Vicente Domínguez

Socioeconomic patterns in the use of public and private health services and equity in health care

BackgroundSeveral studies in wealthy countries suggest that utilization of GP and hospital services, after adjusting for health care need, is equitable or pro-poor, whereas specialist care tends to favour the better off. Horizontal equity in these studies has not been evaluated appropriately, since the use of healthcare services is analysed without distinguishing between public and private services. The purpose of this study is to estimate the relation between socioeconomic position and health services use to determine whether the findings are compatible with the attainment of horizontal equity: equal use of public healthcare services for equal need.MethodsData from a sample of 18,837 Spanish subjects were analysed to calculate the percentage of use of public and private general practitioner (GP), specialist and hospital care according to three indicators of socioeconomic position: educational level, social class and income. The percentage ratio was used to estimate the magnitude of the relation between each measure of socioeconomic position and the use of each health service.ResultsAfter adjusting for age, sex and number of chronic diseases, a gradient was observed in the magnitude of the percentage ratio for public GP visits and hospitalisation: persons in the lowest socioeconomic position were 61–88% more likely to visit public GPs and 39–57% more likely to use public hospitalisation than those in the highest socioeconomic position. In general, the percentage ratio did not show significant socioeconomic differences in the use of public sector specialists. The magnitude of the percentage ratio in the use of the three private services also showed a socioeconomic gradient, but in exactly the opposite direction of the gradient observed in the public services.ConclusionThese findings show inequity in GP visits and hospitalisations, favouring the lower socioeconomic groups, and equity in the use of the specialist physician. These inequities could represent an overuse of public healthcare services or could be due to the fact that persons in high socioeconomic positions choose to use private health services.

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.

Heterogeneity in cause-specific mortality according to birthplace in immigrant men residing in Madrid, Spain.

PURPOSE To evaluate whether mortality in immigrants in the region of Madrid (Spain) differs from mortality in Spanish in-country migrants. METHODS Analyses of mortality in men aged 20 to 64 years residing in Madrid were conducted, using data from the municipal population register and the cause of death register for the period 2000 through 2004. Mortality rate ratios were used to compare mortality in immigrants from different parts of the world with mortality in men residing in Madrid who were born in other regions in Spain. RESULTS After adjustment was made for age and per capita income of the area of residence, the highest mortality rate ratio for the leading causes of death by disease category was observed in immigrants from sub-Saharan Africa and the lowest in those from South America and Asia. In immigrants from Western countries and from North Africa, the mortality rate ratios for most of the diseases studied did not differ significantly from those of Spanish in-country migrants. In general, the mortality rate ratios for external causes of death were higher than 1, and they were very high for mortality from homicide. CONCLUSIONS Mortality from the leading causes of death in immigrants shows important heterogeneity depending on the place of origin and, with some exceptions, shows a pattern similar to that observed in studies carried out in other wealthy countries.

Asociación de los ingresos económicos con la utilización y la accesibilidad de los servicios sanitarios en España al inicio del siglo XXI

Objetivo: Estimar la asociacion de los ingresos economicos del hogar y de la renta provincial con las consultas al medico general y al especialista y con la hospitalizacion. Estimar si el tiempo de espera para acceder a esos servicios varia con esas caracteristicas. Metodo: Datos de la Encuesta Nacional de Salud de 2001. La asociacion se estimo mediante la odds ratio, ajustada por edad y sexo, y en el caso de la renta per capita se ajusto tambien por los ingresos economicos del hogar. Se estimaron los percentiles y la media geometrica de los tiempos de espera en cada servicio sanitario y se evaluo la significacion estadistica de su asociacion con ambas variables economicas. Resultados: Los sujetos con menores ingresos economicos presentan la mayor frecuencia de consultas al medico general y hospitalizacion, aunque esperan mas tiempo para ser hospitalizados. Estos sujetos presentan la menor frecuencia de consultas al especialista: la odds ratio en el cuartil mas bajo de ingresos frente al mas alto fue 0,73 (intervalo de confianza del 95%, 0,62-0,87), aunque en las consultas financiadas publicamente la menor frecuencia se observa en los sujetos con mayores ingresos. No se han encontrado diferencias en la utilizacion y en los tiempos de espera segun la renta provincial. Conclusiones: La frecuencia de consultas al especialista segun los ingresos economicos del hogar muestra un patron distinto al observado en las consultas al medico general y en la hospitalizacion. El mayor tiempo de espera para hospitalizacion se observa en los sujetos con menores ingresos economicos.

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.

Socioeconomic environment, availability of sports facilities, and jogging, swimming and gym use

The aim of the study was to evaluate the association of the availability of sports facilities and socioeconomic environment with jogging, swimming and gym use in Spain. The indicators of availability of sports facilities were the number of swimming pools and the number of gyms per 10,000 population. The indicators of socioeconomic environment were average provincial income and provincial unemployment rate. The number of sports facilities was not related with either swimming or gym use and the indicators of socioeconomic environment were not associated with swimming in either sex, or with gym use in men. The findings of this study do not support the hypotheses proposed in previous investigations to explain the consistent relation between socioeconomic environment and lack of physical activity.

Social inequalities in ischaemic heart and cerebrovascular disease mortality in men: Spain and France, 1980-1982 and 1988-1990

In this study we analyse the trend in socio-economic differences in mortality from ischaemic heart and cerebrovascular diseases in the economically active male population aged 25-64 years in Spain and France. The data used were taken from deaths from these two causes in 1980-1982 and 1988-1990; in the case of Spain the data came from the Eight Provinces Study. Individuals were grouped into four categories - professional/managerial, clerical/sales/service workers, farmers, and manual workers - and the mortality rate ratio was estimated with reference to the professional/managerial group. For ischaemic heart disease in 1980-1982, professionals and managers aged 25-44 years had the lowest risk of mortality in Spain, and the highest risk of mortality in France; in 1988-1990 the socioeconomic differences in mortality in Spain increased, whereas the relation was inverted in France. In 1980-1982, professionals and managers aged 45-64 years had higher mortality from ischaemic heart disease than the other occupational groups in both countries; in 1988-1990 this relation was inverted, except in the case of clerical/sales/service workers in Spain. For cerebrovascular disease, manual workers experienced the highest mortality in the 25-44 year age group in 1980-1982, and the differences increased in 1988-1990 in all groups with respect to professionals and managers in both places. Professionals and managers in France and manual workers in Spain had the highest mortality between 45 and 64 years in 1980-1982; in contrast, in 1988-1990 professionals and managers had the lowest risk of mortality from this disease in both Spain and France, although in Spain the magnitude was similar to that of clerical/sales/service workers. In general terms, mortality from each disease was different in professionals and managers than in clerical/sales/service workers. Thus, the pattern of mortality and its evolution in different socio-economic groups cannot be analysed accurately when the two occupational groups are combined in a single large group of non-manual workers.