that of other working sectors.

Since the problems are transversal and concern all companies, the operators of the sector have joined in A.N.E.V. (National Association of Wind Energy) which, thanks to its specific experience and the high professionalism of the members, is the privileged interlocutor in the hoped-for process of collaboration with the Institutions for the definition of sector legislation and with all the bodies of information sensitive to environmental issues and interested in the dissemination of correct information based on the scientific analysis of the disseminated data.

In 2016 ANEV signed a framework agreement with INAIL which led to the drafting of the first National Guideline concerning standardized procedures and a Safety Management System applicable to the wind sector. Although voluntary, the Guideline has traced the first real path for reflection on the peculiarities of risks in the wind sector in Italy.

Without prejudice to these necessary premises regarding the sensitivity and attention to health and safety issues by the companies in the wind sector, one cannot ignore the issue of the progressive aging of personnel, which could be an element of risk for the health as well as representing a risk management factor for the companies that will have to face it. Since the problem has no historical background to work on, as in Italy the first major companies began to hire staff in the nineties, the discussion in the following document covers a very delicate and difficult to solve issue. As no bibliographic data or comparative elements are available, the study was based starting from a census and a photograph of the risks also in view of the progressive aging of the staff compared with a risk reduction curve thanks to the implementation of all the possible preventive measures referred to in this document.

Assessment of the main risks related to the safety aspects of workers in the wind sector

R= Px I (Damage)  P = Probability of the event – I Impact/Damage Level 

Fig. 8 – matrix of risk (R) = damage x probability

Given the R assessed, the following table indicates the actions to be taken necessary to mitigate the risk.

Risk levelType of Action
1-2-3Ordinary surveillance
4Surveillance actions on existing activities
5Adoption of management actions for risk mitigation (e.g. drafting of procedures, training, and more)
6Adoption of urgent interventions for risk prevention and mitigation with highest priority) (e.g. technical interventions, process replacement or modification)
Tab. 2 – type of action to mitigate the risk

Using this assessment tool, we can compare the risk levels of a wind technician in ordinary conditions and in old age.

Ordinary conditions
Risk factorP=ProbabilityI=ImpactR=Risk
Work at heighthighhigh6
Isolated jobslowhigh4
Evacuation from the turbinelowhigh4
Manual handlinglowhigh4
Vehicle accidentslowhigh4
Tab. 3 – risk assessment of a wind technician in ordinary conditions

Conditions of aggravation due to the risk of aging

Risk factorP=ProbabilityI=ImpactR=Risk
Work at heighthighhigh6
Isolated jobslowhigh6
Evacuation from the turbinelowhigh6
Manual handlinglowhigh6
Vehicle accidentslowhigh6
Work at heightlowhigh6
Tab. 4 – risk assessment in aging conditions

In general, advanced age involves an increase in the estimated risk level, which can still be mitigated through the implementation of targeted and effective prevention and protection measures.

Fig. 9 – assessment of risk levels with and without prevention measures

Proposals for intervention

Original and innovative activities and future challenges to resolve critical issues and compensate for technical and regulatory gaps are to be found in the activities listed below.

  • Business best practices
  • Cooperation and sharing between operators in the sector
  • Establishment of working groups to share common sector problems and synergistically identify solutions
  • Continuous training shaped on the particularities of the wind sector
  • Better implementation and knowledge of the GWO Industry Standard
  • Memoranda of understanding between sector operators and Institutional Bodies
  • Collaboration and exercise between operators in the sector and emergency operators (in particular Saf of the Fire Brigade and the National Alpine and Speleological Rescue Corps – CNSAS)
  • Engineering drawings of the machines more inclined to the comfort and ergonomics of the operators
  • Health protocols that take age differences into account
  • Enhancement of experiences with attention to the intergenerational climate in companies in the sector
  • Secondary prevention activity aimed at researching preclinical alterations
  • Technological innovations regarding equipment, mechanical aids, rescue vehicles and Personal Protective Equipment.
  • Study on the aid of the exoskeleton to favor ergonomics and the manual handling of loads by the operators.
  • Study on the use of virtual augmented reality to allow remote assistance and surveillance of the activities carried out by operators locally
  • Technological tools to assist the ascent to altitude in wind turbines completely without lifts.

Based on the considerations set out above about the risks of the operators in the wind sector, especially in view of the aging of the staff, it becomes necessary to ask up to what age they will be able to:

  • Work at height
  • Go up and down the stairs of the tower
  • Work in confined spaces
  • Work in extreme conditions (temperature, microclimate, etc.)

It is clear that with advancing age the risks of wind energy operators increase exponentially, and therefore the problem arises of how to manage the aging of the technical staff involved in the installation and maintenance of wind turbines in the coming years, addressing the following topics:

  • Will they work at height until retirement age?
  • Will they all undergo a job change?
  • Will they all be fired?

In a few years, companies in the wind sector will have internal organizational problems as they will have to manage a staff with an average age that does not allow them to carry out the same activities in a safe and risk-free way. The problem could also have social repercussions since, as a change of duties or a different relocation within the Company is not practicable for everyone, there could be dismissals and mobility procedures for those who are no longer suitable for the job.

This work therefore aims to identify possible solutions to the problem, with legislative interventions, through the use of the most modern technologies and thanks to an organization of work aimed at protecting the weakest categories, such as wind workers in old age.

We will also report the results we have obtained by applying the working methods suggested within our company, and we will draw the conclusions of our study.

Proposal of solutions and interventions to mitigate the aging risk

Regulatory adaptation

One of the measures that could be more effective and decisive for the protection of the figure of operator in the wind sector would be the recognition of the ‘hard work’ and therefore of a national collective agreement for the sector which provides for all the conditions relating to the related risks.

Reference legislation:

  • D.Lgs 11 August 1993 n.374
  • D.M. 18 May 1999
  • D.Lgs 67/2011
  • Decree of 05/02/2018

In order to include the activity of the wind sector as demanding jobs, the trade associations should instantiate the application to the Government. At the moment our Company is collaborating with ANEV on this topic.

Innovative technologies

Other solutions and risk mitigation interventions of more immediate application are related to the use of technology, and in particular of mechanical aids for climbing and operating at height. Furthermore, the manufacturers of wind turbines can make their important contribution through a design of the machines that takes into account the right level of comfort and ergonomics of the operators.

Hand in hand with the aging of staff, technology also advances and provides innovative tools that companies can use to protect their staff.

Very interesting in this sense are various types of personal protective equipment, such as exoskeletons to give relief to workers who perform physically demanding tasks.

Wrist support

It is a support derived from a medical device aimed at treating conditions such as wrist inflammation. It uses a preventative approach and supports the wrist in numerous applications where the wrist may be fatigued, such as: riveting, welding, moving or installing generators and starters.

Fig. 10 – wrist support in mechanical processing

The advantages at a glance:

  • it relieves tension in the wrist joint when lifting and holding objects
  • it can be mounted with one hand
  • it regulates the temperature of the wrist thanks to the innovative material tested in space
  • it is suitable for both left and right wrists
Fig. 11 –  exoskeleton

A passive exoskeleton supports people who perform physically demanding activities with their arms raised every day. Relieves strain on the shoulder joints and upper arms, for example when working on maintenance lines.

The advantages at a glance:

  • it relieves strain in the shoulder area by over 50% when working above chest height
  • it is quick to put on or take off in less than 20 seconds
  • it weighs 1.9 kg (4.1 lbs) with full freedom of movement
  • it is individually adjustable according to the user’s height from  160 to 190 cm
Support of the cervical spine

A neck support that relieves the neck region and the cervical area of the spine when working over the head.

The shoulder and neck sections can be individually adapted to each user thanks to the different adjustment possibilities. This makes the neck support very comfortable to wear and usable during all types of overhead work, such as installing false ceilings or performing visual inspections.

Fig. 12 – neck support

The advantages at a glance:

  • flexible neck support for excellent comfort
  • easy to put on in seconds, and perfectly adaptable
  • rugged, yet featherweight design
  • it can be worn together with the exoskeleton for effective relief of the neck and shoulders
Support for the lower part of the spine

It can be used when standing or lifting light loads, providing a high level of support for the lower back. It supports an ergonomic body posture when standing and lifting loads.

Possible applications include handling lighter loads and lifting packages.

It also supports the lower spine when standing during prolonged assembly activities.

Fig. 13 – lumbar support

The advantages at a glance:

  • it supports an upright posture when standing and promotes an ergonomic posture when lifting objects
  • very quick to put on and take off
  • discreet design, adjustable with 5 different sizes
  • it can be combined with the Shoulder exoskeleton for effective lower back relief
Climb assistant

A device that helps operators in climbing the towers of wind turbines allowing to give relief and less burdening of the cervical spine.

Fig. 14 – climb assistant
Augmented reality for maintenance support

This new type of technologies based on the principle of remote support is undergoing strong development in recent years and provides simple, fast and secure visual assistance based on augmented reality to identify and solve problems anywhere in the world.

This technological implementation allows on-site technicians to enjoy the direct support of industry experts through whom they can remotely view the plant and participate in the production process, as if they were present together with the technician.

The visualization through the camera of the smartphone supplied to the technician, allows the experts who are in the control rooms to see the problem and help the person on site to solve it.

In this way, field service technicians can be supported in resolving critical issues quickly and efficiently.

Fig. 15 – application of augmented reality to wind maintenance

Through these innovative technologies, operators can be guided in the field worldwide, in real time, with hands-on training courses for more efficient knowledge transfer.

Organization, training and specific health surveillance protocols

Particular importance and relevance with respect to risk mitigation measures are to be reported in the context of the Organizational Models of company management with reference to the application of training protocols that take into account the specific needs of the sector and secondary health surveillance that looks for clinical alterations of the workers.

In fact, in recent years, many companies in the sector have implemented the GWO standard in their training protocols and therefore in their corporate training plans.

GWO (Global Wind Organization) is a non-profit association, founded by representative members of the brands producing wind turbines such as Ge-Vestas-Senvion-Siemens-Acciona-Eon-Enercon-Innogy -etc, established to standardize international the training course that the technician of the wind sector must receive with training programs drawn up and shaped according to the particularities and peculiarities of the wind sector which, as already expressed, contemplates different risks than those of the other industrial sectors.

In the following, there are the main changes introduced by the GWO Standard:

  • standardized training on sector risks
  • continuous updating (all courses must be updated within two years from the first issue)
  • training programs constantly reviewed by industry experts
  • advertising of the skills of the operators through the GWO’s “Winda” portal.

The GWO training, being of a non-mandatory and purely voluntary nature, is considered the Golden Standard of the training of the wind energy sector operator which, integrating in accordance with the training program of the Italian legislation, continuously and constantly improves the skills and awareness of workers.

Another aspect of primary importance among the risk mitigation tools with respect to the aging of the workforce in the wind sector is an effective primary and secondary health surveillance whose purpose, in addition to being to assess the specific suitability for work, is to discover in good time clinical or preclinical anomalies (early diagnosis) to prevent worsening of the health of the worker. It should be emphasized the importance assumed by the many early diagnosis indices available that can allow interventions aimed at preventing the progression of the disease (secondary prevention). In fact, in order to be able to carry out to the maximum of his competences those activities aimed at a health surveillance that takes into account the “age” risk factor, and with the support of the Company Prevention and Protection Services, prescribes internal company protocols, diagnostic and instrumental tests such as the exercise ECG, for particular categories of workers.

About us – IVPC Group

The IVPC Group, Italian Vento Power Corporation, was founded in 1993 from an idea by Oreste Vigorito, one of the pioneers in the renewable energy sector, and within a few years it established itself as the first and still today one of the main national players for the development, construction and management of wind projects.

The activities of production and sale of electricity from renewable sources are managed within the Group by IVPC SERVICE Srl, a specialized company with 25 years of experience in plant maintenance, operated by highly qualified technicians trained in the culture of quality, protection of the environment and safety in the workplace. The Company Management considers the protection of the health of workers and the prevention of risks to be an absolute priority, and for this reason it has put in place and constantly updated an organizational model strongly oriented towards safety, even when dealing with significant investments.

With this in mind, the Organization has adopted an Integrated Management System for Quality, Environment, Health and Safety, Energy and Anticorruption according to the standards UNI EN ISO 9001: 2015, UNI EN ISO 14001: 2015, UNI ISO 45001: 2018, UNI CEI EN ISO 50001: 2018 and UNI CEI 11352: 2014, which gives all areas the mandate to continuously and systematically improve the quality of the product / service offered, reduce the environmental impacts, pursue the prevention of pollution , ensure health and safety performance including risk reduction, improve energy performance, engage in the prevention of corruption. IVPC SERVICE S.r.l undertakes not to supply or manufacture products / services if the work activities cannot be carried out in full safety for the staff, for the environment and for the rights and dignity of people.

The competence of the staff is the basis for ensuring compliance with the requirements of the product / service.

It is therefore necessary that all personnel are always involved in the growth process which includes refresher courses, information seminars and everything that contributes to the understanding of the impact that the phases in charge of individual resources have on the overall conformity of the product / service achieved, on the safety of workers and on the state of the surrounding environment.

What we have done – the work done by the IVPC Group for safety and the results obtained

With regard to all the above discussion and the focus of the paper aimed at the problem of aging staff in the wind sector, we report below the innovative prevention activities implemented by our company and the results achieved thanks to the implementation of risk mitigation measures. Employee accident data and information on company performance were measured through rigorous registration procedures and processed also making use of standard performance indicators (KPI – Key Performance Indicator), in order to make them readable and comparable with standards of the sector (benchmarking).

The most relevant innovative activities implemented by IVPC starting from 2018 are related to advanced training, enhanced health surveillance and the use of latest generation technologies in the industrial field.

Advanced Training (Ex Standard Gwo)

The continuous training to which all IVPC employees are subjected is borrowed from the GWO standard and oriented towards continuous updating aimed at a level of involvement and awareness of the workers well beyond the minimum requirements imposed by the national legislation in force pursuant to Legislative Decree 81 / 08.

Below there is a detailed description of the significant effort that the Company makes annually to achieve the objectives set by the Company Management.

Training courseMinimum duration (hours)Course recipientsLegal requirementsRefresh rate
General training4All workersAgreement for the training of workers, pursuant to article 37, paragraph 2, of the legislative decree 9 April 2008, n ° 81Permanent training credit
Low risk specific training4Administrative clerksAgreement for the training of workers, pursuant to article 37, paragraph 2, of the legislative decree 9 April 2008, n ° 816 hours every 5 years
High risk specific training12Technical staff Technical employeesAgreement for the training of workers, pursuant to article 37, paragraph 2, of the legislative decree 9 April 2008, n ° 816 hours every 5 years
Low Risk Fire Awareness4Firefighters in officeD.M. 10/03/19982 hours every 3 years
Medium Risk Fire Awareness8Technical staffD.M. 10/03/19985 hours every 3 years
First aid course for Group A Companies12First Aid OfficersD.M. 388/20036 hours every 3 years
PES or PAV Personnel training16Technical staff working on wind turbines and / or electrical substationsCEI 11-27 ED2014not applicable
Training course for workers driving self-propelled forklifts with driver on board.12Forklift operatorsAgreement for the identification of work equipment for which specific operator qualification is required pursuant to article 73, paragraph 5 of legislative decree 81/20084 hours every 5 years
Training “Supervisor”8Personnel appointed with the appointment of a supervisorAgreement for the training of workers, pursuant to article 37, paragraph 2, of the legislative decree 9 April 2008, n ° 816 hours every 5 years
Training “Management”16Executives pursuant to Legislative Decree 81/08Agreement for the identification of work equipment for which specific operator qualification is required pursuant to article 73, paragraph 5 of legislative decree 81/20086 hours every 5 years
Work in confined spaces or environments under suspicion of pollution8Personnel carrying out work activities in confined spaces or suspected of pollution.DPR 177/20118 hours every 5 years
R.S.P.P. Module C24People appointed RSPPAgreement 128 State-Regions Conference of 201940 hours every 5 years
Workers’ safety representatives32RLS elected or designated personsD.lgs. 81/20088 hours a year
Safety trainers training24Safety teachersDecree of 6 March 2013, qualification criteria for the figure of the occupational health and safety trainer24 hours every 3 years
Fire Awareness GWO4Technical staffGWO Standard4 hours every 2 years
First Aid GWO16Technical staffGWO Standard8 hours every 2 years
Manual Handling GWO4Technical staffGWO Standard4 hours every 2 years
Working at Heights GWO16Technical staffGWO Standard8 hours every 2 years
Tab. 5 – matrix of the training protocol applied in IVPC
Health Protocol Strengthened With Stress Ecg

IVPC collaborates with a team of occupational doctors, appointed as “competent doctors” pursuant to Legislative Decree 81/08 at the various company offices and coordinated by a “coordinating competent doctor”. As part of this collaboration, the Head of the Company Prevention and Protection Service (RSPP) analyzes and discusses health surveillance plans with these doctors, which are reviewed and updated according to work variations and in the light of the accident data that occur and are recorded during the activities.

In recent years, driven by the greater attention that the Company has placed on the issue of aging staff, the occupational health service has revised the health protocol by strengthening some medical examinations and visits that are considered more effective to prevent risk of accidents, injuries and occupational diseases.

The “strengthened” sanitary protocol adopted by IVPC for all wind technicians is shown in the table below.

Medical serviceRate
Medical examination with clinical-functional evaluation of the cervical spine and attention to the stresses transmitted to the hand-arm system.half yearly
Audiometric examination and balance testshalf yearly
Spirometryhalf yearly
Normal ECG before age 45yearly
Exercise ECG over 45 years of agebiyearly
Laboratory tests also to verify the absence of an alcohol-dependent condition (complete blood count, glycemia, azotemia, cretatininemia, transaminase, QPE, urinalysis, CDT, triglycerides, gamma GT)yearly
Tetanus vaccinationdecennary
Tab. 6 – “strengthened” health protocol IVPC
Technological Aid Tools

The IVPC Group is an industrial company with a high technological content due to the very nature of its production process, based on the use of continuously evolving wind turbines and electromechanical and electronic equipment.

The culture of technological innovation has also been developed in the context of the Prevention and Protection Service, where the RSPP Manager constantly checks the state of the art and submits the use of the latest generation devices to the attention of the Company Management aimed at accidents prevention and workers protection.

Starting from 2018, the Company has given the authorization to purchase “EXOLIFT” uphill aids as already represented in the previous section “Innovative Technologies”, in order to allow technicians to reduce effort and fatigue of the cervical spine during the ascent on the turbines installed more recently and characterized by a greater height of the tubular. This of course also in view of the possibility of involving workers over 45 on these turbines.

Additional technological supports such as exoskeletons or software platforms for augmented reality are currently being evaluated in collaboration with the team of competent doctors.

Results And Kpi Analysis

The average age of the IVPC staff is 43.2 years while that of the only technical staff is 38.5, with 30 workers between 45 and 60 years old.

Since 2019, IVPC has organized 180 training sessions dedicated only to the GWO standard involving 515 profiles of participants, and also in 2020, despite the pandemic, the Company organized 438 events involving staff for 630 hours.

The main objective is that Security is seen as a strategy, and not just as mere legislative compliance, with the aim of measuring and monitoring results in a rigorous and managerial approach.

The information and data were recorded and processed in the logic of measuring the results obtained in a clear and objective way, also making use of performance indicators (KPI) necessary to verify the achievement of the strategic objectives expected by the Company Management by virtue of the actions put in place and useful for benchmarking with similar production realities and with literature data.

Below there is the matrix of information and KPIs developed by IVPC according to the strategic objectives.

Strategic targetKPI
Eliminate fatal injuries in the industrial processNumber of deaths due to accidents at workProgress of projects aimed at eliminating the causes of serious injuries (eg falls from a height, serious electrocution, investments)
Reduce psychosocial factors and improve organizational well-beingResults of analyzes of organizational climate or job satisfactionCases of work-related stress symptoms reported to the competent physician
Reduce road accidentsFrequency of road accidents per km traveledHours of road safety training per employee
Tab. 7 – IVPC Group – strategic objectives for safety and performance indicators

More generally, IVPC has perfected a list of reactive indicators, through which it monitors the accident and near misses phenomenon (recording of accidents, near misses, medications), and a list of proactive indicators used to monitor investments and efforts aimed at safeguarding safety and continuous improvement (training carried out, inspections and maintenance, etc.).

Reactive indicatorsProactive indicators
Frequency Index (number of injuries x 106 / worked hours)Severity Index (number of days lost due to injury 106 / worked hours)Incidence Index (number of injuries / number of employees)Number of reported incidents without injuriesNumber of dressings administered by healthcare personnelNumber of spillsDisease rateHours of safety training carried outProgress on projects concerning safety improvementNumber of safety-relevant inspectionsNumber of maintenance interventionsNumber of observations and security dialoguesInvestments dedicated to improving safety
Tab. 8 – IVPC Group – performance indicators

The complex measurement and monitoring system set up by the Prevention and Protection Service allows the IVPC Group to systematically monitor company performance in terms of workplace safety and changes over the years.

The first and most important result we record is the ” ZERO ” injury data from 2020 to today, unlike previous years where there was 1 injury in 2019, 5 in 2018 and 1 in 2017.

The following is the annual trend of the main injury indices of the IVPC Group.

YearFrequency IndexSeverity IndexIncidence Index
Tab. 9 – IVPC Group – injury rates
* partial data as of 09/15/2021
Fig. 16 – IVPC Group – annual accident index trend 

It is clearly recognizable from these data a progressive improvement trend which has led, after a peak in injuries in 2018, to a reduction of the same up to zero in 2020 and 2021, in a time window perfectly superimposable to the implementation by IVPC of the prevention and protection measures discussed above and implemented starting from the end of 2018.

It is interesting to see in detail the trend between worked hours and recorded injuries, comparing the 2017-2018 period prior to the implementation of risk mitigation actions versus the subsequent two-year period 2019-2020.

YearWorked hoursRecorded injuriesYearWorked hoursRecorded injuries
Tab. 10 – IVPC Group – accident monitoring before and after the implementation of risk mitigation actions

Despite the fact that in the two-year period 2019/2020 there were about 94,000 worked hours more than in 2017/2018, thanks to the measures taken, seven fewer injuries were found by a percentage decrease of 90%.

Finally, the figure for absences due to injury is also comforting, since it shows that thanks to the implementation of the above mitigation actions, the number of days lost due to injury has practically halved in the 2019-2020 two-year period compared to the previous one.

YearWorking days lost due to injuryYearWorking days lost due to injury
Tab. 11 – IVPC Group – monitoring of days lost due to injury before and afterthe implementation of risk mitigation actions


The issue of health and safety at work in the sector of installation and maintenance of wind power plants is highly topical in the industrial scenario of the moment, since the analysis of the operational phases highlights that the workers in this sector are daily exposed to a list of risk factors that must be adequately assessed and treated to ensure “safe” working conditions.

The wind industry, due to its relatively recent history, presents some safety problems that are still outstanding, related to the intrinsic characteristics of the technological systems where the technicians operate, with very different methods and conditions from those of the other working sectors metalworkers.

We have also highlighted that staff aging can increase the likelihood of risk for those companies that, born between the end of the 90s and the beginning of the new millennium, have a staff of technicians with an advanced average age.

The IVPC Group, pioneer and leader in the wind sector in Italy, is structurally committed to the search for reliable solutions to mitigate the risk to which its workers are exposed, and the Company Management has adopted a policy of involvement and collaboration with all the figures interested, from managers to the prevention and protection service head, from competent doctors to operational staff, so that effective actions can be identified and implemented.

In this work, we have presented the innovative activity carried out in the last three years by the Prevention and Protection Service of the IVPC Group, which is operating on various fronts, including: regulatory adaptation aimed at recognizing strenuous work; the implementation of an organizational model of excellence based on “reinforced” training and health surveillance protocols; the research and use of devices derived from scientific and technological progress to support operators in the most dangerous and burdensome maneuvers.

We have presented the results of our work, showing that a correct workplace safety management system, based on the application of innovative measures and on the involvement of personnel, makes it possible to significantly mitigate the risks inherent in wind activity with the consequent benefit of reducing the number of accidents. In particular, the Company data and statistics reported in this article demonstrate the effectiveness of the measures implemented and the achievement from 2020 to date of the “ZERO” injury target, which also corresponds to the significant decrease in occupational diseases and therefore in the number of lost working days.


  1. ANEV tratto da www.anev.org
  2. M. I. Barra, B. Principe, R. Maialetti, G. Tamigio – I rischi per la salute e la sicurezza dei lavoratori impegnati nella green economy: gli impianti eolici – 9° Seminario di aggiornamento dei professionisti INAIL Contarp
  3. F. P. Nigri, R. Bertucci – Turbine eoliche – analisi del rischio per l’accesso degli operatori – Rivista Ambiente&Sicurezza sul lavoro, fasc. 2, EPC, 2015.
  4. INAIL – Linee di indirizzo SGSL per l’esercizio dei parchi eolici – 2019
  5. www.globalwindsafety.org
  6. report dell’Eu-Osha sul settore: nella relazione “Occupational safety and health in the wind energy sector“
  7. IVPC Service Company Data – not to be disclosed except for the purpose of the discussion in question.

Implementation Of An Occupational Health And Safety Management System (OHSMS) For A Two-Phase Mixture Treatment Plant



Giustozzi Lorenzo1, Pieroni Catia2, Principi Massimo3, Mazzuto Giovanni4

1Doctor in Prevention Techniques in the Environment and in the Workplace - TPALL - Polytechnic University of the Marche
2Director of Educational and Professional Activities CdS TPALL - Polytechnic University of Marche
3Tutor CdS TPALL - Polytechnic University of Marche
4Researcher at the Department of Industrial Engineering and Mathematical Sciences - lecturer in Risk Prevention and Protection: Module C in the TPALL course - Polytechnic University of Marche.


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


This work focuses on the study of an experimental plant for the treatment of two-phase mixtures, on which an Occupational Health and Safety Management System (OHSMS) has been implemented, with the aim of demonstrating that the achievement of the “Total Quality” concept can be pursued through continuous improvement and effective and efficient management of Occupational Health and Safety, which are the cardinal principles of the OHSMS.

Thanks to the study of the plant, a risk assessment technique called “Fault Tree Analysis” was used to identify the main risks that could be generated during normal operation, and based on this, all the prevention and protection measures necessary to make the plant safe were planned.

The entire design of the SGSL phases is based on the Deming cycle (Plan, Do, Check, Act – planning, implementation, system monitoring, system review).

Fig.1 – Experimental plant’s model 3D

Methodologies And Materials

The methodologies and materials used for the elaboration of this work are:

  • UNI-INAIL guidelines for the design of Occupational Health and Safety Management Systems (OHSMS);
  • “PDCA cycle”, also known as the “Deming cycle”, used to structure and design the four phases of the system (planning, implementation, monitoring and review)
  • Fault Tree Analysis”, a risk assessment technique, or a symbolic representation of the plant or part of it, aimed at highlighting the interconnections between its various components, in order to trace the possible risks that could develop;
  • Report describing the installation and all its components.
Fig. 2 – PDCA Cycle, Deming cycle

Result And Discussion

The design of a OHSMS allowed the definition, through the concepts of continuous improvement and effective and efficient management of Occupational Health and Safety, of the four phases of the system. 

Phase I_Plan_Planning

The planning phase was structured starting from the definition of the objectives (table 1), then continuing with the identification of the risks (table 2) and of the related prevention and protection measures (tables 3 – 4).

Phase II_Do_Implementation

In the implementation phase all operational procedures (tables 3 – 4) were defined in order to implement and enforce the identified prevention and protection measures.

Phase III_Check_Monitoring

The monitoring phase was designed on the basis of audits, internal controls, to be carried out in order to monitor the progress of the system, through the compilation of registers in which to note objectives achieved and yet to be achieved, non-conformities found and improvements to be made, effective and ineffective measures implemented, so that with data in hand it is possible to review the system.

Phase IV_Act_Review

The OHSMS review phase will consist of reviewing all the data coming from the monitoring phase, therefore all the records produced will be compared, the OHSMS results will be analyzed, the shortcomings will be identified and, on the basis of the data collected, new objectives and new prevention and protection measures will be planned, non-conformities will be eliminated in order to pursue the objective of continuous improvement.

1.Ensure the correct operation of the plant, avoiding as far as possible dangers and risks to the health of the operators
2.To make the plant as safe as possible, eliminating or isolating the possible dangers present
3.Ensure the best possible working conditions, so as to supervise the safe operation of the installation
4.Identify all necessary modifications in order to achieve the best achievable safety level
5.Identify all necessary procedures to maintain the level of safety achieved and identify new ones for the continuous improvement of the safety conditions of the plant
Tab. 1 – OHSMS objectives
1.Ejector explosion risk1.Obstruction of the air intake duct 2.Alteration of the normal vacuum inside the ejector chamber
2.Risk of flooding of air intake duct1.Obstruction in the ejector outlet duct 2.Alteration of vacuum inside the ejector mixing chamber
3.Risk of flooding of entire plant and surrounding area1.Water outlet duct obstruction 2.Puncture of water tank or various pipes 3.Tank valve failure 4.Pump malfunction
4.Risk of tank explosion1.Obstruction of air and water outlet ducts
5.Risk of steams escaping into the air1.Tank valve faults 2.Puncture of tank and air ducts
6.Crushing risk1.Failure of bonded pipe connections, structural parts and tank
7.Risk of access to unauthorized persons1.Unsupervised access
Tab. 2 – Plant’s risks
1.Constant plant supervision1.Use of Digital Twin technology, exploiting the creation of alert signals and operating instructions and generation of signals on the 3D model, on Smart Watch 2.Use of augmented reality 3.Use of RFID TAGs on recognition tags
2.Risk management interventions and related ordinary and extraordinary maintenance1.Daily risk management interventions for the purpose of monitoring conditions and scheduling maintenance based on the results obtained from the above interventions.
3.Monitoring of tank conditions and fluid inside the tank1.Daily monitoring of the structural conditions of the tank and the fluid inside it
4.Installation of sensors for fluid detection1.Location of the sensors in the surrounding area and more importantly near the tank, so as to ventilate the environment and wear personal protective equipment (PPE) in time.
5.Installation of alarm system1.Automatic system connected to the platform, so that in the event of an alarm relating to intrusion, the siren is activated, the entrances are locked and the system stops working
Tab. 3 – Prevention’s measures
1.Installation of containment structure1.Structure to be designed in wire mesh, so that it prevents the above-mentioned risks but allows the view of the system. 2.In addition, design of automatic gates made of wire mesh to allow risk management and maintenance work.
2.Installation of water collection system1.Automatic system of pipes, manhole covers and re-pumping of water into the tank, so that its switching on is linked to flooding episodes
Use of appropriate PPE in the event of spillage of fluids into the air1. PPE should always be available and made available to operators.  Operators must be informed, trained and instructed in their use. 2. PPE should be stored in such a way as to remain intact and after each use it should be cleaned and returned to its container.
Tab. 4 – Protection’s measures

The management of critical points and deficiencies through the adoption of a cyclical organizational model has made it possible to identify a starting structure, a basis on which to adopt the necessary measures to achieve continuous improvement in health and safety at work conditions, a fundamental concept for achieving Total Quality. In conclusion, this model, which always allows the previously designed phase to be improved with the next one, through a dynamic and not static process, is the key that demonstrates how an OHSMS allows effective and efficient management of health and safety.


  1. (2012). Uni-Inail guidelines for design, implementation and enforcement of occupational health and safety management systems. Available at: https://www.inail.it > prevenzione-e-sicurezza > sgsl > uni-inail
  2. (2014). Total quality. Available at: https://www.okpedia.it > qualità_totale.
  3. Hopps, F., Enea, M., La Spisa, P., Li Causi, R., Schifano, L., & Molica Nardo, T. (2008). Il Sistema di Gestione della Sicurezza sul Lavoro (SGSL) sul modello UNI-INAIL ed il Safety Management System (SMS) in ambito aeroportuale a confronto. DE QUALITATE, 17(10), 26-36. Disponibile in: https://iris.unipa.it/retrieve/handle/10447/61927/36204/paper_SMS_SGSL.pdf
  4. Dott.Ing. Daniele Novelli (2010). Il sistema di gestione della sicurezza: cos’è, a cosa serve, i rapporti delle norme tecniche con il D.lgs. 81/08. Disponibile in: https://docplayer.it > 170073-Il-sistema-di-gestione-della-sicurezza: cos’è, a cosa serve, i rapporti delle norme tecniche con il D.Lgs. 81/08
  5. I Sistemi di gestione della sicurezza sul Lavoro. Disponibile in: https://www.gruppoalis.it > sicurezza > sistemi-di-gestione-della-sicurezza

Monitor And Sensors 2.0 For Exposure Assessment To Airborne Pollutants



Fanti Giacomo1, Borghi Francesca1, Spinazzè Andrea1, Rovelli Sabrina1, Campagnolo Davide1, Keller Marta1, Cattaneo Andrea1, Cauda Emanuele2, Cavallo Domenico Maria1

1Dipartimento di Scienza e Alta Tecnologia, Università Degli Studi dell’Insubria, Como, Italia.
2Center for Direct Reading and Sensor Technologies, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Pittsburgh, Pennsylvania, U.S.A.


Pubblication Date: 2022-11
Printed on: Publications, Online Issue


First, we want to explain the meaning of the most used word in this manuscript, in order to avoid any misunderstanding that will occur between the authors and the readers of this work. By “sensor” we mean a component that is part of an instrument which, through physicochemical properties, can translate an electrical signal into environmental concentrations of airborne pollutants. By “monitor” we mean the entire monitoring system, equipped with one or more sensors and the whole components (i.e., batteries, case, display, etc.) which allow it to perform properly. As already said, the aim of this work is to characterize, investigate and suggest some future developments regarding the so-called “next Generation Monitors and Sensors” (NGMSs), or rather the most recent sensors and monitors characterized by the miniaturization and/or by the low cost and/or by the propensity to be worn easily. Regarding the definition of “miniaturized monitors” (MMs) we refer to a previous study [8] which defined as MMs all the devices that have the highest dimension lower than 20cm. This definition can be adopted arbitrarily because in literature doesn’t exist a universal one; more generally it is possible to refer to MM as all the ones which have dimensions smaller than the traditionally used instrumentation. A category of that last ones is the one of “wearable monitors” (WMs) which are identified as all the monitors able to be worn by the subjects in order to obtain real-time data aiming the evaluation of personal exposure. Lastly, when we used the terminology “Low-Cost monitors” we refer to all that monitors which cost is about the order of magnitude of hundreds dollars or euros. 

The interest regarding the environmental and occupational exposure assessment to chemical airborne pollutants can be related to the fact that these are directly associated with a lot of adverse effects, acute and chronic both, on human health, which depends on which are the considered pollutants. The most of the population, both in the occupational and environmental fields, is continuously exposed to airborne pollutants concentrations which frequently exceeds the limits values imposed by the World Health Organization (WHO). So, it is fundamental to evaluate the human exposure to airborne pollutants, aiming to identify the emissions and manage the related risks. In order to obtain a proper evaluation of the impacts on human health, the airborne pollutants exposure, should be continuously monitored (24/7: 24 hours per day, 7 days per week), following the exposome concept. 

Traditionally used instrumentation for the monitoring of pollution levels can provide precise and accurate data but can’t characterize the single subject’s exposure in terms of spatio-temporal resolution, a fundamental aspect to obtain exposure data more reliable as possible and to approach the exposome research field. Due to these facts the development of monitors and sensors which allows measuring personal exposure in a better way it is considered essential. In the last years was been reached important goals concerning the development of innovative monitors and sensors, more and more miniaturized, user-friendly, wireless and smart contributing, in this way, in the spreading of the exposome concept in exposure assessment studies. An emerging technology that deserves to be mentioned is the “Wireless Sensor Network” (WSN) one. This technology consists of a sensors network that is able to communicate with each other and acquire information simultaneously with high spatio-temporal resolution. Given these premises, it can be argued that all these technologies can support occupational exposure assessment studies to airborne pollutants, which must fall within the context of worker health protection in order to develop preventive policies and standards. All these aspects are receiving more and more attention also in the context of occupational risk assessment, following the emerging concepts of “total worker health” and “occupational exposome”, which have numerous points in common with the issues exposed so far in this discussion, and which could certainly benefit from the introduction and development of new NGMSs that are increasingly more and more performing and reliable. The advancement of practices in conducting exposure monitoring studies must be guided by the specific needs of experts in the sector and not by the adaption of the latter based on the availability of available instrumentation. Due to this reason, starting from previous experiences and a systematic review of the most recent scientific literature, the goal of this contribution is to propose the development of a multi-parametric device for monitoring airborne pollutants. The aim is to make available to the final users, not mandatorily only experts, the most up to date sensors/monitors technologies allowing its usage also in exposure assessment studies both occupational and environmental.

Materials and Methods

Thanks to previous monitoring campaigns several criticalities concerning the type of instrumentation traditionally used to acquire airborne pollutant exposure data already emerged. To try to (i) rationalize these criticalities and (ii) identify the most appropriate sensors for the purpose defined in this work, a systematic review of the literature was set up, conducted by inserting a list of keywords in three different databases (i.e., Scopus, ISI Web of Knowledge and PubMed), selecting them from among those related to the assessment of exposure to airborne pollutants, with a look at innovation. More information on the review process can be found in Fanti et al., 2021 but some fundamental aspects will be exposed below. All the papers included in this review process have been analyzed aiming to acquire information regarding sensors used to monitor airborne pollutants concentrations. In particular, if a sensor was assembled within a multi-parameter device it was cataloged as a single sensor. Furthermore, other specifications of interest were also considered such as the use of GPS technology and the presence of sensors capable fo measuring environmental parameters such as temperature and relative humidity. In 2008, the world health organization indicated the reference values concerning the most common airborne pollutants. In this study we analyzed devices concerning the monitoring of some of the most common airborne pollutants, namely nitrogen dioxide (NO2), ozone (O3), carbon monoxide (CO), volatile organic compounds (VOC) and airborne particulate matter (PM) with an aerodynamic diameter lower than 2.5 µm (PM2.5) and lower than 10 µm (PM10) (the PM classification aims to include all those NGMSs capable of simultaneously monitoring both aerodynamic fractions investigated). The evaluation of the results emerged from the systematic review process allows identifying the available sensors on the market which most satisfy the needs of this study.

The next step has been to start to acquire and assemble the components needed to realize the “hardware side” of the project. Preliminary studies were conducted by combining what can be considered the early stage of the prototype with the instrumentation traditionally used in a context of exposure assessment in an occupational context. The prototype used in this occasion (Figure 1) was composed of a sensor for the acquisition data concerning the airborne concentrations of PM1, PM2,5, PM10 (PMS5003, Plantower), a microcontroller board (Arduino Uno by ArduinoTM) connected to a laptop via USB port to allow systems power and data display through the serial port. In order to acquire the data of interest from the sensor, the program, called Sketch, was processed through the Arduino IDE (Integrated Development Environment) software and subsequently loaded on the motherboard of the Arduino Uno board.

Fig. 1 – PMS5003 sensor plugged into Arduino Uno during the preliminary study.

In the next implementation phases, other sensors of interest will be integrated, detailed in Table 1, for the exposure assessment studies in occupational fields. A sketch will also be developed on an Arduino IDE basis, which will allow to obtain all the data necessary for the purposes of this evaluation. Once the prototype is completed, a monitoring campaign will be launched to evaluate its performance and allow the calibration of the devices.

NO2Alphasense NO2-A43FEC20,2×16,5mm48,00€
O3Alphasense OX-A431EC20,2×16,5mm50,00€
COAlphasense CO-A4EC20,2×16,5mm50,00€
PMPlantower pms5003LS38x35x12mm25,39€
Other Parameter
T–RHAosong AM2302 – DHT22CS–TH25,1×15,1×7,7mm7,99€
GCAdafruit Ultimate GPS chipGPS2,55×3,5×0,65mm55,66€
Tab. 1Pollutants and sensors of interest and other parameters (T-temperature; RH-relative humidity; GC-geographic coordinates) investigated and relative technologies (EC-electrochemical; LS-light scattering; CS-capacitive sensing; TH-thermistor; GPS-global positioning system) that will be integrated into the prototype.

Results and discussion

The scientific production regarding this field seems to constantly grow and this is supported by the fact that 66% of considered publications comes from the last 12 months. The principal results are reported hereafter and in Table 2, more information are reported in detail in Fanti et al., 2021. Regarding gaseous pollutants (NO2, O3, CO) the most used sensors are based on electrochemical principles and are the ones produced by Alphasense (www.alphasense.com; July 22th, 2021; Great Notely, Essex, UK). Regarding the sensors used to monitor VOCs concentrations, the most used in the scientific literature are the ones produced by Sensirion. Regarding the monitoring of PM the most common technology on which the devices are based is the light scattering principle and the most used sensors are the ones produced by Plantower. 

As already said, also the temperature (T) and the relative humidity (RH) have been investigated in this review because they can considerably influence the sensors abovementioned and so introduce errors on the airborne pollutants’ concentrations monitored. Moreover, regarding the GPS sensors, wasn’t been found much information except for two papers. This might be due to the fact that these sensors are affected by a high-power supply demand and so is better to acquire the GPS data from smartphones.

Tab. 2Pollutants and other parameters (T-temperature; RH-relative humidity; GC-geographic coordinates) investigated, relative NGMS used (when declared), relative technologies (EC-electrochemical; MOS-metal oxide semiconductor; LS-light scattering; CS-capacitive sensing; Th-thermistor; SBG-silicon band gap; n.a.-not available) and the number of papers in which the NGMSs were used. The monitors were marked with “*” to separate them from the sensors. More information are available in Fanti et al., 2021

A crucial role to increment the interaction between final users and devices is played using mobile apps, which allow to optimize the downloading of data from devices and their upload on cloud platforms in order to make them immediately available for analysis and processing. The most used communication technology was the bluetooth one, which more recently has been further improved in terms of energy consumption, so much so that it has been renamed Bluetooth Low-Energy technology (BLE). As argued by Kanjo et al., 2008 the use of mobile apps for data collection can bring several advantages such as (i) the fact that the vast majority of the population is already equipped with a smart-phone, (ii) many types of data can thus be processed, stored and transferred easily and (iii) as previously mentioned, the whole process is more energy efficient because the acquired information is sent directly to the smart-phone without the need for it to be saved also on the device. 

From the review of the scientific literature emerged that, to date, the usage of NGMSs is mostly spread in environmental exposure assessment studies which often adopt a “citizen science” approach to collect data. In this initial phase, these technologies are used as support tools, in addition to the traditionally used techniques, to evaluate and formulate policies and strategies for the protection of public health. On the other hand, in the occupational field, this instrumentation is not yet systematically used due to the stringent requirements from the point of view of performances (e.g., precision, accuracy, detection limit) that the policies of prevention and human health protection require. Despite this issue, some examples have emerged of how NGMSs can offer great opportunities in the field of safety and human health protection in occupational fields. The NGMSs have been used in studies in the construction sector, with the aim of mitigating the risks deriving from dangerous and physically demanding activities for workers. There are various types of bands, bracelets and watches that can monitor different physical parameters thanks to the integration, within them, of miniaturized sensors. By using these technologies in the occupational field, it is possible to influence the choices of workers, interacting with the environment around them, to reduce any risky situations to which they could be exposed. 

The data acquired by the traditional instrumentation are not made available in a short time (even if they might be useful to adopt immediate mitigation risks actions) and are, in most cases, characterized by information regarding one pollutant per device and one single work shift. In the last decades, industrial hygienists, used Direct Reading Instruments (DRI) and real-time monitors. The NGMSs can continuously monitor several risks factor simultaneously within the workplace. Moreover, they are smaller, lighter, and power efficient if compared to traditional instrumentation. This fact might be an advantage because thanks to real-time monitoring, the immediate availability of data allows preventing risky situations. In the future, once that all these information will be integrated with geo-positioning system within a workplace, (e.g., production plant, building site, and other occupational workplaces) there will be possible to obtain personal exposure of the single workers while they moving around the workspace. Furthermore, by integrating the data acquired in real-time with machine-learning models, which are able to create a system that autonomously learns to manage the acquired data, it will be possible to exponentially increase the probability of limiting or even preventing the potential risks associated with industrial activity. 

Another technology that, thanks to the increasing innovation of microprocessors, is turning out to be an important tool available to health and safety professionals in the workplace is that of Wireless Sensor Networks (WSN). WNS means a network of sensors capable of communicating with each other and with a central control system that collects all the information deriving from the various devices. By modeling this information, it will be possible to obtain plant risk maps, and consequently manage the risks arising from each individual workspace, once again with the aim of increasing safety and health protection in the workplaces. At this point it may be necessary to revise the concept of “exposure assessment” because it cannot be taken for granted that it is the most intrinsically suitable to be associated with the use of NGMSs by industrial hygienists. For example, if the NGMSs instead of being used only for monitoring purposes were also exploited to condition the behavior of workers, this would affect the assessment of the real exposure of the subject. In fact, a risk management process based on the acquisition of data in real time would be applied where the activities of workers (and therefore their exposure) vary continuously depending on the information acquired. 

Despite the various advantages they introduce, it is important to underline that NGMSs must be accurately evaluated before being deployed, especially with regard to precision and accuracy. This is due to the fact that, if compared to reference instrumentation, NGMSs are nowadays affected by an important gap regarding these aspects which, as mentioned, should not preclude their implementation. Moreover, NGMSs have been successfully combined with traditional instrumentation but have not yet been validated as alternative (or even substitute) techniques to the latter, especially for purpose of legislative compliance. For these reasons the NGMSs must be used only by applying rigorous protocols that guarantee the quality of data obtained. Considering the main advantages and disadvantages highlighted in this work, although accurate measurements are very important for monitoring environmental and occupational exposure, depending on the reason behind the monitoring, some pros may outweigh the cons. Considering the advantages and the criticalities that emerged from the systematic review of the scientific literature, to have the least impact on the routine of the mentioned subjects and to be as reliable as possible, the device that we intend to develop must necessarily be miniaturized and able to upload data to a cloud platform. In this way, the development of a dedicated Mobile App, served by Bluetooth technology, will be of fundamental importance. This use will also allow the acquisition of GPS data and therefore the georeferencing of exposure concentrations, a fundamental aspect for including the use of these technologies in risk management and behavioral modification processes. The use of increasingly advanced monitors and sensors will soon be applied, once the measurements have been validated and the wireless sensor networks (WNS) systems have been implemented, also and above all in occupational studies where the concentrations of airborne pollutants tend to be higher, the substances are more dangerous and the risks for human health are consequently greater. Considering the versatility and the wide range of application of the technologies in question, the hope is that these will be validated and used as soon as possible in the risk assessment process in the occupational field. 


The use of new technologies (NGMSs) for the environmental and occupational exposure assessment to airborne chemical agents appears to be increasingly widespread within the scientific community, alongside the use of traditional instrumentation that allows the correction of any errors of the measurements. The continuous growth of interest in this topic is a symptom of the fact that we are going in the right direction to obtain increasingly reliable and performing tools capable of being used in a wide range of studies, characterized by different experimental designs. The device that we aim to develop will be able to fill several gaps which, differently, through the use of traditional instrumentation, would negatively affect the measures and make monitoring campaigns more difficult. The main advantages of this instrumentation are the high spatio-temporal resolution of the data acquired, the possibility to interconnect the sensors building up sensors networks (WSN) and the very low impact on the daily routine of the investigated subjects. 


  1. H. Agrawaal, C. Jones, J.E. Thompson, Personal exposure estimates via portable and wireless sensing and reporting of particulate pollution, Int. J. Environ. Res. Public Health. 17 (2020) 1–15.
  2. M. Balanescu, I. Oprea, G. Suciu, M.A. Dobrea, C. Balaceanu, R.I. Ciobanu, C. Dobre, A study on data accuracy for IoT measurements of PMs concentration, Proc. – 2019 22nd Int. Conf. Control Syst. Comput. Sci. CSCS 2019. (2019) 182–187.
  3. M. Balanescu, G. Suciu, M.A. Dobrea, C. Balaceanu, R.I. Ciobanu, C. Dobre, A.C. Birdici, A. Badicu, I. Oprea, A. Pasat, An algorithm to improve data accuracy of PMs concentration measured with IoT devices, Adv. Sci. Technol. Eng. Syst. 5 (2020) 180–187.
  4. J.M. Barcelo-Ordinas, J. Garcia-Vidal, M. Doudou, S. Rodrigo-Munoz, A. Cerezo-Llavero, Calibrating low-cost air quality sensors using multiple arrays of sensors, IEEE Wirel. Commun. Netw. Conf. WCNC. 2018-April (2018) 1–6.
  5. K.K. Barkjohn, M.H. Bergin, C. Norris, J.J. Schauer, Y. Zhang, M. Black, M. Hu, J. Zhang, Using low-cost sensors to quantify the effects of air filtration on indoor and personal exposure relevant PM2.5 concentrations in Beijing, China, Aerosol Air Qual. Res. 20 (2020) 297–313.
  6. T. Becnel, K. Tingey, J. Whitaker, T. Sayahi, K. Le, P. Goffin, A. Butterfield, K. Kelly, P.E. Gaillardon, A Distributed Low-Cost Pollution Monitoring Platform, IEEE Internet Things J. 6 (2019) 10738–10748.
  7. F. Borghi, A. Spinazzè, D. Campagnolo, S. Rovelli, A. Cattaneo, D.M. Cavallo, Precision and accuracy of a direct-reading miniaturized monitor in PM 2.5 exposure assessment, Sensors (Switzerland). 18 (2018).
  8. F. Borghi, A. Spinazzè, S. Rovelli, D. Campagnolo, L. Del Buono, A. Cattaneo, D.M. Cavallo, Miniaturized monitors for assessment of exposure to air pollutants: A review, Int. J. Environ. Res. Public Health. 14 (2017).
  9. F.M.J. Bulot, S.J. Johnston, P.J. Basford, N.H.C. Easton, M. Apetroaie-Cristea, G.L. Foster, A.K.R. Morris, S.J. Cox, M. Loxham, Long-term field comparison of multiple low-cost particulate matter sensors in an outdoor urban environment, Sci. Rep. 9 (2019) 1–13.
  10. I. Campero-Jurado, S. Márquez-Sánchez, J. Quintanar-Gómez, S. Rodríguez, J.M. Corchado, Smart helmet 5.0 for industrial internet of things using artificial intelligence, Sensors (Switzerland). (2020).
  11. T. Cao, J.E. Thompson, Portable, Ambient PM2.5 Sensor for Human and/or Animal Exposure Studies, Anal. Lett. 50 (2017) 712–723.
  12. N. Castell, F.R. Dauge, P. Schneider, M. Vogt, U. Lerner, B. Fishbain, D. Broday, A. Bartonova, Can commercial low-cost sensor platforms contribute to air quality monitoring and exposure estimates?, Environ. Int. 99 (2017) 293–302.
  13. E. Cauda, M.D. Hoover, Right Sensors Used Right: A Life-cycle Approach for Real-time Monitors and Direct Reading Methodologies and Data. A Call to Action for Customers, Creators, Curators, and Analysts. | | Blogs | CDC, (2019).
  14. L. Chatzidiakou, A. Krause, O. Popoola, A. Di Antonio, M. Kellaway, Y. Han, F. Squires, T. Wang, H. Zhang, Q. Wang, Y. Fan, S. Chen, M. Hu, J. Quint, B. Barratt, F. Kelly, T. Zhu, R. Jones, Characterising low-cost sensors in highly portable platforms to quantify personal exposure in diverse environments, Atmos. Meas. Tech. 12 (2019) 4643–4657.
  15. L.-W.A. Chen, J.O. Olawepo, F. Bonanno, A. Gebreselassie, M. Zhang, Schoolchildren’s exposure to PM2.5: a student club–based air quality monitoring campaign using low-cost sensors, Air Qual. Atmos. Heal. 13 (2020) 543–551.
  16. D. Cheriyan, J.-H. Choi, Data on different sized particulate matter concentration produced from a construction activity, Data Br. 33 (2020) 106467.
  17. A.J. Cohen, H.R. Anderson, B. Ostro, K.D. Pandey, M. Krzyzanowski, N. Künzli, K. Gutschmidt, A. Pope, I. Romieu, J.M. Samet, K. Smith, The global burden of disease due to outdoor air pollution, J. Toxicol. Environ. Heal. – Part A. (2005).
  18. N. Dam, A. Ricketts, B. Catlett, J. Henriques, Wearable sensors for analyzing personal exposure to air pollution, 2017 Syst. Inf. Eng. Des. Symp. SIEDS 2017. (2017) 1–4.
  19. B. Dessimond, I. Annesi-Maesano, J.L. Pepin, S. Srairi, G. Pau, Academically produced air pollution sensors for personal exposure assessment: The canarin project, Sensors. 21 (2021) 1–18.
  20. Q. Dong, B. Li, R.S. Downen, N. Tran, E. Chorvinsky, Di.K. Pillai, M.E. Zaghloul, Z. Li, A Cloud-Connected NO2and Ozone Sensor System for Personalized Pediatric Asthma Research and Management, IEEE Sens. J. 20 (2020) 15143–15153.
  21. Z. Du, F. Tsow, D. Wang, N. Tao, A Miniaturized Particulate Matter Sensing Platform Based on CMOS Imager and Real-Time Image Processing, IEEE Sens. J. 18 (2018) 7421–7428.
  22. R.M. Duvall, R.W. Long, M.R. Beaver, K.G. Kronmiller, M.L. Wheeler, J.J. Szykman, Performance evaluation and community application of low-cost sensors for ozone and nitrogen dioxide, Sensors (Switzerland). 16 (2016).
  23. G. Fanti, F. Borghi, A. Spinazzè, S. Rovelli, D. Campagnolo, M. Keller, A. Cattaneo, E. Cauda, D.M. Cavallo, Features and Practicability of the Next-Generation Sensors and Monitors for Exposure Assessment to Airborne Pollutants: A Systematic Review, Sensors . 21 (2021).
  24. W. Fransman, Strategy for testing compliance with occupational exposure limit values, (n.d.).
  25. L.B. Frederickson, S. Lim, H.S. Russell, S. Kwiatkowski, J. Bonomaully, J.A. Schmidt, O. Hertel, I. Mudway, B. Barratt, M.S. Johnson, Monitoring excess exposure to air pollution for professional drivers in London using low-cost sensors, Atmosphere (Basel). 11 (2020) 1–18.
  26. M. Gao, J. Cao, E. Seto, A distributed network of low-cost continuous reading sensors to measure spatiotemporal variations of PM2.5 in Xi’an, China, Environ. Pollut. 199 (2015) 56–65.
  27. H. Goede, E. Kuijpers, T. Krone, M. le Feber, R. Franken, W. Fransman, J. Duyzer, A. Pronk, Future Prospects of Occupational Exposure Modelling of Substances in the Context of Time-Resolved Sensor Data, Ann. Work Expo. Heal. 65 (2021) 246–254.
  28. S. Hegde, K.T. Min, J. Moore, P. Lundrigan, N. Patwari, S. Collingwood, A. Balch, K.E. Kelly, Indoor household particulate matter measurements using a network of low-cost sensors, Aerosol Air Qual. Res. 20 (2020) 381–394.
  29. R. Huang, R. Lal, M. Qin, Y. Hu, A.G. Russell, M. Talat, S. Afrin, F. Garcia-menendez, S.M.O. Neill, Application and Evaluation of a Low-cost PM Sensor and Data Fusion with CMAQ Simulations to Quantify the Impacts of Prescribed Burning on Air Quality in Southwestern Georgia , USA Application and Evaluation of a Low-cost PM Sensor and Data Fusion with CMA, J. Air Waste Manage. Assoc. 0 (2021).
  30. J.J. Huck, J.D. Whyatt, P. Coulton, B. Davison, A. Gradinar, Combining physiological, environmental and locational sensors for citizen-oriented health applications, Environ. Monit. Assess. 189 (2017).
  31.  A. Iwawaki, Y. Otaka, R. Asami, T. Ishii, S. Kito, Y. Tamatsu, H. Aboshi, H. Saka, Comparison of air dose and operator exposure from portable X-ray units, Leg. Med. 47 (2020) 101787.
  32. C. Jiang, X. Wang, X. Li, J. Inlora, T. Wang, Q. Liu, M. Snyder, Dynamic Human Environmental Exposome Revealed by Longitudinal Personal Monitoring, Cell. 175 (2018) 277-291.e31.
  33. E. Kanjo, S. Benford, M. Paxton, A. Chamberlain, D.S. Fraser, D. Woodgate, D. Crellin, A. Woolard, MobGeoSen: Facilitating personal geosensor data collection and visualization using mobile phones, Pers. Ubiquitous Comput. (2008).
  34. M. Krzyzanowski, WHO air quality guidelines for Europe, J. Toxicol. Environ. Heal. – Part A Curr. Issues. 71 (2008) 47–50.
  35. P. Kumar, A.N. Skouloudis, M. Bell, M. Viana, M.C. Carotta, G. Biskos, L. Morawska, Real-time sensors for indoor air monitoring and challenges ahead in deploying them to urban buildings, Sci. Total Environ. 560–561 (2016) 150–159.
  36. A. Lewis, P. Edwards, Validate personal air-pollution sensors, Nature. 535 (2016) 29–31.
  37. A.C. Lewis, E. von Schneidemesser, R.E. Peltier, C. Lung, R. Jones, C. Zellweger, A. Karppinen, M. Penza, T. Dye, C. Hüglin, Z. Ning, R. Leigh, D.H. Hagan, O. Laurent, G. Carmichael, W.R. Peltier, E. von Schneidemesser, G. Lung, SC Candice and Jones, Rod and Zellweger, Christoph and Karppinen, Ari and Penza, Michele and Dye, Tim and H\”uglin, Christoph and Ning, Zhi and Leigh, Roland and Hagan, David and Laurent, Olivier and Carmichael, GregLung, SC Candice and Jones, Rod a, Low-cost sensors for the measurement of atmospheric composition: overview of topic and future applications, 2018.
  38. J. Liao, J.P. McCracken, R. Piedrahita, L. Thompson, E. Mollinedo, E. Canuz, O. De Léon, A. Díaz-Artiga, M. Johnson, M. Clark, A. Pillarisetti, K. Kearns, L. Naeher, K. Steenland, W. Checkley, J. Peel, T.F. Clasen, V. Aravindalochanan, K. Balakrishnan, D.B. Barr, V. Burrowes, D. Campbell, J.M.P. Campbell, A. Castañaza, H. Chang, Y. Chen, M. Chiang, R. Craik, M. Crocker, V. Davila-Roman, L. de las Fuentes, E. Dusabimana, L. Elon, J.G. Espinoza, I.S.P. Fuentes, S. Garg, D. Goodman, S. Gupton, S. Hartinger, S. Harvey, M. Hengstermann, P. Herrera, S. Hossen, P. Howards, L. Jaacks, S. Jabbarzadeh, A. Jones, M. Kirby, J. Kremer, M. Laws, A. Lovvorn, F. Majorin, E. McCollum, R. Meyers, J.J. Miranda, L. Moulton, K. Mukhopadhyay, A. Nambajimana, F. Ndagijimana, A. Nizam, J. de D. Ntivuguruzwa, A. Papageorghiou, N. Puttaswamy, E. Puzzolo, A. Quinn, S. Rajkumar, U. Ramakrishnan, D. Reardon, G. Rosa, J. Rosenthal, P.B. Ryan, Z. Sakas, S. Sambandam, J. Sarnat, S. Simkovich, S. Sinharoy, K.R. Smith, D. Swearing, G. Thangavel, A. Toenjes, L. Underhill, J.D. Uwizeyimana, V. Valdes, A. Verma, L. Waller, M. Warnock, K. Williams, W. Ye, B. Young, The use of bluetooth low energy Beacon systems to estimate indirect personal exposure to household air pollution, J. Expo. Sci. Environ. Epidemiol. 30 (2020) 990–1000.
  39. C. Lin, X. Xian, X. Qin, D. Wang, F. Tsow, E. Forzani, N. Tao, High Performance Colorimetric Carbon Monoxide Sensor for Continuous Personal Exposure Monitoring, ACS Sensors. 3 (2018) 327–333.
  40. M. Liu, K.K. Barkjohn, C. Norris, J.J. Schauer, J. Zhang, Y. Zhang, M. Hu, M. Bergin, Using low-cost sensors to monitor indoor, outdoor, and personal ozone concentrations in Beijing, China, Environ. Sci. Process. Impacts. 22 (2020) 131–143.
  41. S.C.C. Lung, M.C.M. Tsou, S.C. Hu, Y.H. Hsieh, W.C.V. Wang, C.K. Shui, C.H. Tan, Concurrent assessment of personal, indoor, and outdoor PM2.5 and PM1 levels and source contributions using novel low-cost sensing devices, Indoor Air. (2020) 0–2.
  42. M. Magno, V. Jelicic, K. Chikkadi, C. Roman, C. Hierold, V. Bilas, L. Benini, Low-Power Gas Sensing Using Single Walled Carbon Nano Tubes in Wearable Devices, IEEE Sens. J. 16 (2016) 8329–8337.
  43. S. Mahajan, P. Kumar, Evaluation of low-cost sensors for quantitative personal exposure monitoring, Sustain. Cities Soc. 57 (2020) 102076.
  44. K.R. Mallires, D. Wang, V.V. Tipparaju, N. Tao, Developing a Low-Cost Wearable Personal Exposure Monitor for Studying Respiratory Diseases Using Metal-Oxide Sensors, IEEE Sens. J. 19 (2019) 8252–8261.
  45. M. Mazaheri, S. Clifford, B. Yeganeh, M. Viana, V. Rizza, R. Flament, G. Buonanno, L. Morawska, Investigations into factors affecting personal exposure to particles in urban microenvironments using low-cost sensors, Environ. Int. 120 (2018) 496–504.
  46. G.R. McKercher, J.K. Vanos, Low-cost mobile air pollution monitoring in urban environments: a pilot study in Lubbock, Texas, Environ. Technol. (United Kingdom). 39 (2018) 1505–1514.
  47. M.I. Mead, O.A.M. Popoola, G.B. Stewart, P. Landshoff, M. Calleja, M. Hayes, J.J. Baldovi, M.W. McLeod, T.F. Hodgson, J. Dicks, A. Lewis, J. Cohen, R. Baron, J.R. Saffell, R.L. Jones, The use of electrochemical sensors for monitoring urban air quality in low-cost, high-density networks, Atmos. Environ. 70 (2013) 186–203.
  48. J. Núñez, Y. Wang, S. Bäumer, A. Boersma, Inline infrared chemical identification of particulate matter, Sensors (Switzerland). 20 (2020) 1–14.
  49. A.C. Rai, P. Kumar, F. Pilla, A.N. Skouloudis, S. Di Sabatino, C. Ratti, A. Yasar, D. Rickerby, End-user perspective of low-cost sensors for outdoor air pollution monitoring, Sci. Total Environ. 607–608 (2017) 691–705.
  50. S. Ruiter, E. Kuijpers, J. Saunders, J. Snawder, N. Warren, J.-P. Gorce, M. Blom, T. Krone, D. Bard, A. Pronk, E. Cauda, Exploring Evaluation Variables for Low-Cost Particulate Matter Monitors to Assess Occupational Exposure, Int. J. Environ. Res. Public Health. 17 (2020) 8602.
  51. D. Sinaga, W. Setyawati, F.Y. Cheng, S.C.C. Lung, Investigation on daily exposure to PM2.5 in Bandung city, Indonesia using low-cost sensor, J. Expo. Sci. Environ. Epidemiol. 30 (2020) 1001–1012.
  52. S.N. SM, P. Reddy Yasa, N. MV, S. Khadirnaikar, Pooja Rani, Mobile monitoring of air pollution using low cost sensors to visualize spatio-temporal variation of pollutants at urban hotspots, Sustain. Cities Soc. 44 (2019) 520–535.
  53. A. Spinazzè, G. Fanti, F. Borghi, L. Del Buono, D. Campagnolo, S. Rovelli, A. Cattaneo, D.M. Cavallo, Field comparison of instruments for exposure assessment of airborne ultrafine particles and particulate matter, Atmos. Environ. (2017).
  54. G. Suciu, A. Pasat, M. Balanescu, C. Poenaru, WINS@HI – WEARABLE TECHNOLOGIES FOR MONITORING CRITICAL SITUATIONS IN HAZARDOUS ENVIRONMENTS, in: Int. Multidiscip. Sci. GeoConference Surv. Geol. Min. Ecol. Manag. SGEM, 2020: pp. 433–438.
  55. D. Suriano, G. Cassano, M. Penza, Design and Development of a Flexible, Plug-and-Play, Cost-Effective Tool for on-Field Evaluation of Gas Sensors, J. Sensors. 2020 (2020).
  56. G.W. Thomas, S. Sousan, M. Tatum, X. Liu, C. Zuidema, M. Fitzpatrick, K.A. Koehler, T.M. Peters, Low-cost, distributed environmental monitors for factory worker health, Sensors (Switzerland). 18 (2018) 1–17.
  57. D.B. Topalović, M.D. Davidović, M. Jovanović, A. Bartonova, Z. Ristovski, M. Jovašević-Stojanović, In search of an optimal in-field calibration method of low-cost gas sensors for ambient air pollutants: Comparison of linear, multilinear and artificial neural network approaches, Atmos. Environ. 213 (2019) 640–658.
  58. J. Tryner, C. Quinn, B.C. Windom, J. Volckens, Design and evaluation of a portable PM2.5 monitor featuring a low-cost sensor in line with an active filter sampler, Environ. Sci. Process. Impacts. 21 (2019) 1403–1415.
  59. S. De Vito, F. Formisano, A. Agresta, E. Esposito, E. Massera, M. Salvato, G. Fattoruso, G. Di Francia, A crowdfunded personal air quality monitor Infrastructure for Active Life Applications, 2 (2017) 6–10.
  60. R. Wang, F. Tsow, X. Zhang, J.H. Peng, E.S. Forzani, Y. Chen, O.C. Crittenden, H. Destaillats, N. Tao, Real-time ozone detection based on a microfabricated quartz crystal tuning fork sensor, Sensors. 9 (2009) 5655–5663.
  61. T.H. Wen, J.A. Jiang, C.H. Sun, J.Y. Juang, T.S. Lin, Monitoring street-level spatial-temporal variations of carbon monoxide in urban settings using a wireless sensor network (WSN) framework, Int. J. Environ. Res. Public Health. 10 (2013) 6380–6396.
  62. S.E. West, P. Büker, M. Ashmore, G. Njoroge, N. Welden, C. Muhoza, P. Osano, J. Makau, P. Njoroge, W. Apondo, Particulate matter pollution in an informal settlement in Nairobi: Using citizen science to make the invisible visible, Appl. Geogr. 114 (2020) 102133.
  63. C.P. Wild, Complementing the Genome with an “Exposome”: The Outstanding Challenge of Environmental Exposure Measurement in Molecular Epidemiology, Cancer Epidemiol. Biomarkers Prev. 14 (2005) 1847–1850.
  64. World Health Organisation, WHO Global Ambient Air Quality Database (update 2018), Ambient Air Qual. Database (Update 2018). (2018).
  65. W.Y. Yi, K.S. Leung, Y. Leung, A modular plug-and-play sensor system for urban air pollution monitoring: Design, implementation and evaluation, Sensors (Switzerland). 18 (2018).
  66. H. Zhang, R. Srinivasan, V. Ganesan, Low cost, multi-pollutant sensing system using raspberry pi for indoor air quality monitoring, Sustain. 13 (2021) 1–15.
  67. Q. Zhang, C. An, S. Fan, S. Shi, R. Zhang, J. Zhang, Q. Li, D. Zhang, X. Hu, J. Liu, Flexible gas sensor based on graphene/ethyl cellulose nanocomposite with ultra-low strain response for volatile organic compounds rapid detection, Nanotechnology. 29 (2018).
  68. T. Zhang, S.N. Chillrud, J. Ji, Y. Chen, M. Pitiranggon, W. Li, Z. Liu, B. Yan, Comparison of PM2.5 exposure in hazy and non-hazy days in Nanjing, China, Aerosol Air Qual. Res. 17 (2017) 2235–2246.
  69. N. Zimmerman, A.A. Presto, S.P.N. Kumar, J. Gu, A. Hauryliuk, E.S. Robinson, A.L. Robinson, R. Subramanian, A machine learning calibration model using random forests to improve sensor performance for lower-cost air quality monitoring, Atmos. Meas. Tech. 11 (2018) 291–313.
  70. Y. Zou, M. Young, J. Chen, J. Liu, A. May, J.D. Clark, Examining the functional range of commercially available low-cost airborne particle sensors and consequences for monitoring of indoor air quality in residences, Indoor Air. (2019) 213–234.
  71. C. Zuidema, L. V. Stebounova, S. Sousan, A. Gray, O. Stroh, G. Thomas, T. Peters, K. Koehler, Estimating personal exposures from a multi-hazard sensor network, J. Expo. Sci. Environ. Epidemiol. 30 (2020) 1013–1022.

Smart-working VS office work: how does personal exposure to different air pollutants change?




Pubblication Date: 2022-11
Printed on: Publications


The COVID-19 pandemic is raging around the world and is likely not to end in the short term, with possible structural effects on the labor market in many countries (Baert et al., 2020). In order to limit the number of deaths and hospital admissions due to the novel coronavirus, most governments of developed countries have decided to suspend many economic activities and limit people’s freedom of mobility (Brodeur et al., 2020a, b; Qiu et al., 2020): millions of workers around the world were suddenly forced to work in smart-working mode, due to the implementations of various levels of restrictions (de Klerk et al., 2021).

In this context, the opportunity to work in this way – smart-working (WFH – Working From Home), already governed by Law no. 81/2017, has become of great importance (Acemoglu et al., 2020) as it allows (i) employees to continue working and (ii) employers to continue producing services and revenues, (iii) limiting the spread of COVID-19 and the recessive impacts of the pandemic are complex. Due to the uncertainty regarding the duration of the pandemic and future waves of contagion, the role of WFH in the labor market is further emphasized by the fact that this could become a traditional way of working in many economic sectors.

WFH is not a completely new way of working: in a research conducted in the USA and Europe (Barrot et al., 2020; Boeri et al., 2020) in fact, the results show that 40% of all work activities could be carried out from your home. Furthermore, this way of working appears to be on the rise: the annual rate of smart-workers in the United States has increased, from 9% in 1995 to 37% in 2015 (Jones et al., 2015). As reported by Birimoglu Okuyan and Begen (2020), in Europe, 5.2% of people aged 15-64 worked regularly from home in 2018 and this rate was even higher in certain countries (for example 14 % in the Netherlands, 13% in Finland, 11% in Luxembourg and 10% in Austria) (Messenger et al., 2019; Vilhelmson et al., 2016).

Problem definition and aims of the study

Due to the sudden importance and growth of WFH, several studies have recently investigated this phenomenon, in particular with the intention of identifying the number of works that can be carried out in smart-working mode (Adams-Prassl et al., 2020; Dingel and Neiman, 2020; Koren and Peto, 2020; Leibovici et al., 2020; Mongey et al., 2020), analyzing various aspects such as, but not limited to: its implications (i) on physical activity of workers (Koohsari et al., 2021), (ii) at the psychological level (Conroy et al., 2021; Wang et al., 2021) and (iii) concerning problems related to ergonomics (Reznik et al., 2021). Other studies have been conducted to (iv) analyze the advantages and disadvantages of this way of working: from the literature it emerges that organizational benefits are mainly related to the improvement of employee performance (Conradie and De Klerk, 2019; Lee, 2018; Rudolph and Baltes, 2017), the reduction of absenteeism (Schaufeli, 2013), the improvement of financial returns and the organizational effectiveness of workers (Khodakarami and Dirani, 2020). The disadvantages are related, for example, to social isolation and reduced employee involvement (Vander Elst et al., 2017; Sardeshmukh, Sharma and Golden, 2012).

To date, to the knowledge of the authors, no studies have yet been conducted that consider the differences between the conditions of WFH and WFO (Working From Office), in terms of assessing personal exposure to different air pollutants. This aspect should be of particular interest as exposure to selected air pollutants in the domestic context represents a significant proportion of the total personal exposure of the population (Raw et al., 2004).

In particular, for a comprehensive and fully representative health impact assessment, human exposure to air pollutants should ideally be assessed as a whole, following the concept of the exposome. The concept of exposome concerns the assessment of exposure in its entirety, deriving from a variety of both internal and external sources (chemical and biological agents) (Wild, 2005).

In recent years, several technological developments have been recognized as useful enhancements for personal exposure studies. For example, portable and real-time monitors, increasingly miniaturized, can provide data concentration to selected pollutants characterized by high spatial and temporal resolution (Borghi et al., 2017). Thanks to this instrumentation it is therefore possible to investigate, in addition to the concentrations of personal exposure to a given pollutant, also other useful aspects in the context of exposomics, such as (i) the position of the monitored subject at a given time, (ii) his daily activities and his (iii) lifestyle.

This study therefore aims to evaluate, through portable and real-time monitors, personal exposure to selected atmospheric pollutants (different fractions of PM – particulate matter), during different working conditions (WFO and WFH), for relatively long periods of time (days and weeks), with the assumption of extending the results to even longer periods of time (months, seasons, years), in order to adhere to the approach proposed by the concept of the exposome.

Materials and Methods

Study design

To investigate the differences, in terms of personal exposure to selected atmospheric pollutants in different working conditions, two different measurement campaigns are planned, a “long term” and a “short term” campaign. The “long-term” campaign involves the measurement of different PM fractions (PM1, PM2.5, PM4, PM10 and TSP – total suspended particles), through the use of portable direct-reading instruments (Aerocet 831, Met One Instruments – 1 data per minute). The measurements will be performed in two different seasons (summer and winter) for two consecutive weeks. The data relating to exposure concentrations will be acquired simultaneously from one subject in WFH conditions for 24 hours a day, and from a second subject in WFO conditions for 8 working hours, including in the monitoring period also the important moment of commuting from home to work and back.

The “short-term” campaign involves the analysis of different concentrations of PM (PM1, PM2.5, PM4, PM10 and TSP), using the same instrumentation previously described. In this case, at least 50 subjects will be enrolled, who will carry out two consecutive monitoring days (one in WFO conditions and one in WFH conditions).

The “short term” campaign will last 12 months, in order to carry out monitoring during different seasons and environmental conditions. In both campaigns, the various subjects will be provided with an activity diary, with the aim of correlating the activities carried out by the enrolled subjects (e.g., meal preparation, commuting, exposure to passive smoking) with the measured exposure concentrations.

Data quality

The data obtained from direct-reading instruments are characterized by an intrinsic error of the measurement (Spinazzè et al., 2017). For this reason, data quality verification campaigns are programmed, to (i) quantify the error associated with the instrumentation used and (ii) correct the data obtained from the instrumentation. In particular, during the two weeks of monitoring of the “long-term” campaign, for one day a week (10 h/day), the direct-reading instruments will be placed side by side with a reference gravimetric instrument (Harvard Impactor – HI; operating at a flow rate of 10 L/min). The PM2.5 mass sampled by the gravimetric technique will be collected on a PTFE substrate, diameter: 37 mm; porosity: 2 µm (Marple et al., 1987)): in this way it will be possible to calculate a ratio between the concentrations of PM2.5 measured by the two different techniques (gravimetric and direct-reading), applicable as a posterior correction factor on the data acquired continuously by the direct-reading instrument. The correction factors will be calculated separately for the two environments under study (home and office), in order to apply an ad hoc a posteriori correction factor (Spinazzè et al., 2017). This procedure will also be performed monthly during the “short term” monitoring campaign: during this measurement campaign, instrumentation precision tests will also be carried out on a monthly basis.

Statistical analysis

After a first descriptive analysis, the data will be analyzed with appropriate statistical tests to (i) quantitatively evaluate the differences in terms of personal exposure between the two working conditions (Student’s T-test/Mann Whitney’s U-test) and for (ii) assess which activities contribute most to the daily exposure of the two types of workers (e.g., commuting, meal preparation), through a sensitivity analysis.

The daily data obtained from the “long-term” and “short-term” monitoring campaigns will then be used in a (iii) Monte Carlo simulation, following what is reported by the scientific literature (Spinazzè et al., 2014). Finally, for each subject recruited in the “short-term” campaign, the daily intake (CDI – Chronic Daily Intake, mg/kg day) of each pollutant will be calculated, such as:

CDI=Mean exposure concentration ×Inhalation rate ×Absorption fractionBody weight

where the inhalation rate and body weight are commonly assumed to be 20 m3/day and 70 kg (Morawska et al., 2013).

Problems and solutions

As mentioned, a problem encountered within this project mainly concerns the quality of the data obtained from the direct-reading instrumentation that will be used for the assessment of personal exposure. This problem can be solved by using (i) a correction factor applied a posteriori on the entire dataset, calculated ad hoc within the instruments comparison/validation sessions and (ii) by performing regular (monthly) precision tests between the different instruments used.

Another problem could be related to the large amount of data needed to obtain robust results, especially for the “short term” campaign. In fact, from a statistical power analysis performed a priori, the number of subjects to be enrolled should vary between 73 and 53, respectively for a power of 0.90 and 0.80 (1-β err. Prob.). For this reason, the recruitment phase of the subjects will be carefully planned, to foresee personal measures in the different seasons of the year. If the expected subjects are not reached, the subjects enrolled in the early stages of the project (summer 2021) can be asked to repeat the monitoring in the following months (winter 2021-22).

Preliminary Results and Discussions

Some exploratory analyzes and measurements were carried out: the main preliminary results are reported below. Firstly, the data obtained from the literature were reviewed (Paragraph 3.1.): these data seem to be in contrast with the preliminary measurements carried out according to the study design previously described (Paragraphs 3.2. and 3.3.). For this reason, the aforementioned monitoring campaigns should be conducted (i) in a structured and in-depth way, as described above and (ii) on a large number of cases (N> 50). Table 1 summarizes the preliminary analyzes carried out (reported in this work) and those planned.

StudyExecutionCompleted analyzesFuture analyzesPreliminary results
Literature elaborationsMarch 2021Monte Carlo simulationSensitivity analysisExpo. WFO > Expo. WFH
“Long term” monitoring campaignJune 2021; November 2021Evaluation of the differences between exposure in WFO and WFH conditions (summer campaign; June 2021).Evaluation of the differences between exposure in WFO and WFH conditions (winter campaign; November 2021);   Evaluation of the contribution of the different activities to the total daily exposure, during WFO and WFH;   Monte Carlo simulation;   Calculation of the daily intake, for the different PM fractions considered.Expo. WFO < Expo. WFH
“Short term” monitoring campaignJune 2021 – June 2022Evaluation of the differences between exposure in WFO and WFH conditions (N = 5 subjects).Evaluation of the differences between exposure in WFO and WFH conditions (> 50 subjects);   Evaluation of the contribution of the different activities to the total daily exposure, during WFO and WFH;   Monte Carlo simulation;   Calculation of the daily intake, for the different PM fractions considered.Expo. WFO < Expo. WFH
Tab. 1 Summary of the preliminary analyzes performed (and reported in this work) and those planned. Expo.: exposure to different fractions of PM.
Literature analysis

Using the literature data concerning (i) the use of time of different categories of subjects (males/females and employed/students) (Spinazzè et al., 2014) and (ii) the exposure concentration levels to different fractions of PM (PM1, PM2.5 and PM10) in different environments (office, home and means of transport) in different seasons (summer/winter) (Borghi et al., 2020; Mandin et al., 2017; Rovelli et al., 2014), through a Monte Carlo simulation (Spinazzè et al., 2014) the daily exposure was calculated for the different categories of subjects investigated in different working conditions (WFO and WFH).

The main results of this work show how, in all WFO situations (in terms of season, gender and type of worker – employee or student), the median values ​​of the concentrations of the various PM fractions considered are significantly higher than those associated with a WFH situation (via Mann-Whitney test) (Figure I). The results of this preliminary study show that working from home exposes, probably due to the lack of exposure to traffic-related pollutants during commuting, to PM concentrations lower than those found in a typical office working day. However, it is important to underline that this analysis is to be considered purely indicative as it is characterized by an intrinsic error. As mentioned, in fact, for the purposes of the simulation simplifications and assumptions were necessarily introduced, and the concentration data used for the simulation were obtained from different studies, conducted in a non-contextual manner, therefore not directly comparable with each other.

Fig. 1 – Boxplot concerning the average daily exposure concentrations (µg/m3) estimated for PM1, PM2.5 and PM10 in different situations. The data obtained during the WFH condition are shown in yellow, the data obtained during the WFO condition in blue, divided by status (employee/student), season (summer/winter) and gender (male/female). The extremes of the boxplots represent the first and third quartiles, the black line the median.
Short-term campaign

Preliminary results conducted on a limited number of subjects (N = 5) enrolled in the “short term” campaign indicate that, on average, the levels of exposure to the different PM fractions are higher during the WFH work mode (Table 2). In particular, the WFH/WFO ratios calculated on the different PM fractions are on average equal to 2.4, thus indicating concentrations measured in smart-working conditions twice higher than those measured in the office. Furthermore, the differences in terms of median exposure concentrations measured during the two working conditions are statistically significant (Mann-Whitney U test; p <0.001 for all PM fractions).

Tab. 2 Descriptive statistics of the exposure concentrations (µg/m3) to the different PM fractions measured during the WFO and WFH condition. Min.: minimum; Max.: maximum; S.D.: standard deviation.

Long-term campaign

The preliminary results of the first “long-term” monitoring campaign, conducted in June 2021 (N days WFO = 10; N days WFH = 14; N WFO data > 8,000; N WFH data > 20,000), show how, on average, the exposure levels to the different PM fractions are higher during the WFH work mode (Table 3 and Figure II). More in detail, the ratio between the exposure concentrations measured at home and those measured in the office was equal to 1.87 (min.: 1.6; max.: 2.1), indicating a higher concentration of exposure in the domestic environment. The differences in terms of median exposure concentrations measured during the two working conditions are statistically significant (Mann Whitney’s U test; p <0.001 for all PM fractions). 

Tab. 3 Descriptive statistics of the exposure concentrations (µg/m3) to the different PM fractions measured during the WFO and WFH condition. Min.: minimum; Max.: maximum; S.D.: standard deviation.
Fig. 2 – Boxplot concerning the exposure concentrations (µg/m3) measured for PM1, PM2.5, PM4, PM10 and TSP in different situations. The data obtained during the WFH condition are shown in yellow, the data obtained during the WFO condition in blue. The extremes of the boxplots represent the first and third quartiles, the black line the median.


Advantages and disadvantages

The strengths of this project mainly relate to the fact that, to the knowledge of the authors, no studies have yet been carried out that consider the differences between WFO and WFH conditions, in terms of exposure assessment to different airborne pollutants. This aspect could become of particular interest as, as mentioned, the way of working from home will probably become more and more widespread: the assessment of personal exposure to selected air pollutants could therefore be used to support the choice of the best remote workplace. A second strength of this study refers to the assessment of “long-term” exposure (days/weeks) to air pollutants, intending to extend the results to even longer periods of time (months, seasons, years), to comply to the approach proposed by the concept of exposome.

The limitations of this study are mainly related to the quality of the data obtained through direct-reading instruments, characterized by an intrinsic error of the measurement and by the large number of data necessary to obtain robust results.

Future developments

As described, the monitoring campaigns will mainly be based on the measurement and assessment of personal exposure to different PM fractions, as particulate matter is considered (i) ubiquitous in urban and indoor environments and (ii) identified as one of the “criteria pollutants”, pollutants of great interest for their effects on human health and the environment (EPA).

However, as widely described in the scientific literature (Nandan et al., 2021), other airborne pollutants can come from very different sources: some of the pollution sources can be related, for example to (i) building materials, ( ii) sealants, (iii) cleaning products, (iv) tobacco smoke, (v) household activities, such as preparing meals and (vi) issuing certain appliances such as printers and copiers, as well as (vii) various external sources (such as vehicular traffic, etc.). For these reasons, further developments of this study could concern the analysis of other pollutants. Particular attention should be paid to the measurement and assessment of personal exposure to ozone, carbon and sulfur oxides and heavy metals, as well as semivolatile organic compounds (SVOCs) and volatile organic compounds (VOCs) such as benzene, toluene, xylene and formaldehyde.


  1. Acemoglu, D., Chernozhukov, V., Werning, I. & Whinston, M.D. (2020). A multi-risk SIR model with optimally targeted lockdown. NBER working paper, 27102.
  2. Adams-Prassl, A., Boneva, T., Golin, M. & Rauh, C. (2020). Inequality in the impact of the coronavirus shock: evidence from real time surveys. IZA Discussion Paper, 13183.
  3. Baert, S., Lippens, L., Moens, E., Sterkens, P. & Weytjens, J. (2020). How do we think the COVID-19 crisis will affect our careers (if any remain)?. GLO Discussion Paper, 520, Global Labor Organization (GLO), Essen.
  4. Barrot, J.N., Basile, G. & Sauvagnat, J. (2020). Sectoral effects of social distancing. Covid Economics, Centre for Economic Policy Research, 3, 85–102.
  5. Birimoglu Okuyan, C. & Begen, M.A. (2021). Working from home during the COVID-19 pandemic, its effects on health, and recommendations: The pandemic and beyond. Perspectives in psychiatric care, 1-7. 
  6. Boeri, T., Caiumi, A. & Paccagnella, M. (2020). Mitigating the work-security trade-off. CEPR Press. Covid Economics, 2, 60–66.
  7. Borghi, F., Spinazzè, A., Fanti, G., Campagnolo, D., Rovelli, S., Keller, M., Cattaneo, A. & Cavallo, D.M. (2020). Commuters’ Personal Exposure Assessment and Evaluation of Inhaled Dose to Different Atmospheric Pollutants. Int. J. Environ. Res. Public Health, 17, 3357. 
  8. Borghi, F., Spinazzè, A., Campagnolo, D., Rovelli, S., Cattaneo, A. & Cavallo, D.M. (2018). Precision and Accuracy of a Direct-Reading Miniaturized Monitor in PM2.5 Exposure Assessment. Sensors, 18, 3089. 
  9. Borghi, F., Spinazzè, A., Rovelli, S., Campagnolo, D., Del Buono, L., Cattaneo, A. & Cavallo, D.M. (2017). Miniaturized Monitors for Assessment of Exposure to Air Pollutants: A Review. International Journal of Environmental Research and Public Health, 14, 8, 909.
  10. Brodeur, A., Gray, D., Islam, A. & Bhuiyan Suraiya, J. (2020a). A literature review of the economics of COVID-19. GLO Discussion Paper, 601, Global Labor Organization (GLO), Essen.
  11. Brodeur, A., Grigoryeva, I., Kattan, L. (2020b). Stay-at-home orders, social distancing and trust. Global Labor Organization Discussion Paper, 553.
  12. Conradie, W.J., & De Klerk, J.J. (2019). To flex or not to flex? Flexible work arrangements amongst software developers in an emerging economy. SA Journal of Human Resource Management/SA Tydskrif vir Menslikehulpbronbestuur, 17(0), 1175. 
  13. Legge 22 maggio 2017 n. 81. Misure per la tutela del lavoro autonomo non imprenditoriale e misure volte a favorire l’articolazione flessibile nei tempi e nei luoghi del lavoro subordinato.
  14. Moreira, A., MacKenzie, C., Swanson, L.M., Burgess,H.J., Arnedt, J.T. & Goldstein,C.A. (2021). The effects of COVID-19 stay-at-home order on sleep, health, and working patterns: a survey study of US health workers. J Clin Sleep Med., 17, 2, 185–191.
  15. de Klerk J.J., Joubert, M. & Mosca, H.F. (2021). Is working from home the new workplace panacea? Lessons from the COVID-19 pandemic for the future world of work. SA Journal of Industrial Psychology, 47, 1883.
  16. Dingel, J., & Neiman, B. (2020). How many jobs can be done at home? National Bureau of Economic Research, 26948.
  17. EPA. Criteria Air Pollutants. Disponibile a: https://www.epa.gov/criteria-air-pollutants (ultimo accesso: agosto 2021).
  18. Jones, F (2015). In U.S., Telecommuting for Work Climbs to 37%. U.S., Telecommuting for Work Climbsto.
  19. Khodakarami, N. & Dirani, K. (2020), Drivers of employee engagement: differences by work area and gender. Industrial and Commercial Training, 52, 1, 81-91. 
  20. Koohsari, M.J., Nakaya, T., Shibata, A., Ishii, K. & Oka, K. (2021). Working from Home After the COVID-19 Pandemic: Do Company Employees Sit More and Move Less? Sustainability, 13, 939. 
  21. Koren, M. & Peto, R. (2020). Business disruptions from social distancing.Covid Economics, 2, 13-31.
  22. Lee, A.M. (2018). An Exploratory Case Study of How Remote Employees Experience Workplace Engagement. PhD dissertations, Walden University. 
  23. Leibovici, F., Santacrue, A.M. & Famiglietti, M. (2020). Social distancing and contact-intensive occupations. March: St. Louis Federal Reserve Bank – On the Economy Blog.
  24. Mandin, C., Trantallidi, M., Cattaneo, A., Canha, N., Mihucz, V.G., Szigeti, T., Mabilia, R., Perreca, E., Spinazzè, A., Fossati, S., De Kluizenaar, Y., Cornelissen, E., Sakellaris, I., Saraga, D., Hänninen, O., De Oliveira Fernandes, E., Ventura, G., Wolkoff, P., Carrer, P. & Bartzis, J. (2017). Assessment of indoor air quality in office buildings across Europe – The OFFICAIR study. Sci Total Environ. 1, 579, 169-178.
  25. Marple, V.A., Rubow, K.L., Turner, W. & Spengler, J.D. (1987). Low Flow Rate Sharp Cut Impactors for Indoor Air Sampling: Design and Calibration). JAPCA, 37:11, 1303-1307.
  26. Messenger, J. (2019). Working time and the future of work. European Union and the International Labour Office. 
  27. Mongey, S., Pilossoph, L. & Weinberg, A. (2020). Which workers bear the burden od social distancing?. NBER Working Paper, 27085.
  28. Morawska, L., Afshari, A., Bae, G.N., Buonanno, G., Chao, C.Y., Hänninen, O., Hofmann, W., Isaxon, C., Jayaratne, E.R., Pasanen, P., Salthammer, T., Waring, M. & Wierzbicka, A. (2013). Indoor aerosols: from personal exposure to risk assessment. Indoor Air, 23, 6, 462-87
  29. Nandan, A., Siddiqui, N.A., Singh, C. & Aeri, A. (2021). Occupational and environmental impacts of indoor air pollutant for different occupancy: a review. Toxicol. Environ. Health Sci., 
  30. Qiu, Y., Chen, X. & Shi, W. (2019). Impacts of social and economic factors on the transmission of coronavirus disease 2019 (COVID-19) in China. J Popul Econ., 1127–1172. 
  31. Reznik, J., Hungerford, C., Kornhaber, R. & Michelle Cleary. (2021). Home-Based Work and Ergonomics: Physical and Psychosocial Considerations. Issues in Mental Health Nursing. 
  32. Rovelli, S., Cattaneo, A., Nuzzi, C.P., Spinazzè, A., Piazza, S., Carrer, P. & Cavallo, D.M. (2014). Airborne Particulate Matter in School Classrooms of Northern Italy. Int. J. Environ. Res. Public Health, 11, 1398-1421. 
  33. Rudolph, C. W. & Baltes, B. B. (2017). Age and health jointly moderate the influence of flexible work arrangements on work engagement: Evidence from two empirical studies. Journal of Occupational Health Psychology, 22, 1, 40–58.
  34. Sardeshmukh, S.R., Sharma, D. & Golden, T.D. (2012). Impact of telework on exhaustion and job engagement: a job demands and job resources model. New Technology, Work and Employment, 27, 3, 193-207.
  35. Schaufeli, W.B. (2013). What is engagement?. Employee engagement in theory and practice, 15–36.
  36. Spinazzè, A., Cattaneo, A., Peruzzo, C. & Cavallo, D.M. (2014). Modeling Population Exposure to Ultrafine Particles in a Major Italian Urban Area. Int. J. Environ. Res. Public Health, 11, 10641-10662. 
  37. Spinazzè, A., Fanti, G., Borghi, F., Del Buono, L., Campagnolo, D., Rovelli, S., Cattaneo, A. & Cavallo, D.M. (2017). Field comparison of instruments for exposure assessment of airborne ultrafine particles and particulate matter. Atmos. Environ., 154, 274–284.
  38. Vander, E.T., Verhoogen, R., Sercu, M., Van den Broeck, A., Baillien, E., Godderis, L. (2017). Not Extent of Telecommuting, But Job Characteristics as Proximal Predictors of Work-Related Well-Being. Journal of Occupational and Environmental Medicine, 59(10), 180–186. 
  39. Vilhelmson, B. & Thulin, E. (2016). Who and where are the flexible workers? Exploring the current diffusion of telework in Sweden. New Technology, Work and Employment, 31, 1, 77‐96.
  40. Wang, B., Liu, Y., Qiuan, J. & Parker, S.K. (2021). Achieving Effective Remote Working During the COVID-19 Pandemic: A Work Design Perspective. Applied psychology: an international review, 70, 1, 16-59. 
  41. Wild, C.P. (2005). Complementing the Genome with an “Exposome”: The Outstanding Challenge of Environmental Exposure Measurement in Molecular Epidemiology. Cancer Epidemiol. Biomarkers Prev., 14, 1847–1850.

Effects Of Smartworking On Productivity And Personal And Job Wellbeing In A Sample Of Employees Of The University Of L’aquila



D'Onofrio Simona1, Di Benedetto Pietro2, Guerriero Paola1, Mastrodomenico Marianna1, Mastrangeli Giada1, Di Staso Federico1, Vittorini Pierpaolo1, Tobia Loreta1, Fabiani Leila1

1Department of Life, Health and Environmental Sciences. University of L’Aquila
2University of L’Aquila


Pubblication Date: 2022-11
Printed on: Publications, Online Issue


The recent Covid-19 pandemic emergency and the consequent urgency to contain the spread of the virus by limiting interpersonal contacts, made it necessary to adopt new organizational models in workplace, including the massive use of smartworking. Although in 2017 was enacted a legislative degree (D.Lgs. 22 May 2017, n.81) in order to promote its diffusion, smartworking was not widespread in Italy during the prepandemic period, with only about 4.8% of workers involved During the lockdown almost 70% of Italian workers adopted remote work, while it is estimated that about 81% of workers all over the world have changed work setting [Eurostat. 2020].  Several Authors have focused on smartworking effects on psychophysical health, family and personal well-being and working efficiency. (Cuerdo-Vilches t., 2021, Ghisleri C, 2021, Parent-Lamarche A., 2021). Previous studies results are not always concordant. The most reported advantages are the reduction of travel times, the increase of staff motivation and productivity, a greater ability to respect deadlines, while the difficulty in monitoring the performance, the possible onset of communication problems between colleagues and the absence of ergonomic devices at home, with an increased possibility of musculoskeletal symptoms, the most critical points [Baker R., 2018; Côté P. 2008; Pillastrini P. 2009; Will J.S., 2018]. Some Authors pointed out a greater possibility to experience psychological symptoms such as anxiety, irritability and isolation with negative repercussions on personal well-being [Kotera Y., 2020; Grant C.A., 2013]; other on the contrary, reported a reduction in perceived stress and a  better concentration [Hilbrecht M., 2008; Vittersø J., 2003]. There is not unanimous consensus even regarding the effects that remote work would produce on family life. Some studies reported positive effects, also in relation to the possibility of remote workers to take care more closely of relatives that need assistance, while according to other Authors smartworking would lead to an imbalance between family and professional life, with an overlap of the two areas, and difficulty to effectively manage both [Hartig T., 2007; Mann S., 2003; Nakrošienė A., 2017]. The University of L’Aquila, as early as March 2020, suspended almost all teaching and curricular activities in presence, adopting “remote” attendance models and organizing the administrative activities in “remote” mode. The University had already conceived, in 2018, a pilot project for the gradual introduction of agile work  which had involved a group of employees. This project aimed to propose a work model based on a result-oriented organization, with a large degree of decision-making autonomy of the workers on the methods, times and places of carrying out his / her work activity, and on the management’s ability to organize activities and check its progress according to targets. With the Covid 19 pandemic emergency, special rules were then introduced for agile work valid for all staff, with the aim of protecting the health of workers, by limiting interpersonal contacts and travels. Although the purposes of emergency agile work transcends those of the traditional smartworking (organizational improvement and work / life balance of employees), this experience had led to the establishment of an unusual working context. The works that refer to the university setting are extremely limited in Literature (Cupertino F., 2021).


The purpose of our survey is to monitor the impact of smartworking in terms of perceived productivity, and personal and working well-being among the employees of the University of L’Aquila. Differences between men and women and between the two different groups of University workers were also investigated 

Materials and Method

All employees were invited to participate with an email. The questionnaire, consisting of 24 multiple choice questions, was developed following a model already used in 2018 by the Italian Ministry of Education, University and Research in a pilot study.   Participation was free and voluntary. Socio-demographic and occupational informations were collected together with data on aspects characterizing smartworking. The survey took place between February 19 and March 11, 2021.

Data analysis

Data was analysed by RStudio software. We considered as variables gender (women / men) and job (administrative staff and professors). Normality was verified by Shapiro-Wilk test. Kruskal-Wallis test was used for statistical significance and for comparisons between couples, when necessary. Differences were estimated to be significant for p values ​​<0.05.

Results and discussions

Socio-demographic data and family situation

A total of 510 employees of which 245 men (48%) and 265 women (52%) took part in the survey, out of 919 subjects involved, with a participation rate of 55,5%. 1 subject was <30 years, 49 between 30 and 39 years, 110 between 40 and 49 years, 226 between 50 and 59 years, 124 > 60 years. 70.6% of employees reported having one or more children; 129 employees (25.3%) reported the presence at home of people in need of assistance. 388 (76.1%) and 106 (20.7%) were respectevely University and High School graduated. 247 employees (48.5%) were professors, 228 (44.7%) belonged to administrative staff (147 women and 81 men); 31 (6.8%) did not declare their job (15 women and 16 men).

Smartworking experience

Almost all of the employees (478, corresponding to 94.7%) declared that they had worked at home, 184 (37%) used a supplied pc, 241 (49%) their own pc and 71 (14%) their own pc sharing documents on cloud space.

Perceived work intensity

Work intensity was perceived increased by 73.6% professors (77% women vs 70.1% man) and by 60% of administrative employees (64.1 % women vs  51.3% men) with  statistically significant differences between jobs (professors vs administrative staff, p = 0.012109) but not between women and men (F vs M, p = 0.146327). 

Flexibility and working hours

70.1% professors (73.7% women vs 68.7% of men) and 58.5% administrative employees (63.7%  women vs 47.5% of men) declared that agile work led them to work more hours than usual with a statistically significant difference between genders (p = 0.0198122) and jobs (p = 0.023132). The largest differences could be observed between the subgroups of female teachers and male administrative employees (p = 0.00698) and between male teachers and male administrative employees (p = 0.019903). Over 30% of the total sample declared that it was not possible for them to take adequate breaks, given the intensity of the work.

Effect of agile work on different aspects of working life

Results are reported in Tab. 1. and Tab.2.

PROFESSORSPositive ImpactNo ImpactNegative impact
Efficiency / ability to achieve objectives in adequate time95 (39%)99 (40%)50 (21%)
Ability to take initiatives and propose solutions71(29%)130 (53%)42 (18%)
Relationships with colleagues15 (5%)95 (39%)131(55%)
Relationship with the manager / boss12 (4%)184 (77%)44 (19%)
Dynamics and team working efficiency55 (23%)88 (36%)99 (41%)
Participation in decision making33 (14%)143 (59%)65 (27%)
Tab.1 – Effects of smartworking on different aspects of working life-Professors
ADMINISTRATIVE STAFFPositive ImpactNo ImpactNegative impact
Efficienza/capacita’ di raggiungere gli obiettivi in tempi adeguati111(49%)82 (37%)32 (14%)
Efficiency / ability to achieve objectives in adequate time100 (45%)104 (46%)19 (9%)
Ability to take initiatives and propose solutions48 (21%)109 (49%)66 (30%)
Relationships with colleagues54 (24%)139 (62%)29 (14%)
Relationship with the manager / boss84 (38%)89 (39%)51 (23%)
Dynamics and team working efficiency67 (31%)129 (57%)28 (12%)
Participation in decision making
Tab. 2 – Effects of smartworking on different aspects of working life-Administrative staff

No statistically significant differences were found for the items “efficiency / ability to achieve goals in adequate times” and “ability to take initiatives and propose solutions”. According to 55% professors, smartworking negatively affected the relationship with colleagues vs 30% of administrative staff, with a statistically significant difference (p = 0.02098), particularly evident between female professors vs female administrative employees (p = 3.5e -05), male professors vs female administrative employees (p = 0), male professors and male administrative employees (p = 0.014102). A significant difference between the two groups of workers (p = 8.35e-06) was also found with regard to the effects on the “relationship with the manager / boss”, with the subgroup of female employees reporting the more positive effect (female professors vs female administrative staff (p = 0.001921); male professors vs female administrative staff (p = 0.000359)). Teachers and administrative staff also reported statistically different opinions on the “dynamics and efficiency of team working” (p = 0.0008411), particularly evident in the comparison between female employees respectevely with both female professors (p = 0.00603) and male ones (p = 0.003621). For “participation in the decision-making process”, the subgroup analysis highlighted differences in all the comparisons performed (female teachers vs female administrative staff (p = 0.00661), female teachers vs male administrative staff ( p = 0.027549), male teachers vs female administrative staff (p = 0.000524) and male teachers vs male administrative staff (p = 0.005738)).

Interaction and collaboration with other subjects. 

Almost all of the employees stated  they have continued to interact with colleagues, with the manager and with other team-working members. Only 19 (3.8%) reported having not had interactions or collaborations with other subjects.

Help and support from colleagues.

Table 3. reports the answers provided by the two groups of workers.

Never20 (8,2%)15 (6,6%)35 (7,5%)
Rarely38 (15,6%)26 (11,5%)64 (13,6%)
Sometimes102 (41,8%)83 (36,7%)205 (43,5%)
Often61 (25%)60 (13,6%)121 (25,7%)
Always or almost always23 (9,4%)42 (18,6%)55 (11,7%)
Tab.3 – Help and support from colleagues
Working in agile mode has allowed you to …?

We asked employees to indicate what working at home allowed them to do. Each employee could choose up to 3, among 8 possible options. The results are reported in the table below 

Tab. 4 – “Working in agile mode has allowed you to…?”
Interest in continuing with smartworking

The most of the employees (56,1%) declared to be interested in continuing with the agile work experience vs 20, 4% not interested and 23,5% uncertain (Tab. 5, Graphs G1., G2.) 

Interessed49,5%49%49,2%65,1%61,8%63,9%57,3%55,1%%56,1 %
Not interessed25,5%26,1%25,8%13,4%16%14,1%18,7%21,720,4%
Tab. 5 – Interest in continuing with smartworking
Tab. 6 – G1. Interest in continuing with smartworking- Professors  G2. Interest in continuing with smartworking- Administrative Staff

Statistical differences were appreciated between teaching staff and administrative staff (p = 0.000721) but not between men and women, (p = 0.2828). Female administrative employees was the most positively inclined subgroup especially in comparison with male teachers (p = 0.022733), the most wary of this possibility. Evaluating the presence of people who need assistance at home, no differences were found between employees who declared presence and those didn’t (p = 0.4918).

Reported advantages with regard of working and personal well-being.

Each employee classified six possible options related to plausible adavntages from the one considered most important (6 points) to the least important (1 point) (Table 7).

Tab. 7 – Advantages with regard of working and personal well-being

The most reported advantages were the “reduction of travel times and costs”, appreciated more by the teaching staff with a statistically significant difference compared to the administrative staff (p = 0.2662) and the “greater flexibility” more reported by the administrative staff (p = 0.002278). The comparison between subgroups showed the most satisfied subgroup was represented by female employees, especially in the comparison with male professors (p = 0.005936). No statistically significant differences emerged by gender or by job for the other options.

Disadvantages with regard of working and personal well-being.

Similarly, each employee classified six possible disadvantages from the one deemed most important (6 points) to the least significant (1 point) (Table 8.).

Tab. 8 – Disadvantages with regard of working and personal well-being

Statistical analysis carried out did not reveal significant differences between the two groups of workers, nor between men and women for all possible disadvantages. The most complained disadvantages concerned the “isolation from the working environment” and the “excessive prolungation of working hours”, followed by the “difficulties in managing work spaces at home”.

General and global evaluation of the agile work experience.

The overall evaluation of the agile work experience was reported in Table 9.

Very satisfactory11 (11%)19 (13%)39 (27%)24 (30%)
Satisfactory48 (48%)64 (44%)78 (55%)34 (43%)
Indifferent12 (12%)16 (11%)8 (5%)8 (10%)
Unsatisfactory23 (23%)38 (26%)12 (8%)12 (15%)
Very unsatisfactory5 (6%)8 (6%)9 (5%%)2 (2%)
Tab.9 – General and global evaluation of the agile work experience

A scenario of overall appreciation of the agile work experience emerged, with 59%  teachers and 77%  administrative employees reporting the experience as very satisfactory or satisfactory. The administrative staff group provided the most positive overall rating (very satisfactory or satisfactory) with higher percentages than the teaching staff (p = 0.0007286), with a trend that is even more evident in women. The comparison of subgroups showed a significant difference between male professors vs female administrative employees (p = 0.000295), men professors vs male administrative (p = 0.0148029) and between female professors vs female administrative employees (p = 0.003361). The comparison of female professors vs male administrative staff showed a marginal significance (p = 0.052534). The sub-group expressed the highest degree of satisfaction was therefore represented by the women of the administrative staff.


The recent pandemic emergency has made it necessary to unexpectedly adopt in a short time new organizational models in the workplace, including the massive use of smart working thus determining the possibility of exploring the effects of remote work on the well-being of workers, in professional and personal terms. Our survey, aimed at the administrative and teaching staff of the University of L’Aquila, found a good degree of adhesion, having chosen to participate 55,5% of all  the subjects involved. The questionnaire administered, already used by MIUR, investigated multiple aspects related to smartworking, both concerning work and personal well-being, and relating to perceived work intensity and the advantages and disadvantages identified by employees. Our sample reported as the most positive aspects the greater flexibility and reduction of costs related to travel, while isolation from the workplace and the stress of not being disconnected were the critical issues highlighted. Our analysis showed an increase in working efficiency and perceived productivity, reported above all by administrative staff, as already underlined by some Literature data (Nibusinessinfo, 2020; The Balance Careers, 2020), but not in line with other recent evidence (Moretti A., 2020). Our sample appeared overall satisfied with the smart working experience, with the highest degree of satisfaction expressed by administrative staff, especially women. This finding is not in line with the results of previous studies carried out in the prepandemic period, (Golden T.D., 2005; Golden T.D., 2006), nor with what is reported by more recent studies (Moretti A., 2020). Almost half of the teachers declared themselves interested in continuing the agile work experience, as well as over 60%  the administrative employees who are, in this case too, the subgroup having expressed the most positive opinion. Employees underlined an increase in perceived work intensity and work effectiveness, although most of them, especially teachers, complained of negative effects in the relationship with colleagues. Further investigation studies would be useful to obtain other evidence about the effects of remote work on the personal and working spheres of employees, in order to create organizational models that support the protection of the overall well-being of workers, while maximizing work efficiency and the performance.


  1. Baker R., Coenen P., Howie E., Williamson A., Straker L. The Short Term Musculoskeletal and Cognitive Effects of Prolonged Sitting During Office Computer Work. Int. J. Environ. Res. Public Health. 2018;15:1678. doi: 10.3390/ijerph15081678. 
  2. Côté P., van der Velde G., David Cassidy J., Carroll L.J., Hogg-Johnson S., Holm L.W., Carragee E.J., Haldeman S., Nordin M., Hurwitz E.L. The Burden and Determinants of Neck Pain in Workers. Eur. Spine J. 2008;17:60–74. doi: 10.1016/j.jmpt.2008.11.012. 
  3. Cuerdo-Vilches T, Miguel Ángel Navas-Martín M.A., Ignacio Oteiza I. Working from Home: Is Our Housing Ready? Int J Environ Res Public Health. 2021 Jul; 18(14): 7329.
  4. Cupertino F, Spataro S, Spinelli G, Schirinzi A, Bianchi FP, Stefanizzi P, Di Serio F, Tafuri S. The university as a safe environment during the SARS-COV-2 pandemic: the experience of Bari Politecnico. Ann Ig. 2021 Mar-Apr;33(2):201-202. doi: 10.7416/ai.2021.2425.
  5. Eurostat News , Product code: DDN-20200424-1, published on 24-Apr-2020 , Theme: Population and social conditions
  6. Ghislieri C, Molino M., Dolce V., Sanseverino D., Presutti M. Work-family conflict during the Covid-19 pandemic: teleworking of administrative and technical staff in healthcare. An Italian studyMed Lav. 2021; 112(3): 229–240. Published online 2021 Jun 15. doi: 10.23749/mdl.v112i3.11227
  7. Golden, T.D. The role of relationships in understanding telecommuter satisfaction. J. Organ. Behav. 2006, 27,319–340. 
  8. Golden, T.D.; Veiga, J.F. The impact of extent of telecommuting on job satisfaction. Resolving inconsistent findings. J. Manag. 2005, 31, 301–318. 
  9. Grant C.A., Wallace L.M., Spurgeon P. An exploration of the psychological factors affecting remote e-worker’s job effectiveness, well-being and work-life balance, Empl. Relat. 2013;35:527–546. doi: 10.1108/ER-08-2012-0059. 
  10. Hartig T., Kylin C., Johansson G. The Telework Tradeoff: Stress Mitigation vs Constrained Restoration. Appl. Psychol. 2007;56:231–253. doi: 10.1111/j.1464-0597.2006.00252.x. 
  11. Hilbrecht M., Shaw S.M., Johnson L.C., Andrey J. I’m home for the kids: Contradictory implications for work-life balance of teleworking mothers. Gend. Work Organ. 2008;5:455–471. doi: 10.1111/j.1468-0432.2008.00413.x. 
  12. Kotera Y., Vione K. Psychological Impacts of the New Ways of Working (NWW): A Systematic Review. Int. J. Environ. Res. Public Health. 2020;17:5080. doi: 10.3390/ijerph17145080. 
  13. LEGGE 22 maggio 2017, n. 81 Misure per la tutela del lavoro autonomo non imprenditoriale e misure volte a favorire l’articolazione flessibile nei tempi e nei luoghi del lavoro subordinato.  (GU Serie Generale n.135 del 13-06-2017)
  14. Mann S., Holdsworth L. The psychological impact of teleworking: Stress, emotions and health. New Technol. Work Employ. 2003;18:196–211. doi: 10.1111/1468-005X.00121. 
  15. Moretti A., Manna F., Aulicino M., Paoletta M., Liguori S., Iolascon G. Characterization of Home Working Population during COVID-19 Emergency: A Cross-Sectional AnalysisInt J Environ Res Public Health. 2020 Aug 28;17(17):6284. doi: 10.3390/ijerph17176284.
  16. Nakrošienė A., Bučiūnienė I., Goštautaitė B. Working from home: Characteristics and outcomes of telework. Int. J. Manpow. 2019;40:87–101. doi: 10.1108/IJM-07-2017-0172. 
  17. Nibusinessinfo Employees Working from Home. [(accessed on 26 June 2020)]; Available online: https://www.nibusinessinfo.co.uk/content/advantages-and-disadvantages-employees-working-home.
  18. Parent-Lamarche A., Boulet M. Workers’ Stress During the First Lockdown: Consequences on Job Performance Analyzed With a Mediation ModelJ Occup Environ Med. 2021 Jun; 63(6): 469–475. Published online 2021 Feb 10. doi: 10.1097/JOM.0000000000002172
  19. Pillastrini P., Mugnai R., Bertozzi L., Costi S., Curti S., Guccione A., Mattioli S., Violante F.S. Effectiveness of an ergonomic intervention on work-related posture and low back pain in video display terminal operators: A 3 year cross-over trial. Appl. Ergon. 2010;41:436–443. doi: 10.1016/j.apergo.2009.09.008. 
  20. Savic D. COVID-19 and Work from Home: Digital Transformation of the Workforce. Grey J. (TGJ) 2020;16:101–104. 
  21. The Balance Careers The Pros and Cons of a Flexible Work Schedule. [(accessed on 26 June 2020)]; Available online: https://www.thebalancecareers.com/advantages-and-disadvantages-of-flexible-work-schedules-1917964.
  22. Vittersø J., Akselsen S., Evjemo B., Julsrud T., Yttri B., Bergvik S. Impacts of Home-Based Telework on Quality of Life for Employees and Their Partners. Quantitative and Qualitative Results from a European Survey. J. Happiness Stud. 2003;4:201–233. doi: 10.1023/A:1024490621548. 
  23. Will J.S., Bury D.C., Miller J.A. Mechanical Low Back Pain. Am. Fam. Physician. 2018;98:421–428. 

Stress Lavoro Correlato: l’esperienza dell’ASL Napoli 2 Nord durante la pandemia



Basile Maria Rosaria1, Nardiello Domenico2, Izzo Luigi3, Di Dio Daniele3, De Rosa Annalisa3, Vanni Monica4, D'Amore Antonio5

1Direttore UOC Prevenzione e Protezione Aziendale ASL Napoli 2 Nord
2Referente SLC - UOC Prevenzione e Protezione Aziendale ASL Napoli 2 Nord
3UOC Prevenzione e Protezione Aziendale
4Direttore Sanitario - UOC Prevenzione e Protezione Aziendale;
5Direttore Generale - UOC Prevenzione e Protezione Aziendale.


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


Il biennio 2020-2021, vissuto sotto la minaccia del Sars-Cov-19, ha rappresentato una grande sfida per l’evolversi delle procedure e delle operatività legate alla salute e alla sicurezza sui luoghi di lavoro e al benessere lavorativo: la scoperta di nuovi materiali e tecnologie, dalla ri-organizzazione di pratiche e protocolli fino alla completa riorganizzazione dei processi di cura e di assistenza.

Tutti gli operatori della Salute hanno dovuto accelerare i loro processi percettivi, attentivi, mnemonici e di apprendimento per poter rispondere, arginare e gestire i nuovi rischi lavorativi. Questo scenario ha palesato ai lavoratori l’impatto con nuove tipologie di rischi psicosociali che derivano dal dover operare in contesti rapidamente mutati, e non solo nell’ambito lavorativo, dal dover apprendere e applicare modalità mai sperimentate prima di lavoro da remoto, fino al vedere amplificati i livelli di allerta rispetto al mantenimento della propria e altrui salute.

Il Settore che si interessa della valutazione e della gestione delle componenti di-stressanti legate alle attività lavorative, afferente all’UOC Prevenzione e Protezione Aziendale della ASL Napoli 2 Nord, ha operato, sin dai primi momenti dell’epidemia pensando alla plasticità degli interventi, proponendo misure preventive al disagio psicosociale post-traumatico mai utilizzate prima in Azienda. Il processo organizzativo e applicativo di intervento di sostegno psicologico descritto in questo lavoro è un esempio di come le competenze psico-sociali degli operatori debbano essere pronte e plastiche per dare risposte rapide e attuabili: attagliare il proprio lavoro all’occasione delle esigenze emergenziali, al di là dell’orientamento teorico di riferimento, senza un setting strutturato, in condizioni diverse da quelle ordinarie, e testimonia la plasticità operativa richiesta dal contesto emergenziale come quello pandemico. La competenza psicosociale può, in casi come questo, essere “confezionata” all’occorrenza, secondo necessità. In effetti, le tecniche con le quali i lavoratori hanno fatto esperienza sono state veicolate, a sostegno degli stessi, dalla psicologia delle emergenze, modificate per l’occasione. E’ stata la prima volta che tali tecniche sono entrate nella Sanità Pubblica e hanno evidenziato la differenza tra una “psicologia dei reparti d’emergenza” (Pronto soccorso, rianimazione, ecc) e la Psicologia delle emergenze che al contrario si rivolge a contesti destrutturati. Il lavoro descrive come attraverso il Defusing, il supporto telefonico ai lavoratori in isolamento domiciliare, lo sportello d’ascolto e i gruppi di sostegno sul campo si sono affrontati i fattori di-stressanti legati alla pandemia nelle diverse articolazioni dell’ASL Napoli 2 Nord.

Introduzione: Il lavoro presentato è la descrizione dell’esperienza di valutazione e gestione delle componenti di-stressanti legate alle attività lavorative, durante il primo anno di pandemia, operato dal Settore per la Gestione dello SLC della UOC Prevenzione e Protezione Aziendale ASL Napoli 2 Nord. Ha come obiettivo quello di fornire ai colleghi una serie di informazioni operative che possono rappresentare un esempio di plasticità operativa, solitamente riscontrata nei contesti delle grandi emergenze, dove le competenze psicosociali degli operatori permettono la fruttuosa adattabilità alle necessità che sopraggiungono in uno scenario dinamico.

Metodologia e Materiali

Il supporto psicosociale fornito ai lavoratori della ASL Napoli 2 Nord in periodo pandemico ha utilizzato pratiche classiche come i colloqui individuali di sostegno psicologico e i Focus Group ma ha introdotto nella Sanità Pubblica anche tecniche tipiche della Psicologia delle Emergenze come il Defusing oppure il supporto da remoto per i lavoratori in regime di ricovero ospedaliero o in isolamento domiciliare. Tutte queste pratiche sono state modificate, nel setting e nella procedura per essere conformi ai DPCM emanati ma per continuare a garantire sostegno al personale.

Risultati e Discussione

Si illustrano i dati relativi ai lavoratori coinvolti nell’attività in oggetto, con numero di colloqui, telefonate e sedute di gruppo e si portano in discussione gli elementi qualitativi emersi dall’esperienza.

“….Come nella follia l’uomo deve fare i conti con un mondo interiore che va in pezzi, così nelle Catastrofi un gruppo di persone si confronta con l’andare in frantumi di ciò che lo circonda…Caviglia-Nardiello “Le dinamiche Psicologiche nelle Emergenze”

La condizione pandemica da Sars-Cov-2 ha fatto piombare, nella primavera del 2020 la Sanità mondiale in una situazione improvvisa di catastrofe, come mai dal secondo conflitto mondiale. In situazioni di emergenza il funzionamento mentale segue la curva della Sindrome Generale di Adattamento, con l’acuirsi della competenze cognitive e la messa in secondo piano delle dinamiche emotive, con tutto quanto ne consegue soprattutto per l’intensità degli stress e il loro perdurare nel tempo. Alti livelli di arousal, peri e post-traumatico, possono essere in parte responsabili (McCleery & Harvey, 2004) della frammentazione e della difficoltà legata ai ricordi verbalmente accessibili (Brewin et al., 1996).

Per questi motivi la UOC Prevenzione e Protezione Aziendale ha messo a punto, in tempi brevissimi, un programma di supporto psicosociale ai lavoratori, che ha subito, nel corso di due anni, diversi cambiamenti e adeguamenti seguendo le dimensioni temporo-spaziali dell’emergenza.

Si è privilegiato l’utilizzo di Tecniche di Rilassamento e di Tecniche di Gruppo ispirate al principio secondo cui parlare dei ricordi che fanno paura in un contesto sicuro, aiuta a integrare memoria calda (ricordi percettivi e sensoriali), e la memoria fredda (ricordi autobiografici e contestuali) in una Narrazione Coerente (Narrative Exposure Therapy). Questo permette un miglioramento della sintomatologia e diminuisce il loro impatto negativo, confusivo e terrificante dei ricordi (Schauer, 2011).

La tipologia degli interventi e la loro collocazione temporale hanno seguito la logica di una profilassi che teneva conto del tempo e dei destinatari secondo la seguente matrice: Matrice della Psicoprofilassi (D.Nardiello 2014)

Primaria  Eventi Formativi Aziendali / Informativa di massa  Psico-Educazione/ Sportello d’Ascolto Ordinario
Secondaria  Pubblicazione del Protocollo di Comunicazione di Diagnosi infausta  e di Notizia di Morte    Gruppi di Supporto / Restiamo in contattoSportello d’ascolto individuale periodo Pandemico
Terziaria  Incontri Individuali MINDFULNESS  Supporto Telefonico ai Positivi in isolamentoPsico- Terapia / Consulenza Psichiatrica
Tab. 1

Già a partire dal 2019 la UOC Prevenzione e Protezione Aziendale, attraverso il Settore per la Gestione dello SLC e in accordo con i Medici Competenti, ha istituito lo Sportello d’Ascolto a favore dei lavoratori, come azione di prevenzione primaria selettiva: un servizio di ascolto e supporto psicologico alle problematiche connesse allo Stress Lavoro Correlato. Il lavoratore può afferire a tale servizio su invio del Medico Competente di riferimento, che valuta la necessità di un supporto psicologico e inoltra la domanda allo psicologo afferente all’UOC Prevenzione e Protezione. Se ritiene utile può contattare lo stesso, per le informazioni del caso.

Lo psicologo del servizio, contatta direttamente l’interessato e fissa l’appuntamento in una delle sedi aziendali dello Sportello d’Ascolto, a Quarto, Pozzuoli, Giugliano, Frattamaggiore, Ischia o Procida. Lo Sportello d’Ascolto prevede il supporto psicologico e/o l’orientamento psicodiagnostico (ove richiesto dal Medico) attraverso tre incontri col dipendente, dei quali si relazionerà unicamente al Medico Competente inviante.

Nel caso gli incontri evidenziano una problematica che necessiti di supporto farmacologico e/o situazioni di natura psicopatologica non legata all’attività lavorativa svolta, lo psicologo fornirà indicazioni al Medico Competente per l’invio del dipendente ai servizi di Salute Mentale.

Inoltre, come azione di prevenzione primaria universale, all’interno di tutta la Formazione che eroga la UOC Prevenzione e Protezione Aziendale, riguardo al D.Lgs 81/08, vi sono dei moduli relativi allo stress e alla gestione dello stesso, tenuti da uno psicologo.

Ad evento critico avvenuto, subito dopo l’inizio del primo lock-down del paese, nel marzo del 2020, Fase 1 della pandemia, il Settore per la Gestione dello SLC, afferente alla UOC Prevenzione e Protezione Aziendale, ha attivato tre azioni di prevenzione secondaria universale e selettiva:

  • Pubblicazione e diffusione, alle articolazioni aziendali necessitanti, di un Protocollo per la Gestione della comunicazione di notizia di morte per decessi da COVID-19 e per la riduzione del di-stress nell’operatore, operazione preventiva secondaria universale.

Nel caso dell’epidemia da coronavirus la comunicazione del decesso ai parenti della vittima avviene a distanza, utilizzando il mezzo telefonico, da parte di un operatore significativo (il referente medico del reparto, il primario dell’U.O.) informato dei fatti e in grado di rispondere alle eventuali domande dei familiari. Chi comunica la notizia deve avere grande consapevolezza del suo peso.

E’ importante che la comunicazione sia centrata sulla persona, trovando un equilibrio tra il coinvolgimento emotivo e il mantenimento di un’adeguata modalità professionale che veicola maggiore senso di sicurezza e competenza agli interlocutori.

Aspetti ritenuti molto importanti sono: la privacy, l’atteggiamento e la conoscenza di chi fornisce la cattiva notizia e la chiarezza del messaggio.

Il protocollo della comunicazione di notizia di morte per decessi da COVID-19 segue 5 fasi:

  1. Preparazione;
  2. Trasmissione della notizia di morte;
  3. Contenimento emotivo;
  4. Sostegno informativo;
  5. Congedo.

Il Protocollo pubblicato ha dettagliato queste cinque fasi sinteticamente in modo che possano rappresentare una traccia sulla quale il professionista può muoversi, adattando il proprio orientamento e le proprie modalità di relazione.

  • I Gruppi di Supporto, inizialmente per gli operatori sanitari del 118, Pronto Soccorso, Terap. Intens./Rianimazione COVID-19, per esprimere e condividere, gestire lo stress, apprendere il rilassamento, creare un legame di esperienze (fuori turno ma in orario di servizio). I gruppi sono stati tenuti presso il P.O. S. Maria delle Grazie – Pozzuoli, ogni lunedì, il  P.O. S. Giugliano – Giugliano, ogni mercoledì e presso il P.O. S. Giovanni di Dio – Frattamaggiore, ogni venerdì.

Ogni volta si è data disponibilità per un primo gruppo alle ore 12.30, un secondo gruppo ore 13.15, un terzo gruppo ore 14.15 e un quarto gruppo ore 15.00. Per il rispetto della distanza interpersonale il gruppo ha ospitato massimo 5 operatori. Il Gruppo di Supporto ha rappresentato un intervento di supporto psicosociale al di-stress da COVID-19 che, in una durata di 30 minuti totali, ha offerto la tecnica del Defusing, contratto, attagliato alla situazione epidemica e una tecnica di rilassamento secondo il seguente canovaccio:

5 min. Consegna: “Rispetto a quanto stiamo vivendo, potete esprimervi su quanto vi passa per la mente e su quello che state provando emotivamente, così da condividerlo e se possibile dite come ve la state cavando, qual è la strategia che state utilizzando per andare avanti.

Questo gruppo è tenuto alla riservatezza di quanto viene detto. Prendete la parola uno per volta dicendo il vostro nome e dove lavorate. Gli altri ascoltano. Noi gestiremo il tempo”.

15 min. I partecipanti hanno circa due minuti a testa, due psicologi moderano e passano la parola agli altri. Si utilizzano gli ultimi 5 minuti di questa fase per collegare i vari interventi e “depatologgizzare” le reazioni emerse ove si possano collocare come reazioni alla situazione emergenziale.

10 min. Si invitano i partecipanti alla tecnica di rilassamento, facendola esperire direttamente e invitando chi non vuole provarla a restare come osservatore silenzioso.

  • Il Supporto telefonico “Restiamo in contatto” erogato dagli psicologi, in tempi stabiliti, senza finalità terapeutica, ma esclusivamente di ascolto e contenimento del lavoratore, che usufruisce dello spazio di ascolto. Come scrive Bion “Ogni seduta a cui lo psicoanalista prende parte non deve avere nessuna storia e nessun futuro”, ma rappresenta una possibilità di supporto nell’Emergenza Covid19. “Restiamo in contatto” è una linea telefonica dedicata, dove il lavoratore può chiamare dal lunedì al venerdì e parlare con uno psicologo. Il tempo dell’ascolto, stabilito di mezz’ora, viene gestito dello psicologo che tende ad orientare la comunicazione dell’assistito agli aspetti psicologici, interiori, legati al vissuto emergenziale, tenendo a margine gli aspetti organizzativi e i “fatti” già ampiamente speculati fuori dal setting telefonico.

Informando l’interlocutore che può mantenere l’anonimato, si richiedono il sesso e l’età, la professione, il luogo dell’esercizio professionale e successivamente si lascia spazio alla “parola”, tenendo ben presente quanto l’assistito possa tendere ad utilizzare lo spazio telefonico proiettando i suoi vissuti su bisogni concreti (mascherine, guanti e più in generale tutti i presidi) volti alla sicurezza della propria salute fisica correlata al rischio di infezione da Covid19, piuttosto che a quella psichica, obiettivo di prevenzione e protezione del progetto “Restiamo in  Contatto”.

L’obiettivo è di condurre il lavoratore a poter riflettere che al telefono può parlare: senza mascherina e guanti, senza differenze di ruoli, a volto scoperto. Può far emergere: emozioni, pensieri, rammarichi, desideri.

A circa dieci minuti dal termine del tempo di ascolto stabilito, lo psicologo comunica all’assistito il tempo rimanente; storicizza quanto riportato restituendone il significato emotivo, sostenendo la fiducia e la speranza.

Qualora si avverta il bisogno e la disponibilità di uno spazio interno dell’assistito per un secondo colloquio telefonico, si propone la possibilità di ricontattarlo ed in quel caso concordano un appuntamento telefonico, tenendo ben presente la possibilità che si possano attivare vissuti persecutori e giudicanti.

A conclusione del colloquio telefonico lo psicologo completerà la scheda di ascolto telefonico nella parte conclusiva relativa alla sintomatologia prevalente e informa l’interlocutore dell’offerta completa messa a disposizione dall’UOC Prevenzione e Protezione dell’ASL Napoli 2 Nord (gruppi di supporto o sportello d’ascolto individuale).

Entrando nella Fase 2 della pandemia da Sars-Cov-2, l’offerta di azioni di supporto psicosociale ai lavoratori dell’ASL Napoli 2 Nord si è diversificata con:

  • Sportello d’Ascolto Individuale per il periodo pandemico: offerto da un gruppo di psicologi-psicoterapeuti, afferenti a diversi servizi ASL che hanno collaborato con l’UOC Prevenzione e Protezione dell’ASL Napoli 2 Nord, al quale il lavoratore ha potuto rivolgersi anche direttamente o, come per lo sportello ordinario, attraverso il proprio Medico Competente. I lavoratori possono usufruire del supporto psicosociale COVID-19 fuori turno ma in orario di servizio. L’intervento è gestito dalla UOC Prevenzione e Protezione Aziendale in accordo con la Direzione Sanitaria Aziendale come prevenzione di disturbi post-traumatici ed elaborazione dei vissuti operativi legati al contesto emergenziale in atto.
  • In questa fase si è anche modificato il sostegno a distanza: si è infatti attivato il Supporto Telefonico ai colleghi positivi al Covid in isolamento. Questa azione di prevenzione terziaria selettiva, offre un supporto psicologico al singolo lavoratore, per la prevenzione e la gestione delle componenti di-stress correlate alla condizione clinica emergenziale. I colleghi in isolamento domiciliare oppure in ricovero ospedaliero vengono contattati direttamente da uno psicologo della UOC Prevenzione e Protezione, o in collaborazione con essa, per il supporto psicologico a distanza. I colleghi psicologi di altri servizio hanno volontariamente messo a disposizione la loro professionalità e, ovviamente, i colleghi Psicologi della Salute Mentale non sono coinvolti in questa attività in quanto, considerata la condizione epidemica, hanno dovuto riorganizzare le attività di supporto a distanza a favore dell’utenza a loro afferente.

Si offre un pacchetto minimo di chiamate telefoniche, implementate in base al triage psicologico effettuato, con supporto psicologico, interventi psicoeducativi e tecniche di scarico emotivo.

Di seguito un istogramma che visualizza i segni e i sintomi prioritariamente riferiti dai lavoratori:

Tab. 2

Di seguito un report sintetico delle attività di Supporto Psicosociale rivolte ai lavoratori della ASL Napoli 2 Nord, progettate e coordinate dal settore Stress Lavoro Correlato della UOC Prevenzione e Protezione Aziendale, dall’aprile del 2020 al dicembre del 2021:


Tipologia InterventoPeriodo  n°eventi  n°lavoratori coinvolti
Gruppi di SupportoAprile 2020- Dicembre 202124 incontri67
Supporto Telefonico ai PositiviAprile 2020- Dicembre 2021657 telefonate219
Sportello d’Ascolto IndividualeAprile 2020- Dicembre 2021255 colloqui82
Tab. 3

Inoltre, si sono organizzati e tenuti eventi di supporto straordinario a favore di alcune U.O. che hanno evidenziato particolari elementi di-stressanti, come il DS 41 di Frattamaggiore, il reparto COVID e il Complesso Operatorio del P.O. di Pozzuoli, e la UOC Ginecologia e Ostetricia del P.O. di Ischia. In queste articolazioni si sono tenuti, o sono ancora in corso, eventi formativi/di supporto, si sono condotti gruppi di sostegno e forniti elementi psicoeducativi per la riduzione dello stress. Il personale della stessa UOC Prevenzione e Protezione Aziendale è stata supportata con la conduzione di gruppi di auto-aiuto con cadenza quindicinale o mensile.

Gruppo di Lavoro Aziendale SLC: La UOC Prevenzione e Protezione Aziendale ha coordinato gli incontri del Gruppo di Lavoro Aziendale per lo SLC che durante il 2020 e 2021 hanno trattato l’aggiornamento delle linee procedurali del supporto SLC in tempo di Pandemia, oltra al seguimento di una ricerca effettuata insieme all’Università Federico II di Napoli che ha coinvolto tutti i lavoratori ASL sulle tematiche dello stress legato alle attività, i cui risultati sono al momento in fase di elaborazione dei dati.

Nella Fase attuale dell’epidemia, che si avvia verso l’endemia, la UOC Prevenzione e Protezione Aziendale può nuovamente offrire un’azione di prevenzione universale, che parte come terziaria, scrivendosi in un tempo della riorganizzazione dell’emergenza e perdurando si trasformerà in azione preventiva primaria, quando transiteremo in un tempo cosiddetto ordinario. Questa ultima azione è:

  • Incontri Individuali di Mindfulness, rivolti a tutti i lavoratori dell’ASL Napoli 2 Nord, rappresentano una forma di supporto psico-sociale individuale ai lavoratori ASL, con interventi psicoeducativi, tecniche di scarico emotivo e tecniche di rilassamento. La Mindfulness è una pratica introdotta da Kabat-Zinn, articolata su esercizi psicologici specifici, il cui fine è coltivare l’abitudine alla consapevolezza per conseguire uno stato mentale più incline al benessere. I lavoratori giungono all’incontro, volontariamente e per contatto diretto con lo psicologo della UOC Prevenzione e Protezione Aziendale; non è prevista una relazione finale o una attestazione di presenza; sono garantiti anonimato e privacy.


  1. J.M. Mc Cleery, A.G. Harvey, Journal of traumatic stress : Official 2004 – Wiley on line library
  2. C.R. Brewin et al., A dual representation theory of post-traumatic stress disosder, Psycol Rev. oct. 1996
  3. M. Shauer et al., Narrative Exposure Therapy, books google 2011
  4. Le Dinamiche Psicologiche nelle Emergenze” di G. Caviglia e D. Nardiello, Ed. Idelson-Gnocchi, febbraio 2009, Napoli.
  5. Psicologi nelle Emergenze” di G.Caviglia, R.Felaco e D.Nardiello, Ed. Liguori, settembre 2012, Napoli.
  6. Competenze psicosociali per la sanità e le professioni d’aiuto – dotazioni, strumenti e strategie” di D. Nardiello e G. Caviglia, Franco Angeli, 2020, Milano.
  7. “Il Referto” in La Diagnosi in Psicologia Clinica, a cura di G.Caviglia ed E.Del Castello, Franco Angeli, 2003, Milano.
  9. “Raccogliere la storia di vita: il ruolo dell’Anamnesi nella Diagnosi Psicologica” in La Diagnosi in Psicologia Clinica, a cura di G.Caviglia ed E.Del Castello, Franco Angeli, 2003, Milano.
  10. “Anamnesi e colloquio nella psicodiagnosi” in Il Lavoro Diagnostico dello Psicologo Clinico: Teoria, Strumenti, Competenze, a cura di G.Caviglia, Ed. Melagrana, 2005, Caserta.
  11. “il Referto e la Restituzione” in Il Lavoro Diagnostico dello Psicologo Clinico: Teoria, Strumenti, Competenze, a cura di G.Caviglia, Ed. Melagrana, 2005, Caserta.
  12. Articolo
  13. “La Psicoprofilassi nei diversi tempi dell’emergenza” di D.Nardiello in Il Caduceo USI Vol.16, n°4 – 2014
  14. Poster
  15. “Le Dinamiche Psicologiche negli Scenari delle Catastrofi”, Poster presentato al XI Convegno Nazionale Ufficiali Medici CRI, 15 – 18 ottobre 2009, Paestum (SA);
  16. “Aspetti Psicosociali in scenari di Catastrofe: L’Indifferenza e la Solidarietà” , Poster presentato alla Conference Civil Military Cooperation Enhancing –  Combat Trauma System and Disaster Medical Management Capacities, 12 -14 settembre 2012, Scuola Militare Nunziatella, Napoli;

Study And Testing Of The Use Of Wearable Devices For The Evaluation Of Ergonomic Parameters In The Workplace



Arcangeli Marco1
Co-authors: Bracci Massimo2 Pieroni Catia3 Principi Massimo4

1Degree in Prevention Techniques in the Environment and in the Workplace - Hu.DO S.r.l. Fabriano).
2Associate Professor of Occupational Medicine - Department of Clinical and Molecular Sciences - Professor of Occupational Medicine in the course of Prevention Techniques in the Environment and Workplaces - UNIVPM;
3Director of Educational and Professionalizing Activities of the course Prevention Techniques in the Environment and in the Workplace - UNIVPM;
4Tutor of the course Prevention Techniques in the Environment and in the Workplace - UNIVPM.


Pubblication Date: 2022-11
Printed on: Volume 4, Publications, Online Issue


The increase in the average age of workers (Rodà & Sica, 2020) represents a significant risk factor in the field of Occupational Health and Safety (OSH), as it increases the odds of provoking work-related health problems, such as musculoskeletal diseases, stress, depression and anxiety.

This rapidly growing phenomenon can be partially prevented by applying ergonomic risk assessment methods, including NIOSH, OCRA, INAIL guidelines for work-related stress, etc.

However, due to the variability of tasks, these methodologies are not always sufficient to understand the real working conditions. From this lack arises the necessity to integrate innovative tools, such as wearable devices, with traditional evaluation methods (Papetti et al., 2018).

Wearable devices are a wide range of technological devices worn near and/or on the surface of the skin, that are able to detect, store and exchange data of different types, such as body movements, vital signs and environmental data, allowing in some cases an immediate biofeedback to the wearer (Düking et al., 2018).

In-depth studies, conducted by EU-OSHA (Report EU-OSHA, 2017) at European level and by INAIL at national level, emphasize the beneficial effects that digital technologies (including wearable devices) can have, especially on the delicate theme of health and safety at work.

Therefore, the objective of this study is to undertake a more collaborative approach between man and machine, which makes wearable devices a means not only of productive improvement, but also of worker protection.

Materials And Methods

The case study was carried out within a furniture manufacturing company and specifically in two activities: the drilling of the doors performed by numerical control machines (FA) and the assembly of the drawers (AC) (Figure 1).

Fig. 1 – Workstation analyzed.

The tools used for the case study were the following:

Camera for the evaluation of the ergonomic parameters of biomechanical overload of the spine and biomechanical overload of the upper limbs, obtained by NIOSH methods and OCRA Checklist (Waters et al., 2011, 2015; Colombini, 1998; Occhipinti & Colombini, 2004; UNI ISO 11228, 2009);

Wearable devices (heart strap and smart glasses) for the analysis of physiological parameters such as heart rate, heart rate, blink rate (De Rivecourt et al., 2008; Causse et al., 2010; Veltman & Gaillard, 1996; Bentivoglio et al., 2004; ISO 11226, 2019; Lindh et al., 2009);

NASA TLX questionnaire to determine the workload perceived by the worker (Hart, 2006).

By analyzing and monitoring some of these physiological factors through the use of wearable devices and integrating them with information on the characteristics of the work and the worker, it is possible to obtain information on the working conditions of the operator (physical load, mental workload and back posture) (Scafà et al., 2019) (Figure 2a). 

The monitoring through wearable devices was carried out during the work shift in order to significantly appreciate the progress of the physical and mental response of the workers. 

The collected data was then processed through algorithms (Hu.DO S.r.l. ‘s proprietary) and entered within the Oper.AI platform in order to obtain the aforementioned parameters (Figure 2b).

Fig. 2a, 2b – Mapping of the factors and regulations relating to the parameters analyzed + Oper.AI platform.

Parallel to the analysis of the data obtained from wearable devices, there were performed also the assessment of the biomechanical overload of the back (through the NIOSH – VLI method), the assessment of repetitive movements (through the checklist-OCRA method) and the assessment of the workload (through the NASA-TLX method), thanks to the contribution of the questionnaire and of the filming carried out during the case study.

Results And Discussion

The results of the analyzes obtained through “classic” methods and through wearable devices were compared and synergistically correlated with each other in order to obtain a general summary of the ergonomic conditions of the workstations (Figure 3).

In the first station observed (FA) a high risk of biomechanical overload of the spine was highlighted due both to the excessive weight of some wings lifted by the operator, and to the age of the worker, who is considered a “subject at risk”, because he is more than 45 years old. The posture of the operator’s back was good even though there were some incongruous movements that could have led to injury, if related to the lifting of a weight. On the other hand, no relevant risks were observed for overload of the upper limbs, due to repetitive movements, nor for physiological overload due to physical workload. In the end, the result of the NASA-TLX questionnaire concerning cognitive ergonomic revealed an important presence of mental workload, an aspect which was partly confirmed by the results obtained through wearable devices which, however, did not detect alarm values ​​for the health of the worker.

In the second station observed (AC), a very slight risk of biomechanical overload of the upper limbs was highlighted, mainly due to the high frequency of repetitive actions carried out during the assembly of the drawers.  The posture of the operator’s back was good even though there were some incongruous movements that could have led to injury, if related to the lifting of a weight. On the other hand, no relevant risks were observed for the biomechanical overload of the spine. Furthermore, even though the activity was purely physical, the set of actions and activities carried out during working hours were found to be suitable and proportionate to the characteristics of the operator. Lastly, the NASA-TLX questionnaire showed a normal amount of mental workload, an aspect also confirmed by the results obtained through wearable devices.

Fig. 3 – Summary of the results obtained from the assessments carried out in the workstations (FA) (AC).

Despite the small number of data analyzed (only two workers subjected to the test), the case study confirmed that wearable devices are actually useful for the ergonomic risk assessment process. Thanks to the acquisition of physiological parameters concerning the workers, the application of these technologies has made the risk assessment more detailed and consequently more representative of the real working conditions.

If they are used and developed correctly, wearable devices will bring concrete benefits for both workers and companies, improving working conditions and increasing company productivity.


Special thanks go to Monica Pandolfi and Lorenzo Cavalieri, founders of the startup Hu.DO S.r.l., for providing the instrumentation (heart strap and glasses), the algorithms and the “Oper.AI” platform essential for processing the final results.


  1. Bentivoglio, A. R., Bressman, S. B., Cassetta, E., Carretta, D., Tonali, P., & Albanese, A. (2004). Analysis of blink rate patterns in normal subjects.
  2. Causse, M., Sénard, J. M., Démonet, J. F., & Pastor, J. (2010). Monitoring cognitive and emotional processes through pupil and cardiac response during dynamic versus logical tasks. Applied psychophysiology and biofeedback. 35,115-123.
  3. Colombini, D. (1998). An observational method for classifying exposure to repetitive movements of the upper limbs. Ergonomics. 41, 1261-89.
  4. De Rivecourt, M., Kuperus, M. N., Post, W. J., & Mulder, L. J. M. (2008). Cardiovascular and eye activity measures as indices for momentary changes in mental effort during simulated flight. Ergonomics 51, 1295-1319.
  5. Düking, P., Achtzehn, S., Holmberg, H. C., & Sperlich, B. (2018). Integrated framework of load monitoring by a combination of smartphone applications, wearables and point-of-care testing provides feedback that allows individual responsive adjustments to activities of daily living sensors (basel).
  6. Hart, S. G. (2006). Nasa-task load index (nasa-tlx); 20 years later. NASA-Ames Research Center Moffett Field, CA.
  7. ISO 11226. (2019). Valutazione delle posture di lavoro statiche.
  8. Lindh, W. Q., Pooler, M., Tamparo, C., & Dahl, B. M. (2009). Delmar’s comprehensive medical assisting: Administrative and clinical competencies. Cengage Learning, p. 573.
  9. Occhipinti, E., & Colombini, D. (2004). The OCRA Method: Updating reference values and prediction models of occurrence of work-related musculo-skeletal diseases of the upper limbs (UL-WMSDs) in working populations exposed to repetitive movements and exertions of the upper limbs. La Medicina del lavoro. 95, 305-19.
  10. Papetti, A., Gregori, F., Pandolfi, M., Peruzzini, M., & Germani, M. (2018). IoT to enable social sustainability in manufacturing systems. Advances in transdisciplinary engineering 7, 53-62.
  11. Report EU-OSHA. (2017). Foresight on new and emerging occupational safety and health risks associated with digitalization by 2025. European Risk Observatory, Luxembourg.
  12. Rodà, M., & Sica, F. G. M. (2020). L’economia della terza età: consumi, ricchezza e nuove opportunità per le imprese. Nota dal CSC 2/20.
  13. Scafà, M., Papetti, A., Brunzini, A., & Germani, M. (2019). How to improve worker’s well-being and productivity: a method to identify corrective actions. Procedia CIRP. 81, 162-167.
  14. UNI ISO 11228-1. (2009). Ergonomia – Movimentazione manuale – Parte 1: Sollevamento e trasporto.
  15. UNI ISO 11228-2. (2009). Ergonomia – Movimentazione manuale – Parte 2: Spinta e traino.
  16. UNI ISO 11228-3. (2009). Ergonomia – Movimentazione manuale – Parte 3: Movimentazione di bassi carichi ad alta frequenza.
  17. Veltman, J. A., & Gaillard, A. W. K. (1996). Physiological indices of workload in a simulated flight task. Ergonomics 41, 656-669.
  18. Waters, T. R., Lu, M. L., Piacitelli, L. A., Werren, D., & Deddens, J. A. (2011). Efficacy of the revised NIOSH lifting equation to predict risk of low back pain due to manual lifting: Expanded cross-sectional analysis. Journal of Occupational Environmental Medicine. 53, 1061–1067.
  19. Waters, T. R., Occhipinti, E., Colombini, D., Alvarez-Casado, E., & Fox, R. (2015). Variable lifting index (VLI): A new method for evaluating variable lifting tasks. Human Factors. Advance online publication.

Smart-Working In The Period Of Emergency Due To Covid-19: Study On The Perception Of Work-Related Stress



Antili Lorenzo1
Coauthor: Pieroni Catia2, Principi Massimo3

1Dottore in Tecniche della Prevenzione nell’ambiente e nei luoghi di lavoro – TPALL – Università Politecnica delle Marche
2Direttore Attività Didattiche e Professionalizzanti CdS TPALL – Università Politecnica delle Marche
3Tutor CdS TPALL – Università Politecnica delle Marche


Pubblication Date: 2022-11
Printed on: Volume 4


2020 was distinguish by the development of a new coronavirus, called SARS-CoV-2, that belong to the same virus family as Severe Acute Respiratory Syndrome (SARS). In March 2020 The World Health Organization (WHO) declared a state of global pandemic. The current pandemic had a giant impact and heavy repercussions in economical, organizational, and social themes. During the period January-March 2020, Sars-CoV-2 infections increased dramatically in the world, so governments of many countries, including Italy, adopted containment measures like temporary closuring of work activities, that encourages the development of smart-working. This is defined, by Italian legislation, as “a method of execution of the employment relationship established by agreement between the parties, also with forms of organization by phases, cycles and objectives and without precise time or workplace, with the possible use of technological tools for carrying out the work activity”. Smart-working was initially conceived as a temporary solution but due to the increase of coronavirus cases, it continues to be applied, compatibly with the tasks performed by workers. This left employers and employees a short time to prepare themselves for this new way of working, to be able to guarantee the continuation of production activities and at the same time to preserve workers and all citizens health. This context may have generated situations of work-related stress, which occurs when work environment’s demands exceed the ability of the worker to deal with them. It must be added two factors: continuous technological transformations and new forms and methods of work, that can have relevant implications for workers health and safety. Another important aspect concerns the tendency of individuals in remaining constantly connected to internet, the frequent use of technological equipment known as “hyper connection”; this causes the development of anxiety and tension, which creates a sense of space-time detachment and determines the onset of Technostress.

The Goal

The research aims to investigate, through the administration of an anonymous questionnaire, how agile workers have experienced the stressors, through self-assessment of psycho-physical and environmental conditions during the pandemic.

In particular, the goal is to provide a contribution regarding the application of smart-working, corroborating positive and negative impacts that this model has on both the effectiveness in carrying out the activities, both on satisfaction and work well-being, without neglecting possible benefits and

critical issues. The research is aimed at identifying three main areas:

  1. perception of the main stress factors found among workers interviewee;
  2. psychological and physical repercussions of agile work seen as a remedy during the emergency period;
  3. main positive and negative aspects in the implementation of smart-working during the period of global pandemic.

Items And Methods

In order to implement the research objectives, I made a questionnaire consisting of 29 questions, most of which were multiple choice questions. There was the possibility to add a personal comment, too. For the questionnaire compilation was used Google Forms and the data collection took place in March 2021. The questionnaire was completely anonymous. It was administered online, to both public and private companies (municipalities, schools, etc.), for a total of 114 workers. The data was collected in compliance with the privacy law. It was divided into three sections. The first section collected social information and personal data: sex, age and residence. The second section collected information about field experience of smart-working (instruments, technological supports, places, etc.).  In the third section, I asked workers about psycho/physical consequences related to the agile work.

There was three core questions, namely:

  • main positive aspects from an individual point of view;
  • main negative aspects;
  • determining factors in the onset of stress during the working period.

Data’s Results And Comments

The sample, consisting of 114 questionnaires, is represented for 58.8% by female workers and 41.2% by male workers (Figure 1).

Fig. 1 – Gender of the sample

2.6% of the sample represents people under 25, 14.9% represents a group of people from 25 to 35 years old, 26.3% represents a group from 36 to 45 years old, 39.5% represents a group from 46 to 55 years old and 16.7% represents a group from 56 to 67 years old (Figure 2).

Fig. 2 – Age range of the sample

34.2% of respondents work inside public companies, while the remaining 65.8% within private companies (Figure 3).

Fig. 3 – Public or private company where the sample works

51.8% of subjects live in the same city of the company they work for (Figure 4).

Fig. 4 – Residence compared to the company you work for

I asked participants how long took them to reach the company they work for; 40.4% said it took less than 10 minutes, 43.9% said they reached it in a time between 10 and 30 minutes, while the remaining 15.8% said it took more than 30 minutes (Figure 5).

Fig. 5 – Time taken to reach the workplace

I also asked respondents if smart-working activities were taking place in their companies before the pandemic: only 9.6% replied positively, while the remaining 90.4% implemented this type of work only for the emergency event (Figure 6).

Fig. 6 – Workers who operated in smart-working even before the pandemic event

28.9% of people have been working in smart mode for less than six months, 14% for more than six months and the remaining 57% for about a year (Figure 7).

Fig. 7 – Smart-working time

Taking into consideration the work station inside participants’ house, it is verified that 2.6% of workers did not have everything they needed to carry out their smart-working job, 35.1% said “partially” and the remaining 62.3% declared that they had everything they needed while working in smart mode (Figure 8).

Fig. 8 – Number of workers in possession of the appropriate equipment to carry out the smart-working activity

The company provided workers with adequate equipment only for 28.1% of respondents, 32.5% said “only in part” and the remaining 39.5% claimed they didn’t received it at all (Figure 9).

Fig. 9 – Supply of the instrumentation by the Company

With regard to health and safety training, 33.3% of respondents said they has received it, 20.2% said “only in part” and the remaining 46, 5% said they didn’t received it at all (Figure 10).

Fig. 10 – Workers who declare that they have received adequate training

The company provided guidelines to use software in 55.3% of cases, while the remaining 21.1% and 23.7% claimed to have received them respectively: in part and not at all (Figure 11).

Fig. 11 – Workers who declare that they have received instructions on the use of the software

Furthermore, 14% of respondents said the company they work for did not provide clear objectives, 24.6% stated that objectives were only partially defined and 61.4% declared that company’s objectives were clear (Figure 12).

Fig. 12 – Workers whose objectives and tasks have been clearly defined

With regard to the work activity, I asked workers if their job involved necessarily the use of paper or if the work process could be fully digitized; 27.2% said they couldn’t work without the use of paper, 39.5% said they could work in part without paper, while the remaining 33.3% said they could perform a fully digital job (Figure 13).

Fig. 13 – Workers who are only able to work digitally

Regarding the easy access of assistance in case of problems, 62.3% said they could easily contact support managers, while 21.9% said they were able to contact them only on certain occasions and 15.8% said they could’t contact them at all (Figure 14).

Fig. 14 – Workers who can easily contact assistance

60.5% of respondents stated that, during smart mode, working hours were no longer flexible, 17.5% said they were only partially more flexible and 21.9% said they had managed their working hours more flexibly (Figure 15).

Fig. 15 – Workers who have experienced flexible hours

As for the space inside workers’ home used for work, 43.9% said they have it, 18.4% replied that they only partially own it while 37.7% stated that they had no space (Figure 16).

Fig. 16 – Workers who have a space to be dedicated exclusively to work

71.9% of workers claimed to have full autonomy in carrying out their work, while 28.1% claimed to be partially self-sufficient; no answer regarding the condition of total dependency to other colleagues/superiors (Figure 17).

Fig. 17 – Workers who have autonomy in carrying out their work

I asked workers: “Does your work depend on tasks previously performed by others?”. 34.2% said their job doesn’t depend on previous works carried out by other colleagues, 12.3% said their job depends entirely on previous works and 53.5% declared their job depends only in part on the performance of other workers (Figure 18).

Fig. 18 – Workers whose work depends on the activities of other colleagues

Analyzing emotional/psychological aspects, it emerged that, for 25.4% of respondents, the performance of agile work influenced only partially the emotional state of workers and the relationships within their family, 43.9% did not suffer repercussions and 30.7% experienced changes in emotional aspects and relationships (Figure 19).

Fig. 19 – Workers who have found an influence in relationships and in the emotional state in the family unit

Regarding the working sphere after changes caused by the pandemic, 13.2% said this emergency has not affected their way of working, 21.1% said they have noticed an improvement, 34.2% claimed to have noticed a worsening and the remaining 31.6% claimed to have been influenced only in part (Figure 20).

Fig. 20 – Workers who have perceived an influence on their way of working

The current experience of applying a smart working mode was positive in 60.5% of cases and negative in 25.4% of cases, while 14% of respondents did not take a position (Figure 21).

Fig. 21 – Opinions about the sample’s smart-working experience

Following the end of pandemic, 32.5% of respondents stated that they would continue in carrying out their business in smart-working, while 56.1% said they would not want to continue in this direction; only 11.4% of workers didn’t take a position (Figure 22).

Fig. 22 – Workers who would consider doing their full-time jobs even after the pandemic

To the question “do you frequently feel unwell even if you do not have any pathologies?” only 7% answered positively, while 21.9% answered “more yes than no”, 33.3% said “more no than yes” and the remaining 37.7% said they never felt bad (Figure 23).

Fig. 23 – Workers who declare that they experience malaise

Furthermore, 16.7% of respondents declared that smart-working period made them more irritated and disgruntled, 22.8% said they were more irritated than satisfied, while 28.1% said, on the contrary, that they were more satisfied than disgruntled. The remaining 32.5% of workers declared that they didn’t feel irritated or displeased at all (Figure 24).

Fig. 24 – Workers who feel more irritated and discontented

When I asked about physical repercussions of smart-working, 24.6% said they has experienced physical illness, 48.2% said they hasn’t experienced that and 27.2% of respondents has accused physical pain only sometimes (Figure 25).

Fig. 25 – Workers who experienced physical repercussions

As regards emotional/psychological repercussions of smart-working, 11.4% declared that, after pandemic, they felt “worse”, 46.5% declared to feel “a little worse”, 31.6% declared to feel “indifferent”, 6.1% said they felt “a little better” and the remaining 4.4% declared to feel “much better” than before the emergency (Figure 26).

Fig. 26 – Opinions regarding the emotional / psychological state

It is possible to deduce how the “opportunity to continue the business despite the state of emergency” is the most appreciated criterion by the workers (67.5%). This is followed by the “possibility of managing and organizing time” (60.5%) and the “shorter time spent commuting from home to work” (57%).

In fact, 48.2% of respondents said they reside in a different place than the company they work for and 15.8% take more than 30 minutes to reach their workplace in normal times, while 43.9 % and 40.4% declare, respectively, to take a time between 10 and 30 minutes and less than 10 minutes.

Another relevant aspect was the “decrease in environmental impact thanks to a lower level of displacements” (52.6%), followed by “greater flexibility of working hours” (50%).

42.1% of respondents were pleased both the “reduction in costs” and “greater assistance to children / elderly” (31.6%). 24.6% of people declared that they had “fewer sources of disturbance”.

Only 3.5% of workers declared that they had not found any type of benefit during this smart-working period, while 4.5% responded by writing their own subjective opinion to the question posed.

An interesting information that must be considered is “more time to devote to private life”, considered as a positive aspect only by 15.8% of the interviewees (Figure 27).

Fig. 27 – Main POSITIVE aspects of smart-working

Taking into consideration the responses received in the negative aspects perceived by the workers, 65.8% of them declared that they experienced a “lower separation between private and working life” (Figure 28).

Fig. 28 – Main NEGATIVE aspects of smart-working

Contrary to how smart-working was initially conceived, this last figure turns out to be the first of the negative aspects highlighted by workers. The latter have faced an unfavourable working situation from the implementation of their own and within the home only, without the truly flexible nature that this way of working offers.

One of the consequences in the lower separation between private life and working life appears to be the “difficulty in pulling the plug”, confirmed by 61.4% of respondents, which in numerical terms is the second most popular answer.

This could derive from the fact that workers are always available or carrying out their business even during the weekend and late in the evening.

The third highlighted negative aspect is the problem of “isolation/ loneliness”, caused by less social contact with colleagues and relationships virtualization, which could be less satisfying and engaging.

40.4% consider as a negative aspect the “presence of sources of distraction at home”, due to the presence of children/elderly people, the carrying out of domestic activities, less concentration, etc.

This is followed by the “major organizational problems” with 33.3% and a “greater difficulty in managing time” with 15.8%.

Only 14% complain as a negative consequence of smart-working a lower level of privacy.

This is caused by the sudden digitization and identities virtualization, that forced workers to share private information and passwords.

10.5% say they experienced a cost increase, which could be determined by various factors, such as: a needing to change internet contracts, a lack of telephones, an increasing in bills, etc.

Only 5.3% of respondents say they are afraid of losing their job.

6.3% provided different answers, including: “lack of paper documents”, “work much more and feel not enough”, “greater difficulty in sharing the work done”, “too many hours a day”. 

10.5% declare that they didn’t find any kind of negative aspects in smart-working.

From the analysis of the main factors determining the development of stress, as a possible relationship between psychosocial risk factors and the stress experienced by workers, it was highlighted that three variables are significant for workers (Figure 29).

Fig. 29 – Main factors of STRESS

These variables are:

  • excessive workload;
  • inadequate reward (financial, social approval, career opportunities);
  • lack of support / communication from colleagues.

As the excessive workload increases, the risk of developing work-related stress increases.

The greater the support and communication from colleagues, the lower the risk of developing work-related stress.

The risk of increased stress increases as the reward perceived by workers increases both in economic terms, in terms of social approval, and in terms of career opportunities.

With “workload” we mean an excessive stimulation that can lead the subject to an experience of stress, mainly for two aspects: the amount of work to be done and worker’s fast pace.

The factor also indicates the degree of subject’s adequacy and organization’s resources to perform the assigned tasks.

With “support from colleagues” we mean the availability of people we work and collaborate with, the know-how and the mutual exchange of information and opinions.

With “adequate reward” we indicate the perceptions relating to the feeling of not being remunerated enough compared to the role covered, not being able to organize one’s work by deciding times and operating methods, the expectations of the organization towards it, direct responsibilities, what objectives should be.

Concerns about salary, career opportunities and social approval cause some discomfort among the workers interviewed (43.9%), while to a lesser extent, it’s worrying losing their job (13.2%).

Two risk factors that arouse concerns are excessive workload (70.2%) and difficulty in pulling the plug (61.4%).

As regards the risk profile of workers, it seems to be characterized by an excessive mental load of work for 70.2% of respondents; On the contrary, the level of autonomy possessed by workers is acceptable (71.9%), while the level of support from colleagues is equally negative: 44.7% affirmed that one of the stress development factors is a lack of support/ communication from colleagues.

Furthermore, objectives and tasks assigned by the company appear quite satisfactory (61.4%).

The separation between private life and working life (work-family conflict) is one of the main risks on stress’ onset for the smart-worker (65.8%).

On a sample of 67 women and 47 men, the analysis showed that 31.3% of women reported more physical repercussions from stress (back pain, migraine, dermatitis, insomnia, etc.) than men (14.9%).

Considering consequences of stress in the psycho / emotional area, it emerges from the data that women (44.8%) are more dissatisfied and irritated in carrying out their work in smart-working mode than men (31.9%).

It’s interesting to note that 60.5% of the entire sample defines the current work experience in smart-working as positive, but at the same time 56.1% say that would not evaluate the possibility of doing it full time. In particular, 66.7% of men evaluate the current agile work experience as positive, only 33.3% of these consider it negative. Similarly, women evaluate it positively for 73.6% of cases, while the remaining 26.4% define negatively this way of working.

Final Considerations

Smart-working is one of the many obligatory responses that forced, suddenly and without compromises, the arrival of the current pandemic. In fact, in this period of emergency, many workers became part of this huge work experiment, sometimes without clear rules of conduct. Companies whose workers are used to work from home, are more organized than companies that have been forced to start a remote working activity in a very short time, without a specific and prior organization.

The latter have found themselves and still find themselves facing atypical situations and working environments that do not conform to their needs.

In fact, the structural framework of smart-working is made up of three aspects: principles, levers and benefits as shown in the following image:

Fig. 30 – Smart-working’ structure

At the end of this health emergency, which made working experience a real “test” forced for most of the workers, it can be highlighted that smart-working cannot be applied to all workers and to all companies. That is because, in order to obtain positive effects on productivity and on worker satisfaction, it will be necessary to plan the characteristics of a certain job, of monitoring systems, of evaluation and enhancement of the work activity.

Therefore, the ultimate goal of agile work changes and becomes a prevention tool capable of containing the contagion from Covid-19.

In fact, due to the health emergency, we are witnessing the transition of the smart-working setting as it was conceived: as a tool for balance work and private life to a method of containment and prevention of Sars-CoV-2.

It should be remembered that Law no. 81/2017 says that: “the work is performed in part inside the company premises and partly outside without a fixed location, within the limits of maximum duration of daily and weekly working hours, deriving from the law and the collective bargaining “.

Contrary to what is said in the aforementioned law, since it is an emergency period, work performance is carried out exclusively at the worker’s home, because of the ministerial directives issued to protect workers and all citizens’ health.

Therefore, the “smart” part that characterizes the performance of this working method is lost.

So the drafting of a specific regulation o company agreement could be useful. Also the inclusion of a specific part dedicated to agile workers could help, involving the social partners in regulating worker’s behavior and the company towards him.

Workers who have the opportunity to carry out their work in an autonomous and diversified way are more motivated and more prepared to cope with stressful and pressure situations. The flexibility of hours and places of work promotes and increases employee satisfaction.

If the workload, equipment and workspaces are in line with the needs and requirements ability of a worker, the latter can be more productive and more confident in himself and for the company. If these characteristics are not in line, the worker is likely to feel overloaded; This can generate a state of stress and at the same time can make him lose motivation and create serious psycho/physical repercussions.

Smart-working must not be understood as a simple solution to complex problems; the availability of advanced technologies does not represent a guarantee of effectiveness, and the loss of place and time constraints does not result an automatic increase in the degree of freedom.

This research brings out the difficulties that many workers have found in this situation, also from a psycho-physical point of view, highlighting positives and negatives aspects of smart-working. The research highlights that complex problem need well thought out and well implemented solutions.

In this regard, 70.2% of the sample declares a load of excessive work, demonstrating that the loss of constraints related to the place and time of work is translated into an increase by the so-called “syndrome of the inability to unplug “, as well as a loss of the social dimension of work.

This means that a widespread and effective introduction of this way of working requires careful planning of organizational levers and compensation for the partial loss of sharing with colleagues. The “experiment” to which most individuals were subjected in this period of emergency can lead to the development of a more mature and more aware approach to smart-working. As can be seen in image 2, the stress response is a set of chain reactions that involves the nervous system, the hormonal system and the immune system of the individual subjected to stressors.

Fig. 31 – The stages of stress response

The survey allows to derive information on the extent of the work stress problem-correlated and on the perception of stress and psycho/physical stress-related conditions caused by smart-working during the pandemic period.

These informations could be helpful in raising awareness and making accountable future “intelligent” workers in carrying out their work optimally.

Also, if necessary, they could implement improvement and corrective actions. In this sense it is fundamental to discuss the information that emerged, with the need to interpret them with extreme caution. Indeed, the data collected are related to the condition of workers in a sudden and non-sudden pandemic situation budgeted, without agreement between the parties and without the necessary implementation measures; As a consequence it is impossible to draw precise conclusions even if it’s useful for preventive purposes.


  1. Dusi P. (2021). Smartworking: una trasformazione culturale, non solo un cambio del luogo di lavoro. Avaiable on: Videoconferenza Ambiente Lavoro [1° Dicembre 2021].
  2. ILO. (2020). Il telelavoro dopo e durante la pandemia di COVID-19. Avaiable on: https://www.ilo.org/wcmsp5/groups/public/—europe/—ro-geneva/—ilo-rome/documents/publication/wcms_756435.pdf [30 settembre 2020].
  3. Cappetta R., Del Conte M. (2020). Tutela del lavoro e emergenza da COVID-19. Lo smart working ai tempi del coronavirus. Avaiable on: https://www.treccani.it/magazine/diritto/approfondimenti/diritto_del_lavoro/Cappetta_DelConte_Tutela_del_lavoro_e_emergenza_da_COVID-19_Lo_smart_working_ai_tempi_del_coronavirus.html [31 marzo 2020].
  4. Reati A. (2020). Home working, emergenze e stress lavoro-correlato. Avaiable on: https://www.blog-hr.it/2020/03/16/home-working-emergenze-e-stress-lavoro-correlato/ [16 marzo 2020].
  5. Migliazza Studio Legale. (2021). Smart working e rischio stress lavoro correlato. Avaiable on: https://studiolegalemigliazza.it/smart-working-e-rischio-stress-lavoro-correlato/ [aggiornato il 12 giugno 2021].
  6. Papapicco C. (2020). La sindrome da Workaholism al tempo del lavoro agile. Avaiable on: https://www.stateofmind.it/2020/07/lavoro-agile-workaholism/ [28 luglio 2020].
  7. Guariniello R. (2020). Smart working: attenzione massima agli obblighi di sicurezza sul lavoro. Avaiable on: https://www.ipsoa.it/documents/lavoro-e-previdenza/sicurezza-del-lavoro/quotidiano/2020/10/05/smart-working-attenzione-massima-obblighi-sicurezza-lavoro [5 ottobre 2020].
  8. Chiappetta M. (2020). Il tecnostress. Definizione, sintomi e prevenzione del rischio. Avaiable on: http://www.benessere.com/psicologia/arg00/tecnostress.htm
  9. Regosa G. (2020). Lo smart working fa più male del lavoro in ufficio. Avaiable on: https://www.tecnostress.it/lo-smart-working-fa-piu-male-del-lavoro-in-ufficio.html [21 dicembre 2020].
  10. Regosa G. (2010). Ergonomia e Tecnostress. Avaiable on: https://www.tecnostress.it/ergonomia-e-tecnostress.html [14 febbraio 2010].
  11. Team Eis. (2020). Smart Working in Italia: cosa c’è da sapere. Avaiable on: https://www.teameis.it/voip/smart-working-italia/
  12. Ufficio Stampa. (2020). Un nuovo approccio alla tecnologia: EuTecno e smart working. Avaiable on: https://www.puntosicuro.it/sicurezza-C-80/pubbliredazionale-C-119/un-nuovo-approccio-alla-tecnologia-eutecno-smart-working-AR-16892/ [24 marzo 2017].
  13. Zonca R. (2020). Come si valuta lo stress sui luoghi di lavoro? Avaiable on: http://www.benessere.com/salute/arg00/valutazione_stress.htm
  14. Regosa G. (2020). Valutazione del Tecnostress. Avaiable on: https://www.tecnostress.it/valutazione-del-tecnostress
  15. Nous Srl. (2020). Le 3 B e le 4 leve: oltre il solito significato di smart working. Avaiable on: https://www.nous-srl.com/le-3b-e-il-reale-significato-di-smart-working/
  16. La Vacchia V. (2020). Smart Working: Definizione, caratteristiche e modello di Clapperton e Vanhoutte. Avaiable on: https://vitolavecchia.altervista.org/smart-working-definizione-caratteristiche-e-modello-di-clapperton-e-vanhoutte/
  17. Brusamolino L. (2019). Lo smartworking è molto di più che lavoro da casa. Avaiable on: https://www.ilfattoquotidiano.it/2019/02/06/lo-smartworking-e-molto-piu-che-lavoro-da-casa/4949063/ [6 febbraio 2019].
  18. Ferrari T., Gradinetti F., Martino N., Pellegrino C., Ruggeri C. (2019). Smart work e place. Avaiable on: https://www.slideshare.net/FreeYourTalent/smart-work-e-place [17 giugno 2019].
  19. QuiFinanza. (2020). Smart working senza stress: i consigli per lavorare al meglio. Avaiable on: https://quifinanza.it/interviste/smart-working-senza-stress-i-consigli-della-psicologa-per-lavorare-al-meglio/364191/ [23 marzo 2020].
  20. Solimene A. (2016). Che Differenza c’è tra Flexible, Agile, Remote e Smart Working? Avaiable on: https://www.linkedin.com/pulse/che-differenza-cè-tra-flexible-agile-remote-e-smart-working-solimene [20 novembre 2016].
  21. Pelucchi M. (2014). Smart working: come implementarlo in azienda. Avaiable on: http://www.mauropelucchi.com/blog/smart-working/ [5 dicembre 2014].
  22. UltraSpazio. (2017). Verso lo smart working: i 5 livelli di organizzazione del lavoro nelle aziende. Avaiable on: https://ultraspazio.com/verso_lo_smart_working1/ [17 febbraio 2020].
  23. Gruppo San Donato. (2021). Sindrome da bornout e smartworking: cos’è e come prevenirla. Avaiable on:https://www.grupposandonato.it/news/2021/febbraio/burnout-smartworking-cos-e [2 febbraio 2021].
  24. Corsisicurezza.it (2020). Tecnostress: definizione, cause, effetti, valutazione e rimedi. Avaiable on: https://www.corsisicurezza.it/blog/tecnostress-definizione-effetti-valutazione-rimedi.htm
  25. Salazar P. (2019). Smart working: aspetti di salute e sicurezza sul lavoro. Avaiable on: https://www.altalex.com/documents/news/2019/09/20/smart-working-aspetti-di-salute-e-sicurezza-lavoro [20 settembre 2019].
  26. Famlonga A. (2018). Lo stress: le sue origini, gli effetti e le sue soluzioni. Avaiable on: https://essereintegrale.com/stress/ [28 novembre 2018].
  27. Anfos. (2020). Assistenza sanitaria in azienda: il medico competente. Avaiable on: https://www.anfos.it/sicurezza/assistenza-sanitaria-in-azienda/
  28. Anfos. (2020). Catalogazione dei rischi aziendali. Avaiable on: https://www.anfos.it/sicurezza/catalogazione-dei-rischi-aziendali/
  29. Hse.gov.uk (2021). What are the Management Standards? Avaiable on: https://www.hse.gov.uk/stress/standards/ [11 maggio 2021].
  30. Regosa G. (2010). Tecnostress: ricerche sul rischio tecnostress. Avaiable on: https://www.tecnostress.it/ricerche-sul-tecnostress
  31. Regosa G. (2010). Definizione del Tecnostress. Avaiable on: https://www.tecnostress.it/definizione-del-tecnostress
  32. Accordo Interconfederale per il recepimento dell’accordo quadro europeo sullo stress lavoro-correlato concluso l’8 ottobre 2004 tra UNICE/UEAPME, CEEP e CES. (2008). Avaiable on: https://www.inail.it/cs/internet/docs/stress-lavoro-accordo-interconfederale.pdf?section=attivita [9 giugno 2008].
  33. Italian Tech. (2020). Che effetto fa lo smartworking? Stress, ansia e almeno un’ora di lavoro in più al giorno. Avaiable on: https://www.repubblica.it/tecnologia/2020/05/14/news/che_effetto_fa_lo_smart_working_stress_ansia_e_almeno_un_ora_di_lavoro_in_piu_al_giorno-256601448/ [25 maggio 2020].
  34. World Health Organization. (2019). Born-out an “occupational phenomenon”: International Classification of Diseases. Avaiable on:https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases [28 maggio 2019].
  35. Crespi F. (2020). Smart Working: vantaggi e svantaggi per l’azienda e per i lavoratori. Avaiable on: https://blog.osservatori.net/it_it/smart-working-vantaggi [9 dicembre 2020].
  36. Presidente Della Repubblica. (2017). Misure per la tutela del lavoro autonomo non imprenditoriale e misure volte a favorire l&#39;articolazione flessibile nei tempi e nei luoghi del lavoro subordinato. Avaiable on: https://www.gazzettaufficiale.it/eli/id/2017/06/13/17G00096/sg [22 maggio 2017].
  37. Inail. (2017). Lavoro agile. Legge 22 maggio 2017, n. 81, articoli 18-23. Obbligo assicurativo e classificazione tariffaria, retribuzione imponibile, tutela assicurativa, tutela della salute e sicurezza dei lavoratori. Istruzioni operative. Avaiable on: https://www.inail.it/cs/internet/docs/testo-integrale-circolare-n-48-del-2-novembre-2017.pdf [2 novembre 2017].
  38. Inail. (2020). Lavoro agile in emergenza tra smart working e telelavoro. Avaiable on: https://www.inail.it/cs/internet/comunicazione/news-ed-eventi/news/news-fact-sheet-smart-working-telelavoro-2020.html [18 giugno 2020].
  39. Ministero del Lavoro e delle Politiche Sociali. (2021). Smart Working. Avaiable on: https://www.lavoro.gov.it/strumenti-e-servizi/smart-working/Pagine/default.aspx
  40. Blog Osservatori.net (2020). Smart Working: il lavoro agile dalla teoria alla pratica. Avaiable on: https://blog.osservatori.net/it_it/smart-working-cos-e-come-funziona-in-italia
  41. Jack Nilles. Telèma n. 2. Avaiable on: http://web.tiscalinet.it/urban2/nilles2.htm#1
  42. Il recepimento dell’Accordo-quadro europeo. Telelavoro. http://erc-online.eu/wp-content/uploads/2014/04/2006-01444-EN.pdf [9 giugno 2004].
  43. Hartog L. (2015). Lo Smart Working raccontato da Erik Veldhoen: fondatore del concept in Olanda. Avaiable on: https://www.spremutedigitali.com/lo-smart-working-raccontato-da-erik-veldhoen-fondatore-del-concept-in-olanda-part-12/ [5 marzo 2015].
  44. Legislation.gov.uk (2014). The Flexible Working Regulations 2014. Avaiable on:https://www.legislation.gov.uk/uksi/2014/1398/made

The activity of the speech therapist at the time of COVID 19: survey of the Campania region


Submission Date: 2022-10-26
Review Date: 2022-11-10
Pubblication Date: 2022-11-14

The activity of the speech therapist at the time of COVID 19: survey of the Campania region


In the last century we have had six events between epidemics and pandemics that have in fact affected the human species causing numerous deaths, but above all have produced social, political and economic transformations along with medical and scientific discoveries. From the first, caused by the H1N1 virus, which raged from 1918 to 1919 under the nickname ‘Spanish’, to the devastating effects of the SARS-CoV-2 virus, or as we usually know it, Covid-19.

Severe Acute Respiratory Syndrome by Coronavirus-2 (SARS-CoV-2) is the name given to the new coronavirus of 2019, COVID-19 is the name given to the disease associated with the virus, an acronym thus explained CO” – Corona, “VI” – Virus and “Dfor Disease, while 19 stands for the year in which the virus was first identified. (G. Rezza, A. Bella, F. Riccardo, P. Pezzotti – Infectious Diseases Department, ISS, 2020)

It first emerged as an epidemic and was later declared a pandemic by the World Health Organisation (WHO) in March 2020.

Characteristics of this pathology are low mortality rates, while dangerousness, speed of expansion, and the creation of variants have brought enormous consequences at every level, causing all citizens and all professionals to find themselves in a suddenly peculiar situation. In line with what is indicated by the various DPCMs, rehabilitation activities, including speech therapy, have continued and all professionals, out of ethical and deontological responsibility, have carried out their professional activities both in the presence, through the use of PPE, and at a distance through telerehabilitation. The latter, which was not yet widespread and practised in Italy before, has created the need for a great capacity to reshape work. As highlighted by numerous studies, COVID-19 has significantly implied a large number of psychological consequences on the population (National Conference for a Community Mental Health, Ministry of Health, 2021). We can consider, therefore, that even more circumstances have subjected healthcare professionals to a significant increase in work stress, exposing them to a greater risk of psychological problems arising from the burden of caring for complex patients, the choice of separation from loved ones, the sudden change in care management directives and protocols and/or personal safety. In the light of all this, it was deemed appropriate to consider distributing a questionnaire among the speech therapists belonging to the TSRM-PSTRP professional association of Na-Av-Bn-Ce, investigating this phenomenon in different forms and circumstances that will be fully illustrated in the following paragraphs.

Materials And Methods

Questionnaire structure

The proposed questionnaire was structured in different areas: 6 items deal with the characteristics of the population (employment status, place of work, age, gender, qualification, years of work experience); 1 item investigates the way work was carried out during the first and second period of the COVID-19 pandemic; 3 items detect the Personal Protective Equipment (PPE) provided; 4 items deal with work-related stress; 3 items analyse emotional perception; 1 item studies the characteristics of work organisation; 1 item observes communication between colleagues; finally, 1 item concerns the need for psychological support.

The questionnaire is disseminated via the web thanks to the Google platform (at the link https://docs.google.com/forms/d/e/1FAIpQLSeiVncR4l3pbMfhIRDnR9BTH7M_48DS7mG81POQPKi_4xPnDQ/viewform?usp=pp_url), since 15/06/2020 trying to reach all speech therapists belonging to the interprovincial order of NA-AV-BN-CE. The data was collected up to 15/11/2020 and concerns 161 participants.

Population characteristics

The questionnaire reached 161 Speech Therapists in Campania, of whom only 8.1% were male (91.9% female). The participants’ ages ranged from 21-30 years (34.8%), 31-40 years (39.1%), 41-50 years (13.1%), 51-60 (13%) (Tab.1).

Tab. 1 – Age of participants

A high percentage of the population surveyed is employed in the private health sector on a salaried basis (82.61%), of which 18.66% state that they also work on a freelance basis. The remaining part of the population is employed in public healthcare (6.21%) and in free professional activity (11.18%) (Tab.2).

Tab. 2 – Occupational Status

The academic qualifications possessed by the majority of the population are the Degree in Speech Therapy (75.8%), the remainder have the University Diploma in Speech Therapy 1993-2003 (21.1%), and a small percentage have other University Diplomas in Speech Therapy 1983-1993 (3.1%) (Tab.3).

Tab. 3 – First qualification

Concerning the work experience gained, assessed in years, the analysis of the sample shows values in line with the ages of the respondents: 21.1% had up to 5 years of work experience, 37.3% were in the range of 6 to 10 years, 21.1% from 11 to 15 years, 6.7% from 16 to 20 years and the remainder (13.7%) more than 20 years of professional experience.


The questionnaire proposed to the speech therapists belonging to the interprovincial Order of NA-AV-BN-CE revealed the following values.

Work Activity

The work activity during the pandemic period was mainly carried out in the presence at the outpatient clinics (8.07% worked exclusively in the outpatient clinic and 1.86% carried out first no activity and then outpatient treatment) and in tele-rehabilitation (6.79% worked exclusively remotely and 0.6% carried out first no therapy and then tele-rehabilitation); a large proportion of the professionals used both combined working modes (64.12%). Only 5.6% of the participants continued with home-based activity (of whom 1.2% exclusively performed home-based therapy and 4.4% both outpatient and home-based), 1 participant (0.6%) worked in an RSA, 1 performed hospital-based treatment, 1 participant served in both inpatient ward and telerehabilitation, and 1 suspended all activities for two months and then resumed mixed outpatient and telerehabilitation. A percentage of 10.56% did not perform any type of activity.

Personal Protective Equipment (PPE)

The survey revealed the accessibility of various PPE, such as: sanitising gel (supplied to 90.7% of participants)*, gloves (80.7%)*, face shields (78.9%)*, surgical masks (77.6%)*, disposable labcoats (65.2%)*, FFP2 masks (50.9%)*, and disposable overalls (17.4%)*. Plexiglass breath guards and goggles (both 9.9%)*, socks (4.3%)* and FFP3 masks (1.9%)* were poorly supplied to speech therapists.

* percentages refer to the provision of individual PPE for each participant who worked during the COVID-19 pandemic period. The questionnaire gave, in fact, the possibility to flag all/some/none of the items entered. (to be put as a footnote)

A large majority of the interviewed colleagues considered that the IPRs concretely provided by the companies were sufficient. On a 4-point Likert scale (from ‘not at all’ to ‘very’), 24.2% considered the IPR provided to be absolutely sufficient, 41.6% quite sufficient, 26.1% not very sufficient and 8.1% not at all sufficient. Furthermore, the participants considered the PPE provided to be effective in ensuring their protection against COVID-19 infection (Table 4).

Tab. 4 – Perceived effectiveness of PPE provided
Work-related stress

The management of work-related stress is investigated by 4 items using a 4-point Likert scale (from ‘null’ to ‘high’), and concerns the level of frustration (Tab.5) and emotional overload (Tab.6) perceived by colleagues who used a remote working modality and by professionals who continued in an outpatient and/or home-based modality.

Both the level of perceived frustration and emotional overload were found to be more pervasive in the population that continued rehabilitation activities in the outpatient/domiciliary setting.

Tab. 5 – Job stress management: level of frustration
Tab. 6 – Job stress management: level of emotional overload
Emotional perception

The 3 items which study the emotional perception of the Speech Therapists surveyed, show (on a 4-point Likert scale, from “not at all” to “very much”) a high level of concern regarding the possibility of being a vehicle of contagion for family members (57.8% “very much”, 33.5% “quite a lot”, 6.2% “a little”, 2.5% “not at all”); a strong emotional influence determined by social isolation (51.6% “very much”, 32.59% “quite a lot”, 10.6% “a little”, 5% “not at all”) and a medium/high perceived risk of developing psychological symptoms – such as distress, depressive symptoms, insomnia, anxiety – (34.2% “a lot”, 47.2% “quite a lot”, 16.8% “a little”, 1.9% “not at all”).

Work organisation

One item investigated the characteristics of the company organisation in which the speech therapists interviewed carry out their activities, referring in particular to the aspects that have negatively influenced performance during the pandemic period. 72.6% of the population believed that inadequate remuneration associated with work overload and unsuitable working hours and shifts (of which 53.4% also associated it with a lack of planning), were the main reasons that generated negative feelings and work-related discomfort. The remaining part of the population believes that it is the management and control methods, associated with non-professional specific operational demands, that negatively influence work. Finally, about 3% of the population lists internal conflicts as the main reason for discomfort.

Relations between colleagues

In the working environment, a change in the relationship of collaboration, dialogue and support between colleagues was detected, perceived as ‘fairly permeating’ by 40.4% of the pandemic population (24.2% ‘not at all’, 27.3% ‘a little’, 8.1% ‘a lot’).

Psychological support

All the Speech Therapists interviewed in the medical emergency period consider it necessary to have a support figure in managing the emotional burden (Tab. 7).

Tab. 7 – Professionals’ need for a support figure in managing emotional burden


The proposed questionnaire made it possible to observe phenomena, for the most part expected, that affected speech therapists in Campania. In fact, part of the extrapolated data traced what were the governmental indications transposed in the first pandemic waves. The majority of Speech Therapists affirmed that, in line with national and regional directives, they carried out activities in telerehabilitation and in outpatient regimes, that they kept non-deferrable and non-remote treatments in outpatient clinics and at home, and at the same time implemented the telerehabilitation treatment modality (which had previously been adopted little or not at all in the Campania region’s territorial speech therapy). Telerehabilitation as an acceptable alternative to non-medication has shown several positive aspects: the protection of one’s own and others’ health, less emotional distress arising from the fear of illness, therapeutic continuity and the vision of the home as a place of care. The orientation of digital health care, represented in our case by tele-rehabilitation, is also an effective resource with respect to the critical evolution of the epidemiological context.

Many professionals claimed to have been provided with recommended and/or mandatory devices, which differed according to the type of treatment performed.

Work-related stress, understood both as the level of frustration and emotional overload, was greater for outpatient and home treatments than for remote treatments; the latter, although requiring a strong adaptive capacity, reorganisation of work and remodelling of rehabilitation treatment, eliminated the variable of fear of falling ill and of being a vehicle for the virus. In fact, a very high percentage of participants stated that they were worried about being a vehicle of infection for their family members (and we may assume for the frail elderly), that they strongly suffered from social isolation (in treatment and rehabilitation pathways characterised by multidisciplinary care), and that they feared the development of psychological discomfort deriving from the pandemic from specific professional activities. To exacerbate the situation, further elements of a changed company organisation have strongly impacted on Speech Therapists: a salary defined as inadequate with respect to working hours and work overload turns out to be one of the propelling factors for negative feelings.  On the other hand, the data on dissatisfaction with inadequate pay is not significant, as it is not linked to the specific time of the pandemic.

We can interpret this element by referring it either to a pre-pandemic situation, already unrewarding for the practitioner, or by associating it with the additional tasks required: disinfecting materials and media between one patient and the next, using PPE correctly and monitoring its proper use also by patients/family members/ carers, rescheduling work and the type of activity, using different computer media, etc…

The final question needs special attention: most professionals state that it would be desirable to have a psychological support figure to manage the personal manifestations described above. The presence of support becomes crucial in an emergency period, where the exacerbation of negative feelings affects all parts of society, aggravating the conditions of the classes of professionals exposed to greater risk. The work management resulting from caring for patients and their families, the need to preserve the network of educational and sociomedical integration to achieve objectives, frustration and emotional overload, expose all professionals involved in helping relationships to the phenomenon of burnout. The need for psychological support aimed at overcoming emotional distress and the feeling of isolation due to poor communication between team members must lead one to reflect on the potential lack of individual tools of savoir être: elements that characterise the health professions and are indispensable for operating according to principles of therapeutic effectiveness.


The questionnaire proposed to speech therapists in the Campania Region did not return the expected form of participation. Out of 1650 speech therapists operating in the Naples, Avellino, Benevento and Caserta areas, only 161 replies were received (9.76%). The data extrapolated refer, therefore, to raw and uncorrelated percentage variables of a partial population (only Campania, predominantly female, in the 21-40 age bracket). 

This makes the results rather meagre, numerically unreliable and therefore not generalisable, so we have focused only on observed data and qualitative considerations.                                                                                                      

Interesting phenomena were noted: the new organisation of work, the different way in which rehabilitation treatments are delivered, the potential of telerehabilitation in terms of outcome, and the difficulty in managing the emotional burden.

The questionnaire was proposed as a pilot study to assess its usability and accessibility by colleagues.

For this reason, it lacks validation, as it would have been necessary to carry out a statistical analysis to assess consistency, internal consistency and reliability and to test-retest the test population.

Further research is needed to validate the proposed instrument, examine a larger and more representative population, and perform a statistical analysis of the data in order to establish evidence-based results.


  1. Cantelmi, T., Lambiase, E., Pensavalli, M., Laselva, P., & Cecchetti, S. (2021). Covid-19: Impact on Mental Health and Psychosocial Support. MODELS OF THE MIND, (1), 7-39. https://doi.org/10.3280/mdm1-2020oa10908.
  2. Li, S., Wang, Y., Xue, J., Zhao, N., & Zhu, T. (2020). The impact of covid-19 epidemic declaration on psychological consequences: A study on active weibo users. International Journal of Environmental Research and Public Health, 17(6), 2032. https://doi.org/10.3390/ijerph17062032.
  3. Morelli, N., Rota, E., Immovilli, P., Spallazzi, M., Colombi, D., Guidetti, D., & Michieletti, E. (2020). The hidden face of fear in the COVID-19 ERA: The amygdala hijack. European Neurology, 83(2), 220-221. https://doi.org/10.1159/000508297.
  4. Rossi, R., Socci, V., Pacitti, F., Di Lorenzo, G., Di Marco, A., Siracusano, A., & Rossi, A. (2020). Mental health outcomes among frontline and second-line health care workers during the coronavirus disease 2019 (covid-19) pandemic in Italy. JAMA Network Open, 3(5). https://doi.org/10.1001/jamanetworkopen.2020.10185.
  5. Sarcletti, E., & al., et. (2021). Emotional Impact of Covid-19 on Health Care Workers and Psychological Protection Devices: What Have We Learned? JHA – Journal of HIV and Ageing. https://doi.org/10.19198/jha31518
  6. Spices, M., & Bragantini, D. (2021). Promoting a Pandemic Risk Prevention System in Health Organisations post covid-19. PROJECT MANAGER (THE), (48), 5-9. https://doi.org/10.3280/pm2021-048002

Clinical risk management in the 99m-Tc-MIBI quality control procedure in nuclear medicine. Case study.


Submission Date: 2022-11-07
Review Date: 2022-11-10
Pubblication Date: 2022-11-12


The aim of the work is to highlight and confirm the importance of quality controls on radiopharmaceuticals in nuclear medicine, a mandatory step, not only from a legal point of view, but also from an ethical point of view in order to guarantee patients the injection of suitable radiopharmaceuticals. for use and useful for diagnosis. We want to report the case of the U.O.C. of Nuclear Medicine of the “Moscati” Hospital of Avellino, following the arrival of a new batch of the vector MIBI (methoxy-isobutylisonitrile), used for the execution of cardiac tomoscintigraphies and parathyroid scintigraphies, which showed, at the first quality controls, a discrepancy in the graph depicting the impurities. Moreover, at times, an incorrect physical control in terms of opacity of the preparation has also been documented. Problem solving has shown the usefulness of quality controls also in the context of clinical risk management.

Materials and methods

The case was observed after the arrival of a new batch of MIBI vector (methoxy-isobutylisonitrile) from a company other than the one that usually supplied the vector to the department with the observation, already from the subsequent, first, quality controls on the preparations carried out for the execution of cardiac tomoscintigraphies and parathyroid scintigraphies of a variation in the normal graph depicting the impurities present within the drug labeled with 99mTc with, specifically, the presence of an initial impurity peak, before the actual and corrected peak indicated in the quality control leaflet. The procedure we used with the Radio-TLC method consists in placing 3-4 ml of Ethanol in a beaker. Using a 1 ml syringe, a drop of ethanol is placed on an aluminum oxide strip 1.5 cm from the lower edge. A drop of 99mTc-MIBI solution is deposited over the drop of ethanol. The chromatography is then developed up to 5.0 cm from the deposition point and the graph relating to the radiochemical purity is obtained. The latter is calculated by setting two areas on the graph and obtaining the relative result which must be greater than 94% for a good radiopharmaceutical preparation. In our specific case, it was tried with various tools to understand the appearance of this anomalous peak which reappeared, in an almost similar way, with each preparation carried out by different operators. The quality control procedure was therefore examined by trying to modify the materials required, for example by modifying the quality of the strips used for chromatography, by modifying the structure or by drying them to eliminate any impurities inherent in the strips themselves.

Fig. 1, 2, 3, 4, 5, 6 Comparison of quality controls with dried (1, 2, 5 and 6) and non-dried (3 and 4) strips.

Even by implementing these changes in the procedure it was observed, however, that the anomalous impurity peak was not eliminated and, on the contrary, remained almost stable in its shape and structure. Only after repeated checks did the 99mTc labeling procedure be examined, faithfully following the leaflet relating to the preparation and labeling of the drug. In this regard, we remind you that the procedure involves the injection of 1-5 ml of Sodium Pertechnetate Tc-99m into the vial of the MIBI kit. The vial is then shaken vigorously 5-10 times and placed in the heating block. After 10 minutes of boiling it is extracted and left to cool down to room temperature and then extract the necessary doses. Attention was therefore focused on the particularity that characterizes MIBI and that the other preparations do not have, namely the boiling of the tracer after marking. Specifically, the resistance boiling system available to the department was analyzed and it was noted that the vial containing the tracer did not adhere to the walls of the housing in which the resistance for heating the product was positioned, causing a yoke and a movement of the vial which could, in hypothesis, then confirmed, determine a non-homogeneous and incorrect heating and boiling of the product, consequently. Moreover, since it was necessary to specifically analyze the oven for boiling, it was decided to check the actual temperature reached and indicated by the display on the front of the equipment; then with a specific thermometer provided by the Clinical Engineering service the temperature was monitored, noting, from the first measurement, an excess difference of about 10 ° centigrade with respect to the temperature marked on the display. The bias research method ultimately led to the discovery of an anomaly in the operation of the equipment and a procedural error in the preparation and, specifically, in the boiling of the radiopharmaceutical. Therefore, a request was made to the Clinical Engineering service of the Hospital to send, if possible, a “shirt”, promptly made available, of conductive material, specifically a copper reducer, to be inserted in the oven housing. resistance to obtain a perfect adherence of the vial to the walls and a consequent homogeneous heat distribution. To confirm and verify the presence of the error in the procedure and consequent boiling, we tried to mark the vector and boil the radiopharmaceutical in a bain-marie on a normal kitchen oven, at effective temperature, noting, at the next quality control, the disappearance of the peak anomalous present at the beginning of the investigation and a radiochemical purity of over 95%, with the graph expected from the leaflet. The problem of measuring the temperature by the resistance stove has been solved by setting a temperature 10 ° centigrade higher than the expected one in order to be sure to get to the boiling of the compound which, remember, needs 10 minutes of boiling. Finally, with the appropriate reducer, the quality control was carried out, verifying what had already been hypothesized with the heating in a bain-marie, i.e. that the adhesion of the vial to the heat source and the reaching of the actual temperature that had not previously been observed affects on the labeling and binding of molecules and on the consequent good quality control.

Fig. 7 – MIBI quality control with copper reducer and confirmation of radiochemical purity.

Results and discussion

This investigation has allowed, even more, to confirm how a careful analysis of the compounds prepared in nuclear medicine, combined with the attention of the staff assigned to quality controls and good preparation rules, allows to eliminate bias and errors that would lead to production of a radiopharmaceutical unsuitable for use on patients. The legislative aspect is fundamental, especially in Nuclear Medicine, a method that presents, in addition to the acquisition of PET scintigraphic and tomographic examinations and quality controls on equipment, an important section dedicated to the preparation and quality controls of radiopharmaceuticals used for the acquisition of the exams and which brings with it a professional and ethical responsibility on the part of all personnel operating in Nuclear Medicine who administer and prepare the radiopharmaceuticals (Nuclear Doctor, TSRM, nurses). Furthermore, it has been confirmed that the competence and collaboration between the services and the operating units, in terms of tools and knowledge, always leads to results and resolution of problems in a short time.


The article is based on work procedures and protocols applied in the U.O.C. of Nuclear Medicine of the Hospital of National Relief and High Specialty “San Giuseppe Moscati” of Avellino. The text is the production and intellectual property of the authors.


  1. Italian and European Pharmacopoeia. Procedure for marking and quality control of the radiopharmaceutical 99mTc-MIBI.

4D Free-Breathing Sequence For The Study Of Pancreatic Lesions In MRI 3 Tesla

Article Navigation

Submission Date: 2022-10-02
Review Date: 2022-10-05
Pubblication Date: 2022-10-08



Pancreatic cancer is the fourth leading cause of cancer death in both the United States and Europe. A fundamental role in the characterization, early diagnosis, and staging of pancreatic cancer is played by Magnetic Resonance. An innovative and recently implemented sequence, the 4D Free-Breathing sequence, is demonstrating remarkable efficiency in the characterization of pancreatic lesions, as it allows to obtain images with high temporal resolution on the arterial phase, maintaining high spatial and temporal resolution, with the patient free breathing and with compensation of respiratory movement artifacts. The aim of this study was to analyze the 4D Free-Breathing sequence technique and to evaluate its advantages in terms of image quality and diagnostic value in the characterization of pancreatic lesions. The 4D Free Breathing sequence replaces the acquisition of the classic arterial post-contrast phase obtained with the 3D-THRIVE sequence: after a first acquisition of the k-space data in the non-contrast phase (lasting 58 seconds), multiple arterial subphases, each one lasting about 5 seconds, will be acquired with a complete coverage of the post-contrast phase of about 90 seconds. This sequence exploits the k-space sampling technique called "Stack of Stars", based on a radial sampling in the XY plane. In detail, along the slice phase-encoding direction (kz), uniform Cartesian-grid sampling is maintained. Within each kz-encoded plane, radial data is collected with consecutive views (1 per sequence repetition time TR) rotated by a golden-angle of 111.25°, allowing the sampling of a complete circle, also determining a considerably reduced presence of breath artifacts.


Malignant pancreatic neoplasms, and particularly pancreatic ductal adenocarcinoma, are ranked as the fourth leading cause of cancer death in both the United States and Europe. This high percentage of mortality is due to several factors, including the difficulty of obtaining an early diagnosis. Indeed when lesions cause symptoms, the neoplastic mass in most cases has already reached a considerable size, and it will have already infiltrated adjacent structures. The latter is probably related to the anatomical position: the pancreas is located deep in the abdomen, close to vital vascular structures, which will most likely be involved in the early course of the disease. A fundamental role in the characterization of pancreatic neoplasms is played by diagnostic imaging, which over the years is undergoing a progressive evolution, allowing a diagnosis as early as possible of any malignant lesions needed for appropriate therapies aiming tumors ‘regression. The application of Magnetic Resonance Imaging (MRI) allows to obtain images with high spatial and contrast resolution, without the use of ionizing radiation. To date, in the pancreas study protocol, an innovative sequence is used, namely the “4D Free Breathing” which, through the “stack of stars” sampling technique, allows to acquire multiple arterial phases, with free-breathing and compensation of respiratory movement artifacts, obtaining a greater capacity for correct identification and characterization of lesions. A diagnosis as accurate and early as possible translates into the possibility of adopting therapeutic procedures as targeted as possible.

The aim of this study is to analyze the 4D Free-Breathing sequence technique and evaluate the resulting image quality and diagnostic advantages in the identification and characterization of pancreatic lesions.

Methods And Technical Description

We will describe the technical and technological principles of the 4D Free-Breathing sequence and the MRI pancreatic study protocol performed at our Radiology Unit (“Paolo Giaccone” Polyclinic University Hospital of Palermo), using a 3-T MRI scanner (Philips Ingenia, Philips Healthcare, Eindhoven). Representative images of modern 4D Free-Breathing sequences will then be shown. Finally, the main advantages of applying this sequence in MRI protocols for the study of the pancreas emerging from the analysis of the scientific literature will be discussed.


4D Free-Breathing Sequence: k-space technique and sampling

The 4D Free-Breathing sequence allows to obtain in “Real-Time” different acquisitions in the arterial phase of high quality in terms of Temporal, Contrast and Spatial Resolution, without requesting respiratory apnea, unlike the conventional 3D-THRIVE sequence which employ the Breath-Hold and/or Trigger Gating modalities. This allows a more accurate characterization of pancreatic lesions with the post-contrast study, even in poorly compliant patients.

This sequence uses the sampling technique called “Stack of Stars”, based on a radial sampling of the k-space in the XY plane, unlike the “classic” sequences used for the study of dynamics post-contrastographic, such as the 3D-THRIVE, which are based on a Cartesian type k-space sampling in the XY plane with an associated sequential phase shift along the Z axis to sample again in a Cartesian sequential manner on the XY plane (Fig. 1).

Fig. 1 – Representation of the two different types of sampling. Respectively “2D Cartesian sampling” (left); “2D radial sampling” (right)

The name of the sampling technique called “Stack of Stars”, specific to the 4D Free-Breathing sequence, is due to the way in which the K-space data are sampled (Figs 2 and 3). In fact, unlike the Cartesian sampling which collects data in a sequential manner, this technique allows to collect the K space data, figuratively forming a star, in which each ray will pass rigorously through the center.

It is defined as the golden angle technique, that is a radial sampling with rays always passing through the center, which are spaced from each other with an angle of 111.25 °, defined as golden angle, so called because by exploiting this angle it is possible to sample a full circle, covering only 180 °. The golden angle corresponds to 180° multiplied by the golden ratio.

Fig. 2 – Graphical representation of the “Stack of Star” data sampling method

Resuming, along the slice phase-encoding direction (kz), uniform Cartesian-grid sampling is maintained. Within each kz-encoded plane, radial data is collected with consecutive views (1 per sequence repetition time TR) rotated by a golden-angle of 111.25°, allowing the sampling of a complete circle, The center of each continuously sampled K-space will carry with it along the z axis, in addition to the data relating to the contrast resolution, also the information of the data relating to the respiratory movement which, through the Fourier Transform, along the slices, will determine an estimate of the data over time, which will allow the artifacts related to the patient’s free breath to be corrected through a data system analysis during the dynamic contrast phase.

The 4D Free-Breathing sequence then uses the core data as the midpoint of respiratory motion estimation. The use of the golden angle, that is a radial sampling with rays always passing through the center, which are spaced from each other by 111.25 °, capable of sampling a complete circle, determines a considerably reduced presence of artifacts from an incorrect respiratory movement.

Fig. 3 Graphic representation of the golden angle in the various “stacks” in the various time intervals. It can be seen that, from one “stack” to the next, the gradation of the orientation varies by 111.25 ° (value of the golden angle).

Table 1 shows in detail the acquisition parameters of the 4D Free Breathing sequence. This sequence replaces the acquisition of the classic arterial post-contrast phase obtained with the 3D-THRIVE sequence. In particular, after a first acquisition of k-space data in the pre-contrast phase (lasting 58 seconds), with substantially equal in-plane resolution and slice thickness compared to the classic 3D-THRIVE, multiple (18 in our study protocol) arterial subphases, each lasting about 5 seconds, will be acquired, with a complete coverage of the post-contrast dynamics of about 90 seconds.

Tab. 1 – Acquisition parameters for the sequence 4D Free-Breathing in the pancreas MRI study (MRI 3T, Philips Ingenia, Philips Healthcare, Eindhoven).

MRI study protocol of the pancreas with 4D Free-Breathing sequences

The MRI study protocol of the pancreas performed at our Radiology Unit using the Philips Ingenia 3-T Magnetic Resonance Scanner (Philips Healthcare, Netherlands Eindhoven), equipped with combined gradients with 45 mT/m of amplitude and 200 mT / m / ms of slew rate, is reported below.

The receiving coil used is a dStream TORSO coil surface coil, composed of a front and a rear FlexCoverage coil, which allows to obtain a body coverage of 56 cm and to adopt a maximum of 32 channels, positioned centrally to the area of ​​interest so as to capture a signal as broad and homogeneous as possible from the district concerned. The protocol used for a pancreatic study in 3 Tesla Magnetic Resonance, provides the following sequences: coronal T2 TSE-SSh, axial T2 MVXD, axial T2 SPIR MVXD, axial dual FFE OP-IP (BH), 3D MRCP RT, 2D MRCP Radial, mDIXON-Quant (BH), axial DWI, and finally DIXON dynamic and 4D Free-Breathing after the administration of an extracellular gadolinium-based contrast agent, these latter with the temporal scheme described in detail in Figure 4.

Fig. 4 – Graphic representation of the non- and post-contrast phases in the sequences: m-DIXON basal, 4D FreeBreathing, m-DIXON Thrive PORTAL, m-DIXON Thrive LATE 3 minutes, distinguishing the three main sections of the pancreas: head, body and tail

Discussion And Conclusions

The use of the 4D Free-Breathing sequence in the pancreatic study protocol means that radial acquisitions are significantly less susceptible to movement, thus allowing examinations to be performed without the usual respiratory apneas. Furthermore, this free-breathing technique, eliminating problems related to the patients’ possible difficulties in holding their breath correctly, allows to minimize the failure rates, related to breath artifacts, especially for non-compliant or elderly patients, or patients with respiratory pathologies, allowing to obtain an imaging with high contrast, spatial and temporal resolution. The rapid acquisition allows to optimally compensate for all types of movements, such as those due to the physiological intestinal peristalsis or to the patient’s difficulty in maintaining the necessary immobility. The image artifacts, which can appear as streaks, or as blurring, in particular in a restricted anatomical volume and particular in its morphology, such as that of the pancreas, can in fact invalidate the diagnostic evaluation, making it difficult to identify and distinguish the anatomical structures and any focal pancreatic tumor lesions. The arterial post-contrast phase is a crucial phase, which allows for example the differential diagnosis between neuroendocrine tumors, which frequently show early arterial enhancement and subsequent rapid wash-out, and adenocarcinomas, which are hypointense compared to the remaining pancreatic parenchyma.

Routine clinical use of sequences employing stack of star sampling techniques is feasible with current MRI systems and can serve as a replacement for conventional T1-weighted fat-suppressed sequences in applications where motion is likely to degrade the image quality.

This particular sequence plays an important role not only in pancreatic imaging, but more generally in abdominal imaging considering that the information of the arterial phase is frequently fundamental for a correct and accurate diagnosis of pathologies and that the conventional single arterial phase obtained with 3D THRIVE sequence is not infrequently inadequate for small movements of the patient or for errors in the temporal acquisition of the sequence.

These problems mentioned so far are therefore overcome by including the 4D Free-Breathing sequence in the examination protocol, since through the rapid and consequential acquisitions of 18 arterial phases, each one lasting 5 seconds, it is possible to capture and identify the maximum saturation point of the contrast media in the arterial circulation, with free-breathing, therefore also suitable for non-compliant patients and with correction of breathing artifacts.


  1. Du J, Carroll TJ, Brodsky E, et al. Contrast-enhanced peripheral magnetic resonance angiography using time-resolved vastly undersampled isotropic projection reconstruction. J Magn Reson Imaging 2004; 20:894-900
  2. Chandarana H, Block KT, Winfeld MJ, et al. Free-breathing contrast-enhanced T1-weighted gradient-echo imaging with radial k-space sampling for paediatric abdominopelvic MRI. Eur Radiol 2014; 24:320-326;
  3. Wu X, Raz E, Block KT, et al. Contrast-enhanced radial 3D fatsuppressed T1-weighted gradient-echo (Radial-VIBE) sequence: a viable and potentially superior alternative to conventional fatsuppressed contrast-enhanced T1-weighted studies of the head and neck. Am J Roentgenol 2014:in press;
  4. Chandarana H, Heacock L, Rakheja R, et al. Pulmonary nodules in patients with primary malignancy: comparison of hybrid PET/MR and PET/CT imaging. Radiology 2013; 268:874-881
  5. Lustig M, Donoho D, Pauly JM. Sparse MRI: the application of compressed sensing for rapid MR imaging. Magn Res Med 2007; 58:1182-1195;
  6. Pipe JG. Motion correction with PROPELLER MRI: application to head motion and free-breathing cardiac imaging. Magn Reson Med 1999; 42:963-969;
  7. Cre′millieux Y, Briguet A, Deguin A. Projection-reconstruction methods: fast imaging sequences and data processing. Magn Reson Med 1994; 32:23-32;
  8. Mistretta CA, Wieben O, Velikina J, et al. Highly constrained backprojection for time-resolved MRI. Magn Reson Med 2006; 55:30-40;
  9. Handarana H, Block KT, Rosenkrantz AB, et al. Free-breathing radial 3D fat-suppressed T1-weighted gradient echo sequence: a viable alternative for contrast-enhanced liver imaging in patients unable to suspend respiration. Invest Radiol 2011; 46:648-653;
  10. Azevedo RM, de Campos RO, Ramalho M, Here′dia V, Dale BM, Semelka RC. Free-breathing 3D T1-weighted gradient-echo sequence with radial data sampling in abdominal MRI: preliminary observations. AJR Am J Roentgenol 2011; 197:650-657
  11. 4D Real-Time GRASP MRI at Sub-Second Temporal Resolution, Li Feng, Biomedical Engineering and Imaging Institute and Department of Radiology, Icahn, School of Medicine at Mount Sinai, New York, NY, United States

Refocus flip angle modulation on the pd tse sequences in the magnetic resonance imaging of the knee, for the evaluation of meniscal injuries

Article Navigation

Submission Date: 2022-07-25
Review Date: 2022-11-29
Pubblication Date: 2022-07-30



The Radiofrequency Refocused Echo Spin-Echo Echo-Train Rapid-Acquisition sequences, known as Turbo Spin Echo or Fast Spin Echo are the most commonly used sequences in Magnetic Resonance as they provide a notable contribution in morphological and anatomical terms, thanks to their high spatial and contrast resolution. Furthermore, they allow a higher signal noise ratio than the other families of sequences thanks to the numerous refocusing pulses and thanks to a TR so long as to allow sampling as many K-space phase encodings as possible and with a complete recovery of the Longitudinal Magnetization. Finally, the multiple 180 ° pulses of these sequences reduce the inhomogeneities of the Magnetic Field by minimizing the phenomena of magnetic susceptibility. However, their application, especially in scanners with a high intensity of static magnetic field B0(1.5T and/or 3T)is prevented by the deposition of RF due to the long echo trains, which sometimes involve exceeding the limits of the specific absorption rate for patient safety. Over time, a common solution to the SAR problem has been the use of refocusing angles smaller than 180°(160°-140°-120°),which lead to its reduction at the cost, however, of an obvious penalty in terms of signal-to-noise ratio. In this study we present a modulation method of the Refocus Flip-Angle applied to the DP-TSE sequences in the evaluation of meniscal lesions in the study protocol of the Magnetic Resonance of the Knee, which exploits the phenomenon of the Pseudo-Steady-State(PSS), leading to a noticeable SARreduction without loss of SNR and also providing excellent contrast resolution.


Magnetic Resonance is currently the method of choice in the study of joint pathology, as it is a non-invasive, multiplanar and multiparametric method. The high contrast resolution associated with a high sensitivity for pathological areas and excellent tissue characterization allows extreme diagnostic precision, assuming a role of primary importance in the diagnosis of numerous pathologies. The knee is one of the most studied joints in MRI. It is estimated that about 80-90% of meniscal tears are of a traumatic nature following sports activity and 10-20% of a degenerative nature following degradation due to dehydration with increasing age. The FSE/TSE sequences, in particular those weighted in proton density, are the most used sequences in MRI for joint study, as they allow excellent tissue discrimination (tendons, ligaments and menisci). However, one of the main limitations of these sequences is the excessive heating of the tissues, a direct consequence of a large number of 180 ° iRF echo trains (ETL 15-40). It is known that the energy deposition of an RF pulse is proportional to the square of the inversion angle (α2): this means that a 180 ° pulse deposits a SAR 4 times higher than one pulse at 90 °. To overcome this problem, various strategies have been applied over time with the aim of limiting the SAR, among these the reduction of the refocusing angle with fixed Flip Angles, has allowed lower SAR levels but with an evident reduction of the MR signal. In our study we have implemented various strategies to optimize the contribution of the signals coming from the components of the Mx and My magnetizations, in particular by modulating the Refocus Flip Angle at variable angles with the aim of exploiting the Pseudo -Steady-State (PSS) phenomenon. This strategy allowed to obtain a better visualization (contrast resolution and higher SNR) of the meniscal lesions in the TSE PD sequences of the knee MRI, thus obtaining, with a low SAR and within the expected limits, a more sensitive and specific imaging.


The aim of our study was to modulate the Refocus Flip Angle parameter, exploiting the phenomenon of PSS, applied to the TSE PD sequences, in the MRI of the knee, to obtain a better visualization of the meniscal lesions, achieving a more sensitive and more specific imaging, compared to TSE PD sequences with constant refocusing angles and less than 180°.

Materials And Methods

MRI examinations of the knee were performed at the Department of Radiology of the University hospital “Paolo Giaccone” of Palermo, using a Philips Achieva 1.5 T Philips Healthcare MRI scanner.

The receiving coil used is the Knee-Coil SENSE 8ch, within which the knee under examination is allocated.

Ten volunteer patients underwent MRI of the knee. The examinations were performed after the volunteer patients were properly and adequately informed about the study in progress, and duly signed the informed consent. The various sets of sequences for a single patient were performed in several sessions with an interval of approximately 7 days.

The joint study protocol (standard), carried out at our Institute, provides for the acquisition of Ax T2 TSE, Ax PD TSE SPAIR, Sag DP TSE, Sag T1W, Sag TSE STIR, Cor PD TSE and PD TSE SPAIR sequences.

In the PD-weighted sequences acquired in the coronal and sagittal planes we modulated the Refocus Flip Angle parameter, with the aim of obtaining a better visualization of meniscal lesions. In particular, we started with a set of images with classic 180 ° refocusing iRF, comparing it with a further 3 fixed angle sets at 160 °, 140 ° and 120 ° in terms of SAR and SNR ratio. Finally, we acquired a series in which we modulated the Refocus Flip Angle, by linearly varying the tilting angles from low values ​​of 60 °, then intermediate values ​​of 90 °, to high values ​​of 110 ° along the echo train.

Classically, with the 180 ° iRF pulses the transverse magnetization (TM) is completely and entirely refocused without any contribution from the longitudinal magnetization (LM), instead reducing the RF flip angles below 180 °, there will be a situation in which we will have both the TM and the LM. This implies that at each subsequent cycle of pulses there will be a refocusing contribution of the deflected TM, but also of the “stored” LM, which together with the TM will contribute to the generation of the echo signal. Each subsequent pulse other than 180 ° in the train of echoes will continue to divide the magnetization into longitudinal and transverse components. With this strategy we ensure that the echoes stimulated by the longitudinal component are stored and sampled in the phase encodings with low amplitude (more useful data) thus obtaining a generation of MR signal with more essential information.

In particular, the three parameters, which play a fundamental role in the PSS phenomenon, are the values ​​attributed to the overturning angles along the train of echoes. We will pass in a linear way from a minimum α value, which allows to reduce blood vessel flow artifacts, which would deteriorate the quality of the images and we will then proceed with an intermediate α value, which allows to maintain the relaxation time T2 constant when the signal of the central portion of the k space is sampled, thus obtaining a better resolution of contrast of the image. Finally, we will move on to the maximum α value, thanks to which we will have a higher SNR and, therefore, greater image sharpness.

Fig. 1 – Representative diagram of the variation of the refocusing angle in relation to the MR signal. In the first case (pink) 180 ° iRF pulses are used, in the second case (blue) 160 ° iRF constant pulses are used, in the third (green) and fourth (light blue) lines iRF pulses at 140 ° and 120 ° respectively are used. In red, on the other hand, a strategy with variable refocusing angles (60 ° / 90/110 °) is applied. Theoretical signal intensities are shown below (ignoring T1, T2 and off-resonance effects)


With the implementation of the modulation of the Refocus Flip Angle, following the values ​​α equal to 60 ° – 90 ° – 110 °, identified through the various tests performed at our Institute, as regards the visualization of meniscal lesions, better results were obtained in the series of images acquired in terms of both of contrast resolution and signal/noise ratio, with a considerable reduction in SAR. Tables 1-3 below show in detail, for the PD TSE sequences of the knee MRI protocol, the acquisition parameters compared between the standard sequences with the use of constant Refocus Flip Angle, and the sequences with the application of the technique of the modulation of the Refocus Flip Angle with tilting angles of 60 ° -90 ° -110 °.

Tab. 1 – Acquisition parameters related to the Ax PD TSE SPAIR sequence of the MR study of the knee, with constant Refocus Flip Angle, and with the Refocus Flip Angle modulation technique.
Tab. 2 – Acquisition parameters related to the Cor PD TSE sequence of the MR study of the knee, with constant Refocus Flip Angle, and with the Refocus Flip Angle modulation technique.
Tab. 3 – Acquisition parameters related to the Cor PD TSE SPAIR sequence of the MR study of the knee, with constant Refocus Flip Angle, and with the Refocus Flip Angle modulation technique.
Tab. 4 – Acquisition parameters related to the Sagittal PD TSE sequence of the MR study of the knee, with constant Refocus Flip Angle, and with the Refocus Flip Angle modulation technique.

In figure 2 it is demonstrated how, by reducing the FA from a classic value of 180 ° to 120°, the RM signal is progressively reduced, while applying the strategy of a Variable Flip Angle the RM signal is excellent.

Fig. 2 – Comparison of various refocusing angles applied to images acquired with a 1.5T scanner in Coronal PD (top) and Coronal PD SPAIR (bottom). From left to right constant FAs were applied, respectively at 180 ° 160 ° 140 ° 120 ° and finally a variable FA 60 ° / 90 ° / 110 °.

Discussion And Conclusions

By analyzing the images acquired with Refocus Flip Angle kept constant with a value of α equal to 180 °, we have achieved excellent image quality: this is because all the spins are overturned and refocused by this RF pulse, obtaining a high echo signal. Subsequently, after a careful and accurate evaluation of the various series of images, which were obtained with values ​​of α equal to 160 °, 140 ° and 120 °, it was noted that, compared to the classic iRF 180 ° pulse, both the signal and the resolution overall image contrast are slightly reduced. All these negative aspects were accentuated when reference was made to the visualization of the meniscus. Ultimately, by evaluating the series of images obtained from the Ax PD TSE SPAIR, Cor PD TSE and Cor PD TSE SPAIR and Sag PD TSE sequences with exclusive modulation of the Refocus Flip Angle parameter in variable mode, we have gained a significant reduction of the flow artifact and a significantly lower SAR than previous tests. We then achieved, during the central portion of the echo train, signal amplitudes greater than those achieved with constant RF refocusing pulses at 180 °. During this increase we proceed with the signal sampling of the central portion of the k-space; it follows that the contrast resolution and the signal/noise ratio of the entire image, but with particular emphasis on the meniscal portion, will be high. In conclusion, in the MRI examination of the knee, the choice of the sequences under study must achieve the goal of obtaining the best anatomical detail and contrast between the structures under examination. The TSE PD sequences, in which the Refocus Flip Angle modulation has been performed, satisfies these needs. In fact, the images present a better quality in the visualization of meniscal lesions, thus allowing to perform a morphological study much more accurate than the one performed in the absence of this variation, with lower SAR values.


  1. Hennig, J., Weigel, M., and Scheffler, K. (2003), Multiecho sequences with variable refocusing angles: optimization of signal behavior using smooth transitions between pseudo stationary states (TRAPS). Magn. Resonance. Med., 49: 527-535. https://doi.org/10.1002/mrm.10391
  2. Mugler, JP, III (2014), optimized three-dimensional MRI with fast spin-echo. J. Magn. Resonance. Images, 39: 745-767. https://doi.org/10.1002/jmri.24542
  3. Matthias Weigel, Juergen Hennig, Development and optimization of T2 weighted methods with reduced RF power deposition (Hyperecho-TSE) for magnetic resonance imaging, Zeitschrift für Medizinische Physik, Volume 18, Issue 3, 2008, Pages 151-161, ISSN 0939 -3889, https://doi.org/10.1016/j.zemedi.2008.01.008
  4. Alsop DC “The sensivity of low flip angle RARE imaging. Magn Reson Med 1997; 37:176-184
  5. Allen D. Elster, Reduced flip angle FSE. Why would you want to use reduced flip angles in FSE? Wouldn’t smaller flip angles kill the MR signal? “Courtesy of Allen D. Elster, MRIquestions. Com”. https://mriquestions.com/reduced-flip-angle-fse.htLM
  6. Burstein D. Stimulated echos: descriptions, applications, practical hints. Concepts Mag Reson 1996; 8:269-278.

The Groupal Device: Value And Usage In Neuro And Psychomotor Therapy Of Developmental Age

Article Navigation

Submission Date: 2022-07-20
Review Date: 2022-07-25
Pubblication Date: 2022-07-30



The group represents the social element in which every individual can experience them-selves after the achievement of the main stages of the neuro-psychomotor development, particularly in the affective-relational, neuropsychological and cognitive areas, and is thus identified as a fundamental device to support rehabilitation therapy.
Early in a child’s development, social skills begin to maturate and their development path-way merges with different groups with a specific architecture which modifies and increases these skills over time. As a result, it is necessary to identify the process that leads from the exclusive belonging to the family-group to the need to prioritize comparison with peers to finally arrive at the interdependent social groups in the collectivity/community. Each group has distinct characteristics that move from its social dimension to the cross-sectional com-ponent of its matrix, where individuals’ desires and beliefs are based. The group’s evolution will allow the initial dimensional plan to be expanded, resulting in participants sharing inten-tions and goals. The group is a powerful tool at the therapist's disposal who is capable of monitoring variables that can quickly change the intra/interpersonal dynamics of patients undergoing treatment. The groupal therapy underlies clear rules within it, which ensure the observance of normative and setting parameters and the identification of the parameters of effectiveness to assess its progress.


In the developmental dimension of the human being, promoting and structuring of skills and competencies of various kinds and function goes through numerous experiences which each person feels in an individual/personal way only if immerse within valid and/or appropriate relationships. The relationship arises from continuous interactions that settle over time and produce significant effects on the emotional-affective sphere of the individuals. Every single interaction involves the participation of at least two subjects in a relationship defined as temporary, entailing the sharing of activities without any emotional/affectional involvement. Constant exposure to interactions, combined with temporal continuity, enables individuals to develop relationships that are not merely based on activities performed, but on the emotions felt and aroused by the first interactions and, in particular, those complex interactions, which over time have been distinguished by their share of emotional involvement, devotion, and loyalty. This model primarily defines the structured dyadic relationship between mother and infant, characterized by the strong influence exerted in all the relational dynamics that will be structured from the earliest stages of development, which include the family group first and then the peer group.

The group represent the system of synthesis of social development of an individual: within it there is the possibility to experiment in an all-encompassing way, engraving the functions of the group and accepting to be transformed by the dynamics that the group experience.

Within the group, each subject can experience all the elements gained in the construction of their relational patterns, which will influence their functioning in social and adaptive terms, including:

  • Need for social belonging: centrally placed on Maslow’s Pyramid (A theory of Human Motivation, 1943) as motivation theme conveys the need to be accepted by the social group where one is placed and whereon are built theme as self-confidence, self-control and mutual respect. Membership enables the individual to experience the sense of inclusion and the perception of his value in a predetermined context, to feel welcome and accepted for his quality, otherwise, differences with other group components fade into the background. This need is built on relational motivation- one of the basilar motivation of human being- which constitute for Folks (1977) an intrapsychic competence of the individual hence the internalisation of relationships, interactions, and way of being, which operate on the group in whom the subject belongs. Therefore, being internalised is not an external object but a social relationship, which is the ensemble of interactions and communications in the social-cultural context in which one is born and grows.
  • Need for holding: within a social group, this concept refers to Winnicott’s (1974) construct of attachment; this need is satisfied by the mother who acts as a container, first physical and then psychic, in which each infant (and future individual) has the opportunity to feel welcomed, supported, encouraged and reassured. The need for holding generates in each individual a tendency to develop reflective type capacities, contextually to Self, Self in connection with the other and other individual selves.
  • Principle of identification: defines the entire process that leads the child to think and act as the characteristic of another person were their own. It represents a fundamental aspect of the socialization process, which takes place when the child, after having formed a deep bond with significant persons, wishes to adhere to their modes of behaviour identifying himself with them and at the same time avoid their disapproval of his possible improper conduct (Camaioni e Di Blasio, 2002). Identification represents the mechanism whereby the individual lays the foundation for the construction of his personality, acquiring and absorbing one or more features of other individuals and shaping himself upon them. It is achieved starting from the acceptance and sharing of the group’s values discerning resemblances from differences.

Social development: the family group, the peer group, and the social groups.

The socialization process is for each child typically present from birth and defines oneself during the entire life cycle, weaving personal experiences and complex learning processes together to establish sharing behaviour models.

Socialization development matures from the earliest body contact experiences, which predicts skills of emotional attunement and co-participation mother-child, which will lead to the development of intersubjectivity in the different forms of tested relationships. The progressive child’s ability to distance himself from his parents and grow up in terms of personal autonomies will lead him to open up to his peers in an experience of sociality.

Socialization allows individuals to take part in social life placing themselves as members of groups that are diverse according to their interests, social skills, feelings, and experiences.

Inside the groups two structures may be observed:

  1. Vertical: refers to relationships with the adult, who is deputed to offer care, protection, and to assure the learning and development of the child;
  2. Horizontal (equal): based on reciprocity and learning arena for the acquisition of skills of cooperation and conflict management.

Each individual is continuously crossed by diachronic and synchronic networks. The former represents the results of the interiorization of every group relationship that the subject has already lived in a moment that takes place not necessary in the present and of all the leverages which origins from the previous generations which have left a trace. The latter has to do with everything that occurs in the here and now of the subject, therefore with his current relationships with his family members and with the various groups of social belonging. The existence of diachronic and synchronic networks present in historical and continuous time in the individual’s life enables to configure the groups as a useful instrument for learning social, relational, and emotional skills, and for the achievement of teaching skills. Belong to a group means inextricably and necessarily connecting their own experiences, actions, and results to those of other group members.  Therefore, a significant interdependence rises between subjective elements – typical of each individual or member’s intimacy- and intersubjective which are learned from the contact with the group.

Motivations, behaviours, attitudes, and relational modes take on connotations that make the individual-group relationship dynamically interdependent. It can therefore be affirmed and sustained that the personality of the individual is in part built based on this relational-group plot.

Each person is continually included in different group contexts, -family, school, other communities- and each of these contributes to shaping personality and orienting it in directions that can be shared on various levels. The child is born within the family group and grows within the peer group, thanks to which he defines their identity by comparing his attitudes and personal characteristics, and finally flows into the various group of society:

  • The first significant group for the individual is the family, in which one is placed from the earliest days of life and in which the earliest personal, emotional-affective, relational and cognitive skills are developed. These competencies contribute, as a whole, to the definition of behavioural patterns. The aspects connected to and dependent on the group dimension of the family belong to each individual member: each member of the family group will have built on different levels and typologies of his own individualisation, therefore the general assimilation of each individual trait is a direct expression of an internalized group dimension. The family group provides clear indications about the aspects of the rules and norms that must be considered and internalized in order to directly experience them in society. The family system is an organisation of people who constantly lives changes over time involving the modification of tasks, roles and meanings associated with them thanks to the analysis made by the individuals in relation to the primary and secondary actors of the social fabrics, in which they are inserted into the environment. The family falls within the vertical group structures, characterised by asymmetry, insofar as are established within partners who are on two different levels. These relations serve the fundamental function of providing protection and security from one side and transmitting knowledge from the other side (Corsaro, 2008). The family has a crucial role in characterizing the social developmental trajectories of children who belong to it; the process of socialization embeds both content aspects, which concern “that which is transmitted”, and form aspects that concern “how it is transmitted” (Molpeceres, Musitu & Lila, 1994). Therefore, the style of disciplines adopted by parents, as well as the global representation of social functioning transmitted by parental figures, will influence the child’s development. 
  • Several authors have considered and analysed family-group dynamics. Murray Bowen (1979) outlined the goals that each individual must set in order to merge with and simultaneously emerge from the group. This process occurs in a temporal condition characterised by continuity throughout the development of the subject, with a high level of adaptability, observing all the factors involved, and consists in the evolution of a construct that passes through three components: Differentiation, Self-definition, and Individuation. At one end of the scale is the “Differentiation of the Self” where are placed individuals who are unable to invest in their own resources and find an individual identity because they are tied to the family appendage; at the opposite end are those who have reached a high degree of independence and complete emotional maturity, such as to make decisions and act without being influenced by social opinion. Individuals positioned at this extreme are those who fall within the ideal of the pinnacle of social development: Bowen states that the majority of individuals are at an intermediate level between the two above mentioned extremes.
  • Salvador Minuchin (1978) assumes that human identity is an experience based on two essential principles, which are a “ sense of belonging” and a “sense of separation”, which find meaning within the familiar matrix where they are mixed/merged. The sense of belonging is formed from childhood through the construction and modelling of the sense of identity from the family during the early socialization process, the adaptation to the internal dynamics and assimilation of the transitional process of family structure. The sense of separation, instead, takes shape when the individual is involved both in the family group and in the social group; this permits the family and child to develop adaptive competencies, which will permit them to become independent over time and, as result, separate. The differentiation of a family depends on its composition, level of development, and subculture permitting the participation of different familiar subsystems or extra familiar groups which enables the single subject to create his own space or learn new relational modes, defining his own identity without missing the sense of belonging. In the process of differentiation, the family can encourage the development of self-identity with relationships that facilitate autonomy or it can inhibit development with relationships that hinder differentiation. Minuchin recognizes the importance of the role of the family but views it as a system that acts within other dynamics, which are underlying relationships with other social systems.
  • The second group is that of peers, which allows individuals to fully experience themselves thanks to the development of individual capacities distant from the defined rules and/or predetermined roles of the family context. It Is around 30 months of age that children begin to feel the tendency to stay with their peers for phylogenetic determined reasons; initially, within the group prevails on the single component a still egocentric position from the intellectual point of view, and it is the belonging to the peer group that represents the reason and facilitator of the abandonment of this type of thinking, enriching the affective, communicative, and cognitive competencies of the components and coining more and more adaptive strategies to face the social world. In this experience, the child is guided by two dimensions: the first is fusional and describes the group’s ability to offer protection, holding and guarantees to the single individual in a perspective in which one’s personality is put in the background in favour of integration and fusion in the group as an integral part of it. The second dimension is the affirmative and describes the individual’s ability to enrich his personality by drawing on the characteristics of others, through the mechanisms of projection and introjection. The presence of the group stimulates the action of the individual toward the outside world, increasing his active potentialities. The peer group allows the child to experience horizontal relationships, characterized by the symmetry between the partners that allows the child to learn new skills through sharing, cooperation and active role taking. Symmetry becomes the starting point from which experience situations that lead to living in the immediate the significance of making decisions or undergoing them, so as to be immersed in the condition of learning to reason about one’s point of view and that of others. Therefore, not only there is a constant work of the child in terms of socialization but also a continuous solicitation of higher cognitive systems which encourages the intellectual development of the child. This latter dipped on relationship with peers, is costaneuoulsy solicited in all the development areas, especially on executive functioning insofar as on relational manage are required planning skills, modification of own acts or choices, contextual appropriateness, ability to analyze and synthesize environmental information, to improve resolution time (problem-solving, decision making), inhibitory control, cognitive flexibility, verbal fluency and mnestic skills.
  • The third group is represented by the various communities seen by the individual and his family. These are group entities with a strong sense of belonging. The idea that even socio-cultural roots in smaller or medium-sized social groups (the companies of friends, the group of work colleagues, religious communities, political groups) can make a decisive contribution to the formation of the personality shows how important interpersonal factors are in determining one’s characteristics.
  • Finally, the fourth group corresponds to society in the broadest sense of the term, with the variables relating to the more general organization of the culture and social norms of each people. Also, this aspect should not be neglected since belonging to a social structure partly influences the formation of personality. 
The social groups: Origin and Mentalization

The social groups follow regular cyclic patterns: they originate (initial phase), they develop and grow through dual and group trials (intermediate phase) and finally dissolve (final phase); within various phases, it is possible to appreciate more widespread changes, which are expressed with role changing and the formation of subgroups, who are the pure expression of the dynamism of evolutionary process. Within the group reality, the development of the individual passes through the experimentation of the Self concerning the different situations according to the individual group.

In “primary” groups, individuals are involved in early socialization experiences such as values, attitudes and beliefs that determine the most relevant aspects of personality, influence cognitive patterns, and social behaviours; in “secondary” groups, roles and interpersonal relationships become clear based on the goal to be achieved, so individuals are led to adhere and share the goals of a given group, being conscious that they must integrate preconfigured norms with cultural and social patterns.

The essential characteristics of all social groups are:

  • interdependence and interpersonal relationships among members;
  • sense of belonging experienced as a collective perception of uniqueness;
  • a common objective;
  • the motivation of individuals to pursue their satisfaction;
  • the mutual influence that occurs among participants within the group interaction;
  • shared norms and roles.

The “ Becoming” group involves the structuring of a process which is constantly evolving and needy of commitment from the individual and availability from the groupal reality already placed or pre-established. Tuckman and Forsyth (1965) suggest two explanatory models of the above-mentioned process and configure different stages. In particular, Tuckman’s model unfolds in a continuum of evolution of the individual’s development processes which start from the birth, go through the phases of dependence, revolt,  and socialization and arrive at the adult maturity:

  • Stage I, defined as Forming, represents the initial phase of the group formation, in which individuals experience themselves in accordance with the dynamics of the relational matrix and their previous experiences, as the roles and mutual expectations among members are not clear;
  • Stage II, defined as Storming, reflects the conflicts resulting from the activation and/or definition of roles, norms and tasks/objectives;
  • Stage III, defined as Norming (normative period), is the stage following the period of conflict, characterized by a positive climate, in which cohesion and commitment among members are active concerning the objectives to be pursued. Therefore there is trust and mutual support among members, as well as high levels of sharing following the definition of clear rules;
  • Stage IV, defined as Performing, (period of performance), represents the period of dynamic Intra/inter-groupal maturity, during which group members are focused only on the positive result of the task/goal setting: in fact, relational conflicts between members are overcome.
  • Stage V, the Adjourning (suspension period), constitutes the terminal phase and is characterized by emotional disengagement in preparation for the group’s dissolution phase.

Tuckman’s model analyzes the being of the group as an evolutionary process characterized by the importance of relational exchanges, of whose dynamics the solution of the task becomes a function. It emphasizes the importance of conflicts not as an element to be repressed, interrupted or inhibited, but rather as a physiological phenomenon necessary for the birth and realization of the group.

Forsyth’s second model appears to be more current than Tuckman’s and was subsequently adapted by Smith and Mackie (1995):

  • The first stage is part of the cognitive-exploratory function; if this experience is successful, it can move from the initial orientation stage to the primordial group stage: the individual will be free to see himself as part of the group and the group to see him as part of itself;
  • The second stage, as Tuckman, requires the need to experience the conflict. Conflict for individuals is in both individual and intragroup terms;
  • The third stage represents the normative phase that can only occur if the group survives the conflict phase. Having overcome the conflict, members recognize the group’s existence and its values and they project their identities. Having established best practices and norms to share, real group cooperation begins;
  • The fourth stage, referred to as the executive phase, is characterized by seamless management and high efficiency; members cooperate to solve problems, make decisions, and manage conflicts in a balanced and functional manner about goals;
  • The final phase is called “the death” of the group or dissolution and occurs after achieving the objectives or because of physiological disintegration. If the previous phase has been experienced positively, this last phase can be particularly painful or distressing, so much as to take on the meaning of emotional wounding, and be experienced in a way similar to the end of an intense relationship; the dissolution of the cohesive group can be stressful for the members because it involves the modification of their identity and the loss of the security of the group container. 

The complex process of group building involves several steps, both personal and social, which require mentalization skills. Mentalization, or Reflective Function, is the skill that leads to the process of understanding the interpersonal behaviour of mental states, through the organization of the Self and the affective regulation, within the context of early attachment relationships. Mentalization involves two components, the first self-reflective thanks to which the subject is able to make his cognitive processes the object of reflection, and the second interpersonal, characterized by even greater complexity, whereby is possible to read the cognitive continents of the other in terms of beliefs, goals, desires. Both components involve the ability to distinguish external reality from internal reality, as well as the diversification of internal mental and emotional processes from interpersonal events. During the stages of child development, one proceeds to build one’s mind and the psychological Self through the continuous stimulation of interactions with more mature, attuned, and thoughtful minds. The first object relations must provide the child environment that is inclusive of their own and others’ mental states and promotes mentalization; also through the evolution of the process, it is possible to systematize the object relation over time. Closely related to mentalization is the process of maturation of affective regulation that allows individuals to modulate emotional states and reach a mentalized affectivity, which passes through the verbalization of affection identification, reworked version and re-evaluation of it, as well as the discovery of subjective meanings of their own and other’s feelings that go far beyond the easy understanding of the exclusively cognitive dynamics.

The “GROUP” Therapy and the Therapy “IN-GROUP”

The group is par excellence the place of manifestation, analysis, and evaluation of behaviours. For this reason, it is an important instrument, flexible and adaptable in the clinical area. In the field of Neuro and Psychomotor Therapy of Developmental Age (TNPEE) is necessary to describe how the sessions are articulated on the normative and therapeutic-rehabilitative levels. Within the “group” dimension in developmental age, there is the need to include individuals who have the same level of adaptive, cognitive, and social functioning in order to be able to act through a therapeutic project suitable and similar for all participants. The use of the groupal device may be necessary both at the end of individual rehabilitation interventions in order to create a reality similar to life contexts and to evaluate their transversal skills achieved in their fluid form, and simultaneously to individual treatment in order to have awareness of aspects that would be difficult to emerge with a dual therapeutic relationship. The group arise first in the therapist’s mind who must assess the appropriateness and usefulness of interweaving the clinical histories of individual patients. Within the therapeutic relationship, the therapist will be the conductor and the capillary observer of the group, both in terms of observation of participation and developmental indices and specifically in terms of the organization of roles and activities. The therapist involved, moreover, will have to consider both the vertical and the horizontal structure. Therefore, as will be necessary for him to level out with the participants by adopting competitive attitudes aimed at increasing the levels of motivation, as will be necessary to elevate himself to the group by assuming a mediator role. The foundation phase that follows a new group’s foundation is extremely important because the conductor will have to work actively on the construction of a group matrix, which is an unconscious network of communication that will eventually make significant all the future events.

The four concepts on which the group conception is based are:

  • Relation: the group makes the communicative, conscious, and unconscious aspects more visible;
  • Circularity: everyone is involved in any event that happens and it modifies the perceptual field of the group, giving way to other transformations. This concept represents a mutual interchange among members;
  • Transformation: emphasizes the drive for change that implicitly or explicitly the group induces on the individual;
  • Multiplicity: linked to the plurality of subjects that trigger the confrontation.

There is a need to distinguish two different types of group interventions:

  • The Therapy “in-group”: provides that patients who are undergoing individual treatment can be introduced -on the choice of the therapist who detects the need concerning their functional dynamic profile and their level of psychosocial development- in a small group with multiple conductions. It is important for these types of intervention that the mediation within the group is always conveyed by their therapists, who through strategies of mediation and experimentation lead the child to live peacefully the dynamic enlarged with a peer, who in turn can count initially on their therapeutic reference caregiver. The therapy IN group involves longer latency times: before reaching the full sharing of spaces and activities, as well as the full sharing and exchange of roles among participants, it will be therefore necessary a time of adaption of all the actors present within the setting;
  • The “group” Therapy: can be activated through medical prescription within a reality agreed with the affiliated with NHS and/or public often at the end of the treatment of neuro and psychomotor of developmental age as an exclusive session or in addition to the individual one. The group therapy aims at introducing patients to a social micro-context, encouraging the generalization of strategies and behaviours learned in therapy from more adaptive meaning. With the dynamics exclusively of private nature, the organization of this therapeutic extension can be managed by the professional. Group therapy is conducted by a single one, the leader may not necessarily have had contact with participants or prior knowledge of them and patients are matched by chronological and developmental age as well as by nearly similar clinical frameworks. The optimum number of participants in the group is four patients, as group therapy requires a great ability of the conductor to have control over all the individual personal dynamics of each patient, as well as being able to quickly read the common and extended dynamics among the participants. In fact, the therapist’s flexibility required in the condition of group therapy includes the promotion of therapeutic well-being in the group, the capacity for immediate reading of events, and the functional use of all the natural variables that arise or are induced for the constructive and stable evolution of conflicts that may occur between members or between members and conductor.
Setting Parameters

Within a developmental neuro and psychomotor therapy of developmental age group, the primary actors are the therapists (TNPEE) and the patients, specifically:

  • The TNPEE therapist may be a conductor, mediator, problem solver, and member of the group itself.
  • Patients can be members as well as leaders, complementary leaders, gregarious or antagonists.

In the therapeutic field, the group represents a mediator-regulator/autoregulator, namely a treatment instrument through which it is possible to modify the evolutionary process of the subject undergoing treatment. The change in the functioning of the individual goes through the work of the group, more specifically through the birth of the synchronic transferts to the actions which are performed at that specific moment. The therapy conductor has the function of supervisor and helmsman; whereas the group members, on the other hand, provide references and help the individual to look at themselves and/or recognize parts of themselves.

In the groupal therapy, a decisive role is played by the setting because it includes factors related to the mindset of the therapist who will have to calibrate his attitude according to dynamics that will be structured, the strategies to be built concerning the objectives to be pursued, the operating model to be adopted, the number of participants, the rules, the relative time for each therapy, and the time within which to dissolve the group intended both as a physical place ( room and materials) and as a weekly frequency of meeting. Group therapy, as well as individual therapy, arises first in the mind of the therapist and then it is built first within the personal and then the multiple/groupal dynamics which are built and shared with patients.

Rituals, that derive from the scan of the therapeutic times and spaces, assume relevance within the setting in which the following spatial and temporal timings that make up the session are present:

  • Reception area, in which the initial rituals, of physical nature, take place(e.g. take off the coat, put away the shoes, and wear the non-slip socks for motor activities) or conversational, such as putting the patient in a condition of psycho-physical well-being, overcoming the initial moments of emotional awkwardness typical especially of the very first sessions. To live a condition of serenity at the beginning of the treatment is essential for the preparation of the activities and their development. In this specific space and time, the group discusses relevant events or events of everyday life or the choice of activities with the mediation of the therapist who acts as a conductor;
  • Sensorimotor area, in which the group is able to experience the spontaneity, organization and purpose of the motor act with the full participation of the body in the activity and full exploration of itself with regard to space and other members. The body takes on a significant value within the group: first of all, it allows the members and the conductor to be able to actively observe each other, taking into consideration not only the purely physical connotation but above all the communicative aspects related to posture, non-verbal language, and aspects concerning motor reactivity regarding one’s mood and the capacity for self and hetero-regulation. Through the observation of the body, one becomes aware of one’s existence and that of the other, evolving towards an awareness of one’s own and other’s potential and physical and factual boundaries. In addition, in this space, though the unstructured material- without a specific function- and the motor act meaning as a transformative process the group is able to experience their creativity with full functions related to aspects of symbolism, and the experiment with evolutionary competition in the activities of clear and defined rules;
  • Decentralisation area and dissolution, in which the group members transfer the focus from the action of body dynamics to strictly cognitive skills, reducing the use of the body and investing in levels of mediated interaction through the use of structured material. In this phase, there is a synthesis of the therapeutic experience, the sharing of emotions felt, and the desire to continue the interactions on a more reflective level. In this last phase, the planning of the next therapy takes place. This represents a delicate phase since allows the positive expectations experienced by the group to keep alive. In addition, at this time the members are preparing themselves for the conclusion of the session, for the final ritual which needs to take place calmly and serenely to ensure that the feedback is positive for the individual member of the group. This can happen if, in this space and with the intervention of the therapist, there is a colloquial exchange between members and the resolution of any internal disagreements and conflicts that, if prolonged and unresolved, could affect the future performance of the group and its stability.

The expression of the group within the neuro and psychomotor setting- as well as in relationships between peers with typical development- occurs through the play. In fact, within the setting- although the situation is mixed between natural environment and laboratory built ad hoc initially by the therapist, and then with the participation of all members- the goal of each activity is that it is as likely to reality and in accordance with what outside the therapy room could happen.

The parameters related to the groupal setting are:

  • The Group Space, which evokes a circular dimension, represents the physical space within which the affective and emotional dimensions also coexist. It allows subjects to distinguish what is insider or outsider in the mental dimension of the group. In addition, the space of the group refers to the sense of belonging to what is of the group and of differentiation from what is not of the group.
  • The Time of the Group, which evokes the geometric figure of the spiral, in which time seems to have a circular but also progressive or regressive course. Time is limited, therefore it becomes fundamental that its management takes place in the awareness that it is organized and experienced, alternating with moments of stasis that lead to the reflection of the group itself.
  • The Foundation of the Group predates its inception and can be thought of in terms of fusion-individuation, namely articulated in an initial phase in which a fantasy of undifferentiation prevails ( the individual experiences the anguish of losing his or her personal- individual boundaries) and in a subsequent phase of recovery of one’s subjective dimension that will allow group members to accept and share their principles with those of the group.
  • The Body of the Group is formed through the interactions and relationships between the members that are formed within it and it assumes a central value since in a group the members observe each other and the body communicates with strength and immediacy. The body of the individual represents the physical container of all the individual aspects matured through the interrelation of neurobiological aspects with neuropsychological aspects, it has an expressive potential rich in meanings.

According to Di Maria and Lo Verso, the foundation of the group involves a first therapist’s idea (and of its members) comparable to a semi-empty structure or virtual space, in which the roles of conductor, members and observer are defined. Later, with the formation of a network of interactions, it will be possible to rebuild past and unconscious events and start with the identification play: in this phase, a strong sense of belonging to the group is acquired. Indeed, while in the group’s foundation prevails a fantasy of non-differentiation, in which the individual experiences the anguish of the loss of his individual reality, subsequently there is a phase of recovery of subjectivity that leads to experiencing the group bond as belonging.

The phases which lead to the construction of a group are characterized by spontaneous communications, sharing of emotions, thoughts, and free fantasies. According to Neri’s theory of the group process, there are two stages:

  • The Emerging Group Stage is characterised by an illusory expectation with euphoric, gratifying, narcissistic aspects, which acts as a glue and responds to the member’s need to be together when they are not yet able to establish a relationship. Participants experience phenomena of de-personalisation and de-individualisation, a dynamic loss of the boundaries of self that leads them to feel experiences and emotions referring not only to themselves but also to the context of the group. Specifically, the De-personalisation phase involves a sense of detachment and consequently, a negative perception of the interpersonal relationships of the group members related to the individual’s feeling of not yet being fully part of the group. On the other hand, the De-individualisation process allows individuals to see themselves as a group identity, thus partially losing the perception of their individual identity and considering their behaviour as guided by group norms. The concept of De-identification is strongly related to the concept of opposite significance or the concept of identification. The status of identification promotes the full control of personal acts and a correct valuation of the consequences of performed behaviours; represents the condition in which the individual can make choices which are conscious and respectful of social norms, encouraging the proper functioning of the entire society in which he lives. The identification ensures the order of the individual’s psychic activity and favours the permanence inhibitions (mechanism without which the individual would act almost instinctively, generating serious consequences both because of the negative evaluation he receives from others towards him and for the health of society as a whole). The state of de-identification on the other hand generates a different situation. The forces that prevented the performance of instinctive and harmful acts are weakened and the most unthinkable and miserable acts are reinforced. The control of action is lost and confusion and chaos are generated.
  • The Stage of the Brother’s Community arises when the group is perceived as a collective subject, that is, when the members have reached a state of fusion such that they refer to themselves using ‘we’. In this stage, there is an awareness of the existence and elaborative potential of the group as a collective subject, as a community capable of thought. Participants on the one hand develop feelings towards others as individuals, recognized as similar to themselves with their own identity. On the other hand, they perceive themselves as a brother’s community, namely as holders of a right over the group. At this stage the participants are more willing to get involved, the dependence on the conductor-therapist decreases and they communicate more and more among themselves, feeling more free to plan common goals and ways of achieving them; moreover, in this stage, the issues related to conflicts will no longer be avoided, but there will be an opportunity to confront each other and elaborate precise answers regarding the needs of individuals and of the group. Individuals perceive others symbolically as brothers and feel part of a community of brothers. The group also establishes a precise space, a ‘we-you’ boundary that Anzieu defines as The Skin-Ego: like the skin, the group is an envelope that holds individuals together and contains thoughts, words, and actions. In this way, the group can construct an internal space and its own temporality;
  • Finally, there will be the Dissolution of the Group, which is part of the phase of full maturity with consequent closure and estrangement from the group. This process will be experienced by all members with a different intensity and through different personal, intimate, and individual projections. It represents a delicate phase, in which the therapist must be able to recognize and identify the different asymmetries of the individual experience concerning the group context in order to be able to live the dismissal from the group in complete serenity so as not to be dependent on it in the future. The group must have allowed each individual to take possession of their own individuality within a group community that lives on principles and inertia driven by the fusion of different personalities and temperaments involved. Knowing how to distance oneself from the group represents the attainment of full maturity, through which each member recognizes that are able to live out their desires in full consciousness and serenity, to be part of the different social groups, and adhere to the present group projection, which differs for each social group, with their beliefs and abilities. The full realization of the experience lived in the group context must allow each member to be able to give himself freely to the new enlarged social relations, preserving from the experience lived in the group context all those aspects of evolutionary significance that have allowed the acquisition of more adaptive capacities, and of a specifically affective and relational nature that allowed the individual members to mature socially significant self-regulating and hetero-regulating skills.
Group Norms, Efficacy Parameters and Objectives in Group Therapy and Therapy IN Group

To exist and survive, any group must have Norms that are shared and accepted by all members/individuals. Social norms are all ways of thinking, feeling or behaving that are collectively accepted and identified as appropriate and correct. Norms include functions such as:

  • Individual functions, which serve as a useful reference in otherwise unstructured and anxiety-generating situations;
  • Social functions, which can:
    • help regulate social existence and, consequently, help coordinate group members’ activities. This function of social regulation is linked to the predictability to which norms contribute at an individual level;
    • be closely linked to the group’s objective. When a group develops a clearly defined objective will inevitably emerge norms that facilitate behaviours in line with the goal and discourage those that run counter to its achievement;
    • Serve to enhance or maintain group identity.

Sherif (1969), analysing the Variation of Norms, found that each group defines a certain amplitude of acceptance of norms, thus defining the degree of tolerance regarding the possibility of derogating more or less widely from certain rules.

The definition of the group passes through the specific analysis of the constitutive parameters of the group, which represent the founding links of the group structure. For each group, it is necessary to take into account the elements identified as Parameters of Effectiveness, such as:

  • Cohesion, is the force of attraction that the group exerts on each member and is closely related to the sense of belonging of the members to the group as a whole. When cohesion is strong, the subject is willing to modify relational modalities criticized by the group, but also the group can modify its own evaluation starting the adaptive spiral. The group is usually founded on a certain amount of cohesion, which represents the set of forces that hold the group together and the relational bonds between the members and the therapist. Cohesion represents the degree of solidarity among group members.
  • Alliance, is understood as a collaborative work between interacting individuals that is structured towards members and therapist. The establishment of the alliance involves both the ability to share goals, mutual tasks and the structuring of an emotional bond characterized by respect and trust;
  • Empathy, is the ability of each individual to “put oneself in the other’s shoes, perceiving in this way emotions and thoughts. It is the ability to see the world as others see it in a non-judgmental position and to understand the feelings of others while keeping them distinct from one’s own (Morelli e Poli, 2020). Empathy is a fundamentally important social skill and is one of the basic instruments for effective and rewarding interpersonal communication between individuals, allowing immediate access to the other’s state of mind and the relational world of the other;
  • Resonance, represents the emotional sharing of experiences and moods of others. This ability allows the individuals to participate emotionally in positive or negative situations brought to life within the group dimension in therapy, get emotionally closer, and experience a shared and co-participated emotional condition. Resonance differs from empathy in that it is based on using our “Self” to connect with the other person, being as receptive as possible to their experiences, feelings and ideas, without losing sight at all times of whom they belong. Empathic resonance does not imply being “identical” to the other but maintaining a sort of separation by keeping a distance to allow us to provide the appropriate help. Empathic resonance allows us to experience the other’s situation in a different, often more complete way, without these clouding our rationality because the boundaries of our “Self” are not erased, but acts as a defensive layer necessary to offer the appropriate help. Resonance is the phenomenon whereby the members of a group capture aspects of the experience of the person speaking but are deformed by the strong identifications and emotions with which each member captures them. It is therefore a phenomenon of emotional contagion, that is, the tendency to generalize, to unconsciously spread emotions in the group.
  • Reflection, represents seeing and reflecting oneself in the experiences, behaviours, gestures, words and attitudes of the other and in their respective emotional contents that refer to the awareness that the situations experienced by the individual may concern not only oneself but also and above all the peers. Reflection is of fundamental importance in forming an initial sense of Self and is the basis for creating healthy relationships with others. A mirror reflects our image: we are both the subject and the object, so the image is objectively true, but it is also a reflection of our thoughts and feelings and the way we perceive ourselves.

Finally, it is necessary to take into account what are the Objectives of therapies in the groupal field addressed to developmental age, given the delicate contextual situation related to the speed of modification of events in regard to the rapid evolution of capacities. Therefore, the Developmental Neuro and Psychomotor Therapist, in relation to the priority objectives, should take into account that through groupal  work the child can:

  1. Implement the availability for co-presence and acceptance of spatial and personal sharing;
  2. Evaluate one’s own expressive/interactive modes and identify the most suitable ones to enter into a relationship with the other members of the group;
  3. Evaluate critically the expressive/interactive modes of the group members and the expressive connotation of the group;
  4. Mature personal competencies aimed at the acceptance of the group and its members so that the group can also accept the individual members within it;
  5. Compare emotions, internal states, beliefs and difficulties, sometimes mediated by adults;
  6. Share freely one’s desires and express one’s attitudes according to the modes and characteristics of individual temperamental and personality traits;
  7. Share the action plan common to all the members of the group, going through the phases of proposal, elaboration, conflict and acceptance;
  8. Define one’s own role in relation to the group context, following individual analytical work that takes into account oneself in relation to the plan of action identified and shared;
  9. Improving skills in the motor-praxis area through learning by imitation and taking advantage of the high degree of motivation given by the competitive condition and the consequent capacity for self-evaluation;
  10. Learn to manage competition positively, turning it into an instrument for personal and community growth;
  11. Increase one’s empathic skills in relation to all the members of the group to achieve a high capacity for understanding the other;
  12. Experience the group and its members as “allies”, after having been able to share intimate states of mind (resonance), to learn to manage and cope with personal and group difficulties;
  13. Experience the reflection mechanism, through which, according to the principle of universality, one realizes that one’s difficulties can be common with other-selves;
  14. Learn to relativise personal concerns, giving them the right weight, following the comparison with the other;
  15. Experience oneself as an efficacious subject in shared social dynamics, in order to compensate for any sense of inferiority/diversity experienced with peers with typical development in everyday life environments;
  16. Implement effective communication skills according to the defined action plans and roles, established based on the horizontality and verticality of the exchanges within the therapeutic group relationship;
  17. Experiment with symbolic representations in motor, interactive and reading experiences to support the maturation of higher cognitive processes;
  18. Learn strategies for solving possible conflicts through the maturation of executive functions, in particular problem solving and decision making, within interactive dynamics;
  19. Bring significant elements so that a moral conscience with a solid structure can be built, in which the observation of the rules in the social micro-community leads the individual members to appreciate and generalize respect for them;
  20. Be encouraged to acquire progressive autonomy in the self-regulation processes involved in the personal and individual dimension towards the group, the members and the therapist;
  21. Become aware of his own hetero-regulatory potential concerning the group and its members, in order to be able to manage it consciously and in a flexible manner;
  22. Experiment enriched and more functional interactive modalities, in order to favour a better insertion in the new social micro-contexts first, and then in society in the broad sense;
  23. Generalize in the new enlarged social contexts the relational skills gained personally from therapeutic group experience, through the acquisition of more adaptive tools and skills.


The present article highlights the peculiarities of the rehabilitation treatment in the developmental age and the complexity of the management of the groupal therapy in the field of Neuro and Psychomotor Therapy of Developmental Age (TNPEE). The groupal device represents one of the most powerful instruments in the perspective of rehabilitation if it is used within the parameters described by a skilled therapist capable of multiples readings within the rapid dynamics in which he himself is immersed.

Kaes’s (1994) definitions of the group produce important insights for specialists that are still relevant today, such as:

  • “the group is an intermediate space between the individual and the social”;
  • the complexity of the group is given by the ambivalence between the ability to define the identity of the individual associated with the fear of losing one’s individuality in the undifferentiated whole of the group”;
  • “the group is the space for plural confrontation where different fantasies and thoughts circulate”;
  • “in the group, the bodily dimension is relevant because within the group we observe each other, posture and non-verbal language are involved, and the body communicates with immediacy”.

These statements describe the development of the entire process of structuring the group and its management in the therapeutic context, that is the strength of the groupal instrument to settle between the individual and society, highlighting its therapeutic power. In addition, emphasis is placed on the therapist’s ability to guide each individual in the affirmation of their individuality within the group itself and acceptance of the group dimension in which they are inserted. Finally, the group is seen as an instrument for the comparison of ideas and desires for each participant, in addition to being the place where one’s bodily dimension comes to life, representing the crucial/fundamental aspect of all Neuro and Psychomotor Therapies of Developmental Age (TNPEE).


  1. Anzieu D. L’Io-Pelle. Cortina Editore (2017).
  2. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252-260.
  3. Bowen M. (1980). Dalla famiglia all’individuo. La differenziazione del sé nel sistema familiare. Astrolabio Ubaldini.
  4. Brown, R., Psicologia sociale dei gruppi, Il Mulino, 2000.
  5. Camaioni, L., & Di Blasio, P. (2002). Psicologia dello sviluppo. Il Mulino.
  6. Carugati, F., Perret-Clermont, N. (1999). La prospettiva psicosociale: intersoggettività e contratto didattico. In C. Pontecorvo (a cura di), Manuale di psicologia dell’educazione. Bologna
  7. Cooley, C. H. (1909). Primary groups.
  8. Corsano, P. (2008). Socializzazioni. La costruzione delle competenze relazionali dall’infanzia alla preadolescenza. Roma: Carocci Editore.
  9. Decety, J. & Meyer, M. L. (2008) From Emotion Resonance to Empathic Understanding: A Social Developmental Neuroscience Account. Development and Psychopathology; 20(4): 1053-1080.
  10. Diener, E. (1980). Deindividuation: The absence of self-awareness and self-regulation in group members. The psychology of group influence, 209242.
  11. Dimaggio, G., Montano, A., Popolo, R., Salvatore, G. (2013). Terapia metacognitiva interpersonale. Raffello Cortina, Milano.
  12. Dimaggio, G., Semerari, A. (2007). I disturbi di Personalità. Modelli e trattamento. Stati mentali, metarappresentazione, cicli interpersonali. Laterza, Bari.
  13. Di Maria, F., Di Maria, R., & Francescato, D. (2002). Psicologia del benessere socia- le. McGraw-Hill.
  14. Di Norcia, A. (2009). Valutare la competenza sociale nei bambini. Roma: Carocci.
  15. Foulkes S.H. (1977). Psicoterapia gruppoanalitica, metodi e principi. Astrolabio Ubaldini
  16. Harris, J.R. (1995). Where is the Child’s Environment? A Group Socialization Theory of Development. Psychological Review, 102, pp. 458-489. Citato in: Di Norcia, A. (2009).
  17. Hartup, W.W. (1983). Peer Relations. In P. Mussen (eds.), Handbook of Child Psychology, vol. 4: socialization, Personality and social development. New York: Wiley. Citato in: Corsano, P. (2008).
  18. Hogg, M. A. (1992). The social psychology of group cohesiveness: From attraction to social identity. Harvester Wheatsheaf.
  19. Hogg, M. A., & Hardie, E. A. (1992). Prototypicality, conformity and depersonalized attraction: A self-categorization analysis of group cohesiveness. British Journal of Social Psychology, 31(1), 41-56.
  20. Kaes R. Il gruppo e il soggetto del gruppo. Borla Editore (1994).
  21. Liotti G., & Monticelli F. (2014). Teoria e clinica dell’Alleanza Terapeutica. Una prospettiva cognitivo-evoluzionista, Cortina Editore, Milano
  22. Mackie, D. M., Devos, T., & Smith, E. R. (2000). Intergroup emotions: explaining offensive action tendencies in an intergroup context. Journal of personality and social psychology, 79(4), 602.
  23. Mantovani, G. (Ed.). (2003). Manuale di psicologia sociale. Giunti Editore.
  24. Minuchin S. (1978), “Famiglie e terapia della famiglia”,  Astrolabio Ubaldini.
  25. Molpeceres, M.A., Musitu, G., Lila, M.S. (1994). Psicosociologià de la familia. Valencia: Albatros. Citato in: Caprara, G.V., Bonino, S. (2006).
  26. Palmonari, A. e Cavazza, N. “Ricerche e protagonisti della psicologia sociale”, Il Mulino, 2003.
  27. Safran, J.D, Segal, Z.V.(1990), Il processo interpersonale nella terapia cognitiva, trad.it. Feltrinelli, Milano, 1993
  28. Schaffer, H.R. (1998). Lo sviluppo sociale. Oliviero Ferraris, A. (a cura di). Mila- no: Raffaello Cortina Editore.
  29. Sherif, M. Sherif (1969). Social Psychology. New York: Harper & Row.
  30. Tuckman, B. W. (1965). Developmental sequence in small groups. Psychological bulletin, 63(6), 384.
  31. Vanaerschot, G. (2007) Empathic Resonance and Differential Experiential Processing: An Experiential Process-Directive ApproachAmerican Journal of Psychotherapy; 61(3): 313-331.
  32. Watson, J. C. & Greenberg, L. S. (2009) Empathic resonance: A neuroscience perspective. In J. Decety & W. Ickes (Eds.) The social neuroscience of empathy (pp. 125–137). MIT Press.
  34. ANXIETY DISORDERS IN DEVELOPMENTAL AGE, Acta Medica Mediterranea, 2018, 34:937.
  35. Behavioural Differences in Sensorimotor Profiles: A Comparison of Preschool-Aged Children with Sensory Processing Disorder and Autism Spectrum Disorders, MDPI, Children 2022, 9, 408. https://doi.org/10.3390/ children9030408
  36. Caregivers’ Burden of School-Aged Children with Neurodevelopmental Disorders: Implications for Family-Centred Care, Mdpi, BrainSci.2021,11,875. https:// doi.org/10.3390/brainsci11070875https://www.mdpi.com/journal/brainsci
  38. The assessment of emotional competence in neurodevelopmental disorders through TEC I, Journal of Advanced Health Care (JAHC), https://doi.org/10.36017/jahc2110-001

Application of the ultrafast sequence in the dynamic contrastographic study in the magnetic resonance imaging of the breast: our experience

Article Navigation

Submission Date: 2022-07-19
Review Date: 2022-07-24
Pubblication Date: 2022-07-25



In the last decade, breast MRI has played a role of primary importance, as a "gold standard" method in the early diagnosis of breast cancer in high-risk women, in assessing the extent of the disease and the response to neoadjuvant chemotherapy. Currently, the 3D GRE Rapid-Acquisition sequence in dynamic acquisition without and with endovenous administration of contrast medium, is fundamental for the breast MRI protocol, as the current diagnostic approaches in Magnetic Resonance are based precisely on this sequence, able to guarantee accurate diagnostic performances detecting pathological mass and non-mass-enhancement. Ultrafast sequences are modern sequences based on the 4D Time-Resolved technique with k-space sampling modalities which allow the evaluation of post-contrast images with very high temporal resolution. The purpose of our work is to illustrate in particular the use of the 4D-THRIVE sequence implemented in our breast MRI study protocol.


Magnetic Resonance, thanks to its multiparametricity, achieves higher sensitivity and greater accuracy than mammography and breast ultrasound. These characteristics have made it, in recent years, the reference method in early diagnosis in high-risk women, in the assessment of loco-regional extension and of the response to neoadjuvant chemotherapy in patients with breast cancer, in the follow-up after surgery, as well as in the study of breast implants.

However, although multiple studies have shown that the multiparametricity of the MRI protocol is excellent, technological evolution continues to expand, presenting further innovations that can further improve the diagnosis and characterization of breast lesions.

Dynamic contrast-enhanced MRI (DCE-MRI) of the breast is well established in clinical practice as it provides high sensitivity for breast cancer detection and represents a guide to describe and classify breast lesions in accordance with BI-RADS criteria.  However, it takes a long time, making up about 40% of the total exam duration.

The introduction of Ultrafast sequences allows a desirable balance between high spatial resolution and high temporal resolution, a need that until recently required the research for a compromise between these two objectives, with the possibility of characterizing the lesions in an equally reliable and efficient way.

The aim of our work is to describe the technical characteristics, applications and advantages of modern Ultrafast sequences and in particular of the 4D-THRIVE sequence in the study protocol of Breast MRI.

Materials And Methods

In our study we will describe the technical and technological principles of the 4D-THRIVE sequences and the study protocol of Breast MRI performed at our Radiology Unit with 3 T MRI scanner (Philips Ingenia, Philips Healthcare, Eindhoven). Representative images of modern 4D-THRIVE sequences and related post-processing will then be shown. Finally, the main advantages of applying Ultrafast sequences in Breast MRI protocols, emerging from the analysis of the scientific literature, will be discussed.


Ultrafast 4D-THRIVE sequence in Breast MRI: technique and k-space sampling

The Ultrafast 4D-THRIVE sequence is based on a “Time-Resolved” technique, with Key-hole and CENTRA K-Space sampling methods. This method uses a radial sampling scheme, acquiring a limited number of central Ky-Kz profiles (central disc) in a centric elliptical manner.

The central region is acquired in each scan (low frequencies or those defined as most “useful” for the purposes of the image) while the sub-regions acquired less frequently (high frequencies or those defined as “scattered”), are shared according to a view sharing scheme alternating (Fig. 1)

Fig. 1 – Schematic representation of the centric elliptical technique with alternating view sharing

The combination of all the innovative acceleration techniques such as the CENTRA Keyhole method, the Partial Fourier, and the SENSE Parallel Imaging has allowed to obtain a very high temporal resolution (4-8 sec) while maintaining spatial and contrast resolution efficient in documenting the presence of neoplastic lesions.

In the field of breast MRI, after a complete k space sampling in the pre-contrastographic phase, multiple Ultrafast phases (10-16) are acquired continuously for about 60-90 seconds with a temporal resolution of 4-8 seconds, starting the acquisition simultaneously with the ev injection of  contrast agent, for a total scan time of 102-120 sec.

Breast MRI study protocol with Ultrafast sequences

MRI exams were performed with a very high field MRI scanner, 3T Philips Ingenia (Philips Healthcare, Netherlands Eindhoven) equipped with combined gradients with Amplitude of 45 mT/m and Slew-Rate of 200 T/m/s, using a breast coil dedicated 7-channel phased-array dSTREAM SENSE BREAST Coil. All the patients were studied in prone feet-first position, with the breasts introduced into the two cavities of the coil, with the arms raised above the head, making sure that the hands do not touch each other, in order to avoid closed circuits,  then electrical loops.In all exams, the contrast agent used is Gadobutrol (Gadovist-Bayer-Schering Pharma).

The MR scan protocol includes the evaluation of the breast parenchyma by using 3D TSE T2 (Variable Flip Angle) and STIR (IR-TSE) axial sequences, and subsequently, whereas the conventional protocol consists of a dynamic axial e-THRIVE with SPAIR fat suppression (one phase pre and five phases post-CM bolus injection), in our protocol we have replaced the first two post-CM phases with the Ultrafast 4D-THRIVE sequence consisting of 12 sub-phases each with a temporal resolution of about 5-6 seconds with a coverage overall time of about 80-120 sec. Fig. 2 represented the temporal schemes of the conventional DCE sequence and then of the “hybrid” protocol used in our study.

Fig. 2 – Temporal scheme of the “classic” DCE protocol without the application of the 4D-THRIVE at the top; temporal scheme of the DCE protocol with the acquisition in the first post-contrast phase of the 4D-THRIVE with 12 sub-phases in the first 80 seconds after the ev injection of CM.

The parameters of the conventional e-THRIVE are the following: TR 6.7 ms, TE 3.3ms, field of view (FOV), 320 mm pixel 1.10 x 1.10 x 1.50, partitions = 110, FA = 10 °, acceleration factor Sensitivity Encoding (SENSE), P = 2.3 S = 1; SPAIR fat suppression (p = 2), acquisition time, 92 seconds per phase.

The 4D-THRIVE parameters are the following TR 6.7 ms, TE 3.3ms, field of view (FOV), 320 mm pixel 1.10 x 1.10 x 2.50, partitions = 70, FA = 10 °, acceleration factor Sensitivity Encoding (SENSE), P = 3 S = 1; SPAIR fat suppression (p = 2), Keyhole Central size 32%, reference scan 17sec, TFE = 50, acquisition time 5 seconds for each phase (12).

Ultrafast images visualization and analysis

The most correct way to evaluate Ultrafast images for lesion characterization is to look at the subtraction images (Fig. 3). New parameters will be evaluated from the Ultrafast kinetic curves:

  • “Time To Enhancement (TTE)”, ie the time it takes for the lesion to enhance after the enhancement of the descending aorta (<10 s for malignant lesions);
  • Maximum Slope (unit: percent relative enhancement per second): high values ​​in malignant lesions.

Finally, the MIPs generated from the subtracted images of the Ultrafast sequences provide a real time assessment of the influx of contrast medium into the lesions, and in the case of malignant tumors a “light bulb effect” is observed, in which we see the cancer enhancing in a dark background (Figure 4).

In the case shown in figures 3 and 4, no additional findings were detected from the evaluation of the e-THRIVE images obtained at the 3rd, 4th and 5th minute post-CM (see Fig. 5).

Fig. 3 – Representation of the 4D-THRIVE sequence of the individual arterial sub-phases (12) 12 sub-phases in the first 80 seconds after the injection of gadolinium i.v. Mass-type enhancement of a heteroplastic lesion at the level of the QSE of the left breast can be noted, with a TTE <5 sec. The central vacuum signal is related to the presence of a clip.
Fig. 4 – MIP reconstruction from the individual arterial sub-phases (12) of the subtracted 4D-THRIVE, after administration of the i.v. In addition to the heteropalsic lesion, there is a package of metastatic lymph nodes to the ipsilateral axillary cavity
Fig. 5 – Temporal scheme of the dynamic contrast protocol with the use in the first post-contrast phase of the 4D-THRIVE with 12 sub-phases in the first 80 seconds after the iv injection of gadolinium

Discussion and conclusions

Breast MRI thanks to its high diagnostic accuracy in the loco-regional extension balance in patients with breast cancer and in the detection of occult mammary tumors, it allows to optimize the treatment and prevention path.

Through the acquisition of the 4D-THRIVE sequence it is possible to acquire a number of multiple phases ensuring multiple information in real-time. In particular, the Ultrafast 4D-THRIVE sequence allows to obtain not only a high temporal resolution, but also an optimal spatial and contrast resolution and with a complete anatomical coverage of the mammary gland, resulting in an improvement in the detection and characterization of focal breast lesions in various early post-contrast sub-phases, phases in which it is possible to obtain a higher specificity and sensitivity of the examination.

However, the spatial resolution compared to the e-THRIVE applied in the subsequent phases, inevitably turns out to be lower, moderate because it has resolution in plane and thicknesses slightly higher depending on the intensity of the magnetic field and on the number of channels of the coils. However, the detection rate of additional findings significant for diagnosis in the e-THRIVE sequence not highlighted in the 4D-THRIVE sequence, from scientific literature data, is not relevant or extremely low.

Finally, in recent years, the diagnostic utility of these new parameters (TTE and MS) generated by the Ultrafast sequences has been demonstrated in the differentiation between malignant and benign lesions and in improving the positive predictive value. Furthermore, several studies have shown that these parameters have an accuracy greater than or comparable to that of the classic time/intensity curves reported in the BI-RADS. In conclusion, although Ultrafast sequences are used in practice almost exclusively in combination with the conventional dynamic sequence in resulting hybrid Ultrafast-DCE protocols, there are well-founded assumptions for the Ultrafast sequence to completely replace the conventional DCE sequence in breasts MRI study protocols, resulting in a significant shortening of the acquisition time of the examinations and therefore the possibility of increasing the number of examinations per session.


  1. Levine E, Daniel B, Vasanawala S, Hargreaves B, Saranathan M. ‹‹3D Cartesian MRI with compressed sensing and variable view sharing using complementary poisson-disc sampling››. Magn Reson Med. 2017 May;77(5):1774-1785
  2. Vanzulli A. e Torricelli P. ‹‹Manuale di RM per TSRM››. Milano Poletto Editore Srl, 2013: 195-212.
  3. Sardanelli F., Giuseppetti G.M., Canavese G. et al., «Indications for breast magnetic resonance imaging. Consensus document “Attualità in senologia”, Florence 2007.» La Radiologia Medica, 2008 Vol. 113 Issue 8, 1085-1095
  4. Giess CS, Yeh ED, Raza S, Birdwell RL. ‹‹Background parenchymal enhancement at breast MR imaging: normal patterns, diagnostic challenges, and potential for false-positive and false-negative interpretation››. Radiographics. 2014 Jan-Feb;34(1):234-47.
  5. Kuhl CK, Jost P, Morakkabati N, Zivanovic O, Schild HH, Gieseke J. ‹‹Contrast-enhanced MR imaging of the breast at 3.0 and 1. 5 T in the same patients: initial experience››. Radiology, 2006 June; 239(3):666–76.
  6. Spick C, Szolar DHM, Preidler KW, Reittner P, Rauch K, Brader P, Tillich M, Baltzer PA. ‹‹3 Tesla breast MR imaging as a problem-solving tool: Diagnostic performance and incidental lesions››. PLoS One. 2018 Jan;13(1)
  7. Soher BJ, Dale BM, Merkle EM. ‹‹A review of MR physics: 3T versus 1. 5T. Magnetic resonance imaging clinics of North America.›› 2007 Aug;15(3):277–90.
  8. Curatolo C, Santoro V, ‹‹Risonanza Magnetica della Mammella con i moderni scanner 3T: principi fisici e vantaggi tecnici rispetto alle apparecchiature 1,5 T››. JAHC- Journal of Advanced Health Care. 2019 Sept. Vol.1 Issue 1

Application of the compressed sense in the study of female pelvi in magnetic resonance 3 Tesla for the diagnosis of infertility in women

Article Navigation

Submission Date: 2022-07-13
Review Date: 2022-07-18
Pubblication Date: 2022-07-22



Compressed Sense (CS) is a technological innovation in the field of Parallel Imaging (PI) that allows to reduce up to 50% the acquisition time per single sequence, reducing the whole duration of the MRI examination, and is based on the application of 3 principles: Incoherent k-space subsampling, sparsification transform and nonlinear iterative reconstruction. The purpose of our work was to evaluate the application of CS to the MRI protocol of the female pelvis performed for infertility, evaluating its Temporal Resolution and Signal/Noise Ratio (SNR) compared to the classic PI technique SENSE. MRI exams were performed with RM 3T scanners (Philips Ingenia, Philips Healthcare, Netherlands Eindhoven). The female pelvis MRI protocol included the following sequences: 3D PelvisView T2, 3D PelvisView T1, DWI (b0 and b1000), mDixon 3D THRIVE with ev. contrast media. The parameters of each sequence, with the exception of DWI in which the CS is not applicable, are shown in comparison between the application of Sense and Compressed Sense. The CS allows to obtain at the same spatial resolution, a protocol with faster acquisition times, correcting the effect of aliasing from data subsampling compared to conventional SENSE. In conclusion, the application of CS could bring multiple advantages in the field of MR imaging in the diagnosis of infertility in women, optimizing the image quality and the duration of each individual examination.


The condition of infertility affects about 15-20% of Italian couples. According to the data provided by the Istituto Superiore di Sanità, the cause is male-related (in 35% of cases), female-related (in 35% of cases), a couple factor (in 15% cases), and sine causa (idiopathic infertility) in remaining 15%. In recent years, MRI of the female pelvis has become the gold-standard in the study of infertility in women, thanks to the progressive diffusion of increasingly high-performance and very high-field equipment that allows, compared to hysterosalpingography and transvaginal pelvic ultrasound, an evaluation of the most associated pathologies (congenital anomalies, fibroids, adenomyosis, endometriosis). The application of MRI, a multiplanar and multiparametric method, with high spatial resolution, to research the causes of infertility could represent the turning point for obtaining a more complete study in terms of information and without the use of ionizing radiation in women of childbearing age. In recent years, the birth of Parallel Imaging (PI) has paved the way for overcoming the greatest limitation of MRI, acquisition times, through the use of phased array coils. Compressed SENSE is a modern PI technique that collects only the “essential” components of the MR signal rather than all the K-space data, minimizing the error that derives from having an insufficient number of samples. The k-space is inconsistently subsampled with priority of central data (more useful data); subsequently the sparsification transform is applied and finally a “non-linear” Iterative reconstruction method, with the final goal of achieving a balance between “data consistency” and “sparsification data”, allows to keep all useful data by removing, as much as possible, those without information. In fact, mathematically it is difficult to separate useful data from non-useful ones, but inevitably a part of them with the application of the Wavelet transform alone will be lost. The “non-linear iterative reconstruction” does exactly that: it behaves like a balance through the application of numerous algorithms that are repeated cyclically until the optimal data balance is achieved. Compressed Sense is therefore a PI technique which, by applying its 3 fundamental principles, which are inconsistent subsampling, sparsification transform and non-linear iterative reconstruction, manages to guarantee a reduction of acquisition times up to 50% without qualitative degradation of the images. A reduction in acquisition times of this level is able to balance the increased demand for MRI examinations in general and, more particularly, of the female pelvis, also for reasons related to infertility that cannot be resolved with other imaging methods.


The objective of this study was to evaluate the contribution of the new COMPRESSED-SENSE technique, comparing it with the conventional PI SENSE technique, when applied to the study of the female pelvis with 3T MRI, to the resolution of the diagnostic question of female infertility, with optimization of acquisition times and image quality.

Materials And Methods

MRI examinations of the female pelvis were performed at the Department of Diagnostic Imaging of the University hospital  Policlinico “Paolo Giaccone” (Palermo, Italy), with a Philips Ingenia 3T MRI scanner, equipped with combined gradients with Amplitude of 45 mT / m and Slew-Rate of 200 T / m / s. The receiving coil used is a Philips Healthcare surface coil, the 32-channel d-Stream SENSE Torso, positioned directly on the area of ​​interest in order to obtain the maximum possible signal amplitude. The standard 3T MRI protocol of the female pelvis, performed at our Institute, includes the acquisition of 3DPelvisView T2, 3DPelvisView T1, DWI (b0 and b1000), mDixon 3D THRIVE sequences with MdCev. For each of the sequences listed above, except for the DWI, we acquired the images first with the “SENSE” PI technique and then with the “COMPRESSED SENSE” technique, thus comparing the following parameters: spatial resolution (mm x mm), FOV , matrix, thickness, NSA, acceleration factor R and temporal resolution.


For all 3D TSE sequences (T1, T2 and SPAIR) the time saving with the CS is greater than 50% per sequence, while with mDixon 3D THRIVE the reduction of acquisition time is about 30%. Overall, including the DWI sequence (b0-b1000) which in our protocol lasts about 3 minutes, the total duration of the MRI Pelvis protocol with application of the SENSE is 30 minutes, while with the application of the COMPRESSED SENSE it is about 16 minutes, with a reduction of acquisition time of about 50%, and in particular about 15 minutes.

Tables 1-4 show in detail, for each sequence of the female pelvis MRI protocol analyzed in this study, the acquisition parameters compared with the use of the PI SENSE technique and with the COMPRESSED SENSE technique, and in particular: in plane resolution (mm x mm), FOV, matrix, NSA, acceleration factor R and time resolution.

Tab. 1 – Acquisition parameters for the Ax 3D View T2 (TSE Variable Flip Angle) sequence of the MRI study of the female pelvis with 3T MRI scanner, with the PI SENSE technique and with the COMPRESSED SENSE technique.
Tab. 2 – Acquisition parameters for the Ax 3D View T1 (TSE Variable Flip Angle) sequence of the MRI study of the female pelvis with 3T MRI scanner, with the PI SENSE technique and with the COMPRESSED SENSE technique.
Tab. 3 – Acquisition parameters for the Ax 3D TSE T2 SPAIR sequence of the MRI study of the female pelvis with 3T MRI scanner, with the PI SENSE technique and with the COMPRESSED SENSE technique.
Tab. 4 – Acquisition parameters for the m-DIXON THRIVE sequence of the MRI study of the female pelvis with 3T MRI scanner, with the PI SENSE technique and with the COMPRESSED SENSE technique.
Fig. 1 – Comparison of the images obtained respectively with the SENSE and with the COMPRESSED-SENSE from the sequence AX 3D View T1 (TSE Variable Flip Angle).
Fig. 2 – Comparison of the images obtained respectively with the SENSE and with the COMPRESSED-SENSE from the sequence AX 3D View T2 (TSE Variable Flip Angle).
Fig. 3 – Comparison of the images (obtained with reconstruction) MPR CORONAL of the sequence AX 3D View T2 (TSE Variable Flip Angle) acquired with the SENSE and with the COMPRESSED-SENSE.

Discussion And Conclusions

Our data demonstrated that the application of the COMPRESSED SENSE can led to a considerable reduction of the average scan time of the sequences considered by 30-50%: in particular, about 50% is gained on the 3D TSE T1 sequences, T2 and T2SPAIR, 30% on the m-DIXON THRIVE post-contrast sequence. The images obtained were therefore acquired in a shorter time and were even of better quality than the conventional PI SENSE technique.

The ever increasing technological advances in the field of Magnetic Resonance, and including the development of scanners more and more performing in terms of Amplitude and Slew-Rate, the introduction of ever faster sequences, the development of increasingly efficient Parallel Imaging techniques and robust to allow ever higher acceleration factors R without incurring typical artifacts from K-space data subsampling, up to the introduction of Artificial Intelligence software, have led to exponential improvements and optimizations of Magnetic Resonance imaging. If one of the limits, until recently present in Magnetic Resonance, was the acquisition time, now with the advent of subsampling applied with Compressed Sense this limit is also exceeded, allowing the increase of the number of female pelvis MRI and therefore its use on a wider scale also in the diagnostic study of infertility in women.

Thanks to the COMPRESSED SENSE it is therefore possible to use of 3D T2 sequences for the morphological study of the pelvis in just 4 minutes, instead of 10 minutes with the SENSE in which the risk is to obtain inevitable movement artifacts that can affect the quality of the images. With the CS applied to the 3D sequences it is possible to obtain high resolution images on the axial, sagittal and coronal planes, with image quality comparable to the 2D sequences performed on a single plane which would require much longer acquisition times (about 12 minutes) than the 3D TSE T2 sequences obtainable with the CS in just 4 minutes, therefore with a scan time reduction of up to 67%.

With a total temporal gain of about 50% it is possible to double the number of exams per day. In addition, the acceleration guaranteed by the CS reduces movement artifacts and decreases the degree of fear of patients related to claustrophobia as the time in which they are forced to remain motionless in the context of the MRI scanner is reduced. We can conclude that the COMPRESSED SENSE represents a significant improvement in terms of accuracy and speed of reconstruction, constituting the future of Parallel Imaging.


  1. Lustig M, Donoho D, Pauly JM. Sparse MRI: The application of compressed sensing for rapid MR imaging. Magn Reson Med 2007;58:1182–1195. 10.1002/mrm.21391
  2. Deshmane A, Gulani V, Griswold MA, Seiberlich N. Parallel MR Imaging. J Magn Reson Imaging 2012;36: 55–72. 10.1002/jmri.23639
  3. Curatolo C, Santoro V, (2019) Nuovi scenari sulle tecniche PMRI: il Compressed Sense. JAHC- Journal Of Advanced HealthCare (ISSN 2612-1344)2020-Volume 1- ISSUE I
  4. Geerts-Ossevoort L, de Weerdt E, Duijndam A, van Ijperen G, Peeters H, Doneva M, et al. Compressed SENSE. Speed done right. Every time. Philips Healthcare, Netherlands, May16, 2018.
  5. Yang AC-Y, Kretzler M, Sudarski S, Gulani V, Seiberlich N (2016) Sparse Reconstruction Techniques in MRI: Methods, Applications, and Challenges to Clinical Adoption. Invest radiol 2016;51:349–364. 10.1097/ RLI.0000000000000274
  6. Curatolo C: “Studio Comparativo tra la tecnica Compressed SENSE e SENSE per l’imaging RM della Mammella” XXVIII numero Rivista TSRM FOR EVERYONE 2021- Tecnico-Scientifica Riconosciuta e Patrocinata Dalla Federazione Nazionale Collegi Professionali Tecnici Sanitari di Radiologia Medica Prot. N 496/2012 Nazionale
  7. Pruessmann KP, Weiger M, Scheidegger MB, Boesiger P. SENSE: sensitivity encoding for fast MRI. Magn Reson Med. 1999;42(5): 952–962. doi: 10.1002/(SICI)1522-2594(199911) 42:5<952: AID-MRM16>3.0.CO; 2-S. 
  8. Liang D, Liu B, Wang J, Ying L. Accelerating SENSE using compressed sensing. Magn Reson Med. 2009;62(6):1574–1584. doi: 10.1002/mrm.22161. 

Implementation In The Campania Region Of The Screening For Cancer Of The Uterine Cervix Using HR-HPV

Article Navigation

Submission Date: 2022-06-08
Review Date: 2022-06-30
Pubblication Date: 2022-07-21



Oncological screenings:
The screening program consists of the free and active offer (personal invitation) to the population, at risk by age, of practices that have proved to be able to significantly affect the natural history of the disease (reduction of morbidity and mortality) maintaining A convenient relationship between costs (economic, psychological, social) and the benefits (Omswilson, 1968). Oncological screenings organized currently active in our country are:
The objective of oncological screening programs is the reduction of mortality.
According to the national guidelines (PNLG) "the assumptions that are the basis of the offer of an oncological screening test to a hypothetically healthy population are:
1. that it is possible to identify the neoplasm, if present, when still asymptomatic;
2. that this anticipation of the diagnosis translates into a concrete benefit, first of all in terms of survival extension. Always the PNLG in the document at the evaluation of services stresses that:
"Screening by nature is a tool that requires caution, because it proposes to asymptomatic people, who have a perception of their positive health, a diagnostic test that can reveal the presence of a cancer in its latency period". For this reason, another professional figure represented by the "psycho-oncologist" has also become part of the last decade. As we see below the screening of the uterus's neck cancer falls more than others in the two requirements (A and (B first mentioned. Tumors that affect the uterus must be distinguished in cervix cancers and body tumors based on the segment that comes Struck by neoplasm. This work will pay attention to the first group, which by natural history, risk factors, incidence, clinical trend, therapy and finally survival. For many years, it has been the subject of public health interventions aimed at its Primary and secondary prevention.


Cancer of the uterine cervix ranks second in the world, after the breast, it is among the cancers that affect women.

It represents the first neoplasm to be recognized by the World Health Organization (WHO) as totally attributable to an infection. The etiological factor of this neoplasm consists, in fact, of a pool of high-risk strains of the sexually transmitted human papilloma virus (HPV), whose DNA has been found in almost all cases of carcinoma of the uterine cervix. (IARC Working Groupon the Evaluation of Carcinogenic Risks to Humans . IARC Monographs on the evalutation of carcinogenic risks to humans . Human Papillomaviruses . Vol 64.Lyon :

It is estimated that the risk of developing cervical cancer in a woman’s lifetime is 1 in 158. The incidence trend appears to be slightly decreasing (-0.4% / year) and has North-South gradients, with slightly lower 6 values in the south.

Unfortunately, the South loses the advantage represented by the low incidence not only due to a diagnostic delay compared to the rest of Italy, but also due to the still poor adherence to organized Screening. Unfortunately, this diagnostic advantage is not realized in the screening of mother’s cancer .

In fact, through mammography it is possible to identify only very small lesions, therefore it is not a question of prevention but rather of early diagnosis which is anything but. Especially in relation to the type of intervention, more or less demolishing, and to survival.

In Italy, there are approximately 51,100 living women diagnosed with cervical cancer. The prevalence rate is higher in the Northern Regions.

Over 80% of the prevalent cases have faced the diagnosis for over 5 years. The largest proportion of prevalent cases is observed in the 75+ age group (607 / 100,000), (Cancer numbers in Italy 2020 AIOM, AIRTUM, SIAPEC ) The incidence is influenced not only by gender, but also by age. In females, breast cancer represents the most frequent malignancy in all age groups, albeit with different percentages (40% in the young vs 22% in the elderly). In young women, tumors of the thyroid gland, melanoma, colorectal and cervical cancer appear.

The long preclinical phase of the disease and the possibility of diagnosing and thus intervening on precancerous lesions are the strengths of the Cervical Cancer Screening Program. Below is the representation of the latency of a precancerous lesion starting from the HPV infection and then the wide window in which it is possible to make the diagnosis, monitor and possibly proceed with therapy. Carcinoma represents the final evolutionary phase of a series of progressively higher risk lesions, which, particularly in the initial phases, can also regress spontaneously.

So the advantage in the field of prevention represented by the Pap test consists in the fact that pre -cancerous lesions are diagnosed and even more today, thanks to the HR-HPV DNA Test, it is possible to identify the type of HPV virus from which the woman is infected.

Risk Factors

Cervical cancer ranks second in the world, after breast, among cancers that affect women. The etiological factor of this neoplasm is constituted by a pool of high-risk strains of the sexually transmitted human papilloma virus. Carcinogenesis is long-lasting and carcinoma represents the final evolutionary phase of a series of progressively higher risk lesions, which, particularly in the initial phases, may also regress spontaneously. Among the risk factors were identified:

  1. low socio-economic level (with little access to prevention)
  2. number of partners, sexual promisqueness
  3. young age of onset of sexual activity and parity
  4. immunosuppressive states
  5. smoking of cigarette
  6. hormonal contraception, the latter only if combined with the multiplicity of partners.


Papillloma virus infection Cervical cancer represents the first neoplasm to be recognized by the World Health Organization as totally attributable to an infection.

The etiological factor of this neoplasm consists, in fact, of a pool of high-risk strains of the sexually transmitted human papilloma virus (HPV), whose DNA has been found in almost all cases of carcinoma of the uterine cervix. It is important to emphasize that only in a minority of cases does HPV infection lead to the development of cancer.

In fact, cervical cancer has been defined as the ” rare consequence of a common infection”

Papilloma belongs to the Papovavirus family , it is a virus with a DNA genome that parasites the cells of the epidermis and mucous membranes. The human papillomavirus strains , over a hundred in total, can be divided, on the basis of the possible clinical consequences of the infection, 1) into low-risk HPV, which attack the skin without causing further damage (for example strains 6, 11, 42, 43, 44,) and 2) high-risk HPV, which attack mucous membranes (e.g. strains 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 , 68) and can cause benign tumors, such as genital warts, or malignant tumors, such as cervical cancer, oral cavity, anus, esophagus, larynx.

Of the high-risk HPV strains (or genotypes) 16 and 18 are the most frequently implicated in cervical cancer, accounting for approximately 60% and 10% of all cervical cancers, respectively. Other high-risk types are associated with cervical cancers, but less frequently, while low-risk HPVs (i.e. those not related to severe cancers) can still cause anogenital warts in both sexes.

HPV-related neoplasms in humans mainly concern the genital tract and the oropharyngeal district. 80-95% of anal cancers, at least 50% of penile cancers, and 45-90% of head and neck cancers are HPV-related.

Tumors of the oropharynx are 4 times more frequent in males than in females and are mainly caused, in at least 60% of cases, by HPV WHO GUIDANCE NOTE Comprehensive

 cervical cancer prevention and control: a healthier future for girls and women (2013) schematically represents how early it is possible to intervene and above all how many interventions we now have to fight cervical cancer.

  • Primary prevention: Vaccination
  • Secondary Prevention: Screening
  • Tertiary Prevention: Treatment

Already 12 years ago, the American Cancer Society stated that “the purpose of prophylactic vaccination is to reduce the incidence of all HPV-related genital pathology, including cancers and precancerous lesions of the uterine cervix, penis, vulva, vagina and anus”. Vaccination against the human papilloma virus, offered today as reported below, protects against currently known oncogenic strains. However, since none of the currently available vaccines prevent all cervical cancers, it is still important to carry out regular checks even after vaccination. ( Cochrane Library online 2018, published 9/5 DOI: 10.1002 / 14651858.CD009069.pub3)

Vaccination strategies in Italy

In Italy in December 2007 a State-Regions Agreement was formulated which recommended the active and free offer of vaccination against Hpv to girls during the twelfth year of life (from the age of 11 to the age of 12 ) .

Girls in the twelfth year were chosen as the primary target of the immunization program for:

ensure maximum effectiveness of vaccination, targeting girls before sexual debut to exploit the best immune response to the vaccine

addressing girls who attend compulsory school by facilitating both communication with families and active offerings to groups at risk of social deprivation.

The State-Regions Agreement left to the Regions the possibility of extending the population to be vaccinated, proposing 18 and / or 25 year olds as the recovery age (in this case exploiting access to the cervical cytological screening service).

The Pnpv 2017-2019 introduces in the vaccination calendar, and therefore in the LEA, in addition to the anti-meningococcal B, anti – rotavirus and anti-varicella vaccinations in the newborns; also anti-HPV in 11-year-old males. Twelfth year of life is the preferred age for actively offering HPV vaccination to the entire population (females and males).

Women who have undergone recent treatments for related HPV lesions, in order to reduce the risk of possible relapses, also fall within the expansion of free vaccination coverage.

The non-valent vaccine includes the main viral strains:

seven of the nine HPV types (HPV 16, 18, 31, 33, 45, 52 and 58) at high oncogenic risk that cause about 90% of cervical cancers worldwide, 90% of anal cancer cases HPV related and approximately 80% of high grade cervical lesions. The two HPV types with low oncogenic risk 6 and 11, in addition to causing 90% of genital warts, are in third place among the HPV types that cause cancer of the vagina or penis, fourth in cancer of the vulva and fifths in anus cancer.

On the basis of new and important scientific evidence, in fact, public health today aims to immunize adolescents of both sexes, for maximum protection from all related HPV diseases directly preventable with vaccination.

It is estimated that 70 to 80 percent of sexually active women and men are infected with HPV in their lifetime.

The virus tends to disappear after infection: in 70 percent of cases within one year and in 90 percent within two years.

The particularly affected age group ranges from 16 to 25 years. The frequency of HPV infections increases in proportion to the number of sexual partners; the risk of infection is highest at the start of sexual activity. The most appropriate solution is a vaccination before the start of sexual activity and therefore before any infection by the more dangerous human papilloma viruses.

preconceptional health of Italian university students conducted in the universities of Milan, Brescia, Padua, Rome, Cagliari, Messina, on 8,500 students between 18 and 30 years old, with an average age of 22, it appears that 20% of boys had their first sexual intercourse before the age of 15.

According to other sources, as much as 50% of young people under 15 are sexually active.

In the survey conducted by the ISS, 66% of sexually active students reported using a contraceptive, but 32% of them used an ineffective method against sexually transmitted diseases (STDs). Additionally, 15% of teens reported having sexual intercourse with casual partners .

22% of the girls said they had used emergency contraception on one or more occasions. It is important to underline, however, that while against AIDS, the use of so-called “barrier” contraceptive methods such as the male condom is sufficient o the female condom, protection by these devices against the HPV virus is limited, as transmission can also occur through contact between skin or mucous membranes.

Anyone who has many sexual partners should have regular checks for sexually transmitted infections.

In the case of persistent infection from a high-risk virus, a precancerous lesion can develop from which cancer can develop.

Therefore, the need to vaccinate adolescents before they start sexual activity is now consolidated by irrefutable evidence of efficacy.

Yet despite the fact that vaccination is free of charge, adherence to this important public health intervention falls into the exact same criticality as cancer screening, that is, low adherence.

The situation regarding the 2006 cohort sees Campania drop to 34.2% of membership.

The whole of Italy underwent a progressive worsening in relation to coverage; also Tuscany, which reached 82% of the 1998 cohort for the complete cycle, fell to 58.3% of the 2006 cohort (Data Ministry of Health 2018)


At the moment, screening for cervical cancer by means of colpocytological sampling and cytological Papanicolau test or Pap test is active in all AASSLL Campane. In Italy, the 2014-2018 National Prevention Plan gave indications for the introduction of the new test within the screening protocol by 2019 in all Italian cervical screening programs.

Despite the Campania Region with DCA n. 36 of 01.06.2016 for the purpose: “Transposition of the observations of the Ministry of Health and Approval with amendments to the Regional Prevention Plan of the Campania Region for the years 2014 – 2018” approved action B3 under program B “Wellbeing in the Community” “Implementation of HPV-DNA Test for cervical cancer screening” with the aim of improving the early diagnosis of tumors covered by organized screening programs through the definition and implementation of innovative pathways for cervical cancer screening (HPV-DNA test), this implementation has not started yet. The possibility of performing the HR HPV-DNA test as primary has modified the diagnostic protocols of the Screening as shown below in the flow chart approved by the Italian Cervix Screening Group (GISCI)

HPV screening allows to reduce the incidence of invasive cervical cancer by 60% -70% compared to Pap test screening.

The study also made it possible to define the optimal screening methods with the HPV test: in particular, the results show that the increase in protection mainly affects women between the ages of 30 and 35 and that screening with HPV tests every 5 years is more protective than Pap smear screening every 3 years. (Ronco et al. 2014 reported in “The implementation of DNA-HPV as a primary test in the Italian cervicocarcinoma screening programs .

Indications from the results of the MIDDIR Methods for Investments / Disinvestments and Distribution of health project technologies in Italian Regions “) Screening based on HPV testing should not begin before the age of 30/35, given the higher prevalence of HPV infections compared to older women (Ronco et al. 2015).

There is evidence that under age 30 screening based on HPV testing leads to overdiagnosis of CIN2 which would spontaneously regress, with the consequent risk of overtreatment . Furthermore, some further overdiagnosis is also plausible between 30 and 34 years.

Cytological screening is currently recommended below this age. The examination of the available literature suggests that the introduction of a new method in organized screening programs requires a redefinition of the organizational and management processes of the companies and structures involved in screening.

The Regions listed below have enabled the transition from cytological to molecular using the primary HPV-DNA test

  • Basilicata Region
  • Emilia Romagna region
  • Liguria Region
  • Lazio region
  • Piemonte region
  • Tuscany region
  • Autonomous Province of Trento
  • Umbria Region
  • Veneto region

In Campania the HPV test is currently used only as a triage test in case of low grade cytological abnormalities (L-SIL). The organizational complexity linked to the transition from the cytological to the molecular examination in a region such as Campania has added to a health context that has been suffering for years. Only last year did the Region exit the repayment plan thanks to the achievement of the Score provided for by the LEA grid.

But this delay is not responsible for the real criticality that characterizes all the Screening in Campania and we could say almost all the prevention interventions as we will see later, including the vaccination practice, that is the Low Adhesion. The table below confirms the significant difference in the various areas of our country Effective extent of cervical screening by geographical area (% of women aged 25-64 who receive the invitation letter compared to the target population in 2018) and participation (% of women who undergo the test following the invitation letter) (source survey ONS)

In fact, in the Southern Regions / Islands, where oncological screenings are still not very widespread, the reduction in mortality and the incidence of breast, colorectal and cervical cancer has not been observed as in the rest of the country. The data published in the 2018 ONS Report refer to the activity carried out by the screening programs in 2017 and tell us that, despite everything, progress continues in the development of organized programs, even if a merciless gap is confirmed between the Center, the North and the South. “The two sources: ONS universal survey and sample telephone interview Passi are different methods of investigation; in general, the ONS survey tends to underestimate the real coverage of organized programs, while the Passi survey tends to overestimate it. The combination of the two approaches offers a very realistic cross-section of the cancer prevention offer in the country “(ONS 2018).

In Italy, the monitoring of Screening activities is carried out by the National Screening Observatory (ONS), by the GISCI group and by the Istituto Superiore di Sanità, through the National Center for Epidemiology, Surveillance and Health Promotion ( Cnesps ) through the Studio Passi which is for Progress of the Health Authorities for Health in Italy. The Steps surveillance launched in 2006 is characterized as a public health surveillance with the aim of carrying out a 360-degree monitoring of the health status of the Italian adult population. It is based on sample surveys carried out on the Italian adult population (18-69 years) on lifestyles and behavioral risk factors related to the onset of chronic non-communicable diseases and on the degree of knowledge and adherence to the intervention programs that the country is implementing. for their prevention. The following table shows the data relating to the three-year period 2016-2019 regarding the screening of the cervix by pap-test inside and outside the Organized Program. The tests performed as part of the so-called “Spontaneous Screening” are therefore also considered, ie those Pap tests that are carried out at the request of the woman or on the recommendation of the private gynecologist who in any case do not fall within the path of Organized Screening which instead must respond to strict criteria, such as: Active Offer, Free, Quality Controls, Study Path, Monitoring, computerization of paths, etc. The indicators are monitored by the national GISCI Group. As you can see, Campania, like many other regions, declares a significant percentage of “spontaneous” exams, associated however with a low number of exams within the

Organized Screening

From this it can be deduced that there is a percentage of women who overexpose themselves to the test and another that does not undergo the test at all.

“The anti-HPV vaccination represents a sensational example of underutilization of a high value service: in fact, if in recent years, the evidence of efficacy has progressively consolidated and the monitoring of adverse events has shown that the anti-HPV vaccines have a adequate safety profile, vaccination coverage in Italy has plummeted, contributing to preventable morbidity and mortality, as well as an increase in health care costs.

This paradox testifies that the process of transferring the best evidence to clinical practice, the organization of health services, professional decisions and the choices of citizens and patients is an obstacle course, often unpredictable and not always adequately managed at the institutional level. “

(Anti-HPV vaccine: evidence of efficacy, safety profile and vaccination coverage in Italy FondazioneGIMBE Evidence 2018; 10 (7): e1000184 doi : 10.4470 / E1000184 Published: 9 July 2018)

The two public health interventions taken into consideration for the prevention of Cervical Cancer, Screening and Vaccination, both free for the population at risk by age, are however little exploited by the reference community as shown by the data presented. This low adhesion involves not only an increase in the incidence and mortality from cervical cancer, but also an increase in public health costs which sees a double expenditure commitment for the same woman: the organizational structure of screening modulated on the number of target population 25-64 years, regardless of whether the target is fully achieved or not, and also the cost of surgical and / or medical therapy that the woman will have to resort to for a late diagnosis. While for the pap-test it is now established that the use of private individuals is justified in some cases by the need for a more “confidential” relationship for the execution of the colpocytological sampling , the low adherence to vaccination practice apparently does not find justification. Yet free in a context of high social risk such as that of Campania should be a sufficiently captivating element. “The socio-economic gradient appears to be probably the most important explanatory factor of the quality and quantity of life and this regardless of the cultural humus in the broad sense in which an individual or a population is immersed. As happened on the occasion of the sinking of the Titanic, where survival was positively correlated with the boarding class, so in civil society those who are in a condition of greater socio-economic well-being, will benefit from greater longevity and therefore will have mortality rates. lower. (G. Domenichetti: For a Public Health policy centered on the needs of the population and not on that of services.) But it is also true that extreme social deprivation means that “The less educated and low-class people are less confident about effects that could derive in the future from the change in health-related behaviors, since other risk factors are still beyond their control, such as the adverse conditions of income, home, environment, work that are more widespread in these groups. “

From the data of the Passi Study we talked about previously, it is confirmed that the lowest socio-economic levels of the population use Screening.

Avoidable Mortality If, as previously mentioned, in the South we do not see a decrease in mortality from cervical cancer, as in the rest of the country, it means that there is a slice of the population that escapes both primary and secondary prevention. Since these are deaths that could be avoided thanks to interventions such as vaccination and screening, the latter can fall into the group of so-called Avoidable Mortality. Avoidable deaths are those deaths that occur at certain ages (within 60 years of age) and from causes that could be actively countered with primary prevention, early diagnosis and therapy, hygiene and health care interventions. The graph below shows the relationship between 5-year survival after cancer diagnosis and adherence to screening in the various regions.

“This is a geographical gap entirely within the Italian territory, which does not find a similar response in most European countries. The North-South gradient therefore remains an unsolved node, despite the enormous effort put in place by public health in terms of efficiency and appropriateness. Searching for the root causes of this gap is a complex operation, which goes far beyond the reach of epidemiology or health care, and for which social, political and historical analysis tools would be needed. Certainly, the current crisis of confidence gripping institutions can further jeopardize the participation of the population in public health initiatives such as screening, especially in areas of the country where trust in services and in the state has always been very low ” . Evaluating Avoidable Deaths from Cervical Cancer, identifying the main reasons “is the first, indispensable, tool to remedy them. The reasons are linked to a lack of primary and secondary prevention and to responsibilities linked to health planning and organization ” A.Panà

Just at a time when political planning in Campania had begun to pay attention to two critical issues typical of the region, namely the incidence of Improper Caesarean Section and the spread of cancer screening, also to be included in the LEA indicators. the CoViD -19 pandemic has been brought down, which has momentarily shifted attention to other emergencies. The latest MEV-2019 Report shows that “The component of avoidable mortality that identifies deaths linked to the quality of health services is the one that marks the greatest distances and divides Italy in two: all and only the central-northern regions, Excluding Lazio, they are better than the national average. ” However, the death toll due to lifestyle causes remains higher: smoking, alcohol, incorrect eating habits. At the regional level, the minimum values are recorded in Veneto and Marche, while Campania is confirmed at the other end of the ranking as the region with the maximum number of days lost per capita due to avoidable mortality, an indicator adopted by MEV (i) for the regional and provincial rankings which take into account not only the number of the phenomenon but also the age at death, with the deaths occurring at a younger age weighing more heavily. Among the provinces, Treviso is the one with the lowest value, below 15 lost days, followed by Siena, Florence, Rimini, Monza Brianza, Modena, Trento, all below 16.

It is evident that the low adherence to screening and / or vaccinations fall within a much broader dimension that makes the regional health system a patient who needs urgent and no longer postponable interventions. It is necessary to rebuild a public health system, aimed at a community made up of people aware of the management of their health that has gradually disappeared in recent decades, giving way to an economic-financial vision of “health” no longer understood as an objective. to be achieved, but rather as a “good to sell and therefore to buy”, the person from patient has therefore become a customer. And, while the good health became part of the investments of the Finance, inexorably, public health, especially the territorial one, was sucked into the vortex of inadequacy up to the delegitimization, thanks to the equally inexorable reduction of the resources allocated, especially in those Regions, victims of an at least improper interpretation of Fiscal Federalism.

The current pandemic has unequivocally highlighted the strategic role of public health and territorial medicine in particular, with its low-access services (pediatricians, family doctors, continuity of care doctors, family clinics, vaccination centers , diabetes centers, social and health services for the elderly, the disabled, the mentally ill, drug addicts, etc. ) which represents that advanced point of health that many countries envy us. The social emergency that is emerging post -CoviD opens up difficult scenarios for the future, for our country and in particular for Campania. This moment can represent an opportunity to redefine skills, roles and responsibilities in our very precious Health System. First of all, the requalification of territorial medicine by restoring that widespread distribution of its Agencies which in the past represented its strength by welcoming needs but above all by monitoring the state of health of the community, but the real process of renewal passes through recovery. of that de-legitimization by a non-negligible slice of society which has ended up considering the quality of the healthcare offer as a function of its cost. Furthermore, a stabilization of the regional health planning is indispensable, which pursues the pre-established objectives, whose path indicators are evaluated and monitored in time in order to be able to make appropriate changes in the procedures and that the outcome indicators are achieved. The organizational structure of Oncological Screening, of all three oncological screenings, represents a real revolution not only for the reference community, but also and above all for public health. The Screening path is nothing more than a PDTA, i.e. a therapeutic diagnostic path that starts from the territory, in the case of the Family Consultants where the colpocytological sampling is performed up to the Colposcopic Study Centers and finally to the III level Centers for surgical or chemotherapy therapy . For the path not to be an obstacle course for the patient, that is, not a performance but experienced as a service, it is necessary that there is professional recognition among the various operators involved in the different levels of assistance. Furthermore, it is necessary to identify a communication strategy suited to the needs of that particular context, and above all that the most effective strategy, that is empowerment , is put in place.


The systematic review identified several interventions that proved effective in all contexts, some of which with minimal economic and organizational impact. One of the factors that most influences the effectiveness of cancer screening programs in reducing cancer mortality and / or morbidity is the participation of the target population in the program. High participation rates must be achieved to achieve a significant impact on the health of the affected population. This objective must be achieved by encouraging an informed participation of the individual who, before joining, must be made aware of the benefits, limitations and disadvantages of the screening program.

Among The Improvement Strategies Of Non-Organized Screening:

  • there is solid evidence for systematic reminders to GPs in which people who have not undergone screening are reported;
  • there are very heterogeneous results for information and education campaigns aimed at the individual;
  • very intensive face-to-face promotion interventions proved effective, but were mainly tested in groups of deprived or at risk population;
  • there are indications of the effectiveness of mass campaigns, but they have shown many objective difficulties in the evaluation methodology;
  • there is solid evidence of the effectiveness of interventions to remove economic barriers, specifying that a woman will carry out the blood sampling increases participation in cervical screening. You must never abandon the practice of Screening in the course of adult life.

The State Of The Art In Campania

The identification of human papillomavirus as a necessary cause of cervical cancer has opened up new opportunities for prevention: the vaccine to prevent infection and the HPV test to detect infections and treat pre-invasive lesions early . Some large population trials conducted in Europe have shown that the HPV test is more sensitive than the Pap test; the follow up of these studies has then shown that this greater sensitivity translates into greater diagnostic anticipation of preinvasive lesions , finally in greater efficacy in the prevention of invasive cancer. In light of these findings, many pilot projects have begun to evaluate the feasibility of organized screening programs based on HPV as the primary screening test.

The Italian HTA report anticipates the indications of the European guidelines, the recommendations of the report were adopted by the Ministry of Health, after hearing the opinion of the Health Commission of the State Regions Conference, as a support tool to the Regions for planning cervical screening 15 . Therefore, despite the excellent results of the use of the Pap Test as the main method of screening, in recent years, numerous studies have addressed the problem of overcoming the current screening procedures 40 for cervical cancer, with the aim of verifying whether , new methods, generated by the advancement of diagnostic techniques in molecular biology, could lead to improving the management and results of this prevention path. In the context of this complex topic, which would require a discussion that goes beyond the boundaries of this work, we can simplify, underlining the acquisition of at least three basic points in the scientific literature:

  • There is clear scientific evidence that screening with clinically validated DNA tests for oncogenic HPVs (HPV tests), as a primary screening test and with an appropriate protocol, is more effective than cytology-based screening in preventing invasive neck cancers of the neck. ‘uterus.
  • HPV screening allows to reduce the incidence of invasive cervical cancer by 60% -70%, compared to Pap test screening, with an interval between two tests of 5 years instead of 3 (Ronco et al. 2014).
  • A protocol centered on the HPV test reduces the referral to second level assessments and the overdiagnosis of spontaneously regressive lesions, affecting the containment of costs and the percentages of adherence to the path.

In view of these evidences, in Italy the 2017-2019 National Prevention Plan gave indications for the introduction of the new test within the screening protocol by 2019 in all Italian cervical screening programs.

The Campania Region with DCA n. 36 of 01.06.2016 for the purpose: “Transposition of the observations of the Ministry of Health and Approval with amendments to the Regional Prevention Plan of the Campania Region for the years 2014 – 2018” approved action B3 under program B “Wellbeing in the Community” “Implementation of HPV-DNA Test for cervical cancer screening” with the aim of improving the early diagnosis of tumors covered by organized screening programs through the definition and implementation of innovative pathways for cervical cancer screening (HPV-DNA test) 14. Following these assumptions, to date in some regions the HPV test is progressively replacing the Pap test; in situations where the latter is still being used, the HPV test is used as a triage test in case of low-grade cytological abnormalities.

General objectives of the intervention:

  • Adapt the clinical and organizational path of cervical cancer screening in the Campania Region to the quality standards recommended at national level.
  • Improving the early diagnosis of tumors covered by organized screening programs through the definition and implementation of innovative pathways for cervical screening (HPV-DNA test), in order to promote a homogeneous extension of early diagnosis and an acceptable / desirable adhesion. specific to the intervention.
  • With a regional guiding document, define the methods and times for introducing the new procedure.

Define and organize the reference centers responsible for taking care of the different steps of the path.

  • Promptly initiate training for the operators involved in the program.
  • Promptly activate awareness / empowerment / information campaigns for the target population.
  • Update the operational / technological levers of the program, through the revision of the regional screening software and moving the invitation system of the target population entirely to the web- based telematic platform , guaranteeing with the same tool the informative feed-back to citizens and treating doctors .

Project Proposal

Essential elements for the preparation of an appropriate protocol The consolidated definitions and technical-scientific costrains for the implementation of the intervention must be assumed in advance, considering the evidence present in the literature. These can be summarized as follows:

  • The screening test of choice for the diagnosis and prevention of cervical cancer is the Pap test, with a three-year interval for women aged between 25 and 29, and the HPV test, with a five-year interval, for women aged between 30 and 64.
  • The Pap test is also used as a triage test in HPV positive women, during the follow – up post second level CIN2 + negative tests and post treatment.
  • HPV positive women are not to be sent directly for colposcopy but it is necessary to use cytology ( Pap test) as a triage system. If the cytology is positive, the woman is sent for colposcopy. If the cytology is negative, the woman is asked to perform
  • The Pap test is also used as a triage test in HPV positive women, during the follow – up post second level CIN2 + negative tests and post treatment.
  • HPV positive women are not to be sent directly for colposcopy but it is necessary to use cytology ( Pap test) as a triage system. If the cytology is positive, the woman is sent for colposcopy. If the cytology is negative, the woman is asked to perform a new HPV test one year later. If this test is still positive, the woman is sent for colposcopy while, if it is negative, she is invited to a new screening round within the scheduled intervals.
  • Validated oncogenic HPV DNA tests for sensitivity and specificity for high grade lesions should be used, as reported in the European Guidelines ( Antila et al. 2015).
  • There is no evidence that dual cytology and HPV testing is either more protective than HPV alone as a primary test or that it increases sensitivity. The double test strategy, on the other hand, determines a substantial increase in referral for colposcopy. For this reason, when using the HPV test as the primary test, it is recommended not to add cytology in parallel.
  • The HPV test to be used for primary screening must be a clinically validated test according to the criteria defined by the guidelines for the clinical validation of HPV DNA tests for screening.


  1. International Agency for Research on Cancer . IARC Monograph on the evaluation of carcinogenic risks to humans : Human Papillomaviruses . IARC, Lyon 1995 ( updated 1997). http://monographs.iarc.fr/ENG/Monographs/vol64/volume64.pdf Redburn JC, Murphy MFG.
  2. Hysterectomy prevalence and adjusted cervical and uterine cancer rates in England and Wales. Brit J ObstetGynaecol 2001; 108: 388-95. AIRTUM Working Group. Tumors in Italy – 2016 Report. Survival. EpidemiolPrev 2017; 41 (2): Suppl . 1. AIRTUM Working Group. Italian cancer figures , Report 2014. Prevalence and recovery from cancer in Italy. Prev – alence and cure of cancer in Italy . Italian cancer figures , Report 2014. Prevalence and cure of cancer in Italy . EpidemiolPrev 2014; 38 (6 Suppl . 1): 1-144. National Screening Observatory.
  3. http://www.osser-vatorionazionalescreening.it/content/i-numeri-degliscreening Jeong BK, Choi DH, Huh SJ, et al. The role of squamous cell carcinoma antigen as a prognostic and predictive factor in carcinoma of uterine cervix . RadiatOncol J 2011; 29: 191-8. Burghardt E, Holzer E. Diagnosis and treatment of micro -invasive carcinoma of the cervix uteri. ObstetGyne – with 1977; 49: 641-53. Shepherd JH, Crawford RAF, Oram DH. Radical tra- chelectomy : a way to preserve fertility in the treatment of early cervical cancer ? Br J
  4. ObstetGynaecol 1998; 105: 912-6. Song S, Rudra S, Hasselle MD, et al. The effect of treat – ment time in locally advanced cervical cancer in the era of concurrent chemoradiotherapy . Cancer 2013; 119 (2): 325-31. Gupta S, Maheshwari A, Parab P, et al. Neoadjuvant Chemotherapy Followed by Radical Surgery Versus Concomitant Chemotherapy and Radiotherapy in Patients With Stage IB2, IIA, or IIB Squamous Cervical Cancer : A Randomized Controlled Trial. J ClinOncol . 2018 Feb 12: JCO 2017759985. Tewary K, Sill M, Long IIIH, et al. Improved survival with bevacizumab in advanced cervical cancer . NEJM 2014; 370 (8): 734-43. Frenel JS, Le Tourneau C, O’Neil BH, et al. Pembroli – zumab in patients with advanced cervical squamous cell Cancer : Preliminary results from the phase Ib KEY- NOTE-028 study . J ClinOncol 2016; 34 ( Suppl ., Abstr 5515). Antoine Hollebecque , Tim Meyer , Kathleen N. Moore et al. An open- label , multicohort , phase I / II study of nivolumab in patients with virus- associated tumors ( CheckMate 358): Efficacy and safety in recurrent or metastatic (R / M) cervical , vaginal , and vulvar cancers . JCO 2017 abst 5504 Campania Region: DCA n. 36 of 01.06.2016 for the purpose: “Transposition of the observations of the Ministry of Health and Approval with amendments to the Regional Prevention Plan of the Campania Region for the years 2014 – 2018” Document “HTA reports on cervicocarcinoma screening ” Epidemiol , Prev 2012; 36 (3-4.5) suppl 1
  5. Ronco et al. 2014, Ronco et al. 2015, Antila et al. 2015 Italian Group of Head and Neck Cancer Screening ( GISCI ): Triage cytology in screening programs with HPV as primary test – 2013
  6. SurveyGISCi on follow – up activities of cervical screening programs – 2013 report
  7. Use of the HPV- hr test in the triage of ASC-US, LSIL in women over 35 years, in the follow-up of women with ASC-US + cytology after a second level study negative for CIN2 + and in the follow-up after treatment of CIN2-3 lesions: 2012 update
  8. Recommendations on the HR-HPV test as primary screening test and review of the role of the Pap test. Approved by the GISCi assembly , 2010 edition
  9. 2nd level manual-Recommendations for quality in the diagnosis, therapy and follow-up of cervical lesions, within the screening programs, 2009 edition
  10. GISCI operating document for application in the programs of screening of the Bethesda System 2001, 2009 edition
  11. “HTA reports on cervicocarcinoma screening ” Epidemiol , Prev 2012; 36 (3-4.5) suppl 1

Macroangiopathy In Diabetic Patients. Role Of The Nurse In The Prevention Of Cardiovascular Complications

Article Navigation

Submission Date: 2022-06-08
Review Date: 2022-06-29
Pubblication Date: 2022-07-21



The subject of this paper concerns fundamental aspects of complications, management and education of the diabetic patient, especially the patient with macroangiopathic complications .
The increase in the prevalence of diabetes mellitus is now exponential and its impact on cardiovascular diseases is increasingly evident.
In fact, the patient with diabetes has a significantly increased risk of developing major cardiovascular events.
This is due to the particular aggressiveness of atherosclerotic disease at the level of the vessels, favored by endothelial dysfunction linked to the hyperglycemic state.
Diabetes is a chronic disease with very widespread diffusion all over the world, destined to increase in the near future with the progressive aging of the population and the increasing occurrence of risk conditions that precede its onset.
We are in fact in the presence of a real pandemic confirmed by epidemiological data, which indicate that more than 300 million people in the world are affected by diabetes.
In Italy, the treatment for diabetes absorbs 6.65% of the overall health expenditure, with a cost per patient that is more than double the national average.
Given the significant burden diabetes places on public health, preventing and improving the care of people with diabetes should be a primary goal for most communities and health systems.
The consequences for individuals are due to the complications that the person with diabetes can develop, in terms of a reduction in both the expectation and the quality of life, with significant repercussions, including economic ones.
The organizational quality and efficiency of diabetic care 4 are correlated with better disease control, with a better prognosis of complications, leading to a lower diabetes-related mortality rate.
Reducing morbidity and mortality and improving the quality of life of people with diabetes mellitus represent one of the current challenges for healthcare professionals, healthcare organizations and medical staff working in public healthcare facilities.
The selection and subsequent implementation of therapeutic education interventions, whose efficacy and congruence with needs have been demonstrated, are essential steps towards improving the conditions of people with diabetes.
Diabetes is a chronic disease and as such requires responsible management by those affected. Often people with diabetes forget to live with a silent disease which, in addition to acute complications, also manifests long-term complications which can become fatal.
A structured intervention is therefore necessary that increases the motivation and adherence of patients to the therapeutic plan, thus leading to a good metabolic control, to an acquisition of knowledge that allows them an adequate management of the disease and a consequent better quality of life.
The aim of this thesis is to research the results of lifestyle modification among the most important scientific evidence, taking into consideration aspects such as: metabolic control, acquired knowledge, self-management, self-efficacy, quality of life and satisfaction of the subjects.
The research was carried out by consulting international databases such as “ Pubmed ” and “ google scholar ".
The articles report that education for lifestyle change increases knowledge of one's illness, self-management skills and thus 2 an improvement in the quality of life.
As a result, there will be a reduction in the incidence of diabetes and an improvement in numerous cardiovascular factors. Furthermore, the nurse plays a role of fundamental importance both at the educational level through specific structured interventions, and at the psychological level.

The Diabetes

Definition and classification The denomination of diabetes mellitus derives from the Greek, diabetes = “pass through” (the kidneys) and mellitus = honey (in the sense of sweet, referring to the urine) (Treccani & Istituto della Enciclopedia Italiana, 2013).

Diabetes mellitus is a chronic syndrome characterized by hyperglycemia secondary to a defect in insulin secretion or activity or more often by both.

Chronic hyperglycemia is associated in the long term with damage, dysfunction and collapse of different anatomical areas such as ocular complications, macroangiopathy , nephropathy, neuropathy, erectile dysfunction.

Therefore, it requires continuous and multiple interventions on glycemic levels and cardiovascular risk factors, aimed at the prevention of acute and chronic complications; an educational activity for the patient suffering from diabetes, aimed at acquiring the knowledge necessary for the self-management of the disease; the treatment of complications of the disease, if any.

In order for glucose to enter the cells and be used as “fuel”, the presence of insulin is necessary.

 Insulin is secreted by the beta cells constituting the langherans islands , (which are part of the endocrine portion of the pancreas) which is essential for the metabolism of sugars.

All simple and complex sugars (starches), which are consumed with food, are transformed during digestion into glucose, which is the main source of energy for muscles and organs.

The concentration of glucose in the blood is measured by blood sugar.

In healthy subjects, who have a regular life and a correct diet, generally throughout the day the blood glucose values remain between 60 and 130 mg / dl.

When fasting, blood glucose values can vary from 70 to 110 mg / dl; between 110 and 125 mg / dl it is a condition of impaired fasting glycaemia (IFG), a condition that should encourage the patient to pay more attention to his lifestyle and in particular to his diet.

Blood glucose values equal to or greater than 126 mg / dL, according to American Diabetes Association , are considered probable symptoms of diabetes.

The spread of diabetes is taking on the characteristics of a real epidemic, it is estimated that there are at least 387 million diabetics in the world, and that 4.9 million die from complications of this disease.

The criteria for the classification of diabetes mellitus have undergone continuous modifications and redefinitions in recent decades, with the tendency to become increasingly rigorous and sensitive, but also increasingly simple.

The classification and diagnostic criteria of pre – diabetic states and overt diabetes mellitus were revised and reformulated in 1997 by a commission of experts sponsored by American Diabetes . Association (ADA) and subsequently updated over the years to date.

The current classification of American Diabetes Association (ADA), based on etiopathogenetic criteria, provides four classes:

  • Type I diabetes
  • Type II diabetes
  • Gestational diabetes
  • Other specific pathologies of diabetes
Type 1 diabetes mellitus (DM1)

Type 1 diabetes is a form of diabetes that occurs mainly in childhood and adolescence (although cases of onset in adulthood are not rare ).

For this reason, until recently it was referred to as childhood diabetes.

Type 1 diabetes mellitus falls into the category of autoimmune diseases because it is caused by the production of autoantibodies (antibodies that destroy their own tissues and organs, not recognizing them as belonging to the body but as external organs) that attack the Beta cells that are inside the pancreas. deputies for the production of insulin.

As a consequence, the production of this hormone, whose task is to regulate the use of glucose by the cells, is reduced to zero completely.

Therefore, there is a situation of excess glucose in the blood identified with the name of hyperglycemia.

The lack or scarcity of insulin, therefore, does not allow the body to use the sugars introduced through food which are thus eliminated in the urine.

In this situation the body is forced to produce energy in other ways, mainly through the metabolism of fats, which involves the production of so-called ketone bodies.

The accumulation of ketone bodies in the body, if not intervened in time, can lead to very dangerous consequences up to a coma.

Inadequate control can affect development, increase comorbidities , decrease life expectancy , and increase the risk of acute and chronic diabetes-related complications.

Responsibility for caring for children with diabetes has a psychosocial impact on both the child and his family.

The predisposition to develop diabetes is in part hereditary in fact the first degree relatives are at risk, while for the homozygous twins there is a certain inheritance but not total, because the susceptibility genes for diabetes are at a low degree of penetrance therefore there it must be something else to make it rise.

The regions of the human genome that induce predisposition to diabetes are 20 loci, in particular in the loci that encode human leukocyte antigens for HLA .

Subsequent studies have Subsequent studies have shown a role in the genetic predisposition for diabetes mellitus also for the insulin gene and other genes involved in the immune process.

Furthermore, viral infections are associated in the onset of diabetes in predisposed individuals.

There are 2 mechanisms through which an infection causes diabetes: the virus infecting beta cells induces a modification of the protein antigens represented by HLA class 1 and T lymphocytes or there is an immune response to viral infection which is a cross reaction towards specific antigens of the beta.

Another role is the feeding with cow’s milk as its proteins have a diabetic effect such as beta casein and bovine serum albumin which can lead to cross reactions between milk and cell proteins.

Other proteins are those of wheat such as gluten.

Protective foods are vitamin D which has immune properties modulatory linked to the alteration of vitamin D with the nuclear receptor, chemicals can cause direct toxic damage to the beta causing them to be destroyed.

The characteristic symptoms of diabetes 1 are associated with the progressive worsening of the insulin deficiency.

Initially manifests itself with polyuria, increased urine excretion, as the progressive worsening of the insulin deficiency determines a low action of insulin by reducing the hepatic production of glucose and increasing its uptake at the peripheral level, thus being a hypoglycemic action.

With the presence of deficiency the blood sugar will increase and a certain amount is exceeded or the renal absorption threshold is exceeded, the glucose is no longer reabsorbed and comes out with the urine as it recalls water due to the osmotic effect.

Polyuria is observed in a high sensation of thirst and a state of dehydration of the skin and mucous membranes.

There is an increase in appetite but with a decrease in weight because in the presence of a deficit we have excessive lipolysis and proteolysis, there will be production of ketone bodies that will lead to nausea, vomiting, abdominal pain and if you do not have a correct drug therapy you can get to a coma or to death.

Type 2 diabetes mellitus (DM2)

 It is a disease with a multifactorial etiology characterized by a great heterogeneity of molecular defects characterized by the presence of insulin resistance and often also by a relative insulin deficiency ; for this reason, this form does not provide, except in some cases, the insulin treatment.

– cell destruction does not occur in DM2 .

Type 2 diabetes mellitus typically appears after puberty and affects approximately 90 – 95% of diabetic patients.

Many patients with the aforementioned diabetic form are obese, and obesity itself is a cause of insulin resistance .

Patients who cannot be defined as obese according to the criteria based on the calculation of the BMI, will most likely have a higher percentage of visceral adipose tissue, since this too is associated with insulin resistance .

Furthermore, this diabetic form may remain undiagnosed for some years and this is because the hyperglycemia, developing gradually, may initially be asymptomatic.

We can therefore say that at the base of DM2 there is in any case a defective insulin secretion that fails to compensate for the insulin resistance present in the tissue.

However, this tissue insulin resistance may be improved through weight loss or drug treatment.

The risk of developing this form of diabetes is greater in the obese, in physically inactive people, in women with a history of gestational diabetes mellitus, in hypertensive or dyslipidemic patients , in some ethnic groups and increases with increasing age.

DM2 is often also due to a strong genetic predisposition.

However, these forms are complex and not yet fully defined.

 On the other hand, a different pathogenesis has been reported, which explains that the primary cause of DM2 is of ischemic origin due to a temporary or permanent decrease in the blood supply in the anterior hypothalamic nuclei, which causes over-excitation of the descending parasympathetic pathways and the anterior hypothalamus axis , increase in the concentration of glucose in the blood and lipids, as well as the accumulation of adipose tissue, the latter being the main one involved in insulin resistance and hyperinsulinemia .

Ischemia causes a chronic progressive deficit of insulin secretion, which favors the necrosis of the B lymphocytes due to lack of irrigation. In this sense, islets have been shown to be highly dependent on blood supply, making them very vulnerable to ischemic changes. 

Gestational diabetes mellitus (GDM):

Gestational diabetes refers to an increase in blood sugar (blood sugar levels) when fasting or after meals and which is first observed in pregnancy. The risk of developing it must be evaluated in the initial stages of gestation especially in the presence of predisposing clinical signs such as obesity, previous GDM, familiarity with DM

. It generally appears in the II – III trimester of pregnancy and represents an important risk factor for the pregnant woman and the fetus.

Due to a situation of insulin – physiological resistance that is established in pregnancy, by placental hormones, not balanced by pancreatic function.

GDM is manifesting itself more and more in parallel with the increase in juvenile obesity.

Other specific types of diabetes: These are forms of diabetes that do not fall into the previous classes and which are due to other causes.

They can be the consequence of genetic defects of β – cells (MODY1, MODY 2, MODY3, MODY4, MODY5, MODY6, mitochondrial DNA ) or in insulin action ( insulin resistance type A, leprechaunism , Rabson – Mendenhall syndrome , lipoatrophic diabetes ), exocrine pancreatic diseases (pancreatitis, trauma, neoplasms, cystic fibrosis, hemochromatosis , pancreatopathy fibrocalculosa ), of endocrinopathies (acromegaly, Cushing ‘s syndrome , glucagonoma , pheochromocytoma , hyperthyroidism, etc.) or forms induced by drugs, chemicals and drugs ( vacor , nicotinic acid, pentamidine , glucocorticoids , thyroid hormones, alpha – interferon, thiazides , etc.), infections ( cytomegalovirus , rubella congenita) rather than uncommon forms of immune- mediated diabetes ( Stiff – man syndrome , anti – insulin receptor antibodies, etc.) or deriving from other genetic syndromes (Down syndrome, Prader syndrome – Willi, Klinefelter , Turner, Wolfram, etc.). In particular, MODY diabetes ( Maturity Onset Diabetes of the Young), is characterized by a juvenile onset of type 2 diabetes mellitus in which rare genetic defects in the intracellular mechanisms of insulin action have been identified. Mature-onset diabetes of young people (MODY) is a heterogeneous group of monogenic causes of beta cell dysfunction and diabetes that arise in children and young adults. Making an accurate diagnosis of MODY is important in establishing proper man