Unai Martín

Learning lessons from past mistakes: how can Health in All Policies fulfil its promises?

The Ottawa Charter has exerted a great deal of influence on the public health debate and on health promotion practices over the last 25 years. The Charter shifted the main focus from individual risk behaviours to social determinants of health, and introduced innovative strategies such as participatory processes and empowerment of communities.1 This new public health era is based, essentially, on the introduction of health promotion to increase peoples opportunities to make healthy choices. Building healthy public policies (HPP) is a core area, even an overriding concern for health promotion,2 as it seeks to put health onto the agenda of policy-makers across different sectors, to improve the conditions under which people live.3 HPP is concerned with equity, and has, by its nature, an intersectoral focus with an explicit interest in the impacts of all policies on the health of the population.4 It represents a reaction against the individualistic and victim-blaming approach of curative medicine and the excessive focus previously placed on health education.5

Why is There so Much Controversy Regarding the Population Health Impact of the Great Recession? Reflections on Three Case Studies

In the aftermath of the Great Recession, public health scholars have grown increasingly interested in studying the health consequences of macroeconomic change. Reflecting existing debates on the nature of this relationship, research on the effects of the recent economic crisis has sparked considerable controversy. On the one hand there is evidence to support the notion that macroeconomic downturns are associated with positive health outcomes. On the other hand, a growing number of studies warn that the current economic crisis can be expected to pose serious problems for the public’s health. This article contributes to this debate through a review of recent evidence from three case studies: Iceland, Spain, and Greece. It shows that the economic crisis has negatively impacted some population health indicators (e.g., mental health) in all three countries, but especially in Greece. Available evidence defies deterministic conclusions, including increasingly “conventional” claims about economic downturns improving life expectancy and reducing mortality. While our results echo previous research in finding that the relationship between economic crises and population health is complex, they also indicate that this complexity is not arbitrary. On the contrary, changing social and political contexts provide meaningful, if partial, explanations for the perplexing nature of recent empirical findings.

Inmigración y salud: desigualdades entre la población autóctona e inmigrante en el País Vasco

OBJECTIVE To analyze health inequalities between native and immigrant populations in the Basque Country (Spain) and the role of several mediating determinants in explaining these differences. METHODS A cross-sectional study was performed in the population aged 18 to 64 years in the Basque Country. We used data from the Basque Health Survey 2007 (n=4,270) and the Basque Health Survey for Immigrants 2009 (n=745). We calculated differences in health inequalities in poor perceived health between the native population and immigrant populations from distinct regions (China, Latin America, the Maghreb and Senegal). To measure the association between poor perceived health and place of origin, and to adjust this association by several mediating variables, odds ratios (OR) were calculated through logistic regression models. RESULTS Immigrants had poorer perceived health than natives in the Basque Country, regardless of age. These differences could be explained by the lower educational level, worse employment status, lower social support, and perceived discrimination among immigrants, both in men and women. After adjustment was performed for all the variables, health status was better among men from China (OR: 0.18; 95% confidence interval [CI95%]: 0.04-0.91) and Maghreb (OR: 0.26; 95% CI: 0.08-0.91) and among Latin American women (OR: 0.36; 95% CI: 0.14-0.92) than in the native population. CONCLUSIONS These results show the need to continue to monitor social and health inequalities between the native and immigrant populations, as well as to support the policies that improve the socioeconomic conditions of immigrants.

The impact of the Great Recession on mental health and its inequalities: the case of a Southern European region, 1997–2013

BackgroundNumerous studies have shown that macroeconomic changes have a great influence on health, prompting different concerns in recent literature about the effects of the current recession. The objetive of the study was to assess the changes in the mental health of the working-age population in the Basque Country (Spain) and its social inequalities following the onset of the 2008 recession, with special focus on the role of unemployment.MethodsRepeated cross-sectional study on the population aged 16–64, using four Basque Health Surveys (1997–2013). Age-adjusted prevalences of poor mental health and incremental prevalence ratios (working status and social class adjusted) between years were calculated. Absolute/relative measures of social inequalities were also calculated.ResultsFrom 2008, there was a clear deterioration in the mental health, especially among men. Neither changes in employment status nor social class accounted for these changes. In men, the deterioration affected all working status categories, except the retired but significant changes occurred only among the employed. In women, poor mental health significantly increased among the unemployed. Students were also especially affected. Relative inequalities increased only in men.ConclusionsThe Great Recession is being accompanied by adverse effects on mental health, which cannot be fully explained by the increase of unemployment. Public health professionals should closely monitor the medium and long-term effects of the crisis as these may emerge only many years after the onset of recessions.

Two decades of inequalities in smoking prevalence, initiation and cessation in a southern European region: 1986–2007

BACKGROUND The smoking epidemic is still progressing in southern Europe. We aimed to analyse the magnitude and trend of social inequalities in smoking prevalence, initiation and cessation in the Basque Country, a southern European region, from 1986 to 2007, determining the patterns by sex and age. METHODS This was a cross-sectional time trend study on the population aged >24 years using the Basque Country Health Surveys of 1986, 1992, 1997, 2002 and 2007. Age-adjusted prevalence of current and ever smoking and cessation were calculated, as were relative index of inequality and population-attributable risk by occupational social class and educational level. Relative risk of starting smoking was estimated using Cox proportional hazard regression models. Calculations were performed separately by sex and for two age groups (25-44 years and >44 years). RESULTS Men and young women in the Basque Country have evolved towards the last stage of the epidemic, with an increasing concentration of smoking in disadvantaged groups, by educational level, especially among the youngest population. In older women, smoking continues rising, especially among higher socio-economic groups, though differences between groups are diminishing. The role of initiation and cessation inequalities as determinants of smoking inequalities differed considerably by age and sex. CONCLUSION Inequalities in smoking prevalence widened from 1986 to 2007 in the Basque Country, especially among the youngest population. The changing pattern of these inequalities and the different roles of initiation and cessation dynamics need to be taken into account to improve the results of tobacco control policies and their effect on smoking inequalities.

Changes in social inequalities in disability-free life expectancy in Southern Europe: the case of the Basque Country.

BackgroundHealth expectancy is a useful tool to monitor health inequalities. The evidence about the recent changes in social inequalities in healthy expectancy is relatively scarce and inconclusive, and most studies have focused on Anglo-Saxon and central or northern European countries. The objective of this study was to analyse the changes in socioeconomic inequalities in disability-free life expectancy in a Southern European population, the Basque Country, during the first decade of the 21st century.MethodsThis was an ecological cross-sectional study of temporal trends on the Basque population in 1999-2003 and 2004-2008. All-cause mortality rate, life expectancy, prevalence of disability and disability free-life expectancy were calculated for each period according to the deprivation level of the area of residence. The slope index of inequality and the relative index of inequality were calculated to summarize and compare the inequalities in the two periods.ResultsDisability free-life expectancy decreased as area deprivation increased both in men and in women. The difference between the most extreme groups in 2004-2008 was 6.7years in men and 3.7 in women. Between 1999-2003 and 2004-2008, socioeconomic inequalities in life expectancy decreased, and inequalities in disability-free expectancy increased in men and decreased in women.ConclusionsThis study found important socioeconomic inequalities in health expectancy in the Basque Country. These inequalities increased in men and decreased in women in the first decade of the 21st century, during which the Basque Country saw considerable economic growth.

Social Factors Associated with the Knowledge About HIV of the Immigrants from China, Latin America, the Maghreb and Senegal in the Basque Country (Spain)

The objective of this study was to identify the social factors that explain the differences in knowledge with regards to HIV/AIDS among immigrants in the Basque Country (Spain). We conducted a cross-sectional study based on information obtained in the Basque Health Survey for 754 immigrants from: 86 China, 368 Latin America, 237 the Maghreb and 74 Senegal. Odds ratios (95% CI) were calculated from logistic regression models to measure the degree of association between inadequate knowledge regarding transmission, prevention and places where HIV testing is offered, and the independent variables. We found that this inadequate knowledge is associated with place of birth, sex, a lower level of education, immigration status, difficulties in understanding Spanish, and not receiving advice about AIDS in primary care. These findings indicate that initiatives must be developed to promote equity in the provision of healthcare through clinical guidelines, including details of the specific needs of different groups of immigrants and considering gender issues.

Protocolo del estudio sobre el efecto de la crisis económica en la mortalidad, la salud reproductiva y las desigualdades en salud en España

The aim is to present the protocol of the two sub-studies on the effect of the economic crisis on mortality and reproductive health and health inequalities in Spain. Substudy 1: describe the evolution of mortality and reproductive health between 1990 and 2013 through a longitudinal ecological study in the Autonomous Communities. This study will identify changes caused by the economic crisis in trends or reproductive health and mortality indicators using panel data (17 Autonomous Communities per study year) and adjusting Poisson models with random effects variance. Substudy 2: analyse inequalities by socioeconomic deprivation in mortality and reproductive health in several areas of Spain. An ecological study analysing trends in the pre-crisis (1999-2003 and 2004-2008) and crisis (2009-2013) periods will be performed. Random effects models Besag York and Mollié will be adjusted to estimate mortality indicators softened in reproductive health and census tracts.

Impacto de la morbilidad en la salud de la población del País Vasco 2002-2007: una visión integral a través de las esperanzas de salud

BACKGROUND The estimation of the impact of morbidity on health is essential to health planning. The objective was to estimate this impact using disability free life expectancy, and to analyze whether the hypothetical elimination of various diseases would have led to a compression or expansion of morbidity. METHODS Cross-sectional study on the population of the Basque Country. Data on mortality (2002-2006), health survey data (2007) and population based data were used. The impact of different groups of diseases on mortality rates, years of life and potential years of life lost (PYLL) and disability (absolute number and rates) were calculated. An integrated analysis was also done, using disability free life expectancy (DFLE), using the Sullivan method. RESULTS The diseases causing the greatest impact on mortality were tumours among men (35,2% and 39,3% of deaths and PYLL respectively), and circulatory diseases (34,5% of deaths) and tumours (43,6% of PYLL) among women. Osteomuscular diseases had a major impact on disability, causing the 26,6% and the 45,2% of the total cases in men and women). Circulatory diseases had the highest impact as a whole (4.2 years of DFLE in men and 3.8 in women). However, osteomuscular diseases had the highest influence on years of life with disability. CONCLUSIONS The diseases which caused the overall greatest impact on mortality and disability were circulatory system related ones, tumors, and osteomuscular diseases. The elimination of this last group of diseases would have led to a morbidity compression, meaning the greatest reduction in life years with disability among all the causes.Impact of Morbidity on the Health of the Basque Country Population 2002-2007: A Comprehensive Approach through Health Expectancies Background: The estimation of the impact of morbidity on health is essential to health planning. The objective was to estimate this impact using disability free life expectancy, and to analyze whether the hypothetical elimination of various diseases would have led to a compression or expansion of morbidity. Methods: Cross-sectional study on the population of the Basque Country. Data on mortality (2002-2006), health survey data (2007) and population based data were used. The impact of different groups of diseases on mortality rates, years of life and potential years of life lost (PYLL) and disability (absolute number and rates) were calculated. An integrated analysis was also done, using disability free life expectancy (DFLE), using

Indicadores contextuales para evaluar los determinantes sociales de la salud y la crisis económica española

OBJECTIVE To provide indicators to assess the impact on health, its social determinants and health inequalities from a social context and the recent economic recession in Spain and its autonomous regions. METHODS Based on the Spanish conceptual framework for determinants of social inequalities in health, we identified indicators sequentially from key documents, Web of Science, and organisations with official statistics. The information collected resulted in a large directory of indicators which was reviewed by an expert panel. We then selected a set of these indicators according to geographical (availability of data according to autonomous regions) and temporal (from at least 2006 to 2012) criteria. RESULTS We identified 203 contextual indicators related to social determinants of health and selected 96 (47%) based on the above criteria; 16% of the identified indicators did not satisfy the geographical criteria and 35% did not satisfy the temporal criteria. At least 80% of the indicators related to dependence and healthcare services were excluded. The final selection of indicators covered all areas for social determinants of health, and 62% of these were not available on the Internet. Around 40% of the indicators were extracted from sources related to the Spanish Statistics Institute. CONCLUSIONS We have provided an extensive directory of contextual indicators on social determinants of health and a database to facilitate assessment of the impact of the economic recession on health and health inequalities in Spain and its autonomous regions.