Amaia Bacigalupe

The impact of economic crises on social inequalities in health: what do we know so far?

Since 2008, Western countries are going through a deep economic crisis whose health impacts seem to be fundamentally counter-cyclical: when economic conditions worsen, so does health, and mortality tends to rise. While a growing number of studies have presented evidence on the effect of crises on the average population health, a largely neglected aspect of research is the impact of crises and the related political responses on social inequalities in health, even if the negative consequences of the crises are primarily borne by the most disadvantaged populations. This commentary will reflect on the results of the studies that have analyzed the effect of economic crises on social inequalities in health up to 2013. With some exceptions, the studies show an increase in health inequalities during crises, especially during the Southeast Asian and Japanese crises and the Soviet Union crisis, although it is not always evident for both sexes or all health or socioeconomic variables. In the Nordic countries during the nineties, a clear worsening of health equity did not occur. Results about the impacts of the current economic recession on health equity are still inconsistent. Some of the factors that could explain this variability in results are the role of welfare state policies, the diversity of time periods used in the analyses, the heterogeneity of socioeconomic and health variables considered, the changes in the socioeconomic profile of the groups under comparison in times of crises, and the type of measures used to analyze the magnitude of social inequalities in health. Social epidemiology should further collaborate with other disciplines to help produce more accurate and useful evidence about the relationship between crises and health equity.

Learning lessons from past mistakes: how can Health in All Policies fulfil its promises?

The Ottawa Charter has exerted a great deal of influence on the public health debate and on health promotion practices over the last 25 years. The Charter shifted the main focus from individual risk behaviours to social determinants of health, and introduced innovative strategies such as participatory processes and empowerment of communities.1 This new public health era is based, essentially, on the introduction of health promotion to increase peoples opportunities to make healthy choices. Building healthy public policies (HPP) is a core area, even an overriding concern for health promotion,2 as it seeks to put health onto the agenda of policy-makers across different sectors, to improve the conditions under which people live.3 HPP is concerned with equity, and has, by its nature, an intersectoral focus with an explicit interest in the impacts of all policies on the health of the population.4 It represents a reaction against the individualistic and victim-blaming approach of curative medicine and the excessive focus previously placed on health education.5

Inmigración y salud: desigualdades entre la población autóctona e inmigrante en el País Vasco

OBJECTIVE To analyze health inequalities between native and immigrant populations in the Basque Country (Spain) and the role of several mediating determinants in explaining these differences. METHODS A cross-sectional study was performed in the population aged 18 to 64 years in the Basque Country. We used data from the Basque Health Survey 2007 (n=4,270) and the Basque Health Survey for Immigrants 2009 (n=745). We calculated differences in health inequalities in poor perceived health between the native population and immigrant populations from distinct regions (China, Latin America, the Maghreb and Senegal). To measure the association between poor perceived health and place of origin, and to adjust this association by several mediating variables, odds ratios (OR) were calculated through logistic regression models. RESULTS Immigrants had poorer perceived health than natives in the Basque Country, regardless of age. These differences could be explained by the lower educational level, worse employment status, lower social support, and perceived discrimination among immigrants, both in men and women. After adjustment was performed for all the variables, health status was better among men from China (OR: 0.18; 95% confidence interval [CI95%]: 0.04-0.91) and Maghreb (OR: 0.26; 95% CI: 0.08-0.91) and among Latin American women (OR: 0.36; 95% CI: 0.14-0.92) than in the native population. CONCLUSIONS These results show the need to continue to monitor social and health inequalities between the native and immigrant populations, as well as to support the policies that improve the socioeconomic conditions of immigrants.

The impact of the Great Recession on mental health and its inequalities: the case of a Southern European region, 1997–2013

BackgroundNumerous studies have shown that macroeconomic changes have a great influence on health, prompting different concerns in recent literature about the effects of the current recession. The objetive of the study was to assess the changes in the mental health of the working-age population in the Basque Country (Spain) and its social inequalities following the onset of the 2008 recession, with special focus on the role of unemployment.MethodsRepeated cross-sectional study on the population aged 16–64, using four Basque Health Surveys (1997–2013). Age-adjusted prevalences of poor mental health and incremental prevalence ratios (working status and social class adjusted) between years were calculated. Absolute/relative measures of social inequalities were also calculated.ResultsFrom 2008, there was a clear deterioration in the mental health, especially among men. Neither changes in employment status nor social class accounted for these changes. In men, the deterioration affected all working status categories, except the retired but significant changes occurred only among the employed. In women, poor mental health significantly increased among the unemployed. Students were also especially affected. Relative inequalities increased only in men.ConclusionsThe Great Recession is being accompanied by adverse effects on mental health, which cannot be fully explained by the increase of unemployment. Public health professionals should closely monitor the medium and long-term effects of the crisis as these may emerge only many years after the onset of recessions.

European economic crisis and health inequities: research challenges in an uncertain scenario

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Why does Spain have smaller inequalities in mortality? An exploration of potential explanations.

BACKGROUND While educational inequalities in mortality are substantial in most European countries, they are relatively small in Spain. A better understanding of the causes of these smaller inequalities in Spain may help to develop policies to reduce inequalities in mortality elsewhere. The aim of the present study was therefore to identify the specific causes of death and determinants contributing to these smaller inequalities. METHODS Data on mortality by education were obtained from longitudinal mortality studies in three Spanish populations (Barcelona, Madrid, the Basque Country), and six other Western European populations. Data on determinants by education were obtained from health interview surveys. RESULTS The Spanish populations have considerably smaller absolute inequalities in mortality than other Western European populations. This is due mainly to smaller inequalities in mortality from cardiovascular disease (men) and cancer (women). Inequalities in mortality from most other causes are not smaller in Spain than elsewhere. Spain also has smaller inequalities in smoking and sedentary lifestyle and this is due to more smoking and physical inactivity in higher educated groups. CONCLUSION Overall, the situation with regard to health inequalities does not appear to be more favourable in Spain than in other Western European populations. Smaller inequalities in mortality from cardiovascular disease and cancer in Spain are likely to be related to its later socio-economic modernization. Although these smaller inequalities in mortality seem to be a historical coincidence rather than the outcome of deliberate policies, the Spanish example does suggest that large inequalities in total mortality are not inevitable.

Health impact assessment of an urban regeneration project: opportunities and challenges in the context of a southern European city

Background Social values and the political context have an influence on the use and spread of health impact assessment (HIA). In Spain, there is little experience in HIA but some regional governments are already introducing it. The aim of this article is to describe the health impacts of a local regeneration project to improve accessibility in a neighbourhood of Bilbao (Spain), and discuss the main difficulties, opportunities and challenges of the process, considering the specificities of the social and political context. Methods A concurrent and prospective assessment, based on a broad model of health, was carried out following the Merseyside guidelines. A literature review, community profiling and qualitative data collection were undertaken. Profound involvement of members of the community and key informants was judged as essential in the HIA process. Results The overall expected effect of the new lifts, roads, park and the rainwater collection system was positive. Uncertain or negative impacts were identified in some of those areas, and also concerning the burying of four high-voltage power lines. Historical and current characteristics of the community were highly influential on the way local people perceived the project and its impacts. Likewise, the way in which processes of planning and implementation were developing also played an important role. Conclusion The spread of HIA in southern European countries will depend on the progressive introduction of values underlying HIA, as well as on the promotion of intersectoral work, a better knowledge of the social model of health and communitys participation in policy making.

Two decades of inequalities in smoking prevalence, initiation and cessation in a southern European region: 1986–2007

BACKGROUND The smoking epidemic is still progressing in southern Europe. We aimed to analyse the magnitude and trend of social inequalities in smoking prevalence, initiation and cessation in the Basque Country, a southern European region, from 1986 to 2007, determining the patterns by sex and age. METHODS This was a cross-sectional time trend study on the population aged >24 years using the Basque Country Health Surveys of 1986, 1992, 1997, 2002 and 2007. Age-adjusted prevalence of current and ever smoking and cessation were calculated, as were relative index of inequality and population-attributable risk by occupational social class and educational level. Relative risk of starting smoking was estimated using Cox proportional hazard regression models. Calculations were performed separately by sex and for two age groups (25-44 years and >44 years). RESULTS Men and young women in the Basque Country have evolved towards the last stage of the epidemic, with an increasing concentration of smoking in disadvantaged groups, by educational level, especially among the youngest population. In older women, smoking continues rising, especially among higher socio-economic groups, though differences between groups are diminishing. The role of initiation and cessation inequalities as determinants of smoking inequalities differed considerably by age and sex. CONCLUSION Inequalities in smoking prevalence widened from 1986 to 2007 in the Basque Country, especially among the youngest population. The changing pattern of these inequalities and the different roles of initiation and cessation dynamics need to be taken into account to improve the results of tobacco control policies and their effect on smoking inequalities.

Crisis económica al inicio del siglo xxi y mortalidad en España. Tendencia e impacto sobre las desigualdades sociales. Informe SESPAS 2014

This study aimed to assess the impact of the current economic crisis on mortality trends in Spain and its effect on social inequalities in mortality in Andalusia. We used data from vital statistics and the Population Register for 1999 to 2011, as provided by the Spanish Institute of Statistics, to estimate general and sex- and age-specific mortality rates. The Longitudinal Database of the Andalusian Population (2001 census cohort) was used to estimate general mortality rates and ratios by educational level. The annual percentages of change and trends were calculated using Joinpoint regressions. No significant change in the mortality trend was observed in Spain from 2008 onward. A downward trend after 1999 was confirmed for all causes and both sexes, with the exception of nervous system-related diseases. The reduction in mortality due to traffic accidents accelerated after 2003, while the negative trend in suicide was unchanged throughout the period studied. In Andalusia, social inequalities in mortality have increased among men since the beginning of the crisis, mainly due to a more intense reduction in mortality among persons with a higher educational level. Among women, no changes were observed in the pattern of inequality.

Social Factors Associated with the Knowledge About HIV of the Immigrants from China, Latin America, the Maghreb and Senegal in the Basque Country (Spain)

The objective of this study was to identify the social factors that explain the differences in knowledge with regards to HIV/AIDS among immigrants in the Basque Country (Spain). We conducted a cross-sectional study based on information obtained in the Basque Health Survey for 754 immigrants from: 86 China, 368 Latin America, 237 the Maghreb and 74 Senegal. Odds ratios (95% CI) were calculated from logistic regression models to measure the degree of association between inadequate knowledge regarding transmission, prevention and places where HIV testing is offered, and the independent variables. We found that this inadequate knowledge is associated with place of birth, sex, a lower level of education, immigration status, difficulties in understanding Spanish, and not receiving advice about AIDS in primary care. These findings indicate that initiatives must be developed to promote equity in the provision of healthcare through clinical guidelines, including details of the specific needs of different groups of immigrants and considering gender issues.