Objectives: the Italian National Prevention Plan (PNP) posed the standard to be achieved by Italian Regions for the implementation of cervical, breast, and colorectal cancer screening: to invite all of the target populations and to increase the screening uptake up to 50%, 60%, and 50%, respectively, the standard defined by the Essential Levels of Care (LEA). Moreover, for cervical cancer screening, it requires the implementation of HPV-DNA test and, for breast cancer screening, the PNP demands for the definition of diagnostic and follow up pathways for high familial risk women. The PNP also set up a monitoring system to assess the impact of implemented policies. A conceptual model has been defined to facilitate interpretation of variation in outcome indicators.
Design: after a systematic review, the DPSEEA (Driving forces, Pressure, State, Exposure, Effect, Actions) was identified as the more appropriate framework to assess the results of preventive policies. Factors for each component of the model were identified and indicators that allow measuring the changing of each of these factors were defined.
Results: among the "driving forces", the trust in the health care system and the social capital were included. The presence of opportunistic screening, the competing private clinical activity, the commitment of General Practitioners and "medical" leaders, the attitude to cooperation and to patients' involvement, and the level of agreement between the positions of scientific societies and the recommendations implemented in organized screening programmes were included in the "pressures". In "state", the availability of technological and human resources, the level of management skills and of accessibility were identified. The "exposure" was defined as the coverage of active invitation of the target population and the uptake of screening tests. The "exposure" factors influence the "effect", described as the impact on anticipation of cancer diagnosis, on disease incidence (for cervical and colorectal cancer) and prognosis. The changing in screening programs performance modifies the impact of invitation coverage and test uptake ("exposure").
Conclusions: through the DPSEEA framework, we set up a logical conceptual model, which includes implementable actions and the mechanisms through which these actions should impact on the "exposure" (invitation coverage and screening uptake) and on the screening performance (quality).