Gemma Cano-Serral

Construcción de un índice de privación a partir de datos censales en grandes ciudades españolas (Proyecto MEDEA)

Objectives: a) To describe the methodology used to construct a deprivation index by census tract in cities, to identify the tracts with the least favorable socioeconomic conditions, and b) to analyze the association between this index and overall mortality. Methods: Several socioeconomic indicators (Census 2001) were defined by the census tracts of the following cities: Barcelona, Bilbao, Madrid, Seville and Valencia. The correlations with the standardized mortality ratio (1996-2003), and the dimensionality of the socioeconomic indicators were studied. Finally, the selected indicators were aggregated in an index, in which the results of the factor loadings from extraction of a factor by principal components were used as weighting values. Results: The indicators with the strongest correlations with overall mortality were those related to work, education, housing conditions and single parent homes. In the analysis of dimensionality, a first dimension appeared that contained indicators related to work (unemployment, manual and eventual workers) and education (insufficient education overall and in young people). In all the cities studied, the index created with these 5 indicators explained more than 75% of their variability. The correlations between this index and mortality generally showed higher values than those obtained with each indicator separately. Conclusions: The deprivation index proposed could be a useful instrument for health planning as it detects small areas of large cities with unfavorable socioeconomic characteristics and is associated with mortality. This index could contribute to the study of social inequalities in health in Spain.

Constructing a deprivation index based on census data in large Spanish cities(the MEDEA project)

OBJECTIVES a) To describe the methodology used to construct a deprivation index by census tract in cities, to identify the tracts with the least favorable socioeconomic conditions, and b) to analyze the association between this index and overall mortality. METHODS Several socioeconomic indicators (Census 2001) were defined by the census tracts of the following cities: Barcelona, Bilbao, Madrid, Seville and Valencia. The correlations with the standardized mortality ratio (1996-2003), and the dimensionality of the socioeconomic indicators were studied. Finally, the selected indicators were aggregated in an index, in which the results of the factor loadings from extraction of a factor by principal components were used as weighting values. RESULTS The indicators with the strongest correlations with overall mortality were those related to work, education, housing conditions and single parent homes. In the analysis of dimensionality, a first dimension appeared that contained indicators related to work (unemployment, manual and eventual workers) and education (insufficient education overall and in young people). In all the cities studied, the index created with these 5 indicators explained more than 75% of their variability. The correlations between this index and mortality generally showed higher values than those obtained with each indicator separately. CONCLUSIONS The deprivation index proposed could be a useful instrument for health planning as it detects small areas of large cities with unfavorable socioeconomic characteristics and is associated with mortality. This index could contribute to the study of social inequalities in health in Spain.

Trends in socioeconomic mortality inequalities in a southern European urban setting at the turn of the 21st century

Objective: To analyse trends in mortality inequalities by educational level for main causes of death among men and women in Barcelona, Spain, at the turn of the 21st century (1992–2003). Methods: The population of reference was all Barcelona residents older than 19 years. All deaths between 1992–2003 were included. Educational level was obtained through record linkage between the mortality register and the municipal census of Barcelona city. Variables studied were age, sex, educational level, period of death (four periods of 3 years) and cause of death. Age-standardised mortality rates for each educational level, sex and period were calculated. Poisson regression models were fitted to obtain relative index of inequality (RII) for educational level, adjusted for age for the time-periods. Results: RII for all causes of death was constant (around 1.5), but rate differences were higher in 1995–7 (715.6 per 100 000 in men and 352.8 in women) than in other periods and tended to decrease in men over the periods. Analysis of inequality trends by specific causes of death shows a stable trend for the majority of causes, with higher mortality among those with less education for all causes of death except lung cancer and breast cancer among women having RII below 1. Conclusions: Relative inequalities in total mortality by sex in Barcelona did not change during the 12 years studied, whereas absolute inequalities tended to decrease in men. Our study fills an important gap in southern Europe and Spanish literature on trends during this period.

Desigualdades socioeconómicas relacionadas con el cuidado y el control del embarazo

Objetivo: Describir las desigualdades socioeconomicas relacionadas con el cuidado y el control del embarazo de las gestantes de Barcelona durante 1994-2003. Metodos: Diseno transversal de las gestantes de Barcelona que tuvieron un hijo sin anomalias congenitas. La informacion se obtuvo de las historias hospitalarias y una encuesta realizada a las madres del Registro de Defectos Congenitos de Barcelona, que recoge una muestra aleatoria del 2% del total de nacimientos de esta ciudad (n = 2.299). Se estudiaron las siguientes variables dependientes: visitas al obstetra, trimestre de la primera visita, numero de ecografias, ecografia del quinto mes, realizacion de una prueba invasiva, consumir acido folico, planificacion del embarazo, consumo y abandono del tabaco. Las variables independientes fueron la edad y la clase social. Se ajustaron modelos de regresion logistica para cada variable dependiente. Resultados: Las gestantes de clases sociales con ocupaciones manuales realizan, en mayor proporcion, menos de 6 visitas y la primera visita despues del primer trimestre; ademas, tienen menor probabilidad de realizar alguna prueba invasiva, tomar acido folico, planificar el embarazo, no fumar y abandonar el consumo de tabaco. Y las gestantes de clases no manuales realizan, en mayor proporcion, mas de 12 visitas y mas de 3 ecografias. Conclusiones: Hay desigualdades socioeconomicas relacionadas con el cuidado y el control del embarazo en Barcelona. Las gestantes de las clases sociales mas favorecidas realizan un mejor cuidado y control del embarazo, pero en todas se observa una excesiva medicalizacion. Una racionalizacion del uso de recursos sanitarios y una reduccion de la medicalizacion podria disminuir las desigualdades relacionadas con el cuidado y el control de la gestacion en Barcelona.

Métodos para la suavización de indicadores de mortalidad: aplicación al análisis de desigualdades en mortalidad en ciudades del Estado español (Proyecto MEDEA)

Aunque la experiencia en el estudio de las desigualdades en la mortalidad en las ciudades espanolas es amplia, quedan grandes nucleos urbanos que no han sido investigados utilizando la seccion censal como unidad de analisis territorial. En este contexto se situa el proyecto coordinado «Desigualdades socioeconomicas y medioambientales en la mortalidad en ciudades de Espana. Proyecto MEDEA», en el cual participan 10 grupos de investigadores de Andalucia, Aragon, Cataluna, Galicia, Madrid, Comunitat Valenciana y Pais Vasco. Cabe senalar cuatro particularidades: a) se utiliza como area geografica basica la seccion censal; b) se emplean metodos estadisticos que tienen en cuenta la estructura geografica de la region de estudio para la estimacion de riesgos; c) se aprovechan las oportunidades que ofrecen 3 fuentes de datos complementarias (informacion sobre contaminacion atmosferica, informacion sobre contaminacion industrial y registros de mortalidad), y d) se emprende un analisis coordinado de gran alcance, favorecido por la implantacion de la redes tematicas de investigacion. El objetivo de este trabajo es explicar los metodos para la suavizacion de indicadores de mortalidad en el proyecto MEDEA. El articulo se centra en la metodologia y los resultados del modelo de mapa de enfermedades de Besag, York y Mollie (BYM). Aunque en el proyecto se han suavizado, mediante el modelo BYM, las razones de mortalidad estandarizadas (RME) correspondientes a 17 grandes grupos de causas de defuncion y 28 causas especificas, aqui se aplica esta metodologia a la mortalidad por cancer de traquea, de bronquios y de pulmon en ambos sexos en la ciudad de Barcelona durante el periodo 1996-2003. Como resultado se aprecia un diferente patron geografico en las RME suavizadas en ambos sexos. En los hombres se observan unas RME mayores que la unidad en los barrios con mayor privacion socioeconomica. En las mujeres este patron se observa en las zonas con un mayor nivel socioeconomico.

Methods to smooth mortality indicators: application to analysis of inequalities in mortality in Spanish cities (the MEDEA Project)

Although there is some experience in the study of mortality inequalities in Spanish cities, there are large urban centers that have not yet been investigated using the census tract as the unit of territorial analysis. The coordinated project <<Socioeconomic and environmental inequalities in mortality in Spanish cities. The MEDEA project>> was designed to fill this gap, with the participation of 10 groups of researchers in Andalusia, Aragon, Catalonia, Galicia, Madrid, Valencia, and the Basque Country. The MEDEA project has four distinguishing features: a) the census tract is used as the basic geographical area; b) statistical methods that include the geographical structure of the region under study are employed for risk estimation; c) data are drawn from three complementary data sources (information on air pollution, information on industrial pollution, and the records of mortality registrars), and d) a coordinated, large-scale analysis, favored by the implantation of coordinated research networks, is carried out. The main objective of the present study was to explain the methods for smoothing mortality indicators in the context of the MEDEA project. This study focusses on the methodology and the results of the Besag, York and Mollié model (BYM) in disease mapping. In the MEDEA project, standardized mortality ratios (SMR), corresponding to 17 large groups of causes of death and 28 specific causes, were smoothed by means of the BYM model; however, in the present study this methodology was applied to mortality due to cancer of the trachea, bronchi and lung in men and women in the city of Barcelona from 1996 to 2003. As a result of smoothing, a different geographical pattern for SMR in both genders was observed. In men, a SMR higher than unity was found in highly deprived areas. In contrast, in women, this pattern was observed in more affluent areas.

Socioeconomic inequalities in mortality in Barcelona: A study based on census tracts (MEDEA Project)

The aim of this study is to describe inequalities in socioeconomic indicators and in mortality by sex in the census tracts of Barcelona city during the period 1996-2003. The results show that there is excess mortality in coastal and northern areas. This distribution is similar to that of socioeconomic deprivation and therefore there is an association between mortality and socioeconomic indicators, not only for total mortality but also for the specific causes of death studied. This type of analysis can be useful for planning of public health policy since it allows small areas with high mortality risk to be detected.

Socioeconomic inequalities in the provision and uptake of prenatal care

OBJECTIVE To describe socioeconomic inequalities in the provision and uptake of prenatal care among women in Barcelona (Spain) between 1994 and 2003. METHODS Cross-sectional study of women in Barcelona who delivered a child without birth defects. Information was obtained from hospital medical records and a personal interview with women included in the Barcelona Birth Defects Registry, containing a random sample of 2% of all pregnant women in the city (n = 2299). DEPENDENT VARIABLES number of obstetric visits, the trimester of the first visit, the number of obstetric ultrasound scans, the fifth-month diagnostic ultrasound scan, invasive procedures, prenatal folic acid intake, pregnancy planning, smoking and smoking cessation. The independent variables were maternal age and social class. Logistic regression models were filted for each dependent variable. RESULTS In social classes with manual occupations, there was a higher proportion of pregnant women who attended less than six obstetric visits and who attended the first obstetric visit after the first trimester. Moreover, these women were less likely to have undergone an invasive procedure, to have taken folic acid supplements, to have planned the pregnancy, to be non-smokers and to stop smoking. In the more privileged classes, there was a higher proportion of women who attended more than 12 obstetric visits and who underwent more than three ultrasound scans. CONCLUSIONS Socioeconomic inequalities were found in the provision and uptake of prenatal care in Barcelona. Uptake was greater in the more advantaged social classes but excessive medicalization was found in all classes. Rationalizing the use of healthcare resources and reducing excessive medicalization would reduce inequalities in prenatal care in Barcelona.

Inequalities in caesarean section: influence of the type of maternity care and social class in an area with a national health system

Objective: To analyse the impact of social class inequalities and type of maternity unit in the use of caesarean sections (CSs) among residents in an urban area of Southern Europe. Design: This was a cross-sectional study. The study population consisted of 2186 women resident in Barcelona city who gave birth to an infant without any birth defect during 1994–2003. The dependent variable was the type of delivery. Maternal age, social class and type of maternity unit (public or private) were independent variables. Maternal age-adjusted logistic regression models were used. Results: 30% of deliveries ended in CS; 70% of less privileged women delivered in public maternity units and 72% of more privileged women delivered in private centres. A relationship between CS and social class was observed (OR 1.4; 95% CI 1.1 to 1.7), but disappeared when the analysis was done separately for each stratum of type of maternity unit (both ORs 1.0). In contrast, a relationship between CS and type of maternity unit was found (OR 2.3; 95% CI 1.9 to 2.7), which persisted when the analysis was done separately for each stratum of social class. Conclusion: Although strongly related to higher social class, the main determinant of the high proportion of CSs was delivering in private maternity units.

Breast cancer mortality in Barcelona following implementation of a city breast cancer-screening program

BACKGROUND To assess the impact that the Barcelona city breast cancer-screening program has had in the decline of mortality due to breast cancer among women aged 50-74 years, in the city of Barcelona. METHODS A quasi-experimental study based on breast cancer deaths among women aged between 50 and 74 years residing in Barcelona between 1984 and 2004. The variables used were: age, year, and Primary Health Care District (ABS) grouped into four zones according to the year of implementation of the screening program. We carried out a descriptive analysis of mortality by year and age and fitted Poisson models to calculate the relative risk of dying prior to the existence of the program, after its implementation, and as a function of its degree of implementation. The models are adjusted for ABS socioeconomic level. RESULTS Between 1984 and 2004, 3733 women aged between 50 and 74 years died of breast cancer. The mortality rate fluctuated, reaching its highest level in 1991, having declined since. Prior to implementation of the program, mortality was falling by 1% annually (RR=0.99 95 CI%=0.98-0.99), and since then by 5% (RR=0.95 95 CI%=0.92-0.99). There are no significant differences in mortality reduction between zones where the program was implemented earlier and those where it came in later, even though mortality in the final phase of complete implementation is significantly lower by 17%, with respect to the period prior to its introduction. CONCLUSIONS The results show a reduction in mortality due to breast cancer over the entire period studied, the decline being more marked after the program was introduced. Opportunistic screening and the greater efficacy of the treatment of initial cancers have both influenced the findings. A longer follow up time will be needed in order to obtain more conclusive results.