Marc Marí-Dell’Olmo

Inequalities in mortality in small areas of eleven Spanish cities (the multicenter MEDEA project).

The objectives of this study are to identify inequalities in mortality among census tracts of 11 Spanish cities in the period 1996-2003 and to analyse the relationship between these geographical inequalities and socioeconomic deprivation. It is a cross-sectional ecological study where the units of analysis are census tracts. We obtained an index of socioeconomic deprivation and estimated SMR by each census tract using hierarchical Bayesian models which take into account the spatial structure. In the majority of the cities geographical patterns in total mortality were found in both sexes, which were similar to those for the index of socioeconomic deprivation. Among men, four specific causes of death (lung cancer, ischemic heart diseases, respiratory diseases and cirrhosis) were positively associated with deprivation in the majority of cities. Among women the specific causes diabetes and cirrhosis were positively associated, while lung cancer was negatively associated with deprivation. The excess of mortality related with deprivation was 59,445 deaths among men and 23,292 among women. These results highlight the importance of intra-urban inequalities in health.

Validación de la causa básica de defunción en las muertes que requieren intervención medicolegal

Background: Deaths due to external causes require additional medical tests in order to determine the cause of death. If these results are not incorporated into the death register these causes may be misclassified. The objective of this study is to validate the underlying cause of death of the Mortality Register with information obtained from forensic sources in Barcelona between 2004 and 2006. Methods: Cross-sectional design. The study population consisted of deceased residents in Barcelona with a medicolegal intervention between 2004 and 2006. The sources of information are the Mortality Registry and the forensic pathology file filled in by Institute of Legal Medicine of Catalonia (ILMC) (gold standard). The study variables are the cause of death, sex and age. Sensitivity and percentage of confirmation (PC) with 95% confidence intervals (95% CI) are calculated. Results: The sensitivity of external causes is 59.7% (95% CI:56.5-62.9) and PC is 96.7% (95% CI:94.8-98.0). Traffic injuries, poisonings and suicides are under-reported in the Mortality Register with a sensitivity lower than 45% and a PC higher than 80%. Symptoms, signs and ill-defined conditions are over-reported with a sensitivity of 89.2% (95% CI:83.4-93.4) and a PC of 28.0% (95% CI:24.2-32.1). There are no differences by sex and age. Conclusions: The validity of the external causes in the Mortality Register is low due to under-reporting and the high proportion of symptoms signs and ill-defined causes. According to the results, incorporating information from forensic sources to the Mortality Register increases the quality of mortality statistics.BACKGROUND Deaths due to external causes require additional medical tests in order to determine the cause of death. If these results are not incorporated into the death register these causes may be misclassified. The objective of this study is to validate the underlying cause of death of the Mortality Register with information obtained from forensic sources in Barcelona between 2004 and 2006. METHODS Cross-sectional design. The study population consisted of deceased residents in Barcelona with a medicolegal intervention between 2004 and 2006. The sources of information are the Mortality Registry and the forensic pathology file filled in by Institute of Legal Medicine of Catalonia (ILMC) (gold standard). The study variables are the cause of death, sex and age. Sensitivity and percentage of confirmation (PC) with 95% confidence intervals (95% CI) are calculated. RESULTS The sensitivity of external causes is 59.7% (95% CI:56.5-62.9) and PC is 96.7% (95% CI:94.8-98.0). Traffic injuries, poisonings and suicides are under-reported in the Mortality Register with a sensitivity lower than 45% and a PC higher than 80%. Symptoms, signs and ill-defined conditions are over-reported with a sensitivity of 89.2% (95% CI:83.4-93.4) and a PC of 28.0% (95% CI:24.2-32.1). There are no differences by sex and age. CONCLUSIONS The validity of the external causes in the Mortality Register is low due to under-reporting and the high proportion of symptoms signs and ill-defined causes. According to the results, incorporating information from forensic sources to the Mortality Register increases the quality of mortality statistics.

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.

Diseños evaluativos en salud pública: aspectos metodológicos

Evaluation of public health interventions poses numerous methodological challenges. Randomization of individuals is not always feasible and interventions are usually composed of multiple factors. To face these challenges, certain elements, such as the selection of the most appropriate design and the use of a statistical analysis that includes potential confounders, are essential. The objective of this article was to describe the most frequently used designs in the evaluation of public health interventions (policies, programs or campaigns). The characteristics, strengths and weaknesses of each of these evaluative designs are described. Additionally, a brief explanation of the most commonly used statistical analysis in each of these designs is provided.Evaluation of public health interventions poses numerous methodological challenges. Randomization of individuals is not always feasible and interventions are usually composed of multiple factors. To face these challenges, certain elements, such as the selection of the most appropriate design and the use of a statistical analysis that includes potential confounders, are essential. The objective of this article was to describe the most frequently used designs in the evaluation of public health interventions (policies, programs or campaigns). The characteristics, strengths and weaknesses of each of these evaluative designs are described. Additionally, a brief explanation of the most commonly used statistical analysis in each of these designs is provided.

Trends in socio-economic inequalities in injury mortality among men in small areas of 26 Spanish cities, 1996-2007.

OBJECTIVE To analyse trends in socio-economic inequalities in mortality due to all injuries, as well as, suicide and motor vehicle injuries, in men in the census tracts of 26 Spanish cities for the periods 1996-2001 and 2002-2007. METHODS Ecological study of trends based on two periods (1996-2001 and 2002-2007). The study population consisted of male residents in each city during the period 1996-2007. We fitted a hierarchical Bayesian model which takes into account the spatial structure of the data in order to obtain relative risks (RRs), and their 95% credible intervals (CIs), between mortality and a socio-economic deprivation index, in each period. RESULTS In most of the cities, mortality due to total injuries presents the same geographical pattern as the deprivation index in the two periods. Moreover, inequalities remained stable. In contrast, socio-economic inequalities in mortality due to motor vehicle injuries tended to diminish in the second period in the majority of the cities, particularly Castellón (first period: RR(1)=2.56; 95%CI: 1.19-4.84; second period: RR(2)=1.06; 95%CI: 0.45-2.12), whereas in the case of suicides, the inequalities remain stable but are only significant in large cities. CONCLUSION This study has demonstrated that socio-economic inequalities in mortality due to all injuries in small areas of 26 Spanish cities remain stable over time. These results highlight the importance of intra-urban inequalities in mortality due to injuries and their evolution over time.

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.

Trends in socioeconomic inequalities in preventable mortality in urban areas of 33 Spanish cities, 1996-2007 (MEDEA project)

BackgroundPreventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996–2001 and 2002–2007.MethodsWe analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used.ResultsPreventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996–2001 and 10.9 in 2002–2007), though not so clearly among women (3.3% in 1996–2001 and 2.9% in 2002–2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities.ConclusionsPreventable mortality decreased between the 1996–2001 and 2002–2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process.

Trends in Socioeconomic Inequalities in Ischemic Heart Disease Mortality in Small Areas of Nine Spanish Cities from 1996 to 2007 Using Smoothed ANOVA

The aim of this study was to analyze the evolution of socioeconomic inequalities in mortality due to ischemic heart diseases (IHD) in the census tracts of nine Spanish cities between the periods 1996–2001 and 2002–2007. Among women, there are socioeconomic inequalities in IHD mortality in the first period which tended to remain stable or even increase in the second period in most of the cities. Among men, in general, no socioeconomic inequalities have been detected for this cause in either of the periods. These results highlight the importance of intra-urban inequalities in mortality due to IHD and their evolution over time.

Housing Policies and Health Inequalities

A large body of literature shows the link between inadequate housing conditions and poor physical and mental health. The aim of this paper is to summarize the research on the impact of local housing policies on health inequalities, focusing on the issues of access to housing and fuel poverty as studied in the SOPHIE project. Our case studies in Spain showed that people facing housing insecurity, experienced intense levels of mental distress. We found that access to secure and adequate housing can improve the health of these populations, therefore, public policies that address housing instability and their consequences are urgently needed. Housing conditions related to fuel poverty are associated with poorer health and are unevenly distributed across Europe. We found possible positive effects of façade insulation interventions on cold-related mortality in women living in social housing; but not in men. Policies on housing energy efficiency can reduce the health consequences of fuel poverty, but need to be free to users, target the most vulnerable groups and be adaptable to their needs.

A smoothed ANOVA model for multivariate ecological regression

Smoothed analysis of variance (SANOVA) has recently been proposed for carrying out disease mapping. The main advantage of this approach is its conceptual simplicity and ease of interpretation. Moreover, it allows us to fix the combination of diseases of particular interest in advance and to make specific inferences about them. In this paper we propose a reformulation of SANOVA in the context of ecological regression studies. This proposal considers the introduction in a non-parametric way of one (or several) covariate(s) into the model, explaining some pre-specified combinations of the outcome variables. In addition, random effects are also incorporated in order to model geographical variation in the combinations of outcome variables not explained by the covariate. Lastly, the model permits the decomposition of the variance in the set of outcome variables into different orthogonal components, quantifying the contribution of every one of them. The proposed model is applied to the geographical analysis of mortality due to malignant stomach neoplasm among women resident in the city of Barcelona (Spain). The available outcome variables are deaths grouped into two time periods, and a socioeconomic deprivation index is included as a covariate. The model has been implemented through INLA, a novel inference tool for Bayesian statistics.