Manuti et al. BMC Public Health 2010, 10:350 http://www.biomedcentral.com/1471-2458/10/350 during the 1990s the Italian NHS was decentralized into twenty independent regions, thus increasing the risk of inequality in access to health in the more impoverished places of the South. Indeed, studies have demonstrated a striking imbalance in the provision of preventive health services, especially in breast, cervical and colorec- tal cancer screening, with higher coverage always in Northern and Central Italy compared to Southern Italy, where organised systematic screening activity has not yet been completely implemented [7-9]. Several studies have been published which focused on a narrow set of quality indicators and conditions in selected populations, but they showed limited ability to evaluate the role of specific factors associated with poorer quality [10-12]. Very few studies have examined the quality of preventive care for multiple conditions [13-16]. In the present study, we intend to quantify the access to various preventive services in Southern Italy, and to identify the relationships between patients’ char- acteristics and the quality of preventive care which is supplied by PCPs. Methods Study population A cross-sectional study was conducted at waiting rooms of 20 PCPs in two cities of Southern Italy (Catanzaro and Crotone), randomly selected from lists provided by the Local Health Units. Catanzaro had 60 PCPs and Crotone 38. These two cities, Catanzaro and Crotone, are located in the Calabria Region (2 million inhabitants as a whole) in the extreme southeastern part of Italy; the former is the capital of the region and the latter is a small town, yet they have common urban and demo- graphic characteristics typical of the southern region of the country. The adult population was 77,022 in Catan- zaro and 44,047 in Crotone. From June through Decem- ber 2007 two trained physicians gathered information from adult patients attending PCPs who consented to participate, to determine “technical process quality” (whether or not patients were offered recommended ser- vices for which they were eligible) across a wide spec- trum of preventive healthcare services. On average, 30 patients were attending consultations on each occasion. All information was self-reported by the participants. No medical records or interviews by any PCPs were used as sources of data. Sample size calculation assumed the worst scenario of an estimated proportion of each characteristic of interest in 50% of the population. As we were interested in at least 200 subjects in each subgroup within the sample for each separate estimate required, we decided to be conservative and to increase our sample size to 1500 subjects so that we would have sufficient precision in the estimates on the whole sample. Page 2 of 10 Review instrument The RAND Quality Assessment Tools system is a com- posite of 35 quality indicators, of which we selected 15 [2]: to assess potential problems with underuse of the following preventive services routinely recommended for adults: screening and counseling on health habits (sexual activity, drug abuse, alcohol consumption and smoking cessation), physical examination (blood pressure check and evaluation of hearing difficulties), vaccinations against influenza and pneumococcal disease (in all patients 65 yrs and over and in patients younger than 65 yrs with conditions that represent a risk for severe complications in subjects undergoing influenza and pneumococcal disease) and recommended screening for early diagnosis of cancers according to age and gender (breast, cervical and colorectal). (See Additional file 1). The decision to exclude 20 indicators was suggested for several reasons: 1) we excluded 11 indicators because they needed to be verified by medical records; 2) we excluded 8 indica- tors that pertained to subgroups of populations that would be rarely encountered in our setting and would therefore offer low numbers of eligible subjects (for example, pregnant women not immune to rubella or women with a history of cervical dysplasia or carci- noma-in-situ or HIV infection who have not had Pap smear within the past year ); 3) we excluded one indica- tor that predictably would have an absolute 100% failure rate (that is, counseling regarding the use of seat belts). We defined chronic diseases (using WHO criteria) as diseases of long duration and generally slow progression, such as heart disease, stroke, cancer, chronic respiratory diseases, diabetes etc. [17], and we classified participants as having chronic diseases if they reported ever being advised by a healthcare worker that they had a chronic disease and/or if they were currently in treatment for these conditions. Similarly, we defined participants as hypertensive if they reported ever being advised by a healthcare worker that they had high blood pressure and/or if they were taking an antihypertensive medication. Additional questions were derived from the BRFSS 2007 Questionnaire [18]. These evaluated smoking and alcohol consumption habits, as well as recommendations of physicians on how to reduce behavioral risk factors related to high blood pressure, and on compliance of patients to colorectal, breast and cervix cancer screen- ing. We defined current smokers as people who reported smoking at least 100 cigarettes during their lifetime and who currently smoke every day or some days. Current drinking was defined as consuming alco- hol on one or more of the previous 30 days. Heavy drinking was defined as an average consumption of more than 2 drinks per day during the previous 30 days