Analyzing Current Tobacco Usage and Knowledge Among Migrants and Their Providers in Milan, Italy

May 16, 2019
Opera San Francesco soup kitchen volunteers with GPH students and staff

Pictured: Opera San Francesco soup kitchen volunteers with Andrea Muraca and GPH students Faisal Adam, Enrique Francis, Khaled Kholief, Abigail Merced, Joanna Philips.


In March, six GPH students Faisal Adam, Enrique Francis, Khaled Kholief, Lisa Koop-Yilmaz, Abigail Merced and Joanna Philips, accompanied by Andrea Muraca, MS, MPH, Assistant Director of Student and Alumni Affairs and Michael Weitzman MD, Professor of Global Public Health at GPH did their Capstone Project at Opera San Francesco (OSF), in Milan Italy. Widely regarded as the center of Italian fashion, Milan is situated in northern Italy just two hours from glamorous Lake Como and the Swiss border. Despite its opulent allure, Milan like much of Europe is experiencing a range of complicated social, economic, political and health related challenges, not the least of which is the influx of migrants at a magnitude that has not been seen since World War 2.  Italy has one of the largest migrant populations in Europe, with more than 500,000 undocumented migrants, many of whom live in Milan. These individuals often face profound social, linguistic, cultural, economic, physical and psychosocial problems, with very limited access to health and human services. OSF works to address many of these issues, to develop new services and to advocate throughout the region for the widespread development and implementation of services to address similar such issues by others. 

OSF is a non-profit organization founded in 1959 in Milan by Capuchin Friars with a mission to improve the health and dignity of the community’s most marginalized and vulnerable residents by providing services designed to meet their immediate health and social needs as well as to empower individuals to be self-sufficient and live productive lives in a safe environment. In its 60 years it has grown substantially and those it serves has increasingly consisted of migrants. Services are provided from a number of locations and range from preventive and curative clinical services to meals, showers, clothing distribution and psychosocial services. Of its staff of more than 400, approximately 300 are volunteers, including all of its 200 physicians and dentists! Its mission aligns closely with a broad based vision of public health, its leadership is profoundly committed and effective, and its staff warm, respectful and highly skilled. It was truly inspirational for us to be at OSF and witness the kindness, generosity and quality of care provided to some of the poorest and highest risk individuals in Northern Italy, the majority being migrants.  Clinical services include preventive care; dental care; specialized programs such as a clinic for patients with Chagas Disease (a disease rare to Europe, but not among migrants from South and Central America); outpatient surgical procedures; and social and psychological services. Many of the families served are refugees and have experienced great trauma, dislocation from their culture of origin and social supports. Among its newest and boldest endeavors is their implementation of The Fragile Family Project, a care coordination program for many families with the most complicated medical and social programs, and they have begun discussions with government authorities about creating formal ties with the Italian public health system. OSF perceived the need for a broader takeover of regular migrant patients and Italian patients living in large health difficulties. 

The project is called Fragile as it is aimed at all people suffering from at least one chronic pathology, who are in a condition of psychological and/or social fragility and are excluded from access to the national health system because of:

  • the lack of the bureaucratic requisites necessary to take advantage of the national healthcare system (e.g., immigration status) or 
  • the presence of a psychological and/or social problem of such importance that would compromise the pathology and autonomy in following the path of care (e.g., economic disadvantage, unemployment, difficulty in walking, illiteracy, lack of knowledge of one's rights, unawareness of their own pathology and lack of the necessary requirements to obtain a job). 

On the very first day in Milan our students served meals to 850 people at one of OSF’s food kitchens. The majority of their time, however, was spent at the OSF primary healthcare delivery site. In the past 10 years OSF has provided outpatient clinical services to more than 70,000 individuals from more than 30 countries, with the vast majority being migrants, most from South America, Central America, North and Western Africa, and East Europe. This year’s Capstone Project built upon the work done by our students the two prior years, which concentrated on a description of mental health, dental and vaccination issues, services and patient and provider perceptions of these health areas and the services that OSF was providing.  This year’s Capstone Project  focused on tobacco use among OSF’s migrant population. 

Why focus on tobacco among a population with so many other overwhelming and immediate problems? Tobacco remains the single most preventable source of death in Italy, as it is worldwide. Worldwide, 6 million people die each year of smoking and another one million die of secondhand smoke exposure. More than one out of every 5 Italians 15 years and older smokes and while data are sparse (only 2 relevant articles in the peer-reviewed literature could be identified), it appears that smoking is as high or higher among migrants to Italy as it is among indigenous Italians and to date, anti-smoking efforts have not been at the forefront of efforts to improve immigrant health.


GPH Student and translator recording survey responses.

Pictured: Enrique Francis and Daniele Pala (translator) recording survey responses.


GPH students focused on tobacco use and attitudes toward tobacco cessation among patients and staff at OSF. They did this by first developing and translating a relevant survey and then administered it to 240 OSF clients, in Italian, Spanish, Arabic and English; conducting in-depth qualitative interviews with 20 OSF clients and multiple OSF staff members, as well as focus groups with providers. Not only was the prevalence of smoking among migrants unanticipated (among patients who participated in the qualitative interviews 55% were current smokers and approximately 20% were former smokers). Two thirds of those who were current smokers stated that they would welcome help to stop smoking. Currently, OSF does not offer smoking cessation services or medications, although interviews and focus groups with service providers and administrative leaders demonstrated that our work enhanced their recognition of the importance of developing such services in the future. 

Plans for the future include a commitment to continue to grow the relationship between OSF and GPH, with GPH hopefully playing roles that increasingly are of assistance to OSF and those they serve while at the same time providing a setting where our students can experience and collaborate with a mature, effective and growing organization serving and advocating on behalf migrants in particular and impoverished and disenfranchised individuals in particular.


GPH students, staff and OSF staff

Pictured: Dr. Michael Weitzman, Andrea Muraca, Sara Fadelli (OSF Chief of Staff), Francesco Castelli (translator), Faisal Adam, Enrique Francis, Khaled Kholief, Abigail Merced, Joanna Philips.