Alicia Llácer

The contribution of a gender perspective to the understanding of migrants’ health

In 2005 women represented approximately half of all 190 million international migrants worldwide. This paper addresses the need to integrate a gender perspective into epidemiological studies on migration and health, outlines conceptual gaps and discusses some methodological problems. We mainly consider the international voluntary migrant. Women may emigrate as wives or as workers in a labour market in which they face double segregation, both as migrants and as women. We highlight migrant women’s heightened vulnerability to situations of violence, as well as important gaps in our knowledge of the possible differential health effects of factors such as poverty, unemployment, social networks and support, discrimination, health behaviours and use of services. We provide an overview of the problems of characterising migrant populations in the health information systems, and of possible biases in the health effects caused by failure to take the triple dimension of gender, social class and ethnicity into account.

Accuracy of cancer death certificates in Spain: a summary of available information

OBJECTIVES Differences in mortality rates within Europe might be partly due to the quality of mortality statistics. The present article summarizes the available data on the quality of cancer death certification in Spain. A short description of the temporal distribution of the proportion of deaths due to ill-defined tumors in Spain -an indirect indicator of the quality of cancer death certification- is also provided. METHODS Relevant studies were identified from electronic databases (MEDLINE, EMBASE, IME and IBECS) and from manual searches of the references contained in the articles retrieved. Quality data on death certificates for all tumors and for each specific cancer location were summarized, and all main cancer sites were classified according to their pooled accuracy indicators. Trends for the percentage of deaths due to ill-defined tumors and conditions were studied for the period from 1980 to 2002. RESULTS In Spain, deaths from cancer as a whole and leading cancer sites (lung, colon-rectum, prostate, stomach, pancreas, female breast, uterus, brain, leukemia, lymphomas and myeloma) were well-certified. However, other frequent locations, such as the larynx, esophagus and liver were overcertified, while deaths from bladder, kidney and ovarian cancer were undercertified. The percentage of deaths due to ill-defined tumors and causes was regularly higher in females and decreased in both sexes during the study period. However, the recent introduction of the International Classification of Diseases (ICD)-10 has reversed this trend. CONCLUSIONS Spanish death certificates can be considered as accurate and useful to estimate the burden of cancer, though certification of some frequent sites should be improved. The possible effect of the introduction of the ICD-10 requires careful surveillance.

Gender differences in depressive symptoms among Spanish elderly

Abstract The aim of this study is to describe gender differences in depressive symptomatology among an elderly Spanish population and to see whether women are more at risk than men and whether the effects of known risk factors for depression differ between the genders. Data come from the study Envejecer en Leganés (Growing Old in Leganés), where a representative sample of community residing elderly was screened by an at-home interview for high depressive symptomatology using the Center for Epidemiologic Studies Depression Scale (CES-D). Sociodemographic characteristics, health status, Activities of Daily Living and Instrumental Activities of Daily Living, disability, social support, and locus of control were measured as possible correlates of depressive symptoms. Screening was completed in 1116 subjects. The prevalence of high depressive symptomatology varied, being 19.6% for men and 46% for women (OR=3.4; 95% CI=2.6; 4.5). In addition to gender, comorbidity, low emotional support from children, lack of a confidant, few social activities, and a sense of lack of control were independently associated with high levels of depressive symptoms. None of the interactions of gender by the known risk factors of depression was significant. Although the prevalence of depressive symptomatology is higher in women than in men, the known risk factors do not totally explain the difference between genders in this population of Spanish elderly. This difference could be due to the cultural definitions of gender roles that have affected them throughout their lives.

Sociodemographic characteristics and HIV risk behaviour patterns of male sex workers in Madrid, Spain.

This paper describes the sociodemographic and work characteristics, prevalence of HIV infection and associated risk behaviours among male sex workers (MSWs) in Madrid (Spain). Using an anonymous semi-structured questionnaire, educators attached to a mobile unit under a street-based prostitution programme surveyed 84 MSWs from several Madrid areas. Of the total surveyed: 35% were immigrants, mean age was 23 years, mean period in prostitution was four years; 21% had no primary education; 16% had injected drugs at some time; 11% reported private sexual relationships exclusively with women; 89% always used condoms in anal practices with clients; and 41% were in sexual relationships with their partners. Only 11% had ever used fortified condoms. In the preceding month, 37% had experienced condom failure, 82% without having used any lubricant. In all, 67% reported having undergone HIV testing, with a higher percentage of positive results among injecting (60%) versus non-injecting drug users (17%). Immigrants had a lower level of education, made less use of condoms, had more condom failures and, in their private lives, a greater proportion reported sexual relationships exclusively with women. In Spain, MSWs should be included in HIV prevention programmes, which ought to be specifically adapted to immigrants. Priority should be given to reducing the condom failure rate in anal intercourse, by improving access to fortified condoms.

Discrimination and mental health in Ecuadorian immigrants in Spain

Background: The aim of this study was to examine the effects of ethnic discrimination on the mental health of Ecuadorian immigrants in Spain and to assess the roles of material and social resources. Methods: Data were taken from the “Neighbourhood characteristics, immigration and mental health” survey conducted in 2006 in Spain. Psychological distress measured as “Possible Psychiatric Case” (PPC) was measured by the GHQ-28. A logistic regression was fitted to assess the association between PPC and discrimination. Interactions of discrimination with social and material resources were tested using product terms. Results: Some 28% of the participants met our definition of PPC. About 20% of those who reported no discrimination were PPCs, rising to 30% of those who sometimes felt discriminated against and 41% of those who continually perceived discrimination. The OR for continuous discrimination was 12 (95% CI 3.5 to 40.3) among those with high financial strain, and 10 (2.4 to 41.7) when there was lack of economic support. Emotional support had an independent effect on PPC (OR 1.8, 95% CI 1.0 to 3.6, for those who reported having no friends). Social integration through a community group or association was positively related to the probability of being a PPC (OR 1.7, 95% CI 1.0 to 2.9). Conclusion: Ethnic discrimination is associated with psychological distress in these Ecuadorian immigrants in Spain. Discrimination effects may be exacerbated among those facing economic stress and those without economic support. These particularly vulnerable immigrants should be the subject of social and health interventions.

Mental health in Ecuadorian migrants from a population-based survey: the importance of social determinants and gender roles

PurposeTo describe the prevalence of and the risk factors for poor mental health in female and male Ecuadorian migrants in Spain compared to Spaniards.MethodPopulation-based survey. Probabilistic sample was obtained from the council registries. Subjects were interviewed through home visits from September 2006 to January 2007. Possible psychiatric case (PPC) was measured as score of ≥5 on the General Health Questionnaire-28 and analyzed with logistic regression.ResultsOf 1,122 subjects (50% Ecuadorians, and 50% women), PPC prevalence was higher in Ecuadorian (34%, 95% CI 29–40%) and Spanish women (24%, 95% CI 19–29%) compared to Ecuadorian (14%, 95% CI 10–18%) and Spanish men (12%, 95% CI 8–16%). Shared risk factors for PPC between Spanish and Ecuadorian women were: having children (OR 3.1, 95% CI 1.4–6.9), work dissatisfaction (OR 4.1, 95% CI 1.6–10.5), low salaries (OR 2.5, 95% CI 1.1–5.9), no economic support (OR 1.8, 95% CI 0.9–3.4), and no friends (OR 2.2, 95% CI 1.1–4.2). There was an effect modification between the nationality and educational level, having a confidant, and atmosphere at work. Higher education was inversely associated with PPC in Spanish women, but having university studies doubled the odds of being a PPC in Ecuadorians. Shared risk factors for PPC in Ecuadorian and Spanish men were: bad atmosphere at work (OR 2.4, 95% CI 1.3–4.4), no economic support (OR 3.5, 95% CI 1.3–9.5), no friends (OR 2.5, 95% CI 0.9–6.6), and low social support (OR 1.6, 95% CI 0.9–2.9), with effect modification between nationality and partner’s emotional support.ConclusionsMental health in Spanish and Ecuadorian women living in Spain is poorer than men. Ecuadorian women are the most disadvantaged group in terms of prevalence of and risk factors for PPC.

Características sociales y conductas de riesgo para el VIH en un grupo de travestis y transexuales masculinos que ejercen la prostitución en la calle

Objetivo: Describir las condiciones de vida y de trabajo, las practicas asociadas a la transmision del VIH, la cobertura y los resultados autoinformados de la prueba de VIH, en un grupo de travestis y transexuales que ejercen la prostitucion en la calle. Metodos: Estudio descriptivo de serie de casos de travestis y transexuales masculinos que ejercian la prostitucion en la calle, en Madrid, y que fueron atendidas por la unidad movil de un programa de reduccion de danos en 1998. Se recogieron datos sobre caracteristicas sociodemograficas, condiciones de trabajo, consumo de drogas ilegales, conductas de riesgo sexual y estado serologico frente al VIH autoinformado. Resultados: Se entrevistaron 132 travestis y transexuales masculinos, de las cuales 56% eran espanolas. La mediana de edad era de 30 anos. El 50% tenia un nivel de estudios de EGB o inferior. El 11% se habia inyectado drogas ilegales alguna vez. La mediana de anos de prostitucion era de 8 anos y el 66% habia ejercido solo en la calle. En el ultimo mes, todas dijeron utilizar el preservativo en las practicas anales insertivas con los clientes, el 98% en las anales receptivas y el 49% lo utilizaron siempre con la pareja en el ultimo ano. El 39% tuvieron algun accidente con el preservativo en el ultimo mes. El 73% se habia realizado la prueba del VIH, siendo positivas el 22% (el 16% entre las que nunca se habian inyectado drogas y el 58% entre las que se habian inyectado alguna vez). Conclusiones: En travestis y transexuales que ejercen la prostitucion la prevalencia de VIH es elevada, incluso entre las no inyectoras. El uso del preservativo en el medio laboral es alto, pero tambien su accidentabilidad. Los programas de prevencion del VIH en prostitucion deberian adaptarse mas especificamente a los distintos grupos que la ejercen.

Differences in Preterm and Low Birth Weight Deliveries Between Spanish and Immigrant Women: Influence of the Prenatal Care Received

OBJECTIVES To compare the risk of preterm and low birth weight among newborns from native and immigrant women and to assess the role of prenatal care in the association between the ethnic origin of the women and their reproductive outcomes. METHODS Cross-sectional study of 21,708 women giving birth between 1997 and 2008 in a region of Spain. Multinomial logistic regression models were adjusted to evaluate associations between mothers area of origin and adverse reproductive outcomes and to assess the role of prenatal care in the occurrence of adverse reproductive results. RESULTS Our results indicate a worse prenatal control in immigrants than in natives. Very preterm birth (VPTB) and very low birth weight (VLBW) were greater among immigrants (odds ratio [OR], 1.78; 95% confidence interval [95% CI], 1.14-2.79 for VPTB and OR, 1.73; 95% CI, 0.89-3.33 for VLBW) but after adjustment for prenatal care the differences were substantially reduced (OR, 1.43; 95% CI 0.85-2.42 for VPTB and OR 1.15; 95% CI 0.53-2.52 for VLBW). CONCLUSIONS Given the positive impact of prenatal care on reproductive results, strategies to improve it among immigrant women should be implemented. The difference found in the direction of the association between area of origin and different categories of low birth weight and preterm suggest that very and moderate categories should be analyzed separately in immigrant studies.

Incremento de la mortalidad por Clostridium difficile en España (1999 a 2006)

Clostridium difficile es un bacilo anaerobio, grampositivo, presente en el medio. El espectro clı́nico de la infección oscila desde el portador asintomático (diarrea leve y autolimitada a colitis seudomembranosa) hasta progresar ocasionalmente hacia una colitis fulminante con megacolon tóxico, sepsis y muerte. La enfermedad asociada a C. difficile (EACD) afecta principalmente a mayores de 65 años y el uso de antimicrobianos y la estancia hospitalaria son los principales factores de riesgo de aparición de la enfermedad. La incidencia y gravedad de la EACD ha aumentado en la última década en paı́ses de Norteamérica y de Europa, ası́ como en España. Este aumento podrı́a estar asociado a la aparición de una cepa hipervirulenta de C. difficile. Además, estudios en EE. UU. y en el Reino Unido revelan que la tasa de mortalidad asociada a C. difficile también ha aumentado en los últimos años de forma considerable. El objetivo de este estudio fue conocer cuál es la tasa de mortalidad asociada a C. difficile en España y si ésta ha aumentado en los últimos años, ası́ como describir las caracterı́sticas demográficas de los pacientes fallecidos.

Crisis económica y patología infecciosa. Informe SESPAS 2014

Past economic crises have increased the impact of communicable diseases especially on groups particularly vulnerable to the social and health consequences of the recession. However, it has been shown that the impact of these crises largely depends on the response of governments and the inhabitants of affected countries. We describe the consequences of the current crisis in the causal chain of infectious disease, including the response of the health system, and explore whether there is evidence of its impact in Spain. It is assumed that the possible effect of the crisis on living and working conditions is due to individual and social debt coupled with high unemployment as defining features of the crisis. We highlight the potential negative consequences of healthcare cuts on vulnerable populations, which have been partly excluded with the recent reform of health coverage. We compare mortality and morbidity data between two periods: before and after 2008, integrating, where possible, observed trends and institutional reports. Overall, no effect on infectious disease has been detected so far, although some signs of worsening, which could be compatible with the effects of the crisis, have been observed and need to be monitored and confirmed. We review the limitations of data sources that may not be sufficiently sensitive or up-to-date to detect changes that may require a latency period to become manifest. Instead of cutting resources, surveillance of these diseases should be improved, and an equitable social health response, which targets the population most affected by the crisis, should be guaranteed.