Pedro Navarro

Inequalities in income and long-term disability in Spain: analysis of recent hypotheses using cross sectional study based on individual data.

Abstract Objective: To compare the relation between inequalities in long term disability and income in the 17 regions of Spain. Design: Data were taken from the survey on impairments, disabilities, and handicaps that was carried out in Spain in 1986. For each region the inequality in long term disability associated with income was calculated as the odds ratio associated with reducing monthly household income by 10 000 pesetas (about £50) (estimate of effect of inequality of income) and the odds ratio for the inequality in long term disability between those at the bottom and those at the top of the income hierarchy (relative index of inequality). Main outcome measure: Prevalence of long term disability. Results: Five of the eight regions where lowering income had a greater effect on long term disability were among those with the lowest income per head, while six of the remaining nine regions where the effect was smaller were among those with the highest income per head. Three regions with the highest estimate of relative index of inequality had the highest estimate of effect, and another three regions with the lowest estimate of relative index of inequality had the lowest estimate of effect. In contrast, the relative position of the remaining 11 regions varied from one measure to another. Conclusions: These results support the theory that additional increments in material wellbeing have a negligible effect on health in countries with high socioeconomic development. However, inequality in income distribution did not determine inequality in health between those at the bottom and those at the top of the income hierarchy in many Spanish regions. Key messages The association between income and long term disability is higher in Spanish regions with the lowest income per head Inequality in income is not related to the prevalence of long term disability in the regions of Spain Inequality in the distribution of income does not determine the inequality in health between those at the bottom and top of the social hierarchy in many Spanish regions

Trends in the association between average income, poverty and income inequality and life expectancy in Spain

In this paper, we study the relation between life expectancy and both average income and measures of income inequality in 1980 and 1990, using the 17 Spanish regions as units of analysis. Average income was measured as average total income per household. The indicators of income inequality used were three measures of relative poverty-the percentage of households with total income less than 25%, 40% and 50% of the average total household income-the Gini index and the Atkinson indices with parameters alpha=1, 1.5 and 2. Pearson and partial correlation coefficients were used to evaluate the association between average income and measures of income inequality and life expectancy. None of the correlation coefficients for the association between life expectancy and average household income was significant for men. The association between life expectancy and average household income in women, adjusted for any of the measures of income inequality, was significant in 1980, although this association decreased or disappeared in 1990 after adjusting for measures of poverty. In both men and women, the partial correlation coefficients between life expectancy and the measures of relative income adjusted for average income were positive in 1980 and negative in 1990, although none of them was significant. The results with regard to women confirm the hypothesis that life expectancy in the developed countries has become more dissociated from average income level and more associated with income inequality. The absence of a relation in men in 1990 may be due to the large impact of premature mortality from AIDS in regions with the highest average total income per household and/or smallest income inequality.

Comparing social inequalities in health in Spain: 1987 and 1995/97

To evaluate the trend in social inequalities in health in Spain between 1987 and 1995/97, we carried out a secondary analysis of the Spanish National Interview Surveys from 1987, 1995 and 1997. We studied less-than-good perceived general health and four chronic conditions--heart disease, diabetes mellitus, chronic bronchitis/asthma and allergies--by social class and educational level in men and women aged 25-74 years. Among men, the age-adjusted prevalence rate ratio of less-than-good perceived general health by social class decreased from 1.32 to 1.23 between 1987 and 1995,97: however, the prevalence rate ratio by educational level increased from 1.47 to 1.57. Among women, the prevalence rate ratio of less-than-good perceived general health increased between the first and second period as much by social class from 1.18 to 1.26, as by educational level--from 1.59 to 1.66. For heart disease the age-adjusted prevalence rate ratio by social class among men was 1.12 in 1987 and 0.72 in 1995/97, while the prevalence rate ratio by educational level was around I in both periods, among women, the prevalence rate ratio for heart disease by social class was the same in 1987 and in 1995/97, but the prevalence rate ratio by educational level increased between the first and second period. For diabetes mellitus and chronic bronchitis/asthma, the prevalence rate ratio increased by social class and educational level between the first and second period in both men and women. Finally, the prevalence rate ratio for allergies was always < 1, although its magnitude increased between 1987 and 1995/97. In general, health inequalities were larger by educational level than by social class and were larger in women than in men. Inequalities in perceived general health, diabetes mellitus and chronic bronchitis/asthma increased in Spain between 1987 and 1995/97.

The size of educational differences in mortality from specific causes of death in men and women.

This study examines the association between education and mortality from specific causes of death based on mortality records for 1996 and 1997, and 1996 population census data from the Region of Madrid (Spain). Poisson regression models were used to estimate the percentage increase in mortality associated with 1 year less education. The percentage increases in mortality from stomach cancer, lung, bladder and liver cancers, for aids, chronic obstructive pulmonary disease, pneumonia and influenza, and chronic liver disease and cirrhosis were higher in men than in women, whereas the percentage increases in mortality from colon cancer, diabetes mellitus, ischemic heart disease and nephritis, nephrosis and nephrotic syndrome were higher in women. The results found for some causes of death – lung cancer, ischemic heart disease, diabetes mellitus and chronic obstructive pulmonary disease – reflect the variations by educational level in the prevalence of lifestyle-related risk factors in men and women. Various hypotheses have been suggested for other causes of death, but it is not known why the magnitude of the association between education and mortality from some causes of death differs between men and women. Future studies of this subject may provide some clues as to the underlying mechanisms of this association.

Evolución de las diferencias socioeconómicas en la utilización y accesibilidad de los servicios sanitarios en España entre 1987 y 1995/97

FUNDAMENTO: El objetivo del presente trabajo es evaluar la evolucion de la utilizacion y accesibilidad de los servicios sanitarios en Espana, entre 1987 y 1995/1997, en grupos con diferentes caracteristicas socioeconomicas. METODOS: Los datos utilizados proceden de las Encuestas Nacionales de Salud realizadas por el Ministerio de Sanidad y Consumo a la poblacion adulta en los anos 1987, y 1995/1997. Se ha agregado la informacion de 1995 y 1997 debido al diferente tamano muestral, de forma que las estimaciones asi obtenidas son una media de ambas. La poblacion analizada ha sido la de los individuos mayores de 24 anos de edad. Se han estudiado la consulta medica, la hospitalizacion, la consulta al dentista y la consulta al ginecologo, el tiempo invertido en llegar a la consulta, el tiempo de espera en la misma y el tiempo de espera para un ingreso hospitalario ordinario. Las caracteristicas socioeconomicas utilizadas han sido el nivel de estudios y el grupo socioeconomico de los entrevistados. La medida de la asociacion estimada entre la utilizacion de servicios y las caracteristicas socioeconomicas fue la razon de porcentajes, mediante regresion binomial. Igualmente, se estimo el indice relativo de desigualdad como medida resumen de la desigualdad. RESULTADOS: La consulta medica fue mas frecuente en los individuos sin estudios y en los grupos socioeconomicos bajos, en uno y en otro periodo, mientras que la consulta al dentista y la consulta al ginecologo fueron mas frecuentes en los individuos con estudios superiores y en los grupos socioeconomicos altos en ambos periodos. No se encontraron diferencias socioeconomicas estadisticamente significativas en la frecuencia de hospitalizacion en ambos periodos. Tanto en 1987 como en 1995/1997 no se hallaron diferencias estadisticamente significativas entre los distintos grupos socioeconomicos en el tiempo de llegada a la consulta (p>0,05), pero si en el tiempo de espera en la consulta (p<0,05). En el segundo periodo desaparecieron las diferencias socioeconomicas en el tiempo de espera para ingreso hospitalario ordinario que se observaron en el primer periodo. CONCLUSIONES: En la segunda mitad de los anos noventa se observa el mismo perfil socioeconomico en la utilizacion de los servicios sanitarios y en los tiempos de espera para acceder a los mismos que en la segunda mitad de los anos ochenta, con la excepcion del tiempo de espera para ingreso hospitalario ordinario en el segundo periodo.

Mortalidad según características sociales y económicas: Estudio de Mortalidad de la Comunidad Autónoma de Madrid

Fundamento Estimar el efecto del estado civil, el numero de miembros del hogar, la situacion laboral, el nivel de estudios y la ocupacion sobre la mortalidad. Sujetos y metodo Alrededor de 3.100.000 personas mayores de 24 anos de edad residentes en la Comunidad Autonoma de Madrid el 1 de mayo de 1996. A partir del Registro de Mortalidad se obtuvo de cada uno de esos individuos su estado vital durante los 19 meses siguientes mediante la conexion de la informacion de este registro con la informacion de los residentes contenida en la Estadistica de Poblacion de 1996. Resultados A excepcion del numero de miembros del hogar, el efecto sobre la mortalidad de las caracteristicas analizadas fue mayor en el grupo de 25 a 44 anos que en otros grupos de edad. En general, los casados experimentaron la menor mortalidad, excepto en varones mayores de 64 anos, en quienes la mortalidad mas baja la presentaron los solteros. Los varones de 45 a 64 anos que vivian solos tuvieron mayor mortalidad que los que vivian acompanados, mientras que en las personas mayores de 64 anos la mortalidad aumento con el numero de miembros del hogar. La poblacion inactiva presento mayor mortalidad que la poblacion activa. Un mayor nivel de estudios y una mayor cualificacion profesional se asociaban con una menor mortalidad, excepto en mujeres de 45 a 64 anos. Conclusiones Este estudio ha identificado a grupos de poblacion con alto riesgo de mortalidad. La monitorizacion de la tendencia de mortalidad en esos grupos permitira sentar las bases racionales a la hora de llevar a cabo programas de intervencion sociosanitaria.

Inequalities in mortality in shrinking and growing areas

Modern societies are extremely mobile, yet the influence of population change in residential areas on mortality has rarely been investigated. Davey Smith et al showed that male and female mortality around the time of the 1991 census across 292 areas in Britain was inversely correlated with population growth in the previous two decades.1,2 Molarius and Janson studied 16 municipalities in Sweden and found a similar correlation between population changes from 1975 to 1994 and male mortality in 1992–96, but no correlation with mortality in women.3 The authors of both studies pointed out that, if possible, people leave unfavourable social and physical environments to move to more attractive places, so that relative population shrinkage occurs in areas with high mortality. A subject that has not been investigated is the possible relation between population changes and the magnitude of inequalities in mortality. That is, does population change lead to decreasing or increasing mortality inequalities within areas? As a person’s mobility is related with better health,4 inequalities in mortality are presumably smaller in growing areas than in those that are shrinking because people arriving in an area are healthy but their health is not dependent of their socioecenomic characteristics.5,6 To test this hypothesis, we investigated the association between mortality inequalities in 1996–97 and population changes in the preceding decade in the Region of Madrid (Spain). For this purpose, we calculated the population change between 1986 and 1996 in 200 areas (179 municipalities and 21 districts of the city of Madrid). We …

The magnitude of differences in perceived general health associated with educational level in the regions of Spain.

STUDY OBJECTIVE: To examine and compare the relation between inequalities in perceived general health and education in the 17 regions of Spain. DESIGN AND METHODS: Data were taken from the 1993 Spanish Health Interview Survey. For each region we calculated the magnitude of inequality in perceived general health in association with educational level by a measure of association or effect and by a relative index of inequality. Both measures are odds ratios and were estimated by logistic regression. The first is an odds ratio associated with one year less education, while the second represents the inequality in perceived general health between those at the bottom and those at the top of the educational hierarchy. MAIN RESULTS: The six regions with the highest relative indices of inequality also have the highest odds ratios associated with one year less education, and five of the six regions with the lowest relative indices of inequality have the lowest odds ratios associated with one year less education. Pearsons correlation coefficient between the odds ratio and the relative index of inequality is 0.94. CONCLUSIONS: Regional differences in levels of inequality in perceived general health are attributable exclusively to the effect of education on health and not to the distribution of the population among the different educational levels. It is not known why the magnitude of this effect of education on health varies from one area to another.

Occupational social class and mortality in a population of men economically active: The contribution of education and employment situation

This study examines how education and employment situation contribute to the association between a classification of occupational class based on skill assets and mortality from different causes of death. Data were obtained by linking records from the 1996 population census for Spanish men aged 35–64 residing in Madrid with 1996 and 1997 mortality records. The risk of mortality was higher in skilled, semi-skilled and unskilled workers than in higher and lower managerial and professional workers. Adjusting for educational level substantially decreased the magnitude of the gradient. The decrease in the gradient after adjusting for employment situation was much smaller. Except in the case of mortality from respiratory diseases, the mortality gradient disappeared after adjusting for both variables. These results show that education and, to a much lesser degree, employment situation explain part of the social gradient observed in mortality from all causes and from broad causes of death, except from respiratory diseases.

Circunstancias socioeconómicas y mortalidad prematura por enfermedades crónicas

Fundamento y objetivo Investigar la asociacion entre las circunstancias socioeconomicas de la infanciao adolescencia y de la etapa de adulto y la mortalidad prematura por varias causas de muerte. Sujetos y metodo Se incluyo a todos los varones y mujeres de 25 a 74 anos residentes en la Comunidad Autonoma de Madrid el 1 de mayo de 1996. A partir del Registro de Mortalidad se obtuvo su estado vital durante los 19 meses siguientes y la causa de muerte en caso de fallecimiento. Se estimo la mortalidad por 5 tipos de cancer y 4 enfermedades cronicas segun el nivel de estudios –como indicador de las circunstancias socioeconomicas de la infancia o adolescencia– y segun el nivel de ingresos economicos –como indicador de las circunstancias socioeconomicas en la etapa de adulto. Resultados Cuando se incluyeron simultaneamente ambas variables en el analisis, la razon de tasas de mortalidad en los varones con estudios de segundo grado, segundo ciclo y superiores frente a los varones con estudios de segundo grado, primer ciclo e inferiores y la razon de tasas de mortalidad de los varones perteneciente a los cuartiles inferiores de ingresos 3 y 4 frente a los varones pertenecientes a los cuartiles superiores de ingresos 1 y 2 fueron, respectivamente, 1,15 (intervalo de confianza [IC] del 95%, 1,01-1,31) y 1,22 (IC del 95%, 1,09-1,36) en cancer de pulmon; 1,46 (1,19-1,93) y 1,13 (0,90-1,41) en cancer de estomago; 1,80 (1,32-2,44) y 1,46 (IC del 95%, 1,18-1,80) en enfermedad pulmonar obstructiva cronica, y 1,18 (IC del 95%, 0,77-1,81) y 0,68 (IC del 95%, 0,47-0,98) en diabetes mellitus. Por su parte, esas razones de tasas de mortalidad en mujeres fueron, respectivamente, 0,63 (IC del 95%, 0,43-0,92) y 0,72 (IC del 95%, 0,52-0,99) en cancer de pulmon; 1,68 (IC del 95%, 0,99-2,83) y 1,17 (IC del 95%, 0,86-1,60) en cancer de estomago; 0,76 (IC del 95%, 0,61-0,94) y 0,98 (IC del 95%, 0,82-1,16) en cancer de mama; 1,36 (IC del 95%, 0,95-1,95) y 1,20 (IC del 95%, 0,97-1,48) en enfermedad isquemica del corazon; 1,72 (IC del 95%, 1,19-2,50) y 0,93 (IC del 95%, 0,75-1,16) en enfermedad cerebrovascular, y 2,23 (IC del 95%, 0,94-5,27) y 1,51 (IC del 95%, 1,02-2,25) en diabetes mellitus. Conclusiones La mortalidad prematura durante la etapa de adulto se asocia a diversas circunstancias socioeconomicas a lo largo de la vida. La contribucion de estas circunstancias a la mortalidad varia dependiendo de la causa de muerte y del sexo.