Laia Palència

Socio-economic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program

BACKGROUND The aim of this study was to describe inequalities in the use of breast and cervical cancer screening services according to educational level in European countries in 2002, and to determine the influence of the type of screening program on the extent of inequality. METHODS A cross-sectional study was performed using individual-level data from the WHO World Health Survey (2002) and data regarding the implementation of cancer screening programmes. The study population consisted of women from 22 European countries, aged 25-69 years for cervical cancer screening (n =11 770) and 50-69 years for breast cancer screening (n = 4784). Dependent variables were having had a PAP smear and having had a mammography during the previous 3 years. The main independent variables were socio-economic position (SEP) and the type of screening program in the country. For each country the prevalence of screening was calculated, overall and for each level of education, and indices of relative (RII) and absolute (SII) inequality were computed by educational level. Multilevel logistic regression models were fitted. RESULTS SEP inequalities in screening were found in countries with opportunistic screening [comparing highest with lowest educational level: RII = 1.28, 95% confidence interval (CI) 1.12-1.48 for cervical cancer; and RII = 3.11, 95% CI 1.78-5.42 for breast cancer] but not in countries with nationwide population-based programmes. Inequalities were also observed in countries with regional screening programs (RII = 1.35, 95% CI 1.10-1.65 for cervical cancer; and RII = 1.58, 95% CI 1.26-1.98 for breast cancer). CONCLUSIONS Inequalities in the use of cancer screening according to SEP are higher in countries without population-based cancer screening programmes. These results highlight the potential benefits of population-based screening programmes.

The evolution of mental health in Spain during the economic crisis

We analyse how mental health and socioeconomic inequalities in the Spanish population aged 16-64 years have changed between 2006-2007 and 2011-2012. We observed an increase in the prevalence of poor mental health among men (prevalence ratio = 1.15, 95% CI 1.04-1.26], especially among those aged 35-54 years, those with primary and secondary education, those from semi-qualified social classes and among breadwinners. None of these associations remained after adjusting for working status. The relative index of inequality by social class increased for men from 1.02 to 1.08 (P = 0.001). We observed a slight decrease in the prevalence of poor mental health among women (prevalence ratio = 0.92, 95% CI 0.87-0.98), without any significant change in health inequality.

Influence of Macrosocial Policies on Women's Health and Gender Inequalities in Health

Gender inequalities in health have been widely described, but few studies have examined the upstream sources of these inequalities in health. The objectives of this review are 1) to identify empirical papers that assessed the effect of gender equality policies on gender inequalities in health or on womens health by using between-country (or administrative units within a country) comparisons and 2) to provide an example of published evidence on the effects of a specific policy (parental leave) on womens health. We conducted a literature search covering the period from 1970 to 2012, using several bibliographical databases. We assessed 1,238 abstracts and selected 19 papers that considered gender equality policies, compared several countries or different states in 1 country, and analyzed at least 1 health outcome among women or compared between genders. To illustrate specific policy effects, we also selected articles that assessed associations between parental leave and womens health. Our review partially supports the hypothesis that Nordic social democratic welfare regimes and dual-earner family models best promote womens health. Meanwhile, enforcement of reproductive policies, mainly studied across US states, is associated with better mental health outcomes, although less with other outcomes. Longer paid maternity leave was also generally associated with better mental health and longer duration of breastfeeding.

Social class inequalities in the utilization of health care and preventive services in Spain, a country with a national health system

In Spain, despite the existence of a National Health System (NHS), the utilization of some curative health services is related to social class. This study assesses (1) whether these inequalities are also observed for preventive health services and (2) the role of additional private health insurance for people of advantaged social classes. Using data from the Spanish National Health Survey of 2006, the authors analyze the relationships between social class and use of health services by means of Poisson regression models with robust variance, controlling for self-assessed health. Similar analyses were performed for waiting times for visits to a general practitioner (GP) and specialist. After controlling for self-perceived health, men and women from social classes IV-V had a higher probability of visiting the GP than other social classes, but a lower probability of visiting a specialist or dentist. No large class differences were observed in frequency of hospitalization or emergency services use, or in breast cancer screening or influenza vaccination; cervical cancer screening frequency was lower among women from social classes IV-V. The inequalities in specialist visits, dentist visits, and cervical cancer screening were larger among people with only NHS insurance than those with double health insurance. Social class differences in waiting times were observed for specialist visits, but not for GP visits. Men and women from social classes IV-V had longer waits for a specialist; this was most marked among people with only NHS insurance. Clearly, within the NHS, social class inequalities are still evident for some curative and preventive services. Further research is needed to identify the factors driving these inequalities and to tackle these factors from within the NHS. Priority areas include specialist services, dental care, and cervical cancer screening.

Socioeconomic inequalities in the incidence and prevalence of type 2 diabetes mellitus in Europe

OBJECTIVE The aim of this study was to analyze socioeconomic position (SEP) inequalities in the prevalence and incidence of type 2 diabetes mellitus (T2DM) in people aged 50 years and over in Europe and to describe the contribution of body mass index (BMI) and other possible mediators. METHODS This was a cross-sectional and longitudinal study including men and women ≥ 50 years old in 11 European countries in 2004 and 2006 (n = 21,323). The prevalence and cumulative incidence of T2DM were calculated with self-reported T2DM or when the individual took drugs for diabetes. Prevalence ratio (PR) and relative risk (RR) of prevalent and incident T2DM were calculated according to educational level and adjusted by BMI and other possible mediators. RESULTS The age-adjusted and country-adjusted prevalence of T2DM in 2004 was 10.2% in men and 8.5% in women. Compared to those with higher education, men and women with lower education had a PR [95% CI] of T2DM of 1.29 [1.12-1.50] and 1.61 [1.39-1.86], respectively. SEP-related inequalities in incidence (RR [95%CI]) were 1.88 [1.35-2.62] in women and 1.04 [0.78-1.40] in men. Adjusting for potential mediators reduced inequalities in the prevalence and incidence of T2DM among women by 26.2% and 21.6%, respectively, and inequalities in prevalence among men by 44.8%. CONCLUSIONS We observed significant inequalities in the prevalence and incidence (women only) of T2DM as a function of socioeconomic position. These inequalities were mediated by BMI.

Socioeconomic inequalities in cause-specific mortality in 15 European cities

Background Socioeconomic inequalities are increasingly recognised as an important public health issue, although their role in the leading causes of mortality in urban areas in Europe has not been fully evaluated. In this study, we used data from the INEQ-CITIES study to analyse inequalities in cause-specific mortality in 15 European cities at the beginning of the 21st century. Methods A cross-sectional ecological study was carried out to analyse 9 of the leading specific causes of death in small areas from 15 European cities. Using a hierarchical Bayesian spatial model, we estimated smoothed Standardized Mortality Ratios, relative risks and 95% credible intervals for cause-specific mortality in relation to a socioeconomic deprivation index, separately for men and women. Results We detected spatial socioeconomic inequalities for most causes of mortality studied, although these inequalities differed markedly between cities, being more pronounced in Northern and Central-Eastern Europe. In the majority of cities, most of these causes of death were positively associated with deprivation among men, with the exception of prostatic cancer. Among women, diabetes, ischaemic heart disease, chronic liver diseases and respiratory diseases were also positively associated with deprivation in most cities. Lung cancer mortality was positively associated with deprivation in Northern European cities and in Kosice, but this association was non-existent or even negative in Southern European cities. Finally, breast cancer risk was inversely associated with deprivation in three Southern European cities. Conclusions The results confirm the existence of socioeconomic inequalities in many of the main causes of mortality, and reveal variations in their magnitude between different European cities.

Socioeconomic inequalities in mortality in 16 European cities

Aims: To explore inequalities in total mortality between small areas of 16 European cities for men and women, as well as to analyse the relationship between these geographical inequalities and their socioeconomic indicators. Methods: A cross-sectional ecological design was used to analyse small areas in 16 European cities (26,229,104 inhabitants). Most cities had mortality data for a period between 2000 and 2008 and population size data for the same period. Socioeconomic indicators included an index of socioeconomic deprivation, unemployment, and educational level. We estimated standardised mortality ratios and controlled for their variability using Bayesian models. We estimated relative risk of mortality and excess number of deaths according to socioeconomic indicators. Results: We observed a consistent pattern of inequality in mortality in almost all cities, with mortality increasing in parallel with socioeconomic deprivation. Socioeconomic inequalities in mortality were more pronounced for men than women, and relative inequalities were greater in Eastern and Northern European cities, and lower in some Western (men) and Southern (women) European cities. The pattern of excess number of deaths was slightly different, with greater inequality in some Western and Northern European cities and also in Budapest, and lower among women in Madrid and Barcelona. Conclusions: In this study, we report a consistent pattern of socioeconomic inequalities in mortality in 16 European cities. Future studies should further explore specific causes of death, in order to determine whether the general pattern observed is consistent for each cause of death.

Twenty years of socio-economic inequalities in type 2 diabetes mellitus prevalence in Spain, 1987–2006

BACKGROUND To analyse trends in socio-economic inequalities in the prevalence of diabetes among men and women aged ≥35 years in Spain during the period 1987-2006. METHODS We analysed trends in the age-standardized prevalence of self-reported diabetes and obesity in relation to level of education using data from the Spanish National Health Survey for the years 1987, 1993, 1995, 1997, 2001, 2003 and 2006 (86 345 individuals aged ≥35 years). To assess the relationship between education level and diabetes and obesity, we computed the Slope Index of Inequality and the Relative Index of Inequality (RII) for each year. Additional models were fit to take into account mediator variables in socio-economic position (SEP) diabetes inequalities. RESULTS The prevalence of self-reported diabetes was higher among persons of low educational level, increasing more rapidly over time among people with lower education level (5.0-12.6% in men, and 8.4-13.1% in women between 1987 and 2006) than among those with higher education level (6.3-8.7% in men and 3.8-4.0% in women). Relative inequalities showed a weak tendency to increase. In women, the RII of self-reported diabetes increased from 3.04 (1.95-4.74) in 1987 to 4.28 (2.98-6.13) in 2006, while in men were constant since 1993. Trends in SEP inequalities in diabetes prevalence were attenuated when mediator variables were taken into account in women but not in men. CONCLUSION SEP inequalities in diabetes existed >20 years ago and have increased, especially among women. These patterns may be explained by trends in health behaviours and obesity, but only to a limited extent.

Social differences in avoidable mortality between small areas of 15 European cities: an ecological study

BackgroundHealth and inequalities in health among inhabitants of European cities are of major importance for European public health and there is great interest in how different health care systems in Europe perform in the reduction of health inequalities. However, evidence on the spatial distribution of cause-specific mortality across neighbourhoods of European cities is scarce. This study presents maps of avoidable mortality in European cities and analyses differences in avoidable mortality between neighbourhoods with different levels of deprivation.MethodsWe determined the level of mortality from 14 avoidable causes of death for each neighbourhood of 15 large cities in different European regions. To address the problems associated with Standardised Mortality Ratios for small areas we smooth them using the Bayesian model proposed by Besag, York and Mollié. Ecological regression analysis was used to assess the association between social deprivation and mortality.ResultsMortality from avoidable causes of death is higher in deprived neighbourhoods and mortality rate ratios between areas with different levels of deprivation differ between gender and cities. In most cases rate ratios are lower among women. While Eastern and Southern European cities show higher levels of avoidable mortality, the association of mortality with social deprivation tends to be higher in Northern and lower in Southern Europe.ConclusionsThere are marked differences in the level of avoidable mortality between neighbourhoods of European cities and the level of avoidable mortality is associated with social deprivation. There is no systematic difference in the magnitude of this association between European cities or regions. Spatial patterns of avoidable mortality across small city areas can point to possible local problems and specific strategies to reduce health inequality which is important for the development of urban areas and the well-being of their inhabitants.

Socioeconomic inequalities in injury mortality in small areas of 15 European cities.

This study analysed socioeconomic inequalities in mortality due to injuries in small areas of 15 European cities, by sex, at the beginning of this century. A cross-sectional ecological study with units of analysis being small areas within 15 European cities was conducted. Relative risks of injury mortality associated with the socioeconomic deprivation index were estimated using hierarchical Bayesian model. The number of small areas varies from 17 in Bratislava to 2666 in Turin. The median population per small area varies by city (e.g. Turin had 274 inhabitants per area while Budapest had 76,970). Socioeconomic inequalities in all injury mortality are observed in the majority of cities and are more pronounced in men. In the cities of northern and western Europe, socioeconomic inequalities in injury mortality are found for most types of injuries. These inequalities are not significant in the majority of cities in southern Europe among women and in the majority of central eastern European cities for both sexes. The results confirm the existence of socioeconomic inequalities in injury related mortality and reveal variations in their magnitude between different European cities.