Carlos Álvarez-Dardet

Effect of democracy on health: ecological study

Can political regimes be singled out as a factor affecting health? Rating countries by the extent of their freedom is a useful proxy for measuring the effects of democracy on health related variables

Will austerity cuts dismantle the Spanish healthcare system

In the face of austerity, a series of disconnected “reforms” could, without corrective measures, lead to the effective dismantling of large parts of the Spanish healthcare system, with potentially detrimental effects on health. Helena Legido-Quigley and colleagues explain

Perceived discrimination and health by gender, social class, and country of birth in a Southern European country.

OBJECTIVES.: This study aimed to examine the association between perceived discrimination and five health outcomes in Spain as well as to analyze whether these relationships are modified by sex, country of birth, or social class. METHODS.: We used a cross-sectional design. Data were collected as part of the 2006 Spanish Health Interview Survey. The present analysis was restricted to the population aged 16-64 years (n=23,760). Five dependent variables on health obtained through the questionnaire were examined. Perceived discrimination was the main independent variable. We obtained the prevalence of perceived discrimination. Logistic regression models were fitted. RESULTS.: Perceived discrimination was higher among populations originating from low income countries and among women and showed positive and consistent associations with all poor health outcomes among men and with 3 poor health outcomes among women. Poor mental health showed the largest difference between people who felt and those who did not feel discriminated (prevalence for these 2 groups among men was 42.0% and 13.3%, and among women, was 44.7% and 22.8%). The patterns found were modified by gender, country of birth, and social class. CONCLUSION.: This study has found a consistent relationship of discrimination with five health indicators in Spain, a high-income Southern European country. Public policies are needed that aim to reduce discrimination.

Erosion of universal health coverage in Spain

1 La Secretaría General del Congreso de los Diputado. Presupuesto por programas y memoria de objetivos. http://www.sepg.pap. minhap.gob.es/Presup/PGE2011Ley/ MaestroTomos/PGE-ROM/doc/L_11_E_G16. PDF (accessed Nov 29, 2013). 2 Gobierno de España. Programa Nacional de Reformas de España 2013. http://www. mineco.gob.es/stfl s/mineco/comun/pdf/PNR_ Espana_2013.pdf (accessed Dec 2, 2013). 3 Medicos del Mundo. El impacto de la reforma sanitaria sobre el Derecho a la Salud. http:// www.medicosdelmundo.org/index.php/mod. conts/mem.detalle_cn/relmenu.111/id.3306 (accessed Nov 25, 2013). 4 Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health eff ects of fi nancial crisis: omens of a Greek tragedy. Lancet 2011; 378: 1457–58. 5 Boletin Ofi cial del Estado. Resolución de 10 de septiembre de 2013, de la Dirección General de Cartera Básica de Servicios del Sistema Nacional de Salud y Farmacia, por la que se procede a modifi car las condiciones de fi nanciación de medicamentos incluidos en la prestación farmacéutica del Sistema Nacional de Salud mediante la asignación de aportación del usuario. http://www.boe.es/diario_boe/ txt.php?id=BOE-A-2013-9709 (accessed Nov 25, 2013) 6 La Federación de Asociaciones para la Defensa de la Sanidad Pública. Las repercusiones del copago sobre la utilización de medicamentos por los pensionistas. http://imagenes.publicoestaticos.es/resources/archivos/2013/3/14/136 3292203193informe%20fadsp%20copago%20 jubilados.pdf (accessed Nov 25, 2013). 7 The Council of Europe. Report by Nils Muižnieks, Council of Europe Commissioner for Human Rights, following his visit to Spain, from 3 to 7 June 2013. https://wcd.coe.int/ViewDoc. jsp?id=2106465&Site=COE (accessed Nov 25, 2013). for drugs. Pensioners will have to pay an increasing part of the cost of medicines. From October, 2013, patients with hepatitis C, HIV, rheumatoid arthritis, and some cancers will also have to pay 10% of their treatment costs in hospital pharmacies up to €4·20 per prescription. Even small out-of-pocket expenses are a barrier to effective treatment. The Federation of Associations Defending Public Health reports that 17% of pensioners could not complete the course of their treatment because of their high and increasing costs. At the European level, several reports are worth mentioning. According to Eurostat’s At risk of poverty or social exclusion in the EU27, austerity measures could aff ect children in particular—they are disproportionately aff ected by the fi nancial crisis with nearly 30% being at risk of poverty or social exclusion. The Council of Europe has raised concerns regarding the diffi culties some children (ie, undocumented migrants) are facing in accessing health care. In its recent recommendations, the European Council has clearly emphasised the need for an assessment of the eff ects of austerity measures on vulnerable groups in Spain. Austerity measures adopted by Spain and other European countries have failed to heal their economies, and there is growing evidence that these measures threathen the health of their citizens. There is still time to save the Spanish health system and reverse the restrictions limiting universal protection. It is possible to re-establish universal access to quality health-care services, free at the point of delivery, in line with the UN resolution.

Violencia del compañero íntimo en España

Objective: To estimate mortality and the incidence of formal complaints of intimate partner violence (IPV) by age groups and Spanish provinces. Methods: We performed a descriptive, epidemiological study of murders by intimate partners registered in the database of the Divorced and Separated Women’s Federation (1998-2001) and of formal complaints of IPV in The Home Affairs database (1997-2000). The percentage of increase in formal complaints and deaths and the individual risk of dying from IPV and of reporting this crime was calculated through the simple accumulative method, specific mortality rates by age, average rates by provinces, and specific incidence rates of formal complaints of IPV by provinces. Finally, a simple regression analysis was performed to assess the relation between mortality and the incidence of formal complaints of IPV. Results: Between the first and the last year of the study, formal complaints increased by 27% and murders increased by 49%. In Spain, during the period analyzed, one out of every 100,000 women was murdered by an intimate partner and one out of every 200 women reported IPV. Women aged 22-41 years and those aged 82-86 years presented the highest rates of mortality from IPV. Mortality from IPV and the incidence of formal complaints of IPV showed no clear geographical pattern. No correlation between mortality and the incidence of formal complaints of IPV by provinces was found (corrected r 2

Perfil sociodemográfico de las mujeres afectadas por violencia del compañero íntimo en España

OBJECTIVE To determine the prevalence of reported intimate partner violence (IPV) and to analyze the main sociodemographic characteristics of affected women. METHODS We performed a cross-sectional study based on the Spanish National Health Survey of 2006. The sample comprised 13,094 women who agreed to answer questions about violence (87.2% of the total interviewees). Bivariate and multivariate analyses were performed. The dependent variable was reported IPV and the independent variables were educational level, employment, marital status, living arrangements with the partner or analogous individual, number of children at home, nationality (Spanish vs. foreign women) and age. RESULTS IPV was reported by 1% (n=128) of the sample. Women with primary school education or without studies (odds ratio [OR]: 3.63 [1.90-6.92]), with three or more children (OR: 3.51 [1.78-6.90]), and those who were separated or divorced (OR: 2.81 [1.89-4.97]) were most likely to experience IPV when the effect of the remaining variables was controlled. The likelihood of IPV was also higher in women born outside Spain (OR: 2.83 [1.87-4.28]). CONCLUSIONS IPV seems not to affect Spanish and foreign women equally. The characteristics most closely associated with women affected by IPV were educational level, the number of children at home and marital status. The sensitivity of current measures against IPV should be considered in relation to the needs of affected women.

Desigualdades socioeconómicas y planes de salud en las comunidades autónomas del Estado español

Objetivo: Analizar la sensibilidad a las desigualdades de nivel socioeconomico (NSE) en los planes de salud en vigor de las comunidades autonomas (CCAA) del Estado espanol. Metodos: Revision sistematica de 14 planes de salud. Los contenidos introductorios se denominaron «contenidos simbolicos» y las propuestas de accion «contenidos operativos». En los contenidos simbolicos se valora la presencia de desagregacion por NSE del analisis de la situacion de salud, de principios y valores para reducir las desigualdades y de objetivos generales enunciados con este fin (indice de sensibilidad simbolica, rango 0-3). En los contenidos operativos se evalua la consideracion del NSE en el analisis de situacion y en las intervenciones propuestas. Resultados: El Pais Vasco y Extremadura obtuvieron el maximo indice de sensibilidad simbolica (ISS = 3). Otras 6 CCAA (Canarias, Cataluna, Castilla y Leon, Galicia, Murcia y Navarra) presentan ISS = 0. En cuanto a los contenidos operativos destacan el Pais Vasco, Galicia y Canarias por ser las CCAA que mas tienen en cuenta las desigualdades de NSE. El alcohol, las drogas y la salud reproductiva son las areas relacionadas con la salud en las que con mayor frecuencia se analiza la situacion teniendo en cuenta el NSE. Conclusiones: Se pone de manifiesto la escasa atencion que se presta al NSE en los planes de salud, con excepcion del Pais Vasco. Es necesario que el Gobierno del Estado espanol y los de las comunidades autonomas situen las desigualdades en salud por NSE mas claramente en la agenda politica, lo que se traduciria tambien en su presencia en los planes de salud.

Democratisation and health after the fall of the Wall

Objectives: The fall of the Wall in 1989 can be seen as a natural experiment in the epidemiological sense to further examine the relation between democracy and health. Design and setting: Ecological study in the 23 post-communist countries, during the last decade of the 20th century, exploring the relations between the level of democratisation and health, taking into account as relevant confounders wealth and the level of inequality. Main results: A significant correlation (p<0.01) was found of the democratic deficit of the countries with the health indicators circa 2000, with values of Pearson’s coefficient of −0.629 for life expectancy, 0.760 for infant mortality, and 0.555 for maternal mortality. These associations remain significant after adjustment by lineal regression for GNP per capita and the Gini coefficient, with R2 values of 0.336 for life expectancy, 0.575 for infant mortality, and 0.529 for maternal mortality. Conclusions: These findings add pieces of evidence to the previously reported cross sectional association between democracy and health.

Mapping public policy options responding to obesity: the case of Spain

This study assesses the opinions of the main Spanish stakeholders from food and physical exercise policy networks on public policy options for responding to obesity. We followed the multi‐criteria mapping methodology in the framework of the European project ‘Policy options in responding to obesity’ (PorGrow), through a structured interview to 21 stakeholders. A four‐step approach was taken: options, criteria, scoring and weighting, obtaining in this way a measure of the performance of each option which integrates qualitative and quantitative information. In an overall analysis, the more popular policy options where those grouped as educational initiatives: include food and health in the school curriculum, improve health education to the general public, improve the training of health professionals in obesity care and prevention, incentives to caterers to provide healthier menus and improve community sports facilities. Fiscal measures as subsidies and taxes had the lowest support. The criteria assessed as priorities were grouped as efficacy and societal benefits. Obesity in Spain can be approached through public policies, although the process will not be easy or immediate. The feasibility of changes requires concerned public policymakers developing long‐term actions taking into account the map of prioritized options by the stakeholders.

Historia reciente de la cobertura periodística de la violencia contra las mujeres en el contexto español (1997-2001)

Objetivos: Explorar el tratamiento periodistico de la violencia contra las mujeres entre 1997 y 2001, y describir la evolucion temporal de las muertes por esta causa en Espana para ilustrar el contexto social en el que acontecen los eventos mediaticos. Metodos: Analisis de contenido cuantitativo de 865 noticias de violencia contra las mujeres en El Pais, ABC y El Mundo (1997-2001). Calculo de frecuencias absolutas y relativas y riesgos relativos (RR) con intervalos de confianza (IC) del 95%. Calculo de las tasas de mortalidad brutas (1998-2003) basado en los datos del Registro de la Federacion de Mujeres Separadas y Divorciadas. Resultados: Se observaron incrementos de la cobertura periodistica coincidiendo con acontecimientos dramaticos y respuestas politicas al problema. En este contexto, la mortalidad por esta causa se mantiene. Las noticias sobre sucesos (65%) superan a las de medidas de intervencion (35%). En las noticias en que se pudo identificar el sexo (35% del total), las mujeres (n = 151) y los varones (n = 150) compartieron el papel de fuente informativa principal. Los varones juristas (RR = 1,77; IC del 95%, 1,44-2,17), las mujeres sanitarias (RR = 0,39; IC del 95%, 0,14-1,08) y las asociaciones (RR = 0,33; IC del 95%, 0,13-0,81) tienen mayor probabilidad de ser fuente informativa principal en comparacion con sus companeros. Los varones tienen una probabilidad mayor que las mujeres de ser fuente informativa principal en las noticias de medidas de castigo (RR = 1,42; IC del 95%, 1,12-1,81). Conclusiones: En un contexto de estabilidad en la mortalidad por violencia contra las mujeres, las noticias sobre este tema han aumentado, coincidiendo con acontecimientos dramaticos y respuestas politicas al respecto. Los politicos de ambos sexos, los varones juristas y las mujeres sanitarias y de diversas asociaciones son las fuentes informativas principales. Los varones son la fuente informativa principal en las noticias de medidas de castigo.