[The economic-financial crisis and health in Spain. Evidence and viewpoints. SESPAS report 2014]

Evaluation of the concerns of Spanish university students in the face of current major challenges

The concerns of students and young people have been on the rise in recent years. Recent events such as the Covid-19 pandemic or the invasion of Ukraine have contributed to this. Mental health, the high cost of living, the need to re-evaluate the way we work or the fight against climate change are among the main concerns of young people. The aim of this work is to find out the level of concern of university students about these problems that can condition their current life and to analyze whether these concerns can affect their academic performance, also distinguishing according to gender and age. To this end, a nationwide survey was carried out among this group in Spain. This work is the first of its kind to be carried out in Spain. The results obtained may be of great use to both educational institutions and government agents, with a view to offering policies that will improve the educational level and welfare of university students.

Stress at Work: Can the Spiritual Dimension Reduce It? An Approach From the Banking Sector

Stress at work motivated by pressures and labour control can alter the behaviour of workers. Since the 2008 economic crisis, banking in Spain has suffered a series of massive lay-offs to adjust to the new market situation. This new financial restructuring has meant greater labour pressure to achieve the required results. Faced with this adversity, employees have experienced greater stress at work. This work analyses the effect of reinforcing employees' spiritual dimension to transcend and correctly manage work pressure and stress at work. In so doing, 601 employees from 294 financial entities of five large IBEX banks participated in this pilot project. Through a participatory methodology based on a review of the literature, the study indicators have been delimited. The data obtained have been treated using the SEM-PLS method. The results propose the incorporation of a series of tools to reinforce values and transcendent employee behaviour.

Influence of Gender Determinants on Informal Care and Health Service Utilization in Spain: Ten Years after the Approval of the Equality Law

The existence of gender inequalities in health, in the use of health services, and in the development of informal care has been demonstrated throughout scientific literature. In Spain, a law was passed in 2007 to promote effective equality between men and women. Despite this, different studies have shown that the previous gender inequalities are still present in Spanish society. For all these reasons, the objective of this paper is to study the differences by sex in informal care and in the use of emergency care, and to identify the existence of gender inequalities in Spain 10 years after the adoption of the aforementioned equality law. In this case, we development a cross-sectional study based on the 2017 Spanish National Health Survey of the Spanish population aged 16 and over. To analyze the influence of gender determinants on informal care and emergency care utilization, logistic regressions were performed, model 1 was adjusted for age, and model 2 was further adjusted too by the variables of the Andersen care demand model. The results showed that informal care and the use of the emergency care continues to be higher in women than in men. Informal care in women was related to a higher level of education. In emergency care, the older the age, the lower the probability of utilization, and living in a rural municipality was related to a higher probability of utilization for both sexes. Finally, we concluded that there is still a need for studies that analyze gender inequalities in different contexts, such as the informal care and the use of health services. This is especially relevant in Spain, where economic changes have led to a change in roles, mainly for women, and new management strategies are needed to achieve equity in care and effective equality between men and women.

Investigating the Relationship between Stress and Self-Rated Health during the Financial Crisis and Recession in 2008: The Mediating Role of Job Satisfaction and Social Support in Spain

Background: the 2008 financial crisis and subsequent recession had a strong impact on employment and certain health indicators, such as mental health. Many studies carried out with diverse samples attest to the negative influence of stress on health. However, few studies focus on stress and self-rated health among the Spanish workforce, or analyse which variables can act as a buffer against the negative effects of stress on self-perceived health. Aim: to analyse the mediator role of social support and job satisfaction in the relationship between work-related stress and self-rated health among the Spanish working population between 2006 and 2017. Method: repeated cross-sectional study using Spanish Surveys from 2006 to 2017, a total of 32.105 participants (47.4% women) aged 16 years and over (M = 42.3, SD = 10.7) answered a series of questions about work-related stress (PV), self-rated health (CV), job satisfaction, and social support (mediator variables) through the National Health Survey (NHS) prevalences of work-related stress, self-rated health, job satisfaction, and social support were calculated (standardised by age). We performed mediation/moderation analysis with Macro Process for SPSS to analyse the role of social support and job satisfaction in the relationship between self-rated health and work-related stress among the Spanish working population. Results: three mediation analyses were conducted, one for each time point in the study period. The results revealed a significant direct association between stress and job satisfaction. In the 2006 model, both job satisfaction and social support acted as mediators between stress and self-rated health, while in the 2011 and 2017 models, only job satisfaction acted as a mediator. The data reveal that the working population in Spain has a good capacity for resilience, since no drop in health indicators was observed. Conclusion: following the economic recession, employment has partially recovered. However, social and employment policies are required to help the population face the recent situation triggered by the Coronavirus crisis.

Physical inactivity as a risk factor to mortality by ischemic heart disease during economic and political crisis in Brazil

Background

To investigate the burden of mortality due to ischemic heart disease (IHD) attributable to low levels of physical activity in the Brazilian population (aged ≥ 25 years) before, during and after economic and political crises (2007–2017).

Methods

This study was focused on IHD as a cause of death. The International Statistical Classification of Diseases (10th revision) codes related to IHD have been mapped. The data used for the physical activity estimates of the present study refer to surveys with random sampling carried out in the Brazilian territory that considers all domains of physical activity. The contribution of physical activity for mortality due to IHD was estimated using a comparative risk assessment approach. In addition, we verified the association between mortality due to IHD attributable to low levels of physical activity according to the Socio-demographic Index of the Brazilian states.

Results

For males it was estimated that in 2007 and 2017 there were, respectively, 9,585 and 11,821 deaths due to IHD as a result low physical activity. For females there were 8,689 deaths in 2007 and 10,779 deaths in 2017 due to IHD attributable to low physical activity. From 2007 to 2017, there was 12.0% (for males) and 16.0% (for females) of reduction in age-adjusted mortality rate due to IHD attributable to low physical activity. This reduction was not observed in the Northern and Northeastern regions of Brazil for the male population. Brazilian states with better socioeconomic conditions showed greater reductions in age-adjusted mortality rate due to IHD attributable to low physical activity (male: ρ = −0.74; female: ρ = −0.54)

Conclusion

The fiscal austerity policies implemented and the lower investment in social programs in the period of economic and political crisis highlighted the social inequalities between Brazilian geographic regions for the burden of mortality due to IHD attributable to low levels of physical activity.

Qualitative Analysis by Experts of the Essential Elements of the Nursing Practice Environments Proposed by the TOP10 Questionnaire of Assessment of Environments in Primary Health Care

Background: A short TOP10 scale based on the Practice Environment Scale-Nursing Work Index questionnaire measures the characteristics of nursing work environments. Positive environments result in better quality care and health outcomes. Objective: To identify a small number of core elements that would facilitate more effective interventions by nurse managers, and compare them with the essential elements proposed by the TOP10. Method: Qualitative research by a nominal group of eight experts. The content analysis was combined with descriptive data. Results: Ten most important items were selected and analyzed by the expert group. A high level of consensus in four items (2, 15, 20, 31) and an acceptable consensus in five items was reached (6, 11, 14, 18, 26). The tenth item in the top ten was selected from content analysis (19). The expert group agreed 90% with the elements selected as essential to the TOP10. Conclusion: The expert group achieved a high level of consensus that supports 90% of the essential elements of primary care settings proposed by the TOP10 questionnaire. Organizational changes implemented by managers to improve working environments must be prioritized following our results, so care delivery and health outcomes can be further improved.

Relationship between the actual fine dust concentration and media exposure that influenced the changes in outdoor activity behavior in South Korea

The one reason of the decrease of walking time for adults in South Korea among various factors is the sense of fear about fine dust sparked by media reports, which has created a negative perception of fine dust. This study aimed to assess the change in concentration of fine dust, as well as individuals' walking time and health status, in South Korea, and to investigate the relationship between the media reports on fine dust. Using the national government statistics data, we analyzed the relationship between walking time, concentration of fine dust, and amount of media reports on fine dust. From 2008 to 2017, the average walking time and PM10 levels decreased from 76.17 to 49.47 min and 52 to 45 μg/m³; whereas PM10 media frequency increased from 349 to 9,234. No positive correlation existed between walking time in South Korea and exposure to fine dust. However, media reports on fine dust increased steadily from 2012 and peaked in 2015. The decrease in average walking time in South Korea was due to the negative perception created by the increase in media reports on fine dust, rather than the increase in the actual concentration of fine dust.

[Assessment of the consensus document on food in educational centres to evaluate school menus]

OBJECTIVE

To explore the applicability of the Consensus Document on School Food Programmes in Educational Centres (DCSECE) to evaluate the adaptation of school menus to healthy eating recommendations.

METHOD

Transversal study that analyzes monthly school menus from 28 early-childhood education and primary education centres in Andalusia and Canary Islands (Spain). Data were collected using an ad-hoc protocol based on the DCSECE recommendations and divided into food categories and subcategories. We studied the weekly menu offering of each of the foods by category and subcategory and compared them to the DCSECE recommendations.

RESULTS

The majority of the schools offered better meals than as specified by the recommendations, in terms of vegetables, other garnishes and other deserts. They offered poorer quality meals in the categories of rice, pasta, prepared foods and salads, and had an equivalent offering in terms of pulses, meats, fish and eggs. By subcategory, we observed the predominance of cooked vegetables in the vegetable category as compared to salads, and the predominance of processed meats in the meats category.

CONCLUSIONS

The DCSECE could be a useful instrument for evaluating the nutritional offering of school menus. However, there is a need for greater specificity in the recommendations, in order to identify whether these menus adhere to healthy eating recommendations.

[Different classification of an adult population by two validated indexes of adherence to the Mediterranean diet]

Introduction

Background: the Mediterranean diet (MD) has been related to a good state of health. There are different index to evaluate the adherence to Mediterranean dietary pattern. Objective: the purpose of the study was to evaluate the classification of the adult population of the Comunitat Valenciana according to their suitability to the MD using two validated indexes, and analyze the degree of agreement between them. Methods: methodological study of the concordance of classification of a population through two instruments for measuring adherence to MD, of a representative sample of 2,728 adult of the Comunitat Valenciana. Data obtained from Encuesta de Nutrición de la Comunitat Valenciana 2010-2011. The adhesion was determined by "Puntuación Modificada de Dieta Mediterránea" and "Cribado de Adherencia de Dieta Mediterránea". The population was classified as low, medium or high according to each index. A statistical analysis was performed for qualitative and quantitative variables. The concordance of the indexes was evaluated by the Kappa test. Results: in both indixes, the highest percentage (41% and 71%, respectively) of the population was in medium adherence to MD. Between both indexes, the value of the kappa index was 0.169, for men 0.163 and for women 0.174. By age groups: 0.158 for those aged 16-24 years, 0.139 for 25-44 years, 0.185 for 45-64 years, and 0.161 for those over 64 years. Conclusions: the two indexes tested showed a degree of poor agreement and classified the same population differently.

Effect of the Financial Crisis on Socioeconomic Inequalities in Mortality in Small Areas in Seven Spanish Cities

Background: The aim of this study was to analyze the trend in socioeconomic inequalities in mortality in small areas due to several specific causes before (2001–2004, 2005–2008) and during (2009–2012) the economic crisis in seven Spanish cities. Methods: This ecological study of trends, with census tracts as the areas of analysis, was based on three periods. Several causes of death were studied. A socioeconomic deprivation index was calculated for each census tract. For each small area, we estimated standardized mortality ratios, and controlled for their variability using Bayesian models (sSMR). We also estimated the relative risk of mortality according to deprivation in the different cities, periods, and sexes. Results: In general, a similar geographical pattern was found for the socioeconomic deprivation index and sSMR. For men, there was an association in all cities between the deprivation index and all-cause mortality that remained stable over the three periods. For women, there was an association in Barcelona, Granada, and Sevilla between the deprivation index and all-cause mortality in the third period. Patterns by causes of death were more heterogeneous. Conclusions: After the start of the financial crisis, socioeconomic inequalities in total mortality in small areas of Spanish cities remained stable in most cities, although several causes of death showed a different pattern.

Bayesian smoothed small-areas analysis of urban inequalities in fertility across 1999-2013

Background

Since the 2008 economic crisis in Spain, overall fertility has continued to decrease, while urban inequalities have increased. There is a general lack of studies of fertility patterns in small-areas of Spanish cities. We explored the effects of the economic crisis on fertility during three time periods in urban settings in Spain.

Methods

We studied the distribution of fertility rates among women (15–49 years) from Spain and low-middle income countries (LIC) who were living in 13 Spanish cities. We mapped fertility and the MEDEA socioeconomic deprivation index in small-areas, and analyzed age-related trends in fertility rates. We performed an ecological regression analysis of fertility and the deprivation index in two pre-crisis periods (1999–2003 and 2004–2008) and one crisis period (2009–2013). Fertility rates were calculated and smoothed using the hierarchical Bayesian model (BYM).

Results

Higher fertility was generally associated with socioeconomic deprivation, with adjustment for the mothers’ age and nationality. While Spanish citizens tended to delay childbearing throughout the three study periods, fertility increased among Spanish adolescents from deprived urban areas during the economic crisis. There was a general decline in fertility among immigrants after the crisis, especially in southern cities. Overall, fertility appeared to be stable, with higher fertility in more deprived areas.

Conclusion

Increased unemployment and changes to government family policies may have contributed to delayed childbearing in Spain. For immigrants, more restrictive immigration policies may have played a crucial role in decreasing fertility rates. Reforming such policies will be key for better reproductive rights and improved fertility rates across all population cohorts in Spain.

The impact of financial crisis and austerity policies in Andalusia, Spain: disentangling the mechanisms of social inequalities in health through the perceptions and experiences of experts and the general population

Background

Andalusia has been one of the regions most damaged by the economic crisis in Spain. A qualitative study of the effects of the economic crisis and austerity policies in this region has been conducted within the framework of the IMPACT-A project. This research seeks to analyse the perceived impact of the crisis upon the health of the Andalusian population through the first-hand discourses of professionals from the health and social sectors on the one hand, and citizens of different socioeconomic status (SES) on the other.

Methods

A total of five focus groups and ten semi-structured interviews were conducted and analysed following an inductive process based on Grounded Theory (GT).

Results

Our results show a general perception among professionals: the financial crisis has either directly or indirectly affected population health in Andalusia, though mostly impacting low-income individuals who were already at risk of social exclusion. Professionals’ perceptions have been confirmed through the discourses of citizens of a lower SES, which differ from those of middle and upper SES.

Conclusion

Findings reveal some of the most salient consequences on the socially vulnerable groups and people at risk of social exclusion. In particular, our study highlights the importance of addressing three areas of priority action: mental health, unmet (basic and medical) needs, and decline in the health system.

The effects of the economic recession on spending on private health insurance in Spain

The paper seeks to analyse the evolution of expenditure on private health insurance (PHI) in Spain. We consider the factors that influence PHI demand and level of spending before and during the economic recession, along with identifying the effect of the recession on these factors. The data is obtained from the Spanish Family Budget Survey (SFBS) for 2006 and 2012. Due to the data structure and the demand function, the analysis is performed using a sample selection model in order to avoid sample selection bias. We estimate three models: a pre-recession model (2006), a model for the recession period (2012) and a third one covering both periods (2006 and 2012) and where we include a dummy variable that establishes the effect of the economic recession. The results show that the effect of the economic recession on PHI demand is not significant, but it is on the level of spending.

The effect of the economic crisis on health in Spain according to educational level and employment status: Does the duration of the crisis also matter?

The objective of this study is to explore the possible impact of the economic crisis on the health of the Spanish-born population not of retirement age (between 30 and 59 years). Specifically, using data from the European Union Statistics on Income and Living Conditions (EU-SILC) for the years 2006, 2010 and 2014, we analyze differences in self-perceived health by socioeconomic profile and position occupied in the household. According to our results, the health of men and women show similar levels of association with certain factors (such as education) and different levels with others (women's health is more sensitive to household income level while men's is more sensitive to employment status). Finally, while substantial improvements in self-perceived health were observed during the first period in almost all socioeconomic groups, during the second period there was almost no change, and for the most disadvantaged men (inactive in the labor market and with low educational levels), health worsened.

[The perspective of migrants on access to health care in the context of austerity policies in Andalusia (Spain)]

OBJECTIVE

To conduct an assessment of migrant people regarding their access to the health system following entry into force of Royal Decree-Law 16/2012 along with the impact of economic cuts on such access.

METHOD

Qualitative phenomenological study with semi-structured interviews, conducted in Andalusia (Spain), in two phases (2009-2010 and 2012-2013), with 36 participants. The sample was segmented by length of stay, nationality and area of residence. The nationalities of origin are Bolivia, Morocco and Romania.

RESULTS

Elements facilitating access in both periods: regular administrative situation, possession of Individual Health Card, knowledge of the language, social networks and information. The results show differences in access to health care for migrants before and after the enforcement of the RDL 16/2012, within austerity policies. In the second period, access barriers such as waiting times or incompatibility of schedules are aggravated and the socio-economic and administrative conditions of participants worsen.

CONCLUSIONS

The design of policies, economic and regulatory health care, should take into account barriers and facilitators of access as fundamental main points of health protection for migrants and, therefore, for the general population.

Moving towards an organized cervical cancer screening: costs and impact

Background

HPV screening has been shown to be more cost-effective than cytology screening under most scenarios. Furthermore, it should be offered only in organized programmes with good quality assurance mechanisms. This study analyses the comparative cost of the current policy of opportunistic cytology screening vs. a hypothetical organized programme based on primary HPV screening.

Methods

Total cervical cancer expenditure was defined as the sum of three cost elements: (i) direct (medical and non-medical) costs, obtained from a calibrated Markov model of the natural history of HPV and cervical cancer; (ii) programmatic costs, estimated based on other organized screening programmes; and (iii) indirect costs, extrapolated from previously published data.

Results

Organized HPV screening at 5-year intervals costs consistently less across all coverage levels than opportunistic cytology screening at 3-year intervals. The current annual direct medical cost to the public health system of the opportunistic cytology at 40% coverage is estimated at €33.2 per woman screened aged 25-64. Under an organized programme of primary HPV screening at 70% coverage, the cost is estimated to be €18.4 per woman screened aged 25-64.

Conclusion

Our study concludes that the economic resources currently devoted to providing opportunistic cytology screening to 40% of the target population at 3-year intervals could be more effectively used to screen 70% of the target population at 5-year intervals by switching to an organized programme based on primary HPV screening. This finding is of relevance to other European countries or regions with similar screening policies and health infrastructures.

Crisis, austeridad y áreas rurales: estudio cualitativo de las percepciones sobre los impactos en el sistema sanitario y la salud en Navarra, España

Resumen La crisis financiera ha impulsado severas medidas de austeridad al sistema español de atención a la salud, entre las que se destacan la reducción del gasto público, la modificación del principio básico de cobertura universal, el copago y las reformas laborales. En este artículo se presentan los resultados de un estudio cualitativo sobre la percepción del personal sanitario y de la población de los impactos de la crisis en el sistema sanitario y de la salud en las áreas rurales. Se consideró la metodología cualitativa como la opción idónea para el estudio de un fenómeno complejo, en el que se buscó profundidad en su comprensión, teniendo en cuenta los significados y el contexto. El estudio se realizó en tres valles del Pirineo navarro. Se llevaron a cabo 22 entrevistas semiestructuradas a informantes clave y de perfiles no expertos, que fueron analizadas según el análisis sociológico del discurso. La desigual accesibilidad a los servicios de salud por parte de la población rural fue el factor identificado de forma unánime como la mayor amenaza y desafío para estos territorios. Una desigualdad que se consideró agravada en la población más envejecida. Las personas entrevistadas no refirieron un impacto negativo en la calidad del servicio de atención primaria, sino que lo localizaron en el entorno urbano y en la asistencia especializada. Los impactos diferenciados de las políticas en las zonas rurales exigen más investigación atendiendo a sus particularidades y de esta forma comprender el impacto específico de la crisis en estos territorios.

Socioeconomic inequalities in health and the use of healthcare services in Catalonia: analysis of the individual data of 7.5 million residents

Background

The aim of this study is to analyse the health status, the use of public healthcare services and the consumption of prescription drugs in the population of Catalonia, taking into consideration the socioeconomic level of individuals and paying special attention to vulnerable groups.

Methods

Cross-sectional study of the entire population resident in Catalonia in 2015 (7.5 million people) using administrative records. Twenty indicators are analysed related to health, the use of healthcare services and consumption of prescription drugs. Rates, frequencies and averages are obtained for the different variables stratified by age groups (under 15 years, 15–64 years and 65 years or older), gender and socioeconomic status (calculated on the basis of pharmacy copayment levels and Social Security benefits received).

Results

A socioeconomic gradient was observed in all the indicators analysed, in both sexes and in all age groups. Morbidity, use of mental healthcare centres, hospitalisation rates and probability of drug consumption among children is 3–7 times higher for those with low socioeconomic level respect to those with a higher one. In children and adults, the steepest gradient was found in the use of mental health services. Moreover, there are gender inequalities.

Conclusion

There are significant socioeconomic inequalities in health status and in the use of healthcare services in the population of Catalonia. To respond to this situation, new policies on health and other areas, such as education and employment, are required, especially those that have an impact on early years.

Employment stability and mental health in Spain: towards understanding the influence of gender and partner/marital status

Background

The growing demand for labour flexibility has resulted in decreasing employment stability that could be associated with poor mental health status. Few studies have analysed the whole of the work force in considering this association since research on flexible forms of employment traditionally analyses employed and unemployed people separately. The gender division of work, and family characteristics related to employment situation, could modify its association with mental wellbeing. The objective of the study was to examine the relationship between a continuum of employment stability and mental health taking into account gender and partner/marital status.

Methods

We selected 6859 men and 5106 women currently salaried or unemployed from the 2006 Spanish National Health Survey. Employment stability was measured through a continuum from the highest stability among employed to lowest probability of finding a stable job among the long-term unemployed. Mental health was measured with the 12-item version of the General Health Questionnaire. Logistic regression models were fitted for each combination of partner/marital status and gender.

Results

In all groups except among married women employment stability was related to poor mental health and a gradient between a continuum of employment stability and mental health status was found. For example, compared with permanent civil servants, married men with temporary contract showed an aOR = 1.58 (95%CI = 1.06–2.35), those working without a contract aOR = 2.15 (95%CI = 1.01–4.57) and aOR = 3.73 (95%CI = 2.43–5.74) and aOR = 5.35 (95%CI = 2.71–10.56) among unemployed of up to two years and more than two years, respectively. Among married and cohabiting people, the associations were stronger among men. Poor mental health status was related to poor employment stability among cohabiting women but not among married ones. The strongest association was observed among separated or divorced people.

Conclusions

There is a rise in poor mental health as the distance from stable employment grows. This result differs according to the interaction with gender and partner/marital status. In Spain this relationship seems to follow a pattern related to the gender division of work in married people but not in other partner/marital situations. Family and socioeconomic context can contribute to explain previous mixed results. Recommendations for research and for action are given.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5282-3) contains supplementary material, which is available to authorized users.

Trends in cancer mortality in Spain: the influence of the financial crisis

OBJECTIVE

To determine if the onset of the economic crisis in Spain affected cancer mortality and mortality trends.

METHOD

We conducted a longitudinal ecological study based on all cancer-related deaths and on specific types of cancer (lung, colon, breast and prostate) in Spain between 2000 and 2013. We computed age-standardised mortality rates in men and women, and fit mixed Poisson models to analyse the effect of the crisis on cancer mortality and trends therein.

RESULTS

After the onset of the economic crisis, cancer mortality continued to decline, but with a significant slowing of the yearly rate of decline (men: RR = 0.987, 95%CI = 0.985-0.990, before the crisis, and RR = 0.993, 95%CI = 0.991-0.996, afterwards; women: RR = 0.990, 95%CI = 0.988-0.993, before, and RR = 1.002, 95%CI = 0.998-1.006, afterwards). In men, lung cancer mortality was reduced, continuing the trend observed in the pre-crisis period; the trend in colon cancer mortality did not change significantly and continued to increase; and the yearly decline in prostate cancer mortality slowed significantly. In women, lung cancer mortality continued to increase each year, as before the crisis; colon cancer continued to decease; and the previous yearly downward trend in breast cancer mortality slowed down following the onset of the crisis.

CONCLUSIONS

Since the onset of the economic crisis in Spain the rate of decline in cancer mortality has slowed significantly, and this situation could be exacerbated by the current austerity measures in healthcare.

Socio-economic factors linked with mental health during the recession: a multilevel analysis

BACKGROUND

Periods of financial crisis are associated with higher psychological stress among the population and greater use of mental health services. The objective is to analyse contextual factors associated with mental health among the Spanish population during the recession.

METHODOLOGY

Cross-sectional, descriptive study of two periods: before the recession (2006) and after therecession (2011-2012). The study population comprised individuals aged 16+ years old, polled for the National Health Survey. There were 25,234 subjects (2006) and 20,754 subjects (2012). The dependent variable was psychic morbidity.

INDEPENDENT VARIABLES

1) socio-demographic (age, socio-professional class, level of education, nationality, employment situation, marital status), 2) psycho-social (social support) and 3) financial (GDP per capita, risk of poverty, income per capita per household), public welfare services (health spending per capita), labour market (employment and unemployment rates, percentage of temporary workers). Multilevel logistic regression models with mixed effects were constructed to determine change in psychic morbidity according to the variables studied.

RESULTS

The macroeconomic variables associated with worse mental health for both males and females were lower health spending per capita and percentage of temporary workers. Among women, the risk of poor mental health increased 6% for each 100€ decrease in healthcare spending per capita. Among men, the risk of poor mental health decreased 8% for each 5-percentage point increase in temporary workers.

CONCLUSIONS

Higher rates of precarious employment in a region have a negative effect on people's mental health; likewise lower health spending per capita. Policies during periods of recession should focus on support and improved conditions for vulnerable groups such as temporary workers. Healthcare cutbacks should be avoided in order to prevent increased prevalence of poor mental health.

Economic Crisis, Austerity Policies, Health and Fairness: Lessons Learned in Spain

This paper reviews economic and medical research publications to determine the extent to which the measures applied in Spain to control public health spending following the economic and financial crisis that began in 2008 have affected healthcare utilization, health and fairness within the public healthcare system. The majority of the studies examined focus on the most controversial cutbacks that came into force in mid-2012. The conclusions drawn, in general, are inconclusive. The consequences of this new policy of healthcare austerity are apparent in terms of access to the system, but no systematic effects on the health of the general population are reported. Studies based on indicators of premature mortality, avoidable mortality or self-perceived health have not found clear negative effects of the crisis on public health. The increased demands for co-payment provoked a short-term cutback in the consumption of medicines, but this effect faded after 12-18 months. No deterioration in the health of immigrants after the onset of the crisis was unambiguously detected. The impact of the recession on the general population in terms of diseases associated with mental health is well documented; however, the high levels of unemployment are identified as direct causes. Therefore, social policies rather than measures affecting the healthcare system would be primarily responsible. In addition, some health problems have a clear social dimension, which seems to have become more acute during the crisis, affecting in particular the most vulnerable population groups and the most disadvantaged social classes, thus widening the inequality gap.

General and Abdominal Obesity Is Related to Physical Activity, Smoking and Sleeping Behaviours and Mediated by the Educational Level: Findings from the ANIBES Study in Spain

The aim of the present study was to analyze the association of socioeconomic (SES) and lifestyle factors, with the conditions of overweight (OW), general (OB) and abdominal obesity (AO) in Spanish adults. A representative sample of 1655 Spanish adults (18 to 65 years) from the ANIBES Study was investigated. Collected data included measured anthropometry (weight, height and waist circumference), demographic and SES data (region and habitant population size, educational level, family income, unemployment rate), physical activity (PA) and other lifestyle factors (sleeping time and frequency of viewing television). OW, OB and AO were determined in each participant. Being male, older than 40 years, and watching television more frequently were associated with higher risk of OB and AO, whereas those with a higher level of education, smokers, and more time in sleeping and in vigorous PA, but not in moderate-vigorous PA, were associated with a lower risk. Living in the Atlantic region and stating no answer to the question regarding family income were also associated with lower risk of AO. Strategies for preventing and reducing OB and AO should consider improving sleeping habits and PA. They should also pay more attention to the most vulnerable groups such as those less educated.

[Cardiovascular risk factors in the population at risk of poverty and social exclusión]

Objetivos

Detectar si hay diferencias en prevalencia, distribución de factores de riesgo y riesgo cardiovascular según las funciones REGICOR y Score, entre poblaciones pertenecientes a diferentes clases sociales ocupacionales y población en riesgo de exclusión.

Diseño

Descriptivo transversal.

Emplazamiento

Ayuntamiento de Córdoba. Unidad de salud laboral.

Participantes

Muestra disponible de 628 personas. El grupo de trabajadores municipales fue obtenido por aleatorización, mientras que se tomó la totalidad de las contratadas por riesgo de exclusión.

Intervención

No se aplicaron acciones preventivas ni terapéuticas que modificaran el curso de la situación previa de los trabajadores.

Mediciones principales

Tabaco, glucosa, lípidos, presión arterial e IMC como principales variables. Se emplearon la t de Student para comparar medias y Chi² para porcentajes. La significación estadística fijada para error alfa fue < 5% e IC 95%. Se realizaron curvas operador receptor (COR) para conocer qué variables explicativas predicen la pertenencia al grupo en riesgo de exclusión.

Resultados

Las variables tabaquismo (IC 95%: –0,043;–0,224), síndrome metabólico (IC 95%: –0,285;–0,069), hipercolesterolemia (IC 95%: –0,320;–0,127), obesidad (IC 95%: –0,214;–0,005) y diabetes (IC 95%: –0,176;–0,017) presentan mayor prevalencia en hombres en riesgo de exclusión, al igual que el riesgo cardiovascular a 10 años. En mujeres hubo diferencias en las mismas variables, salvo en tabaquismo (p = 0,053).

Conclusiones

Se comprueba una desigual prevalencia de factores de riesgo cardiovascular en población en riesgo de exclusión. En un contexto de crisis social, los programas de prevención primaria dirigidos a la población más vulnerable son necesarios para mitigar la desigualdad.

Health Care Austerity Measures in Times of Crisis

The current financial crisis has seen severe austerity measures imposed on the Spanish health care system, including reduced public spending, copayments, salary reductions, and reduced services for undocumented migrants. However, the impacts have not been well-documented. We present findings from a qualitative study that explores the perceptions of primary health care physicians in Madrid, Spain. This article discusses the effects of austerity measures implemented in the public health care system and their potential impacts on access and utilization of primary health care services. This is the first study, to our knowledge, exploring the health care experiences during the financial crisis of general practitioners in Madrid, Spain. The majority of participating physicians disapproved of austerity measures implemented in Spain. The findings of this study suggest that undocumented migrants should regain access to health care services; copayments should be minimized and removed for patients with low incomes; and health care professionals should receive additional help to avoid burnout. Failure to implement these measures could result in the quality of health care further deteriorating and could potentially have long-term negative consequences on population health.

Social inequality in morbidity, framed within the current economic crisis in Spain

INTRODUCTION

Inspired by the 'Fundamental Cause Theory (FCT)' we explore social inequalities in preventable versus relatively less-preventable illnesses in Spain. The focus is on the education-health gradient, as education is one of the most important components of an individual's socioeconomic status (SES). Framed in the context of the recent economic crisis, we investigate the education gradient in depression, diabetes, and myocardial infarction (relatively highly preventable illnesses) and malignant tumors (less preventable), and whether this educational gradient varies across the regional-economic context and changes therein.

METHODS

We use data from three waves of the Spanish National Health Survey (2003-2004, 2006-2007, and 2011-2012), and from the 2009-2010 wave of the European Health Survey in Spain, which results in a repeated cross-sectional design. Logistic multilevel regressions are performed with depression, diabetes, myocardial infarction, and malignant tumors as dependent variables. The multilevel design has three levels (the individual, period-regional, and regional level), which allows us to estimate both longitudinal and cross-sectional macro effects. The regional-economic context and changes therein are assessed using the real GDP growth rate and the low work intensity indicator.

RESULTS

Education gradients in more-preventable illness are observed, while this is far less the case in our less-preventable disease group. Regional economic conditions seem to have a direct impact on depression among Spanish men (y-stand. OR = 1.04 [95 % CI: 1.01-1.07]). Diabetes is associated with cross-regional differences in low work intensity among men (y-stand. OR = 1.02 [95 % CI: 1.00-1.05]) and women (y-stand. OR = 1.04 [95 % CI: 1.01-1.06]). Economic contraction increases the likelihood of having diabetes among men (y-stand. OR = 1.04 [95 % CI: 1.01-1.06]), and smaller decreases in the real GDP growth rate are associated with lower likelihood of myocardial infarction among women (y-stand. OR = 0.83 [95 % CI: 0.69-1.00]). Finally, there are interesting associations between the macroeconomic changes across the crisis period and the likelihood of suffering from myocardial infarction among lower educated groups, and the likelihood of having depression and diabetes among less-educated women.

CONCLUSION

Our findings partially support the predictions of the FCT for Spain. The crisis effects on health emerge especially in the case of our more-preventable illnesses and among lower educated groups. Health inequalities in Spain could increase rapidly in the coming years due to the differential effects of recession on socioeconomic groups.

Governance, Government, and the Search for New Provider Models

A central problem in designing effective models of provider governance in health systems has been to ensure an appropriate balance between the concerns of public sector and/or government decision-makers, on the one hand, and of non-governmental health services actors in civil society and private life, on the other. In tax-funded European health systems up to the 1980s, the state and other public sector decision-makers played a dominant role over health service provision, typically operating hospitals through national or regional governments on a command-and-control basis. In a number of countries, however, this state role has started to change, with governments first stepping out of direct service provision and now de facto pushed to focus more on steering provider organizations rather than on direct public management. In this new approach to provider governance, the state has pulled back into a regulatory role that introduces market-like incentives and management structures, which then apply to both public and private sector providers alike. This article examines some of the main operational complexities in implementing this new governance reality/strategy, specifically from a service provision (as opposed to mostly a financing or even regulatory) perspective. After briefly reviewing some of the key theoretical dilemmas, the paper presents two case studies where this new approach was put into practice: primary care in Sweden and hospitals in Spain. The article concludes that good governance today needs to reflect practical operational realities if it is to have the desired effect on health sector reform outcome.

Understanding the impact of the economic crisis on child health: the case of Spain

INTRODUCTION

The objectives of the study were to explore the effect of the economic crisis on child health using Spain as a case study, and to document and assess the policies implemented in response to the crisis in this context.

METHODS

Serial cross-sectional data from Eurostat, the Spanish Health Interview Survey, and the database of childhood hospitalisation were analysed to explore impacts on child health, and key determinants of child health. A content analysis of National data sources/government legislation, and Spanish literature was used to describe policies implemented following the crisis.

RESULTS

Unemployment rates in the general population (8.7% in 2005 and 25.6% in 2013), and children living in unemployed families (5.6% and 13.8%) increased in the study period. The percentage of children living under the poverty line, and income inequalities increased 15-20% from 2005 to 2012. Severe material deprivation rate has worsened in families with Primary Education, while the number of families attending Non-Governmental Organisations has increased. An impact on children's health at the general population level has not currently been detected; however an impact on general health, mental health and use of healthcare services was found in vulnerable groups. Investment in social protection and public policy for children showed a reduction as part of austerity measures taken by the Spanish governments.

CONCLUSIONS

Despite the impact on social determinants, a short-term impact on child health has been detected only in specific vulnerable groups. The findings suggest the need to urgently protect vulnerable groups of children from the impact of austerity.

Health inequality between immigrants and natives in Spain: the loss of the healthy immigrant effect in times of economic crisis

BACKGROUND

The immigrant population living in Spain grew exponentially in the early 2000s but has been particularly affected by the economic crisis. This study aims to analyse health inequalities between immigrants born in middle- or low-income countries and natives in Spain, in 2006 and 2012, taking into account gender, year of arrival and socioeconomic exposures.

METHODS

Study of trends using two cross-sections, the 2006 and 2012 editions of the Spanish National Health Survey, including residents in Spain aged 15-64 years (20 810 natives and 2950 immigrants in 2006, 14 291 natives and 2448 immigrants in 2012). Fair/poor self-rated health, poor mental health (GHQ-12 > 2), chronic activity limitation and use of psychotropic drugs were compared between natives and immigrants who arrived in Spain before 2006, adjusting robust Poisson regression models for age and socioeconomic variables to obtain prevalence ratios (PR) and 95% confidence interval (CI).

RESULTS

Inequalities in poor self-rated health between immigrants and natives tend to increase among women (age-adjusted PR2006 = 1.39; 95% CI: 1.24-1.56, PR2012 = 1.56; 95% CI: 1.33-1.82). Among men, there is a new onset of inequalities in poor mental health (PR2006 = 1.10; 95% CI: 0.86-1.40, PR2012 = 1.34; 95% CI: 1.06-1.69) and an equalization of the previously lower use of psychotropic drugs (PR2006 = 0.22; 95% CI: 0.11-0.43, PR2012 = 1.20; 95% CI: 0.73-2.01).

CONCLUSIONS

Between 2006 and 2012, immigrants who arrived in Spain before 2006 appeared to worsen their health status when compared with natives. The loss of the healthy immigrant effect in the context of a worse impact of the economic crisis on immigrants appears as potential explanation. Employment, social protection and re-universalization of healthcare would prevent further deterioration of immigrants' health status.

Determinants of Subjective Social Status and Health Among Latin American Women Immigrants in Spain: A Qualitative Approach

This qualitative study was carried out to better understand factors that determine the subjective social status of Latin Americans in Spain. The study was conducted following a theoretical framework and forms part of broader study on subjective social status and health. Ten immigrant participants engaged in semi-structured interviews, from which data were collected. The study results show that socioeconomic aspects of the crisis and of policies adopted have shaped immigrant living conditions in Spain. Four major themes that emerged from the analysis were related to non-recognition of educational credentials, precarious working conditions, unemployment and loneliness. These results illustrate the outcomes of current policies on health and suggest a need for health professionals to orient practices toward social determinants, thus utilizing evaluations of subjective social status to reduce inequalities in health.

[Professional quality of life in workers of the Toledo primary care health area]

OBJECTIVE

To determine the professional quality of life in the workers of the Toledo Primary Care Health Area and to analyse its components.

MATERIAL AND METHODS

Descriptive, cross-sectional study, performed on workers of the Toledo Primary Care Health Area with an online self-administered questionnaire.

MAIN VARIABLES

age, sex, health centre, professional group, seniority, management experience, collaboration in working groups, employment situation, and the PQL-35 professional quality of life questionnaire.

RESULTS

A total of 430 completed questionnaires were received (45.3%), of which 68.4% were women. The mean age was 47.7±8.6 years old. Mean seniority was 21.5±9.7 years. PQL-35 results were: perception of management support 4.8±1.5; perception of workload 6.2±1.3; intrinsic motivation 7.9±1.1; job disconnection capacity 6.3±2.6; and professional quality of life 5.2±2.1. Gender differences were found in perception of management support (4.5±1.5 in males vs 4.9±1.5 in females; P=.031) and professional quality of life (4.9±2.0 vs 5.3±2.1; p=.044). Depending on the professional group, differences were found in the perception of workload (6.4±1.1 in physicians, 6.3±1.3 in nurses, 5.9±1.6 in non-sanitary professionals, and 5.3±1.2 in support units professionals; P<.001). Depending on the employment situation, differences were found in the intrinsic motivation (7.8±1.1 in proprietors, 8.3±1.1 in temporary workers, and 8.2±1.1 in substitutes; P=.002).

CONCLUSIONS

The professional quality of life in the workers of the Toledo Primary Care Health Area is similar to that of other Spanish Health Areas, even in a time of economic crisis. The intrinsic motivation of the professionals is very high, in contrast with their high perception of workload and their low perception of management support.

Changes in access to health services of the immigrant and native-born population in Spain in the context of economic crisis

AIM

To analyze changes in access to health care and its determinants in the immigrant and native-born populations in Spain, before and during the economic crisis.

METHODS

Comparative analysis of two iterations of the Spanish National Health Survey (2006 and 2012). Outcome variables were: unmet need and use of different healthcare levels; explanatory variables: need, predisposing and enabling factors. Multivariate models were performed (1) to compare outcome variables in each group between years, (2) to compare outcome variables between both groups within each year, and (3) to determine the factors associated with health service use for each group and year.

RESULTS

unmet healthcare needs decreased in 2012 compared to 2006; the use of health services remained constant, with some changes worth highlighting, such as the decline in general practitioner visits among autochthons and a narrowed gap in specialist visits between the two populations. The factors associated with health service use in 2006 remained constant in 2012.

CONCLUSION

Access to healthcare did not worsen, possibly due to the fact that, until 2012, the national health system may have cushioned the deterioration of social determinants as a consequence of the financial crisis. Further studies are necessary to evaluate the effects of health policy responses to the crisis after 2012.