Trends in socioeconomic inequalities in preventable mortality in urban areas of 33 Spanish cities, 1996-2007 (MEDEA project)

Classification of patients with osteoarthritis through clusters of comorbidities using 633 330 individuals from Spain

OBJECTIVES

To explore clustering of comorbidities among patients with a new diagnosis of OA and estimate the 10-year mortality risk for each identified cluster.

METHODS

This is a population-based cohort study of individuals with first incident diagnosis of OA of the hip, knee, ankle/foot, wrist/hand or 'unspecified' site between 2006 and 2020, using SIDIAP (a primary care database representative of Catalonia, Spain). At the time of OA diagnosis, conditions associated with OA in the literature that were found in ≥1% of the individuals (n = 35) were fitted into two cluster algorithms, k-means and latent class analysis. Models were assessed using a range of internal and external evaluation procedures. Mortality risk of the obtained clusters was assessed by survival analysis using Cox proportional hazards.

RESULTS

We identified 633 330 patients with a diagnosis of OA. Our proposed best solution used latent class analysis to identify four clusters: 'low-morbidity' (relatively low number of comorbidities), 'back/neck pain plus mental health', 'metabolic syndrome' and 'multimorbidity' (higher prevalence of all studied comorbidities). Compared with the 'low-morbidity' cluster, the 'multimorbidity' cluster had the highest risk of 10-year mortality (adjusted hazard ratio [HR]: 2.19 [95% CI: 2.15, 2.23]), followed by the 'metabolic syndrome' cluster (adjusted HR: 1.24 [95% CI: 1.22, 1.27]) and the 'back/neck pain plus mental health' cluster (adjusted HR: 1.12 [95% CI: 1.09, 1.15]).

CONCLUSION

Patients with a new diagnosis of OA can be clustered into groups based on their comorbidity profile, with significant differences in 10-year mortality risk. Further research is required to understand the interplay between OA and particular comorbidity groups, and the clinical significance of such results.

Spatial Inequities in Life Expectancy in Small Areas of Buenos Aires, Argentina 2015-2017

Studies of life expectancy (LE) in small areas of cities are relatively common in high-income countries but rare in Latin American countries. Small-area estimation methods can help to describe and quantify inequities in LE between neighborhoods and their predictors. Our objective was to analyze the distribution and spatial patterning of LE across small areas of Ciudad Autónoma de Buenos Aires (CABA), Argentina, and its association with socioeconomic characteristics. As part of the SALURBAL project, we used georeferenced death certificates in 2015-2017 for CABA, Argentina. We used a spatial Bayesian Poisson model using the TOPALS method to estimate age- and sex-specific mortality rates. We used life tables to estimate LE at birth. We obtained data on neighborhood socioeconomic characteristics from the 2010 census and analyzed their associations. LE at birth was higher for women (median of across neighborhoods = 81.1 years) compared to men (76.7 years). We found a gap in LE of 9.3 (women) and 14.9 years (men) between areas with the highest and the lowest LE. Better socioeconomic characteristics were associated with higher LE. For example, mean differences in LE at birth in areas with highest versus lowest values of composite SES index were 2.79 years (95% CI: 2.30 to 3.28) in women and 5.61 years (95% CI: 4.98 to 6.24) in men. We found large spatial inequities in LE across neighborhoods of a large city in Latin America, highlighting the importance of place-based policies to address this gap.

Socioeconomic correlates of face mask use among pedestrians during the COVID-19 pandemic: An ecological study

Background

Many countries have recommended using face masks for the general population in public places to reduce the risk of COVID-19 transmission. This study aimed to assess the effects of socioeconomic status on face mask use among pedestrians during the COVID-19 pandemic.

Methods

This cross-sectional study was conducted in Ahvaz, southwest Iran in August 2020. A total of 10,440 pedestrians have been studied from 92 neighborhoods of the city. Three socioeconomic indicators including Land price, Literacy rate, and the Employment rate for each neighborhood were used in this study. Analysis of Covariance and partial correlation coefficients were applied to assess the relationship between prevalence rates of mask usage and SES indicators.

Results

The mean ± SD age of the pedestrians was 32.2 ± 15.1 years. Of 10,440 observed participants, 67.9% were male. The overall prevalence of face mask usage was 45.6%. The prevalence of mask usage in older people and women was significantly higher than the others. The three assessed socioeconomic indicators were directly correlated to the prevalence of mask usage at individual and neighborhood levels.

Conclusion

We found that literacy had the strongest correlation with the prevalence of mask usage compared to the land price and employment rate among the three assessed SES indicators. Hence, it can be concluded that the social component of socioeconomic status has a greater effect on mask usage by people than the economic component of socioeconomic status.

Significant Regional Differences in Lung Cancer Incidence in Hungary: Epidemiological Study Between 2011 and 2016

Objective: Hungary has one of the highest incidences and mortality rates of lung cancer (LC), therefore the objective of this study was to analyse and compare LC incidence and mortality rates between the main Hungarian regions.

Methods: This nationwide, retrospective study used data from the National Health Insurance Fund and included patients aged ≥20 years who were diagnosed with lung cancer (ICD-10 C34) between Jan 1, 2011 and Dec 31, 2016. Age-standardized incidence and mortality rates were calculated and compared for the main regions.

Results: The highest incidence rate in males was recorded in Northern Hungary (146.8/100,000 person-years [PY]), while the lowest rate was found in Western Transdanubia (94.7/100,000 PY in 2011). All rates showed a declining trend between 2011 and 2016, with the largest decrease in the Northern Great Plain (−20.0%; p = 0.008). LC incidence and mortality rates in women both showed a rising tendency in all regions of Hungary, reaching the highest in Central Hungary (59.86/100,000 PY in 2016). Lung cancer incidence and mortality rates in males correlated with the level of education and smoking prevalence (p = 0.006 and p = 0.01, respectively) in the regions. A correlation with GDP per capita and Health Development Index (HDI) index could also be observed in the Hungarian regions, although these associations were not statistically significant. No correlations could be detected between these parameters among females.

Conclusion: This analysis revealed considerable differences in the epidemiology of LC between the 7 main Hungarian regions. LC incidence and mortality rates significantly correlated with smoking and certain socioeconomic factors in men, but not in women. Further research is needed to explain the regional differences.

Socioeconomic deprivation and cancer survival in a metropolitan area: An analysis of cancer registry data from Hamburg, Germany

Background

Few studies have investigated socioeconomic inequalities within cities. Yet, such analyses are particularly important given the increasing international trend to urbanization. Here we investigated area-based socioeconomic inequalities in cancer survival in Hamburg, a port city in the North of Germany (population: 1.84 million people).

Methods

Patients with a diagnosis of colorectal, lung, female breast, and prostate cancer in 2004–2018 (follow-up until 31.12.2018) and registered in the Hamburg cancer registry were included. Area-based socioeconomic deprivation on urban district level was assigned to the patients and grouped in five quintiles. Relative survival in 2014–2018 was calculated using the period approach. Trend analyses between 2004 and 2018 were conducted. Relative excess risks adjusted for age and stage were computed with model-based period analyses.

Findings

For the 73,106 included patients, age-standardized 5-year relative survival in 2014–2018 decreased with increasing deprivation with significant differences between the most and least deprived group of 14·7 (prostate), 10·8 (colorectal), 8·0 (breast), and 2·5 (lung) percent units. Standardization by cancer stage decreased the difference for prostate cancer to 8·5 percent units and for breast cancer to 3·6 percent units but had only a minor effect for colorectal and lung cancer. Similar socioeconomic inequalities were already present in 2004–08.

Interpretation

Strong socioeconomic inequalities in cancer survival were observed in Hamburg, which could be partly explained by differences in the stage distribution. Further research including information on screening participation as well as information on cancer care are important to further understand and finally overcome these inequalities.

Funding

10.13039/501100005972German Cancer Aid.

Avoidable Mortality Rates Decrease but Inequity Gaps Widen for Marginalized Neighborhoods: A Population-Based Analysis in Ontario, Canada from 1993 to 2014

Avoidable mortality (AM) is a health indicator used to examine trends in avoidable deaths amenable to public health and medical interventions. AM is more likely amongst marginalized populations. Our objective was to examine trends in AM rates by level of neighborhood marginalization. Decedents under age 75 years in Ontario from 1993 to 2014 (n = 691,453) were assigned to a quintile-level of each Ontario Marginalization (ON-Marg) Index dimension: material deprivation, residential instability, dependency, and ethnic concentration. We calculated ON-Marg Index dimension and quintile specific age- and sex-standardized AM incidence rates. We then calculated annual AM rate ratios between the most (Q5) and least (Q1) marginalized quintiles for each ON-Marg dimension. To describe the inequity gap in AM over time we calculated the absolute difference in the Q5/Q1 rate ratio between 2014 and 1993 for each dimension. AM rates in Ontario were almost halved (48.6%) from 1993 to 2014 (216 vs. 111 per 100,000 population). This decline was greater for treatable AM (75 vs. 36 per 100,000 population) than preventable AM (128 vs. 88 per 100,000 population). The inequity gap in AM Q5/Q1 rate ratios (RR) between 1993 and 2014 widened for all marginalization dimensions: dependency (RR 2.11-2.58), ethnic concentration (RR 0.59-0.48), material deprivation (RR 1.63-2.23), and residential instability (RR 2.01-2.43). To attain further declines in AM, policymakers and governments must address AM due to preventable deaths in neighborhoods highly marginalized by dependency, material deprivation, and residential instability.

The Association between Material Deprivation and Avoidable Mortality in Lisbon, Portugal

There is considerable evidence pointing to the existence of a socioeconomic gradient in mortality, which tends to be steeper in urban areas. Similar to other European cities, Lisbon is far from homogeneous since considerable geographical inequalities exist between the more advantaged and the more deprived neighborhoods. The main goals of this study are to describe the geographical pattern of premature deaths (before 65 years old), avoidable deaths (preventable and amenable to healthcare) and cause-specific mortality (HIV/AIDS and suicide) in Lisbon, at the lower administrative level (civil parish, in Portuguese: Freguesia), and analyze the statistical association between mortality risk and deprivation, before (1999–2003) and during the economic crisis (2008–2012). Smoothed Standardized Mortality Ratios (sSMR) and Relative Risk (RR) with 95% credible intervals were calculated to identify the association between mortality and deprivation. The analysis of the geographical distribution of cause-specific mortality reveals that civil parishes with high sSMR in the first period continued to present higher mortality rates in the second. Moreover, a significant statistical association was found between all the causes of death and deprivation, except suicide. These findings contribute to understanding how social conditions influence health outcomes and can offer insights about potential policy directions for local government.

Effect of Income Level and Perception of Susceptibility and Severity of COVID-19 on Stay-at-Home Preventive Behavior in a Group of Older Adults in Mexico City

Early information on public health behaviors adopted to prevent the spread of coronavirus (COVID-19) may be useful in controlling the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission. The objective of this study was to assess the role of income level (IL) and the perception of older adults, regarding COVID-19 susceptibility and severity, on adopting stay-at-home preventive behavior during the first week of the outbreak in Mexico. Participants in this cross-sectional study were urban community dwellers, aged ≥ 65 years from Mexico City. A total of 380 interviews were conducted over the phone. The mean respondent age was 72.9 years, and 76.1% were women. Over half (54.2%) of the participants perceived their susceptibility to COVID-19 as very low or low. Similarly, 33.4% perceived COVID-19 severity as being very low or low, and 57.6% had decided to stay at home: this behavior was associated with IL (β = 1.05, p < 0.001), and its total effect was partially mediated (15.1%) by perceived severity. Educational attainment was also associated with staying at home (β = 0.10, p = 0.018) and its total effect was partially mediated (15.0%) by perceived susceptibility. Interventions aimed at low income and less educated older adults should be developed to improve preventive behaviors in this vulnerable group during the COVID-19 pandemic.

Changes in Socioeconomic Inequalities in Amenable Mortality after the Economic Crisis in Cities of the Spanish Mediterranean Coast

Several studies have described a decreasing trend in amenable mortality, as well as the existence of socioeconomic inequalities that affect it. However, their evolution, particularly in small urban areas, has largely been overlooked. The aim of this study is to analyse the socioeconomic inequalities in amenable mortality in three cities of the Valencian Community, namely, Alicante, Castellon, and Valencia, as well as their evolution before and after the start of the economic crisis (2000–2007 and 2008–2015). The units of analysis have been the census tracts and a deprivation index has been calculated to classify them according to their level of socioeconomic deprivation. Deaths and population were also grouped by sex, age group, period, and five levels of deprivation. The specific rates by sex, age group, deprivation level, and period were calculated for the total number of deaths due to all causes and amenable mortality and Poisson regression models were adjusted in order to estimate the relative risk. This study confirms that the inequalities between areas of greater and lesser deprivation in both all-cause mortality and amenable mortality persisted along the two study periods in the three cities. It also shows that these inequalities appear with greater risk of death in the areas of greatest deprivation, although not uniformly. In general, the risks of death from all causes and amenable mortality have decreased significantly from one period to the other, although not in all the groups studied. The evolution of death risks from before the onset of the crisis to the period after presented, overall, a general pro-cyclical trend. However, there are population subgroups for which the trend was counter-cyclical. The use of the deprivation index has made it possible to identify specific geographical areas with vulnerable populations in all three cities and, at the same time, to identify the change in the level of deprivation (ascending or descending) of the geographical areas throughout the two periods. It is precisely these areas where more attention is needed in order to reduce inequalities.

Socioeconomic Inequalities in Mortality among Foreign-Born and Spanish-Born in Small Areas in Cities of the Mediterranean Coast in Spain, 2009-2015

Many studies have analysed socioeconomic inequalities and its association with mortality in urban areas. However, few of them have differentiated between native and immigrant populations. This study is an ecological study of mortality by overall mortality and analyses the inequalities in mortality in these populations according to the level of deprivation in small areas of large cities in the Valencian Community, from 2009 to 2015. The census tract was classified into five deprivation levels using an index based on socioeconomic indicators from the 2011 census. Rates and relative risks of death were calculated by sex, age, level of deprivation and country of birth. Poisson regression models have been used. In general, there was a higher risk of death in natives at the levels of greatest deprivation, which did not happen in immigrants. During the 2009-2015 period, there were socioeconomic inequalities in mortality, particularly in natives, who presented a higher risk of death than immigrants. Future interventions and social policies should be implemented in order to reduce inequalities in mortality amongst socioeconomic levels and to maintain the advantage that the immigrant population enjoys.

Self-rated health inequalities in the intersection of gender, social class and regional development in Spain: exploring contributions of material and psychosocial factors

Background

Inequalities in health across social class, gender and regional context in Spain are well-known; however, there is a lack of research examining how these dimensions of inequality interact. This study explores self-rated health (SRH) inequalities across intersectional positions of gender, social class and region, and the contribution of material and psychosocial factors to these inequalities.

Methods

Participants were drawn from the cross-sectional 2015 National Living Conditions Survey of Spanish residents aged 19–88 years (N = 27,215; 77% response rate). Eight intersectional positions were formed by combining dichotomous variables of gender, social class and regional development. Poisson regression was used to estimate intersectional inequalities in SRH as prevalence ratios, and the contributions of material and psychosocial factors.

Results

Results showed both cumulative and heterogeneous inequalities within and across intersectional positions. Inequalities in the intersection of social class and regional development were best explained by the joint contributions of material and psychosocial factors, while gender inequalities within non-manual social class were better explained by material factors alone.

Conclusions

The results illustrate the complexity of interacting inequalities in health and their underpinnings in Spain. Local and national policies taking this complexity into account are needed to broadly improve equity in health in Spain.

Time Trends and Sociodemographic Factors Associated With Overweight and Obesity in Children and Adolescents in Spain

IMPORTANCE

Time-trend studies of overweight and obesity in childhood by sociodemographic factors are important for prioritizing public health initiatives. However, little is known about these trends in Spain, where high levels of obesity are found and where important demographic changes have occurred during the last 2 decades.

OBJECTIVE

To examine how time trends in the prevalence and incidence of overweight and obesity among children and adolescents differ by age, sex, socioeconomic status, urban/rural residence, and nationality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 1.1 million children and adolescents (aged 2-17 years) with at least 1 measure of height and weight in Catalonia, Spain, from 2006 to 2016. Electronic health records were accessed from the Information System for Research in Primary Care. Data analysis was conducted from January to December 2018.

MAIN OUTCOMES AND MEASURES

Prevalence and incidence rates and trends of overweight/obesity and obesity (overweight/obesity defined as having of BMI z score greater than 2.0 among children aged <5 years and greater than 1.0 among children aged ≥5 years; obesity defined as having of BMI z score greater than 3.0 among children aged <5 years and greater than 2.0 among children aged ≥5 years) between 2006 and 2016 were calculated and stratified by sociodemographic characteristics (ie, age, sex, deprivation index, urban/rural residence, and nationality).

RESULTS

The study population included 1 166 609 children and adolescents (570 982 [48.9%] girls; median [interquartile range] age at entry to electronic health record system, 2.4 [0-7.7] years; 1 006 892 [86.3%] with Spanish nationality). Of 941 041 children (80.7%) who lived in urban areas, 197 427 (20.7%) lived in the most deprived areas. Overall, the prevalence of overweight/obesity and obesity decreased between 2006 and 2016 in all sex and age groups; for example, among boys and girls aged 6 to 11 years, overweight/obesity prevalence decreased from 41.9% (95% CI, 41.5%-42.2%) to 39.9% (95% CI, 39.6%-40.3%) and from 39.7% (95% CI, 39.3%-40.2%) to 37.6% (95% CI, 37.3%-38.0%), respectively. Incidence rates of overweight/obesity and obesity were highest among children aged 6 to 7 years (overweight/obesity among boys: 11.9 [95% CI, 11.8-12.0] new cases per 100 person-years; obesity among boys: 4.9 [95% CI, 4.8-4.9] new cases per 100 person-years). Prevalence and incidence rates were highest in the most deprived areas, in urban areas, and among children with North, Central, or South American nationalities. Between 2006 and 2016, prevalence increased in the most deprived areas in almost all sex and age groups. Among girls aged 6 to 11 years living in the most deprived areas, the obesity prevalence ratio increased from 1.59 (95% CI, 1.46-1.74) to 2.03 (95% CI, 1.88-2.19) compared with those living in the least deprived areas. Furthermore, during this period, prevalence increased among children with non-Spanish nationalities, especially in the African and Asian nationality groups (eg, boys aged 6-11 years with Asian nationality compared with Spanish nationality, 2006: prevalence rate, 0.78 [95% CI, 0.60-1.01]; 2016: prevalence rate, 1.27 [95% CI, 1.15-1.39]). Incidence rates decreased among younger groups (eg, ≤7 years: incidence rate ratio for January 1, 2006, to June 30, 2011, vs July 1, 2011, to December 31, 2016: 0.94; 95% CI, 0.91-0.98) but remained stable in older groups.

CONCLUSIONS AND RELEVANCE

In this study, the overall prevalence and incidence rates of childhood overweight/obesity and obesity slightly decreased during the last decade. However, increased deprivation disparities in childhood obesity were found, given that the prevalence increased among children living in deprived areas and with non-Spanish nationalities.

The Role of Cohesion Policy Funds in Decreasing the Health Gaps Measured by the EURO-HEALTHY Population Health Index

Social, economic, and environmental differences across the European Union significantly affect opportunities to move forward in achieving greater equity in health. Cohesion Policy (CP) funds can contribute positively through investments in the main determinants of health. The aim of this study is to analyze to what extent the planned investments for 2014-2020 are addressing the regional health gaps, in light of the population health index (PHI), a multidimensional measure developed by the EURO-HEALTHY project. The operational programs of all regions were analyzed, namely, the CP planned investments by field of intervention. Analysis of variance was performed to examine whether the regional scores in the PHI dimensions were statistically different across regions with different levels of development (measured by gross domestic product (GDP)). Results show that 98% of regions with worse performances on the PHI are less developed regions. Overall, all regions present planned investments in intervention fields linked to dimensions appraised within the PHI (e.g., employment, income, education, pollution). Yet, more needs to be done to focus regional investments in health determinants where regions still lag behind. The PHI has the potential to inform future CP restructuring, providing evidence to extend the current eligibility criteria to other dimensions beyond the GDP.

[Deprivation index by enumeration district in Spain, 2011]

OBJECTIVE

To present the methodology used in the design and implementation of a deprivation index by enumeration district, and to describe the socioeconomic situation of Spain in 2011.

METHOD

The unit of analysis was the enumeration district (N=35,960). Data came from the 2011 Population and Housing Census of Spain. Given both the sampling nature of the Census and the regulatory limitations of data confidentiality, variables were calculated indirectly by using the complement of the available variables. Checks were made to ensure reliability. The selection of the indicators took into account comparability with the MEDEA index. The inclusion of additional information was explored. A deprivation index was built using Principal Component Analysis. Sensitivity analysis of the index was performed for urban areas and the rest of the regions.

RESULTS

Using the census information, 22 indicators were calculated for 35,917 enumeration districts. The deprivation index was based on six indicators: manual and temporary workers, unemployment, insufficient education overall and in young people (aged 16 to 29 years), and dwellings without access to the internet. The map of Spain shows a gradient of decreasing deprivation from south-west to north-east.

CONCLUSIONS

The socioeconomic information of the 2011 census by enumeration district was used systematically. The drafted index, similar to the MEDEA, will facilitate the updated study of health inequalities for Spain overall following the economic recession that began in 2008.

Assessing the Effects on Health Inequalities of Differential Exposure and Differential Susceptibility of Air Pollution and Environmental Noise in Barcelona, 2007-2014

The hypotheses we intended to contrast were, first, that the most deprived neighborhoods in Barcelona, Spain, present high exposure to environmental hazards (differential exposure) and, secondly, that the health effects of this greater exposure were higher in the most deprived neighborhoods (differential susceptibility). The population studied corresponded to the individuals residing in the neighborhoods of Barcelona in the period 2007–2014. We specified the association between the relative risk of death and environmental hazards and socioeconomic indicators by means of spatio-temporal ecological regressions, formulated as a generalized linear mixed model with Poisson responses. There was a differential exposure (higher in more deprived neighborhoods) in almost all the air pollutants considered, when taken individually. The exposure was higher in the most affluent in the cases of environmental noise. Nevertheless, for both men and women, the risk of dying due to environmental hazards in a very affluent neighborhood is about 30% lower than in a very depressed neighborhood. The effect of environmental hazards was more harmful to the residents of Barcelona’s most deprived neighborhoods. This increased susceptibility cannot be attributed to a single problem but rather to a set of environmental hazards that, overall, a neighborhood may present.

Cardiologists and the Cardiology of the Future. Vision and proposals of the Spanish Society of Cardiology for the Cardiology of the 21st Century

The Cardiology of the Future is a project of the Spanish Society of Cardiology (SEC) whose objectives are as follows: to define the action policies of the SEC; to analyze the trends and changes in the environment that will influence the practice of cardiology in Spain; to define the profile of the cardiologists needed in the future; to propose policies to achieve the objectives resulting from the identified needs; and to identify the role of the SEC in the development and implementation of these policies. This article describes the methodology and the most relevant findings of the final report of this project and the strategic lines to be developed by the SEC in the immediate future, resulting from the analysis performed.

Population Health Inequalities Across and Within European Metropolitan Areas through the Lens of the EURO-HEALTHY Population Health Index

The different geographical contexts seen in European metropolitan areas are reflected in the uneven distribution of health risk factors for the population. Accumulating evidence on multiple health determinants point to the importance of individual, social, economic, physical and built environment features, which can be shaped by the local authorities. The complexity of measuring health, which at the same time underscores the level of intra-urban inequalities, calls for integrated and multidimensional approaches. The aim of this study is to analyse inequalities in health determinants and health outcomes across and within nine metropolitan areas: Athens, Barcelona, Berlin-Brandenburg, Brussels, Lisbon, London, Prague, Stockholm and Turin. We use the EURO-HEALTHY Population Health Index (PHI), a tool that measures health in two components: Health Determinants and Health Outcomes. The application of this tool revealed important inequalities between metropolitan areas: Better scores were found in Northern cities when compared with their Southern and Eastern counterparts in both components. The analysis of geographical patterns within metropolitan areas showed that there are intra-urban inequalities, and, in most cities, they appear to form spatial clusters. Identifying which urban areas are measurably worse off, in either Health Determinants or Health Outcomes, or both, provides a basis for redirecting local action and for ongoing comparisons with other metropolitan areas.

Trends of socioeconomic equality in mortality amenable to healthcare and health policy in 1992-2013 in Finland: a population-based register study

OBJECTIVE

To study trends in socioeconomic equality in mortality amenable to healthcare and health policy interventions.

DESIGN

A population-based register study.

SETTING

Nationwide data on mortality from the Causes of Death statistics for the years 1992-2013.

PARTICIPANTS

All deaths of Finnish inhabitants aged 25-74.

OUTCOME MEASURES

Yearly age-standardised rates of mortality amenable to healthcare interventions, alcohol-related mortality, ischaemic heart disease mortality and mortality due to all the other causes by income. Concentration index (C) was used to evaluate the magnitude and changes in income group differences.

RESULTS

Significant socioeconomic inequalities favouring the better-off were observed in each mortality category among younger (25-64) and older (65-74) age groups. Inequality was highest in alcohol-related mortality, C was -0.58 (95% CI -0.62 to -0.54) among younger men in 2008 and -0.62 (-0.72 to -0.53) among younger women in 2013. Socioeconomic inequality increased significantly during the study period except for alcohol-related mortality among older women.

CONCLUSIONS

The increase in socioeconomic inequality in mortality amenable to healthcare and health policy interventions between 1992 and 2013 suggests that either the means or the implementation of the health policies have been inadequate.

Economic Crisis and Amenable Mortality in Spain

Background: Both overall mortality and avoidable mortality have decreased in recent years in most European countries. It has become clear that less privileged socioeconomic groups have an increased risk of death. In 2008, most countries went into a severe economic recession, whose effects on the health of the population are still ongoing. While on the one hand, some evidence associates the economic crisis with positive health outcomes (pro-cyclical effect), on the other hand, some other evidence suggests that the economic crisis may pose serious public health problems (counter-cyclical effect), which has given rise to controversy. Objectives: To describe the evolution of overall mortality and amenable mortality in Spain between 2002⁻2007 (before the economic crisis) and 2008⁻2013 (during the economic crisis), nationally and by province, as well as to analyse trends in the risks of death and their association with indicators of the impact of the crisis. Methods: Ecological study of overall mortality and amenable mortality describing the evolution of the risks of death between 2002⁻2007 and 2008⁻2013. Age Standardised Rates were calculated, as well as their percentage change between periods. The association between percentage changes and provincial indicators of the impact of the crisis was analysed. Amenable mortality was studied both overall and categorised into five groups. Results: Amenable mortality represented 8.25% of overall mortality in 2002⁻2007, and 6.93% in 2008⁻2013. Age Standardised Rates for overall mortality and global amenable mortality generally declined, with the sharpest decline in amenable mortality. Decreases in overall mortality and amenable mortality were directly related to vulnerability indicators. The most significant decreases were registered in ischaemic heart disease, cerebrovascular disease, and other amenable causes. The relationship with vulnerability indices varied from direct (cancer) to inverse (hypertensive disease). Conclusions: Amenable mortality shows a more significant decrease than overall mortality between both study periods, albeit unevenly between provinces causes of death. Higher vulnerability indicators entail greater declines, although this trend varied for different causes. Mortality trends and their relationship with socioeconomic indicators in a situation of crisis must be conducted cautiously, taking into consideration a possible pro-cyclical effect.

[Drug using risks screening in primary care patients using the ASSIST test: Cross sectional study]

Objetivo

El objetivo es estimar la prevalencia de consumos de riesgo de drogas y patrones de consumo en atención primaria.

Diseño

Estudio multicéntrico descriptivo transversal.

Emplazamiento

Cinco centros de salud del área Sur de Madrid.

Participantes

Población consultante en atención primaria entre 16-100 años.

Mediciones

Se utilizó el test ASSIST validado al castellano de la Organización Mundial de la Salud para el cribado de consumo de drogas. Se calculó la puntuación total para cada droga.

Resultados

Se realizaron un total de 441 cribados. La edad media fue de 51,3 años y un 56,1% presentó algún consumo de riesgo moderado o grave para alguna de las 9 sustancias cribadas. Las drogas con cribado de riesgo más consumidas fueron el tabaco (41,7%), el alcohol (15,4%), los sedantes o los hipnóticos (13,7%) y el cannabis (5,7%), encontrándose algunas diferencias: los hombres consumían más alcohol y cannabis; las mujeres tenían mayor consumo de sedantes/hipnóticos que los hombres. Se observó policonsumo en un 16% de los sujetos.

Conclusiones

Existen riesgos derivados del consumo tabaco, alcohol, sedantes y cannabis en atención primaria. Existe una mayor prevalencia de sedantes e hipnóticos.

[Influence of postcode on paediatric admissions in Seville]

INTRODUCTION

The postcode (where the home is situated) is an indicator of socioeconomic status and is associated with morbidity, mortality, and the use of health services. The aim of this study was to analyse its effects on paediatric admissions and to determine the rates of the most common causes of paediatric admissions in Seville.

MATHERIAL AND METHODS

An observational cross-sectional study with two analysis units: under 15 year-old "admissions" in public hospitals in Seville (n=2,660) and "city districts" of Seville (n=11). The independent variable analysed was whether the postcode of the admitted patients was within a Regional Government designated "area with social transformation needs". The analysis of the admissions was performed using X²-test, Fisher test and Student-t test, with the description of rates using the calculation of crude and specific rates, and by rate ratio.

RESULTS

Children living in districts with a lower socioeconomic status were on average 7 months younger (P<.001), and they were significantly more likely to be admitted via the emergency department (P<.001). There was no statistical difference detected in either the length of hospital stay or mortality. The crude admission rate ratio was higher in districts with a lower socioeconomic status (1.8), with a higher specific rate ratio detected in admissions due to asthma, respiratory infections, inguinal hernia, and epilepsy/convulsions.

CONCLUSIONS

Paediatric hospital admission rates of the main diagnoses were higher in districts with a lower socioeconomic status. Children living in these districts were more likely to be admitted younger and via the emergency department.

The burden of cardiovascular morbidity in a European Mediterranean population with multimorbidity: a cross-sectional study

BACKGROUND

Cardiovascular diseases are highly represented in multimorbidity patterns. Nevertheless, few studies have analysed the burden of these diseases in the population with multimorbidity. The objective of this study was to identify and describe the cardiovascular diseases among the patients with multimorbidity.

METHODS

We designed a cross-sectional study in patients ≥19 years old assigned to 251 primary health care centres in Catalonia, Spain. The main outcome was cardiovascular morbidity burden, defined as the presence of one or more of 24 chronic cardiovascular diseases in multimorbid patients (≥2 chronic conditions). Two groups were defined, with and without multimorbidity; the multimorbidity group was further divided into cardiovascular and non-cardiovascular subgroups. The secondary outcomes were: modifiable major cardiovascular risk factors (smoking, hypertension, hypercholesterolaemia, diabetes) and cardiovascular risk score (REGICOR, Registre Gironí del Cor). Other variables analysed were: sex, age (19-24, 25-44, 45-64, 65-79, and 80+ years), number of chronic diseases, urban setting, active toxic habits (smoking and alcohol), physical parameters and laboratory tests.

RESULTS

A total of 1,749,710 individuals were included (mean age, 47.4 years [SD: 17.8]; 50.7 % women), of which nearly half (46.8 %) had multimorbidity (95 % CI: 46.9-47.1). In patients with multimorbidity,, the cardiovascular burden was 54.1 % of morbidity (95 % CI: 54.0-54.2) and the four most prevalent cardiovascular diseases were uncomplicated hypertension (75.3 %), varicose veins of leg (20.6 %), "other" heart disease (10.5 %) and atrial fibrillation/flutter (6.7 %). In the cardiovascular morbidity subgroup, 38.2 % had more than one cardiovascular disease. The most prevalent duet and triplet combinations were uncomplicated hypertension & lipid disorder (38.8 %) and uncomplicated hypertension & lipid disorder & non-insulin dependent diabetes (11.3 %), respectively. By age groups, the same duet was the most prevalent in patients aged 45-80 years and in men aged 25-44 years. In women aged 19-44, varicose veins of leg & anxiety disorder/anxiety was the most prevalent; in men aged 19-24, it was uncomplicated hypertension & obesity. Patients with multimorbidity showed a higher cardiovascular risk profile than the non-multimorbidity group.

CONCLUSIONS

More than 50 % percent of patients with multimorbidity had cardiovascular diseases, the most frequent being hypertension. The presence of cardiovascular risk factors and the cardiovascular risk profile were higher in the multimorbidity group than the non-multimorbidity group. Hypertension, diabetes and dyslipidaemia constituted the most prevalent multimorbidity pattern.

Comparative observational study of mortality amenable by health policy and care between rural and urban Finland: no excess segregation of mortality in the capital despite its increasing residential differentiation

Background

Large cities are often claimed to display more distinct geographical and socioeconomic health inequalities than other areas due to increasing residential differentiation. Our aim was to assess whether geographical inequalities in mortality within the capital (City of Helsinki) both exceeded that in other types of geographical areas in Finland, and whether those differences were dependent on socioeconomic inequalities.

Methods

We analysed the inequality of distribution separately for overall, ischemic heart disease and alcohol-related mortality, and mortality amenable (AM) to health care interventions in 1992–2008 in three types of geographical areas in Finland: City of Helsinki, other large cities, and small towns and rural areas. Mortality data were acquired as secondary data from the Causes of Death statistics from Statistics Finland. The assessment of changing geographical differences over time, that is geographical inequalities, was performed using Gini coefficients. As some of these differences might arise from socioeconomic factors, we assessed socioeconomic differences with concentration indices in parallel to an analysis of geographical differences. To conclude the analysis, we compared the changes over time of these inequalities between the three geographical areas.

Results

While mortality rates mainly decreased, alcohol-related mortality in the lowest income quintile increased. Statistically significant differences over time were found in all mortality groups, varying between geographical areas. Socioeconomic differences existed in all mortality groups and geographical areas. In the study period, geographical differences in mortality remained relatively stable but income differences increased substantially. For instance, the values of concentration indices for AM changed by 54 % in men (p < 0.027) and by 62 % in women (p < 0.016). Only slight differences existed in the time trends of Gini or in the concentration indices between the geographical areas.

Conclusions

No geographical or income-related differences in the distribution of mortality existed between Helsinki and other urban or rural areas of Finland. This suggests that the effect of increasing residential differentiation in the capital may have been mitigated by the policies of positive discrimination and social mixing. One of the main reasons for the increase in health inequalities was growth of alcohol-related mortality, especially among those with the lowest incomes.

Regional inequalities in self-rated health and disability in younger and older generations in Turkey: the contribution of wealth and education

Background

In Turkey, large regional inequalities were found in maternal and child health. Yet, evidence on regional inequalities in adult health in Turkey remains fragmentary. This study aims to assess regional and rural/urban inequalities in the prevalence of poor self-rated health and in disability among adult populations in Turkey, and to measure the contribution of education and wealth of individual residents. The central hypothesis was that geographical inequalities in adult health exist even when the effect of education and wealth were taken into account.

Methods

We analyzed data of the 2002 World Health Survey for Turkey on 10791 adults aged 20 years and over. We measured respondents’ rating of their own general health and the prevalence of five types of physical disability. Logistic regression was used to estimate how much these two health outcomes varied according to urban/rural place of residence, region, education level and household wealth. We stratified the analyses by gender and age (‹50 and ≥50 years).

Results

Both health outcomes were strongly associated with educational level (especially for older age group) and with household wealth (especially for younger age group). Both health outcomes also varied according to region and rural/urban place of residence. Higher prevalence rates were observed in the East region (compared to West) with odd ratios varying between 1.40–2.76. After controlling for education and wealth, urban/rural differences in health disappeared, while regional differences were observed only among older women. The prevalence of poor self-rated health was higher for older women in the Middle (OR = 1.69), Black Sea (OR = 1.53) and East (OR = 2.06) regions.

Conclusion

In Turkey, substantial geographical inequalities in self-reported adult health do exist, but can mostly be explained by differences in socioeconomic characteristics of residents. The regional disadvantage of older women in the East, Middle and Black Sea may have resulted from life-long exposure to gender discrimination under a patriarchal ideology. Yet, not geographic inequalities, but the more fundamental socioeconomic inequalities, are of key public health concern, also in Turkey.