Juana M. Santos

Decreasing income inequality and emergence of the association between income and premature mortality: Spain, 1970-2010.

This study evaluates the relationship between income and mortality in Spain over a long period of declining in income inequality. The ratio between income in the richest and poorest provinces was 2.74 in 1970 and 2.10 in 2010. Pearson correlation coefficients for the association between provincial income and the measures of mortality were estimated, as well as absolute and relative differences between the mortality rates of the poorest and richest provinces. The correlation coefficient between income and infant mortality decreased from -0.59 in 1970 to -0.17 in 2010, and lost significance from 1995 onwards. The coefficient for premature all-cause mortality increased from -0.04 in 1970 to -0.40 in 2010, and acquired significance beginning in 2005. The coefficient also increased in mortality from cardiovascular, respiratory and digestive diseases. No association was found between provincial income and cancer mortality or mortality from injuries. The findings on premature mortality do not support the theory that decreasing income inequality will lead to reduced inequalities in mortality.

Sports facilities in Madrid explain the relationship between neighbourhood economic context and physical inactivity in older people, but not in younger adults: a case study

Background Neighbourhood characteristics may contribute to differences in physical inactivity. Purpose To evaluate whether the availability of sports facilities helps explain the differences in physical inactivity according to the economic context of the neighbourhood. Methods 6607 participants representative of the population aged 16–74 years, resident in Madrid (Spain) in 2005, were analysed. Using ORs calculated by multilevel logistic regression, the association between per capita income of the neighbourhood of residence and physical inactivity was estimated, after adjusting for age, population density, individual socioeconomic characteristics and the availability of green spaces. The analysis was repeated after further adjustment for the availability of sports facilities to determine if this reduced the magnitude of the association. Results Residents in the neighbourhoods with the lowest per capita income had the highest OR for the prevalence of physical inactivity. In participants aged 16–49 years, after adjusting for the availability of sports facilities, the magnitude of the OR in the poorest neighbourhoods with respect to the richest neighbourhoods increased in men (from 2.22 to 2.35) and declined by 13% in women (from 2.13 to 1.98). In contrast, in the population aged 50–74 years, this adjustment reduced the magnitude of the OR by 21% in men (from 2.00 to 1.80) and by 53% in women (from 2.03 to 1.48). Conclusions The poorest neighbourhoods show the highest prevalence of physical inactivity. The availability of sports facilities explains an important part of this excess prevalence in participants aged 50–74 years, but not in younger individuals.

New findings do not support the neomaterialist theory of the relation between income inequality and infant mortality

One issue that attracted the attention of public health researchers in the 1990s was the possible relationship of income inequality with life expectancy and other indicators of population health in rich countries. However, the findings of various investigations at the beginning of this century showed that therewas little support for a contextual effect of income inequality on population health, with the exception of infant mortality (Lynch et al., 2001; Mackenbach, 2002). The relationship between income inequality and infant mortality was confirmed by numerous studies during the first decade of the 21st century, using data for the period between 1970 and the mid 1990s (Macinko, Shi, & Starfield, 2004; Navarro et al., 2006; Spencer, 2004). The authors of these studies attributed these findings to policies promoting full employment, universal social health, benefits coverage and aid to families – characteristics associated with the Nordic countries – some of which would contribute to low income inequality and low infant mortality. In contrast, higher infant mortality and increased income inequality have been observed in countries with underdeveloped welfare states, such as Southern European countries. At the beginning of 21st century, infant mortality rates among the rich countries have converged, but the difference in the

Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level

OBJECTIVE This study aimed to investigate the relationship between education and different indicators of material wealth with mortality, and to analyze whether this relationship varies with the leading causes of death. METHODS All persons aged 65 and older residing in Spain in 2001 were followed up for 7 years to determine their vital status. The relationship between mortality and four indicators of socioeconomic position (education, number of rooms in home, surface area of home and number of vehicles) was estimated in three age groups: 65-74, 75-84 and 85 and older. Rate ratios and relative index of inequality (RII) were calculated for general mortality and for the leading causes of death by Poisson regression. RESULTS In women, the mortality rate ratio for low vs. high educational level was 1.48 for persons aged 65-74, 1.43 for those aged 75-84 and 1.40 for those aged 85 and older. The respective rates for men were 1.30, 1.25 and 1.29. For the indicators of material wealth, the differences between morality rates in the lower vs. the higher socioeconomic categories decline with age. Mortality differences by the leading causes of death decline with age, except in the case of cancer in women and cardiovascular and digestive mortality in men according to educational level. CONCLUSIONS Relative socioeconomic differences in mortality in the older Spanish population decrease with age using indicators of material wealth but not using educational level. The variation in the pattern of mortality by cause of death by level of education may be responsible for these findings.

The role of population change in the increased economic differences in mortality: a study of premature death from all causes and major groups of causes of death in Spain, 1980–2010

BackgroundAn increase has been observed in differences in mortality between the richest and poorest areas of rich countries. This study assesses whether one of the proposed explanations, i.e., population change, might be responsible for this increase in Spain.MethodsObservational study based on average income, population change and mortality at provincial level. The premature mortality rate (ages 0–74 years) was estimated for all causes and for cancer, cardiovascular disease and external causes across the period 1980–2010. In the years analysed, provinces were grouped into tertiles based on provincial income, with the mortality rate ratio (MMR) being estimated by taking the tertile of highest-income provinces as reference. Population change was then controlled for to ascertain whether it would modify the rate ratio.ResultsIn all-cause mortality, the magnitude of the MRR for provinces in the poorest versus the richest tertile was 1.01 in 1980 and 1.12 in 2010; in cardiovascular mortality, the MMRs for these same years were 1.08 and 1.31 respectively; and in the case of cancer and external-cause mortality, MMR magnitude was similar in 1980 and 2010. The magnitude of the MMR remained unchanged in response to adjustment for population change, with the single exception of 1980, when it increased in all-cause and cardiovascular mortality.ConclusionThe increase in the difference in premature mortality between the richest and poorest areas in Spain is due to the increased difference in cardiovascular mortality. This increase is not accounted for by population change. In rich countries, more empirical evidence is thus needed to test other alternative explanations for the increase in economic differences in mortality.

Consejo y prevención a pacientes mayores en hospitales y residencias geriátricas en España

OBJECTIVE To establish the profile of elderly patients, and to assess current preventive actions in hospitals, geriatric residences, and different health-care centres in Spain. DESIGN Cross-sectional descriptive study, based on a questionnaire to be answered by doctors who treat the elderly population in Spain (2013). SETTING Health-care centres from different regions of Spain. PARTICIPANTS A total of 420 practitioners from hospitals, residences and other community centres, with data from 840 geriatric clinics. MAIN MEASUREMENTS Main outcome variables are: dependence, reason for assistance, comorbidity, professional consultation, and life style recommendations. Association factor, type of institution where patients have been attended. Analysis of prevalence and association using Chi-squared test. OUTCOMES Two-thirds (66.7%) of the study population were shown to be dependent, with a higher percentage among women than men: 68.9% vs. 62.4% (P=.055). It was also found that among the population aged 85 or more, 88.6% of the women and 85.2% of the men suffered comorbidity. In spite of these results, only 6.6% of the patients suffering comorbidity received additional advice concerning healthy-lifestyle. A large majority (79.6%) of the patients treated in hospitals received advice concerning healthy lifestyle, while 59.62% of those treated in nursing homes received it (P<.001). CONCLUSIONS It was observed that there is a lack of preventive action related to health promotion among the elderly, with differences between hospitals and geriatric residences. This suggests that it is time to put forward new specialised programs addressed to health professionals, in order to reinforce health promotion attitudes and preventive interventions in gerontology clinical practice.

Patrones Geográficos de la Mortalidad y de las Desigualdades Socioeconómicas en Mortalidad en España

Fundamentos: Las estimaciones sobre desigualdades socioeconomicas en mortalidad a partir de registros individuales de defunciones y poblacion son escasas y proceden unicamente de la la ciudad de Barcelona, la Comunidad de Madrid y el Pais Vasco. El objetivo del presente estudio fue mostrar el patron geografico de mortalidad en diferentes grupos socioeconomicos, asi como el de las desigualdades en mortalidad en el conjunto del territorio espanol. Metodos: Se realizo el seguimiento de todos los individuos mayores de 25 anos del censo de poblacion 2001 durante siete anos y dos meses para conocer su estado vital (196.470.401 personas-ano a riesgo y 2.379.558 defunciones). Se calculo la tasa de mortalidad ajustada por edad en hombres y mujeres por provincia y nivel de estudios. Las desigualdades en mortalidad provinciales se estimaron mediante la razon de tasas de mortalidad en los sujetos con nivel de estudios primarios o inferiores respecto a los sujetos con estudios universitarios. Resultados: En mujeres, las razones de tasas mas bajas -entre 1,06 y 1,16- se observaron Palencia, Segovia, Guadalajara y Avila. Las mas altas -entre 1,53 y 1,75- en Malaga, Las Palmas, Ceuta, Toledo y Melilla. En hombres, las razones de tasas mas bajas -entre 1,00 y 1,12- se observan en Guadalajara, Teruel, Cuenca, La Rioja y Avila y las mas altas -entre 1,47 y 1,73- en Las Palmas, Cantabria, Murcia, Melilla y Ceuta. Conclusiones: El patron geografico de las tasas de mortalidad en Espana varia segun el nivel educativo. Las desigualdades en mortalidad muestran menor magnitud en las provincias del centro peninsular.

Desigualdades en inactividad física según el nivel de estudios en España, en 1987 y 2007

Resumen Objetivo Comparar la magnitud de las desigualdades en la frecuencia de inactividad física en España en 1987 y 2007. Diseño Estudio descriptivo, diseño transversal, nivel nacional. Participantes Datos de la Encuesta Nacional de Salud de 1987 y 2007, población adulta de 25 a 64 años. Tamaño muestral 30.000 sujetos (1987) y 29.478 (2006/7). Mediciones principales Variable principal de resultados, inactividad física en tiempo libre. Factor de exposición, nivel educativo. Análisis de prevalencias y asociación a través de odds ratio (OR). Ajuste por variables socioeconómicas: edad en decenios, estado civil, situación laboral, clase social del cabeza de familia e ingresos del hogar. Resultados Descenso de la prevalencia de inactividad física en tiempo libre en 2007 respecto a 1987, tanto en mujeres como hombres. Mayores descensos observados entre los sujetos con estudios universitarios. La magnitud de las desigualdades en salud ha aumentado con el tiempo. Así ocurrió por ejemplo con el grupo de varones de 45 a 64 años, con OR de 2,43 (1,91-3,09) en 1987, a OR de 2,77 (2,17-3,54) en 2007, ajustadas por todas las variables socioeconómicas), en el caso de sujetos con peor nivel de estudios. Conclusiones La prevalencia de inactividad física descendió entre 1987 y 2007, y los mayores descensos fueron en sujetos con estudios universitarios. La brecha de las diferencias en prevalencias y OR de inactividad física en tiempo libre, ha aumentado con el tiempo. Parece necesario contribuir, desde estrategias de Educación para la Salud y promoción de la equidad, a la reducción de las desigualdades en conductas de riesgo.

Socioeconomic position and health services use in Germany and Spain during the Great Recession

Objective The relationship of socioeconomic position with the use of health services may have changed with the emergence of the economic crisis. This study shows that relationship before and during the economic crisis, in Germany and in Spain. Methods Data from the 2006 and 2011 Socio-Economic Panel carried out in Germany, and from the 2006 and 2011 National Health Surveys carried out in Spain were used. The health services investigated were physician consultations and hospitalization. The measures of socioeconomic position used were education and household income. The magnitude of the relationship between socioeconomic position and the use of each health services was estimated by calculating the percentage ratio by binary regression. Results In Germany, in both periods, after adjusting for age, sex, type of health insurance and need for care, subjects belonging to the lower educational categories had a lower frequency of physician consultations, while those belonging to the lower income categories had a higher frequency of hospitalization. In the model comparing the two lower socioeconomic categories to the two higher categories, the percentage ratio for physician consultation by education was 0.97 (95%CI 0.96–0.98) in 2006 and 0.96 (95%CI 0.95–0.97) in 2011, and the percentage ratio for hospitalization by income was 1.14 (95%CI 1.05–1.25) in 2006 and 1.12 (95%CI 1.03–1.21) in 2011. In Spain, no significant socioeconomic differences were observed in either period in the frequency of use of these health services in the fully adjusted model. Conclusion The results suggest that the economic crisis did not alter accessibility to the health system in either country, given that the socioeconomic pattern in the use of these health services was similar before and during the crisis in both countries.

The Association of Geographic Coordinates with Mortality in People with Lower and Higher Education and with Mortality Inequalities in Spain.

Objective Geographic patterns in total mortality and in mortality by cause of death are widely known to exist in many countries. However, the geographic pattern of inequalities in mortality within these countries is unknown. This study shows mathematically and graphically the geographic pattern of mortality inequalities by education in Spain. Methods Data are from a nation-wide prospective study covering all persons living in Spains 50 provinces in 2001. Individuals were classified in a cohort of subjects with low education and in another cohort of subjects with high education. Age- and sex-adjusted mortality rate from all causes and from leading causes of death in each cohort and mortality rate ratios in the low versus high education cohort were estimated by geographic coordinates and province. Results Latitude but not longitude was related to mortality. In subjects with low education, latitude had a U-shaped relation to mortality. In those with high education, mortality from all causes, and from cardiovascular, respiratory and digestive diseases decreased with increasing latitude, whereas cancer mortality increased. The mortality-rate ratio for all-cause death was 1.27 in the southern latitudes, 1.14 in the intermediate latitudes, and 1.20 in the northern latitudes. The mortality rate ratios for the leading causes of death were also higher in the lower and upper latitudes than in the intermediate latitudes. The geographic pattern of the mortality rate ratios is similar to that of the mortality rate in the low-education cohort: the highest magnitude is observed in the southern provinces, intermediate magnitudes in the provinces of the north and those of the Mediterranean east coast, and the lowest magnitude in the central provinces and those in the south of the Western Pyrenees. Conclusion Mortality inequalities by education in Spain are higher in the south and north of the country and lower in the large region making up the central plateau. This geographic pattern is similar to that observed in mortality in the low-education cohort.