Asthma control in children, socioeconomic inequality and health care

INTRODUCTION

Socioeconomic inequality (SEI) can adversely affect asthma control. The aim of this study was to establish the association of SEI with asthma control in children and caregiver quality of life.

METHODS

We assessed socioeconomic status based on the area of residence, according to the at risk of poverty rate (ARPR). After stratifying the paediatric population of Castilla y León (Spain) in ARPR tertiles, we selected participants by stratified random sampling, and identified children with asthma aged 6-14 years from the health records of primary care centres. We collected data through questionnaires completed by parents. The primary outcomes were asthma control and caregiver quality of life. We assessed their association with SEI, health care quality measures and individual factors (such as parental educational attainment) by means of multivariate regression models.

RESULT

The ARPR tertile was not associated with asthma control, quality of life or health care quality. A medium or high maternal educational attainment was associated with a lower risk of making an unscheduled or urgent visit (OR = .50; 95% CI, .27-.95; P = .034) and paternal educational attainment was associated with a lower risk of uncontrolled asthma (OR = 0.51; 95% CI, .28-.94; P = .030).

CONCLUSION

In the sample under study, SEI assessed at the local level was not associated with asthma control in children. Other factors, such as parental educational attainment, may have a protective effect.

Inequalities in diabetes mortality in Mexico: 2010-2019

BACKGROUND

The impact of diabetes mellitus has been shown to be differentially expressed between social groups.

OBJECTIVE

To estimate inequality gaps in diabetes mellitus mortality through absolute and relative measures according to geographic distribution and social conditions.

MATERIAL AND METHODS

Diabetes mellitus-related deaths recorded in Mexico between 2010 and 2019 were analyzed, and inequality measurements at the state level were calculated by gender.

RESULTS

National age-adjusted diabetes mellitus mortality rate showed an increase during the study period.

CONCLUSION

The inequalities present in diabetes mortality should be considered for the design of health strategies.

[The preventive efforts of the Spanish autonomous regions and socio-economic inequality in childhood obesity or overweight]

OBJECTIVE

To explore trends in childhood overweight/obesity according to socio-economic status and in relation to the preventive effort developed by the Spanish autonomous regions.

METHOD

A series of multilevel cross-sectional studies were conducted using data from different waves of the Spanish National Health Survey, namely 2003, 2006, 2011 and 2017. Hierarchical logistic regression models were estimated, with individuals (level 1) nested within the region-period of study (level 2) and these, in turn, within the region (level 3). The main independent variables were the average effort made by the Spanish autonomous regions in child overweight-obesity prevention policies and the change in the effort made in these policies over the periods studied.

RESULTS

The likelihood of obesity and/or overweight increases substantially if the adult respondent in the household is also obese or overweight. The joint effect of the policies implemented by the autonomous regions is associated with a significant decrease in prevalence only for children belonging to high and middle social classes (odds ratio [OR]: 0.89, 95% confidence interval [95%CI]: 0.82-0.96, and OR: 0.93, 95%CI: 0.88-0.97, respectively).

CONCLUSIONS

The policies implemented by the Spanish autonomous regions seem to have a limited capacity to achieve significant reductions in the prevalence of childhood overweight and obesity. The results suggest that it is the middle and upper-middle class groups that seem to benefit most from these policies, which could indirectly contribute to increasing inequalities in childhood obesity.

Improving mental health and wellbeing in elderly people isolated at home due to architectural barriers: A community health intervention

OBJECTIVES

To explore the health effects of a community health intervention on older people who are isolated at home due to mobility problems or architectural barriers, to identify associated characteristics and to assess participants' satisfaction.

DESIGN

Quasi-experimental before-after study.

SETTING

Five low-income neighbourhoods of Barcelona during 2010-15.

PARTICIPANTS

147 participants, aged ≥59, living in isolation due to mobility problems or architectural barriers were interviewed before the intervention and after 6 months.

INTERVENTION

Primary Health Care teams, public health and social workers, and other community agents carried out a community health intervention, consisting of weekly outings, facilitated by volunteers.

MEASUREMENTS

We assessed self-rated health, mental health using the General Health Questionnaire (GHQ-12), and quality of life through the EuroQol scale. Satisfaction with the programme was evaluated using a set of questions. We analysed pre and post data with McNemar tests and fitted lineal and Poisson regression models.

RESULTS

At 6 months, participants showed improvements in self-rated health and mental health and a reduction of anxiety. Improvements were greater among women, those who had not left home for ≥4 months, those with lower educational level, and those who had made ≥9 outings. Self-rated health [aRR: 1.29(1.04-1.62)] and mental health improvements [β: 2.92(1.64-4.2)] remained significant in the multivariate models. Mean satisfaction was 9.3 out of 10.

CONCLUSION

This community health intervention appears to improve several health outcomes in isolated elderly people, especially among the most vulnerable groups. Replications of this type of intervention could work in similar contexts.

[Training for Roma health advocacy: a case study of Torreblanca, Seville]

OBJECTIVE

The objective of this study is to build advocacy capacity among a group of gipsy Roma neighbours living in contexts of risk of social exclusion.

METHODS

A Community Based Participatory Action Research design was used, in which 4 members of the community participated in the process of collecting evidence by photo-voice, analysing it using the ReACT method and disseminating the results.

RESULTS

A total of 96 pieces of evidence were collected and analysed for qualitative data analysis. These were categorised according to (a) the type of unhealthy conditions and (b) the area of the neighbourhood where they were located. The subsequent thematic grouping made it possible to identify the causes: (a) the abandonment of public services; (b) discrimination; and (c) the lack of Roma presence in community spaces. The consequences identified were (a) mental and physical health problems and (b) the normalisation of undignified living conditions. The plan was designed to advocate for the presence of Roma in community spaces.

CONCLUSIONS

Our study highlighted the relevance of the photo-voice to transcend the biomedical perspective and develop advocacy actions based on the knowledge created by the community. Future research should look more deeply into the impact of health advocacy on reducing inequalities and consider the importance of involving researchers, public health professionals and the community in addressing it.

Barcelona Salut als Barris: Twelve years' experience of tackling social health inequalities through community-based interventions

Community health can reduce inequalities in health and improve the health of the most disadvantaged populations. In 2007, Barcelona Salut als Barris (Barcelona Health in the Neighbourhoods) was launched, a community health programme to reduce social inequalities in health. In 2018, this programme reached the 25 most disadvantaged neighbourhoods of the city. This article shares the lessons learned after 12 years of work. The programme was initially funded by a research grant and the funds were maintained during the economic crisis and were tripled when the programme became a political priority in the last municipal government. During the 12-year period, partnerships with stakeholders were generally stable and productive. Maximum community participation was obtained in the detection of health assets and needs and in action plans. During 2018, Barcelona Salut als Barris worked with more than 460 agents that co-produced 183 interventions involving more than 13,600 people. Most of the interventions assessed showed improvements in the health of participants, which could help to reduce health inequalities. The greatest difficulties were: a) citizen participation, b) the sustainability of working groups over the years, c) conflicts of interest, d) the sustainability of interventions, e) reaching certain minority groups and f) evaluation. The increase in resources in the last period contributed to the maturity and expansion of the programme. Key factors in its scope and results were political will, strong technical capacity and methodology, strong intersectoral partnerships and continued community work.

Social inequalities in cardiovascular mortality in Spain from an intersectional perspective

INTRODUCTION AND OBJECTIVES

There is an interaction between age, sex, and educational level, among other factors, that influences mortality. To date, no studies in Spain have comprehensively analyzed social inequalities in cardiovascular mortality by considering the joint influence of age, sex, and education (intersectional perspective).

METHODS

Study of all deaths due to all-cause cardiovascular disease, ischemic heart disease, heart failure, and cerebrovascular disease among people aged ≥ 30 years in Spain in 2015. Data were obtained from the Spanish Office of Statistics. The relative index of inequality (RII) and the slope index of inequality (SII) were calculated by using Poisson regression models with age-adjusted mortality. The RII is interpreted as the relative risk of mortality between the lowest and the highest educational level, and the SII as the absolute difference in mortality.

RESULTS

The RII for all-cause cardiovascular mortality was 1.88 (95%CI, 1.80-1.96) in women and 1.44 (95%CI, 1.39-1.49) in men. The SII was 178.46 and 149.43 deaths per 100 000, respectively. The greatest inequalities were observed in ischemic heart disease and heart failure in younger women, with a RII higher than 4. There were no differences between sexes in inequalities due to cerebrovascular disease.

CONCLUSIONS

Cardiovascular mortality is inversely associated with educational level. This inequality mostly affects premature mortality due to cardiac causes, especially among women. Monitoring this problem could guide the future Cardiovascular Health Strategy in the National Health System, to reduce inequality in the first cause of death.

[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.

[Health inequalities as a political priority in Barcelona]

There is a wealth of information and research on health inequalities in Barcelona, but this issue has not been clearly prioritised on the political agenda. The arrival in government of a new left-wing party (Barcelona en Comú) in 2015, gave an important boost to the political agenda to reduce inequalities and health inequalities. The aim of this review is to describe the progress made in relation to health inequalities in these four years and especially in the areas involving public health. With respect to evidence and communication on health inequalities, the progress made is presented in the Barcelona annual health report and the creation of the Observatory on Health, Inequalities and Impacts of Municipal Policies. The policies presented refer to different municipal strategies, the Health Plan, the promotion of the Barcelona Health in the Neighbourhoods programme and the Plan for Tackling Inequalities in the Barcelona Public Health Agency. The combination of political will, technical capacity and the drive of citizens have facilitated progress in the city of Barcelona in policies to reduce social inequalities in health.

[Association between socioeconomic determinants and environmental tobacco smoke exposure in children]

OBJECTIVE

To assess the association between exposure to environmental tobacco smoke (ETS) and different socioeconomic determinants among Spanish children.

METHOD

We analyzed the data of 5495 children included in the 2011-2012 Spanish National Health Survey. We estimated the prevalence of exposure to ETS and adjusted logistic regression models to identify variables related to exposure to ETS: total exposure and exposure in the home in addition to ETS exposure in enclosed public places/transport.

RESULTS

Total exposure to ETS among children aged 15 and younger was 11.8%, 11.5% of whom were exposed at home and 0.8% in enclosed public places/transport. The prevalence odds ratio (POR) of exposure at home increased with age (6-9 years: 2.19; 10-14 years: 2.28), in children with parents of low or medium education levels (1.97 and 1.29), of social class IV-VI (1.42), among those living in a household with a composition other than a "couple with children" (1.43), and in smaller-sized homes (1.39). Total exposure results were similar to home exposure results.

CONCLUSION

The prevalence of ETS is higher among children younger than 15 years with a more difficult economic situation. These inequalities must be considered in the establishment and development of public health policies.

[A deprivation index to reform the financing model of primary care in Catalonia (Spain)]

OBJECTIVE

To build a deprivation index for the assignation of the budgets of the primary healthcare teams in Catalonia (Spain) valid for both urban and rural environments and updatable with greater frequency than indices built from census variables.

METHOD

Starting from a review of the most common deprivation indices, variables were selected from sources that allow frequent updating and are representative at the territorial level of primary care. The correlations were calculated between the chosen variables and variables of need for healthcare and morbidity. principal components analysis was applied. Finally, the correlations of the index built with the MEDEA index and with variables of use of healthcare resources and morbidity was calculated stratifying by geographical dispersion.

RESULTS

The variables of income, occupation and education are the ones with the highest correlation with the need for healthcare and morbidity. The composed socioeconomic index (CSI) ranges from -.01 to 5.68, with an average value of 2.60 and a standard deviation of .91. The correlation between the CSI and the MEDEA index is .89. The CSI correlates with use for healthcare in both urban and rural environments, although in rural environments the association is lower.

CONCLUSIONS

The CSI was built with data that allow frequent updating and was integrated in the model for allocating resources to primary healthcare starting in 2017.

[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.

[Contextual indicators to assess social determinants of health and the Spanish economic recession]

OBJECTIVE

To provide indicators to assess the impact on health, its social determinants and health inequalities from a social context and the recent economic recession in Spain and its autonomous regions.

METHODS

Based on the Spanish conceptual framework for determinants of social inequalities in health, we identified indicators sequentially from key documents, Web of Science, and organisations with official statistics. The information collected resulted in a large directory of indicators which was reviewed by an expert panel. We then selected a set of these indicators according to geographical (availability of data according to autonomous regions) and temporal (from at least 2006 to 2012) criteria.

RESULTS

We identified 203 contextual indicators related to social determinants of health and selected 96 (47%) based on the above criteria; 16% of the identified indicators did not satisfy the geographical criteria and 35% did not satisfy the temporal criteria. At least 80% of the indicators related to dependence and healthcare services were excluded. The final selection of indicators covered all areas for social determinants of health, and 62% of these were not available on the Internet. Around 40% of the indicators were extracted from sources related to the Spanish Statistics Institute.

CONCLUSIONS

We have provided an extensive directory of contextual indicators on social determinants of health and a database to facilitate assessment of the impact of the economic recession on health and health inequalities in Spain and its autonomous regions.

Time trends in health inequalities due to care in the context of the Spanish Dependency Law

OBJECTIVE

In Spain, responsibility for care of old people and those in situations of dependency is assumed by families, and has an unequal social distribution according to gender and socioeconomic level. This responsibility has negative health effects on the carer. In 2006, the Dependency Law recognised the obligation of the State to provide support. This study analyses time trends in health inequalities attributable to caregiving under this new law.

METHODS

Study of trends using two cross-sectional samples from the 2006 and 2012 editions of the Spanish National Health Survey (27,922 and 19,995 people, respectively). We compared fair/poor self-rated health, poor mental health (GHQ-12 >2), back pain, and the use of psychotropic drugs between non-carers, carers sharing care with other persons, and those providing care alone. We obtain prevalence ratios by fitting robust Poisson regression models.

RESULTS

We observed no change in the social profile of carers according to gender or social class. Among women, the difference in all health indicators between carers and non-carers tended to decrease among those sharing care but not among lone carers. Inequalities tend to decrease slightly in both groups of men carers.

CONCLUSIONS

Between 2006 and 2012, trends in health inequalities attributable to informal care show different trends according to gender and share of responsibility. It is necessary to redesign and implement policies to reduce inequalities that take into account the most affected groups, such as women lone carers. Policies that strengthen the fair social distribution of care should also be adopted.

Effectiveness of an intervention to improve diabetes self-management on clinical outcomes in patients with low educational level

OBJECTIVE

To determine whether an intervention based on patient-practitioner communication is more effective than usual care in improving diabetes self-management in patients with type 2 diabetes with low educational level.

METHODS

12-month, pragmatic cluster randomised controlled trial. Nine physicians and 184 patients registered at two practices in a deprived area of Granada (Andalusia, Spain) participated in the study. Adult patients with type 2 diabetes, low educational level and glycated haemoglobin (HbA1c) > 7% (53.01 mmol/mol) were eligible. The physicians in the intervention group received training on communication skills and the use of a tool for monitoring glycaemic control and providing feedback to patients. The control group continued standard care. The primary outcome was difference in HbA1c after 12 months. Dyslipidaemia, blood pressure, body mass index and waist circumference were also assessed as secondary outcomes. Two-level (patient and provider) regression analyses controlling for sex, social support and comorbidity were conducted.

RESULTS

The HbA1c levels at 12 months decreased in both groups. Multilevel analysis showed a greater improvement in the intervention group (between-group HbA1c difference= 0.16; p=0.049). No statistically significant differences between groups were observed for dyslipidaemia, blood pressure, body mass index and waist circumference.

CONCLUSIONS

In this pragmatic study, a simple and inexpensive intervention delivered in primary care showed a modest benefit in glycaemic control compared with usual care, although no effect was observed in the secondary outcomes. Further research is needed to design and assess interventions to promote diabetes self-management in socially vulnerable patients.

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

The objectives of the SESPAS 2014 Report are as follows: a) to analyze the impact of the economic crisis on health and health-related behaviors, on health inequalities, and on the determinants of health in Spain; b) to describe the changes in the Spanish health system following measures to address the crisis and assess its potential impact on health; c) to review the evidence on the health impact of economic crises in other countries, as well as policy responses; and d) to suggest policy interventions alternative to those carried out to date with a population health perspective and scientific evidence in order to help mitigate the impact of the economic downturn on health and health inequalities. The report is organized in five sections: 1) the economic, financial and health crisis: causes, consequences, and contexts; 2) the impact on structural determinants of health and health inequalities; 3) the impact on health and health-related behaviors, and indicators for monitoring; 4) the impact on health systems; and 5) the impact on specific populations: children, seniors, and immigrants. There is some evidence on the relationship between the crisis and the health of the Spanish population, health inequalities, some changes in lifestyle, and variations in access to health services. The crisis has impacted many structural determinants of health, particularly among the most vulnerable population groups. Generally, policy responses on how to manage the crisis have not taken the evidence into account. The crisis may contribute to making public policy vulnerable to corporate action, thus jeopardizing the implementation of healthy policies.

[Equality in clinical practice. Proposals for patients, professionals and managers and policies to limit discrimination]

OBJECTIVE

To make feasible and practical proposals to improve equality in the course of clinical care during the patient-provider encounter.

METHODS

Design: A focus group study was conducted with a qualitative approach from the perspective of reducing health inequalities in the clinic. Setting: A classroom discussion focused on equality in clinical work. Subjects: 98 professionals from several countries. Measurement tools: An analysis of the responses was performed, grouped by themes interpreted by analysts, and restructured to provide consistency and uniformity to responses given. Data were collected using a questionnaire with open answers, allowing free-form answers to three general questions that addressed improving equality from the perspective of the professional themselves, patients, and health policy managers. No saturation horizon of analytical discourses was set, to understand that from this subjective prioritization of opinion there is no possibility that discourses reached saturation.

RESULTS

Responses were added to the 3 principal axes, recommending that professionals be aware of their discriminatory ability. Patients were asked to trust their health professionals and that they should be assigned to a professional. It was also proposed that managers provide information systems, help reduce health inequalities, and encourage professional freedom.

CONCLUSIONS

The paper presents concrete measures to promote improved equality in clinics during the delivery of health care.

[Self-rated health in adults: influence of poverty and income inequality in the area of residence]

OBJECTIVE

To evaluate the influence of income inequality and poverty in the towns of Bogotá, Colombia, on poor self-rated health among their residents.

METHODS

The study was based on a multipurpose survey applied in Bogotá-Colombia. A hierarchical data structure (individuals=level1, locations=level 2) was used to define a logit-type multilevel logistic model. The dependent variable was self-perceived poor health, and local variables were income inequality and poverty. All analyses were controlled for socio-demographic variables and stratified by sex.

RESULTS

The prevalence of self-reported fair or poor health in the study population was 23.2%. Women showed a greater risk of ill health, as well as men and women with a low educational level, older persons, those without work in the last week and persons affiliated to the subsidized health system. The highest levels of poverty in the city increased the risk of poor health. Cross-level interactions showed that young women and men with a low education level were the most affected by income inequality in the locality.

CONCLUSIONS

In Bogotá, there are geographical differences in the perception of health. Higher rates of poverty and income inequality were associated with an increased risk of self-perceived poor health. Notable findings were the large health inequalities at the individual and local levels.