Carmen Sánchez-Cantalejo

Area deprivation and mortality in the provincial capital cities of Andalusia and Catalonia (Spain)

Objective: To study the linkage between material deprivation and mortality from all causes, for men and women separately, in the capital cities of the provinces in Andalusia and Catalonia (Spain). Methods: A small-area ecological study was devised using the census section as the unit for analysis. 188 983 Deaths occurring in the capital cities of the Andalusian provinces and 109 478 deaths recorded in the Catalan capital cities were examined. Principal components factorial analysis was used to devise a material deprivation index comprising the percentage of manual labourers, unemployment and illiteracy. A hierarchical Bayesian model was used to study the relationship between mortality and area deprivation. Main results: In most cities, results show an increased male mortality risk in the most deprived areas in relation to the least depressed. In Andalusia, the relative risks between the highest and lowest deprivation decile ranged from 1.24 (Malaga) to 1.40 (Granada), with 95% credibility intervals showing a significant excess risk. In Catalonia, relative risks ranged between 1.08 (Girona) and 1.50 (Tarragona). No evidence was found for an excess of female mortality in most deprived areas in either of the autonomous communities. Conclusions: Within cities, gender-related differences were revealed when deprivation was correlated geographically with mortality rates. These differences were found from an ecological perspective. Further research is needed in order to validate these results from an individual approach. The idea to be analysed is to identify those factors that explain these differences at an individual level.

Socio-economic level, farming activities and risk of cancer in small areas of Southern Spain

An ecological design was used to study the relationship between cancer incidence and both socio-economic and environmental features in Southern Spain. Twenty-four sites and 26,380 cases diagnosed in 1985–1996 were analysed. Generalised Additive Models were used for data analysis. Except for lip cancer, the urban areas showed an increase in cancer risk for all sites. The relative risks among urban and rural municipalities ranges between 1.09 for skin non-melanoma (95% CI: 1.00–1.18) and 1.64 for cervix cancer (95% CI: 1.28–2.12). The relative risk among areas with high and low unemployment was 1.29 for stomach cancer (95% CI: 1.07–1.57), 1.45 for oral cavity cancer (95% CI: 1.10–1.93) and 1.77 for oesophagus cancer (95% CI: 1.02–3.05). Areas with highest unemployment showed the lowest incidence of melanoma. Risk for leukaemia, gall bladder, breast and prostate cancer showed a significant decreases by approximately 28% in the municipalities with the highest illiteracy score. A high percentage of land under cultivation was related to uterine tumours, larynx, rectum, lung, skin non-melanoma and brain cancers. For these sites, the risk had a significant increase by between 23%(skin non-melanoma) and 70%(rectum). Areas with high intensive farming showed a significant increase in cancer risk for lip, oral cavity, larynx, oesophagus, colon, lung, and bladder cancer. The relative risks ranges between 1.16 for colon cancer (95% CI: 1.04–1.29) and 1.47 for oesophagus cancer (95% CI: 1.15–1.87). The results of this study reveal how important socio-economic and environmental factors are for the analysis of cancer incidence in small areas of Southern Spain.

Atlas interactivo de mortalidad en Andalucía (AIMA)

Los atlas de mortalidad publicados hasta la fecha son estaticos. La mayoria describen la distribucion geografica de la mortalidad agrupando datos de varios anos y usando razones de mortalidad estandarizadas que resumen la mortalidad de todos los grupos de edad. Sin embargo, esta metodologia presenta limitaciones para estudiar cambios temporales en la distribucion geografica de la mortalidad o diferencias entre grupos etarios. Aplicando una metodologia alternativa surge el Atlas Interactivo de Mortalidad en Andalucia (AIMA), un Sistema de Informacion Geografica dinamico que permite visualizar en web-site mas de 12.000 mapas y 338.000 graficos de tendencias correspondientes a la distribucion espacio-temporal de las principales causas de muerte en Andalucia por grupos de edad y sexo desde 1981. El objetivo de este trabajo es describir la metodologia utilizada para el desarrollo de AIMA, dar a conocer sus caracteristicas y especificaciones tecnicas y mostrar las posibilidades interactivas que ofrece. El sistema esta disponible en el hipervinculo productos de www.demap.es. AIMA es el primer SIG interactivo de estas caracteristicas implementado en Espana. Para el analisis de datos se han utilizado modelos jerarquicos bayesianos espacio-temporales, integrando posteriormente los resultados en web-site utilizando entorno PHP y cartografia dinamica en formato Flash. La seleccion de mapas tematicos muestra el caracter dinamico de la distribucion geografica de la mortalidad, con un patron diferente para cada ano, grupo de edad y sexo. La informacion contenida actualmente en este sistema y las futuras actualizaciones contribuiran a la reflexion sobre el pasado, presente y futuro de la salud en Andalucia.

Uncontrolled migrations as a cause of inequality in health and mortality in small-area studies.

Mortality is one of the most widely used indicators in small-area ecologic studies. Both accessibility to mortality data and advances in the development of new disease mapping techniques have contributed to an abundance of mortality maps and atlases over the last decade. Results may be biased in this kind of study if there has been unmeasured geographic mobility of the population. Most published papers tend to neglect this possibility. We use the theory of dynamics systems to demonstrate that migratory flows unmonitored by official population registers may lead to major errors in mortality rates and relative risks. Simulations in 4 scenarios showed more than 8% underestimation of the mortality rate and more than 11% underestimation of relative risk in areas with high uncontrolled emigration, and above 19% overestimation of mortality rate and above 15% overestimation of relative risk in areas with high uncontrolled immigration. Researchers conducting small-area epidemiologic studies should explore the reliability of population information in geographic areas before drawing hypothesis or conclusions on other possible causes of mortality differences.

Age, Period, and Cohort Effects on Mortality From Ischemic Heart Disease in Southern Spain

INTRODUCTION AND OBJECTIVES Ischemic heart disease is the leading cause of death and one of the top 4 causes of burden of disease worldwide. The aim of this study was to evaluate age-period-cohort effects on mortality from ischemic heart disease in Andalusia (southern Spain) and in each of its 8 provinces during the period 1981-2008. METHODS A population-based ecological study was conducted. In all, 145 539 deaths from ischemic heart disease were analyzed for individuals aged between 30 and 84 years who died in Andalusia in the study period. A nonlinear regression model was estimated for each sex and geographical area using spline functions. RESULTS There was an upward trend in male and female mortality rate by age from the age of 30 years. The risk of death for men and women showed a downward trend for cohorts born after 1920, decreasing after 1960 with a steep slope among men. Analysis of the period effect showed that male and female death risk first remained steady from 1981 to 1990 and then increased between 1990 and 2000, only to decrease again until 2008. CONCLUSIONS There were similar age-period-cohort effects on mortality in all the provinces of Andalusia and for Andalusia as a whole. If the observed cohort and period effects persist, male and female mortality from ischemic heart disease will continue to decline.

Protocolo de investigación del atlas de mortalidad de las capitales de provincia de Andalucía y Cataluña (Proyecto AMCAC)

El proposito de este trabajo es dar a conocer el proyecto multicentrico AMCAC, que tiene como objetivos describir la distribucion geografica de la mortalidad por todas las causas en las secciones censales de las capitales de provincia de Andalucia y Cataluna durante el periodo 1992-2002 y 1994-2000 respectivamente, asi como estudiar la relacion entre las caracteristicas sociodemograficas de las secciones censales y la mortalidad. Es un estudio ecologico donde la unidad de analisis es la seccion censal. Se analizaran los datos relativos a 298.731 individuos (152.913 hombres y 145.818 mujeres) fallecidos en las ciudades de Almeria, Barcelona, Cadiz, Cordoba, Girona, Granada, Huelva, Jaen, Lleida, Malaga, Sevilla y Tarragona durante los periodos de estudio. La variable dependiente es el numero de muertes observadas por seccion censal. Las variables independientes son el porcentaje de desempleo, de analfabetismo y de trabajadores manuales. La estimacion del riesgo relativo suavizado y el estudio de la relacion entre las caracteristicas sociodemograficas de las secciones censales y la mortalidad se realizara para cada ciudad y sexo mediante el modelo Besag-York-Mollie. La difusion de los resultados ayudara a mejorar y ampliar los conocimientos sobre la salud de la poblacion, siendo un punto de partida importante para conocer la influencia de variables contextuales en la salud de la poblacion urbana.

Derivaciones en los centros de salud de Andalucía según el sexo de profesionales y pacientes: un análisis de género

Fundamentos: En atencion primaria se han identificado diferencias de practica segun sexo del profesional y, simultaneamente, existen desigualdades de genero en la asignacion de recursos sanitarios, aspectos ambos que suscitan un interes creciente en la gestion y provision de servicios de salud. El objetivo del estudio es conocer si existen diferencias de practica en las derivaciones sanitarias realizadas por medicas y medicos de familia (MF) de centros de salud de Andalucia, si existen desigualdades en las derivaciones recibidas por hombres y mujeres, y si existe interaccion sexo de profesional sexo de paciente. Metodos: Estudio transversal y multicentrico. Poblacion: MF de 4 distritos sanitarios (DDSS). Muestra: 382 MF. Variables: tasa de derivaciones por visita (TDxV), tasa de derivaciones por cupo (TDxC), sexo de paciente; sexo, edad, y formacion postgraduada en medicina familiar de MF, tamano del cupo por sexo, media de visitas/paciente por sexo, edad media del cupo por sexo, y proporcion de hombres en el cupo; centro de salud urbano/rural, tamano del equipo, poblacion adscrita y acreditacion docente. Fuentes: bases de datos de los DDSS. Analisis estadistico: descriptivo. Bivariante y multivariante mediante analisis multinivel de la TDxV con modelo mixto de Poisson. Resultados: En 2010 los/as 382 MF realizaron 129.161 derivaciones a especialistas. La TDxC fue 23,47 y la TDxV es 4,92. Las TDxC de las medicas fue 27,23 en mujeres y 19,78 en hombres y las de los medicos 27,37 en mujeres y 19,51 en hombres. La TDxV de las medicas fueron 4,92 en mujeres y 5,48 en hombres y para los medicos 4,54 y 4,93 respectivamente. Conclusiones: No existen diferencias en las derivaciones segun sexo de MF, sin embargo, existen indicios de que las mujeres son menos derivadas. No existe interaccion sexo profesional-sexo paciente.