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

Mechanism substitution in preventive innovations: Dissecting the reproduction of health inequalities in the United States

In the last three decades, numerous studies in different countries have corroborated the main postulates of the Fundamental Cause Theory (FCT), providing evidence showing how health inequalities are reproduced as society increases its capacity to control disease and/or avoid its consequences through preventive innovations. However, documenting the reproductive logic proposed by the theory requires the development of a dynamic analytical approach to consider socioeconomic disparities in the incorporation of multiple preventive innovations over time, which could act as mediating mechanisms of the durable relationship between socioeconomic status and health/mortality. This study draws on data from different waves of the National Health Interview Survey and the National Health and Nutrition Examination Survey to analyze the diffusion processes of various innovations in the U.S. The results of the study show that educational inequalities emerge, are amplified, and are reduced by the continuous diffusion of preventive innovations, supporting the meta-hypothesis of substitution of mediating mechanisms according to the interconnections of FCT and Diffusion of Innovation Theory.

Trends of amenable deaths due to healthcare within the European Union countries. Exploring the association with the economic crisis and education

The study of premature deaths from causes that are generally preventable given the current availability of healthcare - called amenable deaths due to healthcare - provides information on the quality of services. However, they are not only impacted by healthcare characteristics: other factors are also likely to influence. Therefore, identifying the association between amenable deaths due to healthcare and health determinants, such as education, might be the key to preventing these deaths in the future. Still unclear however, is how this works and how amenable deaths due to healthcare are distributed and evolve within the European Union (EU) below the national level. We therefore studied the geographical and temporal patterns of amenable deaths due to healthcare in the 259 EU regions from 1999 to 2016, including the 2007-2008 financial crisis and the post-2008 economic downturn, and identified whether any association with education exists. A cross-sectional ecological study was carried out. Using a hierarchical Bayesian model, we estimated the average smoothed Standardized Mortality Ratios (sSMR). A regression model was also applied to measure the relative risks (RR) at 95% credible intervals for cause-specific mortality association with education. Results show that amenable deaths due to healthcare decreased globally. Nevertheless, the decrease is not the same across all regions, and inequalities within countries do persist, with lower mortality ratios seen in regions from Central European countries and higher mortality ratios in regions from Eastern European countries. Also, the evolution trend reveals that after the financial crisis, the number of these deaths increased in regions across almost all EU countries. Moreover, educational disparities in mortality emerged, and a statistical association was found between amenable deaths due to healthcare and early exit from education and training. These results confirm that identifying and understanding the background of regional differences may lead to a better understanding of the amenable deaths due to healthcare and allow for the application of more effective policies.

A retrospective on fundamental cause theory: State of the literature, and goals for the future

Fundamental Cause Theory (FCT) was originally proposed to explain how socioeconomic inequalities in health emerged and persisted over time. The concept was that higher socioeconomic status helped some people to avoid risks and adopt protective strategies using flexible resources - knowledge, money, power, prestige and beneficial social connections. As a sociological theory, FCT addressed this issue by calling on social stratification, stigma, and racism as they affected medical treatments and health outcomes. The last comprehensive review was completed a decade ago. Since then, FCT has been tested, and new applications have extended central features. The current review consolidates key foci in the literature in order to guide future research in the field. Notable themes emerged around types of resources and their usage, approaches used to test the theory, and novel extensions. We conclude that after 25 years of use, there remain crucial questions to be addressed.

Environmental, Health and Sociodemographic Determinants Related to Common Mental Disorders in Adults: A Spanish Country-Wide Population-Based Study (2006-2017)

Common mental disorders (CMD) represent a serious, growing public health concern, especially in women. The aims of this study were to report the prevalence of CMD among the adult population in Spain, to analyze the time trends from 2006 to 2017 and to explore the associations between CMD and gender, in relation to the perceived environmental and sociodemographic problems and clinical factors. A nationwide cross-sectional study was conducted including 48,505 participants aged 16 to 64 years old who had participated in the Spanish National Health Surveys in 2006, 2011/2012 and 2017. A logistic regression analysis was performed to identify the variables associated with CMD by gender. The prevalence of CMD was 20.4% in 2006, 20.8% in 2011/2012 and 16.9% in 2017 (p = 0.36). In women, the probability of having a CMD was higher in widowed or separated/divorced compared with single individuals and as the perception of distressing noise levels from outside the home increased. The probability of CMD was lower as the level of education increased in men. Foreigners and those with limitations due to health problems, chronic conditions and worse perceived health were more likely to suffer from a CMD in both women and men.

Educational inequalities in high- vs. low-preventable health conditions: Exploring the fundamental cause theory

AIM

To explore variations in educational gradients or gaps between high- and low-preventable health conditions.

BACKGROUND

This is one of the first European studies to test whether the association between socioeconomic status and morbidity is stronger for 10 high- than three low-preventable health conditions, by gender across 20 countries.

DATA AND METHODS

The 2014 European Social Survey included questions on 11 health conditions experienced over the last 12 months, cancer at any age, and symptoms of depression during the last week. We include respondents from 20 countries (N_men = 12,073; N_women = 13,488) aged 25 to 69. We estimated age-adjusted educational gradients on 13 conditions using logistic or OLS-regression stratified by country and gender, and high- and low-preventable pooled conditions variables on pooled country samples.

RESULTS

Both among men and women the proportion of educational gaps were larger for the high-preventable than the low-preventable conditions in most countries, supporting the Fundamental Cause Theory (FCT) hypothesis. However, there was large variations in the number of significant associations across countries and between genders. In the pooled conditions and countries analysis, no associations were significant among the low-preventable conditions. For the high-preventable conditions there was a weak significant educational gap among men, and a weak but nevertheless more distinctive and complete sigificant educational gradient among women.

CONCLUSION

In a first explorative comparative European analysis we found support for the FCT hypothesis. Thus, the FCT can be used on morbidity data classified as low- versus high-preventable. We recommend extending this framework with institutional theories to explain within- and between-country health inequalities.

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.

Economic crisis and obesity in the Canary Islands: an exploratory study through the relationship between body mass index and educational level

Background

The Canary Islands is one of the Spanish Regions with the highest obesity prevalence, and one of the Autonomous Communities that was hit hard by the economic crisis that arrived to Spain in 2008. This research studies the education-related inequalities in adult obesity in the Canary Islands and their evolution in recent years, considering the possible impact of the economic recession.

Methods

A repeated cross-sectional analysis is carried out with data obtained from the Canary Islands Health Surveys of 2004, 2009 and 2015. Obesity is measured through the body mass index (BMI). The analysis is performed using linear regression models for the general population and by gender, adjusting by age, educational attainment and island of residence. Likewise, the models also include dummy variables for each year and the corresponding interactions between the years and the education variable.

Results

The results show a decrease in the obesity prevalence in 2015 compared to 2009 (from 19.54 to 18.64%). An increase in the BMI of the population and that of women (+ 0.33 and + 0.59 units, respectively) in 2009, as well as a decline in the BMI of women with medium education (− 0.21 units) are also observed. Besides, there is an inverse correlation between education and BMI, and statistically significant differences among some islands.

Conclusions

Obesity figures in the Canary Islands have decreased and women have been more greatly affected by the changes in BMI during the economic crisis. Due to the fact that educational attainment is a protective factor in general (and for women with medium education levels in times of crisis, in particular), regional authorities should implement actions that promote access to education and healthy lifestyles, paying attention to territorial disparities.

Studying the impact of the Eurozone's Great Recession on health: Methodological choices and challenges

Europe's Great Recession provides an opportunity to study the impact of increased financial insecurity on health. A number of studies explored the impact of the Recession on health, but they often reached different conclusions. To understand the root of this debate, we undertook a systematic literature review. Articles were analysed thematically based on: geography, data type, operationalisations of wealth and health, and study design. A critical appraisal was also undertaken. Forty-two studies, published from January 2010 to October 2018, were included in our review. Twenty-six of the forty-two studies found that the Great Recession worsened physical health indicators in the Eurozone. In terms of geography, a large concentration of studies focussed on Spain and Greece, indicating that there may be a gap in understanding the health consequences for EU countries with less severe experiences of the Recession. Regarding data type, nearly all studies used secondary datasets, possibly meaning that studies were constrained by the data available. In terms of operationalisations of wealth and health, a majority of studies used single/simple measures of both, so that these multi-faceted concepts were not fully reflected. Further, fewer than half included studies used panel data, with the remaining studies unable to undertake more causal analyses. The results of the critical appraisal showed that lower-quality studies tended to not find a negative impact of the Recession on health, whereas higher quality studies generally did. In future, we recommend conducting cross-country comparisons, using (inter)nationally-representative panel data conducted over a minimum of a ten-year time horizon, and employing multi-faceted operationalisations of wealth and health. This could provide more common ground across studies, and a clearer indication of whether the Recession impacted health.

Evaluation of the Biases in the Studies that Assess the Effects of the Great Recession on Health. A Systematic Review

BACKGROUND

Our main objective was to evaluate the fundamental biases detected in studies assessing the effects the Great Recession had on health for the case of Spain. As secondary objectives we presented methods to control these biases and to discuss the results of the studies in question if they had controlled for them.

METHODS

We carried out a systematic review of the literature published up to June 2018. We evaluated the biases that could have happened in all the eligible studies.

RESULTS

From the review, we finally selected 53 studies. Of the studies we reviewed, 60.38% or 32 out of 53, were evaluated as having a high risk of bias. The main biases our review revealed were problems with evaluation, time bias, lack of control of unobserved confounding, and non-exogeneity when defining the onset of the Great Recession.

CONCLUSIONS

The results from the studies that controlled the biases were quite consistent. Summing up, the studies reviewed found that the Great Recession increased the risk of declaring poor self-rated health and the deterioration of mental health. Both the mortality rate and the suicide rate may well have increased after the Great Recession, probably after a three- to four-year delay.

Excess winter mortality and morbidity before, during, and after the Great Recession: the Portuguese case

Although winter mortality and morbidity are phenomena common to most European countries, their magnitude varies significantly from country to country. The geographical disparities among regions with similar climates are the result of several social, economic, demographic, and biological conditions that influence an individual's vulnerability to winter conditions. The impact of poor socioeconomic conditions may be of such magnitude that an economic recession may aggravate the seasonal mortality pattern. This paper aims to measure the seasonal winter mortality, morbidity, and their related costs during the Great Recession (2009-2012) in mainland Portugal and its Regional Health Administrations (RHAs) and to compare it with the periods preceding and following it. Monthly mortality and morbidity data were collected and clustered into three periods: Great Recession (2009-2012), Pre-Recession (2005-2008), and Post-Recession (2013-2016). The impact of seasonal winter mortality and morbidity during the Great Recession in Portugal and its Regional Health Administrations was measured through the assessment of age-standardized excess winter (EW) death and hospital admissions rate and index, expected life expectancy gains without EW deaths, EW rate of potential years of life lost, and EW rate of emergency hospital admission costs. Important increases of winter deaths and hospital admissions were identified, resulting in an important number of potential years of life lost (87 years of life lost per 100,000 inhabitants in 2009-2012), life expectancy loss (1 year in 2009-2012), and National Health Service costs with explicit temporal and spatial variations. These human and economic costs have decreased consistently during the analyzed periods, while no significant increase was found during the Great Recession. Despite its reduction, the winter excess morbidity and mortality highlight that Portugal still faces substantial challenges related to a highly vulnerable population, calling for investments in better social and health protection.

Socioeconomic inequalities in health during the Great Recession: A scoping review of the research literature

Aims: The so-called ‘Great Recession’ in Europe triggered widespread concerns about population health, as reflected by an upsurge in empirical research on the health impacts of the economic crisis. A growing body of empirical studies has also been devoted to socioeconomic inequalities in health during the Great Recession. The aim of the current study is to summarise this health inequality literature by means of a scoping review. Methods: We have performed a scoping review of the research literature (English language) published in the years 2012–2017. Only empirical papers with (a) health status measured on the individual level, (b) information on socioeconomic position (i.e. employment status, educational level, income/wealth, and/or occupational class), and (c) data from European countries in both pre- and post-crisis years were considered relevant. In total, 49 empirical studies fulfilled these inclusion criteria. Results: The empirical findings in the 49 included studies predominantly show that socioeconomic inequalities in health either increased or remained stable from pre- to post-crisis years. Two-thirds (65%) of the studies found evidence of either increasing or partially increasing health inequalities. Thus, people in lower socioeconomic strata fared worse overall in terms of health during the Great Recession, compared to people with higher socioeconomic status. Conclusions: The Great Recession in Europe tends to be followed by increasing socioeconomic inequalities in health. Policymakers should take note of this finding. Widening socioeconomic inequalities in health is a major cause of concern, in particular if health deterioration among ‘vulnerable groups’ is caused by accelerating cumulative disadvantages.

Depressed during the depression: has the economic crisis affected mental health inequalities in Europe? Findings from the European Social Survey (2014) special module on the determinants of health

Background

Economic crises constitute a shock to societies with potentially harmful effects to the mental health status of the population, including depressive symptoms, and existing health inequalities.

Methods

With recent data from the European Social Survey (2006–14), this study investigates how the economic recession in Europe starting in 2007 has affected health inequalities in 21 European nations. Depressive feelings were measured with the CES-D eight-item depression scale. We tested for measurement invariance across different socio-economic groups.

Results

Overall, depressive feelings have decreased between 2006 and 2014 except for Cyprus and Spain. Inequalities between persons whose household income depends mainly on public benefits and those who do not have decreased, while the development of depressive feelings was less favorable among the precariously employed and the inactive than among the persons employed with an unlimited work contract. There are no robust effects of the crisis measure on health inequalities.

Conclusion

Negative implications for mental health (in terms of depressive feelings) have been limited to some of the most strongly affected countries, while in the majority of Europe persons have felt less depressed over the course of the recession. Health inequalities have persisted in most countries during this time with little influence of the recession. Particular attention should be paid to the mental health of the inactive and the precariously employed.

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.

Health outcomes during the 2008 financial crisis in Europe: systematic literature review

OBJECTIVE

 To systematically identify, critically appraise, and synthesise empirical studies about the impact of the 2008 financial crisis in Europe on health outcomes.

DESIGN

 Systematic literature review.

DATA SOURCES

 Structural searches of key databases, healthcare journals, and organisation based websites.

REVIEW METHODS

 Empirical studies reporting on the impact of the financial crisis on health outcomes in Europe, published from January 2008 to December 2015, were included. All selected studies were assessed for risk of bias. Owing to the heterogeneity of studies in terms of study design and analysis and the use of overlapping datasets across studies, studies were analysed thematically per outcome, and the evidence was synthesised on different health outcomes without formal meta-analysis.

RESULTS

 41 studies met the inclusion criteria, and focused on suicide, mental health, self rated health, mortality, and other health outcomes. Of those studies, 30 (73%) were deemed to be at high risk of bias, nine (22%) at moderate risk of bias, and only two (5%) at low risk of bias, limiting the conclusions that can be drawn. Although there were differences across countries and groups, there was some indication that suicides increased and mental health deteriorated during the crisis. The crisis did not seem to reverse the trend of decreasing overall mortality. Evidence on self rated health and other indicators was mixed.

CONCLUSIONS

 Most published studies on the impact of financial crisis on health in Europe had a substantial risk of bias; therefore, results need to be cautiously interpreted. Overall, the financial crisis in Europe seemed to have had heterogeneous effects on health outcomes, with the evidence being most consistent for suicides and mental health. There is a need for better empirical studies, especially those focused on identifying mechanisms that can mitigate the adverse effects of the crisis.