Economic Crisis, Austerity Policies, Health and Fairness: Lessons Learned in Spain

Experience of primary care nurses applying nurse-led management of patients with acute minor illnesses

AIM

The aim of this study is to determine the experience of primary health care nurses regarding the application of nurse-led management in patients with acute minor illnesses.

BACKGROUND

Nursing leadership of care for acute minor illnesses is a new challenge faced by nurses in Spain.

DESIGN

Qualitative, hermeneutical, interpretive phenomenological approach is used. The Consolidated criteria for reporting qualitative research guidelines were applied.

METHODS

Twenty primary care nurses participated; three focus group discussions and nine semi-structured interviews were conducted between November 2019 and October 2020. All the focus group discussions and interviews were recorded, transcribed verbatim and analysed using content analysis.

RESULTS

Seven main themes emerged from the focus group discussions and interviews: concept, perception of the other actors, practice, history and social context, competencies, training, and legality.

CONCLUSION

The study shows the diversity and complexity of nurses' experience when applying nurse-led management in acute minor illnesses. This work has helped to show the gaps perceived by nurses, including the lack of training in the treatment of conditions historically attended by physicians, the lack of definition of the legal framework and the limitations on nurse prescribing. It also highlighted the power of the nursing profession in terms of autonomy, competencies and role expansion.

Financing of health services for undocumented immigrants in Iran: common challenges and potential solutions

INTRODUCTION

Iran is host to one of the largest urban refugee populations worldwide, about two million of whom are undocumented immigrants (UIs). UIs are not eligible to enroll in the Iranian health insurance scheme and have to pay out-of-pocket to access most health services. This increases the likelihood that they will delay or defer seeking care, or incur substantial costs if they do seek care, resulting in worse health outcomes. This study aims to improve understanding of the financial barriers that UIs face in utilizing health services and provide policy options to ensure financial protection to enhance progress towards UHC in Iran.

METHODS

This qualitative study was conducted in 2022. A triangulation approach, including interviews with key informants and comparing them with other informative sources to find out the complementary findings, was applied to increase data confirmability. Both purposive and snowball sampling approaches were used to select seventeen participants. The data analysis process was done based on the thematic content analysis approach.

RESULTS

The findings were explained under two main themes: the financial challenges in accessing health services and the policy solutions to remove these financial barriers, with 12 subthemes. High out-of-pocket payments, high service prices for UIs, fragmented financial support, limited funding capacity, not freeing all PHC services, fear of deportation, and delayed referral are some of the barriers that UIs face in accessing health care. UIs can get insurance coverage by using innovative ways to get money, like peer financing and regional health insurance, and by using tools that make it easier, like monthly premiums without policies that cover the whole family.

CONCLUSION

The formation of a health insurance program for UIs in the current Iranian health insurance mechanism can significantly reduce management costs and, at the same time, facilitate risk pooling. Strengthening the governance of health care financing for UIs in the form of network governance may accelerate the inclusion of UIs in the UHC agenda in Iran. Specifically, it is necessary to enhance the role of developed and rich regional and international countries in financing health services for UIs.

Austerity Measures and Underfunding of the Spanish Health System during the COVID-19 Pandemic-Perception of Healthcare Staff in Spain

Insufficient pandemic preparedness and underfunding of human and economic resources have conditioned the response to COVID-19 in Spain. This underfunding has continued since the austerity measures introduced during the 2008 financial crisis. This study aims to understand the perceptions of healthcare staff in Spain on the relationship between the funding of the health system and its capacity to respond to the COVID-19 pandemic. To this end, we carried out a thematic content analysis, based on 79 online semi-structured interviews with healthcare staff across the regions most affected by the COVID-19 first wave. Participants reported a lack of material resources, which had compromised the capacity of the health system before the pandemic. The lack of human resources was to be addressed by staff reorganisation, such as reinforcing hospital units to the detriment of primary health care. Staff shortages continued straining the COVID-19 response, even after material scarcities were later partially alleviated. Personnel shortages need to be adequately addressed in order to adequately respond to future health crises.

Effect of the 2008 economic crisis on oral health in Spain: analysis of serial cross-sectional, population-based health surveys

OBJECTIVES

To evaluate the impact of the economic crisis on the oral health of individuals in Spain based on variables including sex, unemployment, social class and educational level.

DESIGN

This was an analysis of serial cross-sectional, population-based health surveys conducted before the crisis (2003 and 2006) and during the crisis (2011, 2014 and 2017).

SETTING

National Health Surveys of Spain and the European Health Survey in Spain.ParticipantsA total of 189 543 participants were recruited.

OUTCOME MEASURES

The independent variables were sex, employment, social class and educational level. The dependent variables were related to oral health. Descriptive statistics, χ² tests and the Cochran-Mantel-Haenszel test were performed.

RESULTS

The results showed that there were differences (p<0.001) in all oral health indicators before and after the crisis. Compared with the precrisis period, men had a higher probability of tooth extractions (OR 1.41, 95% CI 1.37 to 1.45), dental fillings (OR 1.30, 95% CI 1.27 to 1.34), prostheses (OR 1.04, 95% CI 1.01 to 1.07) and missing teeth (OR 1.35, 95% CI 1.31 to 1.39). Unemployed individuals were more likely to have dental caries (OR 1.08, 95% CI 1.00 to 1.16) and missing teeth (OR 1.36, 95% CI 1.27 to 1.46). Working class individuals had a higher probability of tooth extractions (OR 1.63, 95% CI 1.59 to 1.67), bleeding gums (OR 1.04, 95% CI 1.01 to 1.07), prostheses (OR 1.05, 95% CI 1.02 to 1.07) and missing teeth (OR 1.36, 95% CI 1.33 to 1.39). Participants with a basic or intermediate level of education had a higher probability of dental mobility (OR 1.13, 95% CI 1.07 to 1.19), prostheses (OR 1.11, 95% CI 1.08 to 1.14) and missing teeth (OR 1.42, 95% CI 1.38 to 1.46).

CONCLUSIONS

The economic crisis affected the oral health of the Spanish population, with a more significant deterioration among men, working class individuals and unemployed individuals.

Economic change and population health: lessons learnt from an umbrella review on the Great Recession

OBJECTIVES

Worldwide, the COVID-19 pandemic triggered the sharpest economic downturn since the Great Recession. To prepare for future crises and to preserve public health, we conduct an overview of systematic reviews to examine the evidence on the effect of the Great Recession on population health.

METHODS

We searched PubMed and Scopus for systematic reviews and/or meta-analyses focusing specifically on the impact of the Great Recession on population health (eg, mental health). Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed throughout this review and critical appraisal of included systematic reviews was performed using Assessing the Methodological Quality of Systematic Reviews.

RESULTS

Twenty-one studies were identified and consistently showed that the Great Recession was most risky to health, the more a country's economy was affected and the longer strict austerity policies were in place. Consequently, a deterioration of health was highest in countries that had implemented strict austerity measures (eg, Greece), but not in countries that rejected austerity measures (eg, Germany). Moreover, the impact of the Great Recession fell disproportionately on the most vulnerable groups such as people in unemployment, at risk of unemployment and those living in poverty.

CONCLUSIONS

The experiences of the last economic crisis show that it is possible to limit the consequences for health. Prioritising mental healthcare and prevention, foregoing austerity measures in the healthcare system and protecting vulnerable groups are the most important lessons learnt. Moreover, given the further aggravating social inequalities, a health in all policies approach, based on a comprehensive Health Impact Assessment, is advised.

Association between Economic Growth, Mortality, and Healthcare Spending in 31 High-Income Countries

This study aims to investigate the association between gross domestic product (GDP), mortality rate (MR) and current healthcare expenditure (CHE) in 31 high-income countries. We used panel data from 2000 to 2017 collected from WHO and OECD databases. The association between CHE, GDP and MR was investigated through a random-effects model. To control for reverse causality, we adopted a test of Granger causality. The model shows that the MR has a statistically significant and negative effect on CHE and that an increase in GDP is associated with an increase of CHE (p < 0.001). The Granger causality analysis shows that all the variables exhibit a bidirectional causality. We found a two-way relationship between GDP and CHE. Our analysis highlights the economic multiplier effect of CHE. In the debate on the optimal allocation of resources, this evidence should be taken into due consideration.

Scabies in Spain? A comprehensive epidemiological picture

INTRODUCTION

Scabies is a neglected disease stablished worldwide with a fairy well determined incidence. In high-income countries, it often causes outbreaks affecting the residents and staff of institutions and long-term facilities, usually hard to detect and control due to the difficult diagnosis and notification delay. This study aim at characterizing the affected population, geographical distribution, and evolution of scabies in Spain from 1997-2019 as well as to describe the main environments of transmission using different data sources.

METHODS

We carried out a nationwide retrospective study using four databases, which record data from different perspectives: hospital admissions, patients attended at primary healthcare services, outbreaks, and occupational diseases. We described the main characteristics from each database and calculated annual incidences in order to evaluate temporal and geographical patterns. We also analyzed outbreaks and occupational settings to characterize the main transmission foci and applied Joinpoint regression models to detect trend changes.

RESULTS

The elderly was the most frequent collective among the hospital admitted patients and notified cases in outbreaks, while children and young adults were the most affected according to primary care databases. The majority of the outbreaks occurred in homes and nursing homes; however, the facilities with more cases per outbreak were military barracks, healthcare settings and nursing homes. Most occupational cases occurred also in healthcare and social services settings, being healthcare workers the most common affected professional group. We detected a decreasing trend in scabies admissions from 1997 to 2014 (annual percentage change -APC- = -11.2%) and an increasing trend from 2014 to 2017 (APC = 23.6%). Wide geographical differences were observed depending on the database explored.

DISCUSSION

An increasing trend in scabies admissions was observed in Spain since 2014, probably due to cutbacks in social services and healthcare in addition to worsen of living conditions as a result of the 2008 economic crisis, among other reasons. The main transmission foci were healthcare and social settings. Measures including enhancing epidemic studies and national registries, reinforcing clinical diagnosis and early detection of cases, hygiene improvements and training of the staff and wide implementation of scabies treatment (considering mass drug administration in institutions outbreaks) should be considered to reduce the impact of scabies among most vulnerable groups in Spain.

Development of medicines consumption in Portugal before and during the financial crisis

BACKGROUND

In May 2011, the Portuguese Government signed a Memorandum of Understanding with the European Commission, the European Central Bank and the International Monetary Fund, including detailed measures to control health costs, allowing Portugal to receive a financial rescue package. This study aims to investigate medicines utilization in the outpatient sector during Troika's financial rescue.

METHODS

Using Defined Daily Dose per million inhabitants per year as a measurement unit, we compared medicines utilization with other relevant indicators over 5-year intervals for a total period of 20 years, based on a built-in inventory of national outpatient drug use using the Intercontinental Medical Statistics Health and Anatomical Therapeutic Chemical index of the World Health Organization databases. The calculation was made on the basis of both compound and year-on-year growth rates.

RESULTS

With the exception of the interval 2009-11, an absolute rise in consumption was observed over the 20-year period. The downturn occurred prior to financial rescue, when expenditure management mechanisms were already in place, and coincided with an increase in out-of-pocket spending. With the decline of cost for patients, the access trend returned to being positive, but at a slower pace.

CONCLUSION

The rise in out-of-pocket and austerity measures may have led to decreased access to medicines. The findings of this study suggest that this impact was influenced by public cost-saving policies implemented even before the financial rescue. The results show that price reduction attenuated the repercussion of the measures.

The economic crisis impact on the body mass index of children living in distinct urban environments

OBJECTIVES

Little is known about the impact of the 2008 global economic recession on childhood obesity in Portugal. Thus, this study's goals were to compare weight status of children during and after the economic crisis according to their neighbourhood environment features and to assess changes in specific dietary habits during the economic crisis.

STUDY DESIGN

Cross-sectional study.

METHODS

Data including weight, height, residence address to allow its geocoding and dietary habits changes during the crisis from children living in Lisbon municipality were collected in 2009 (N = 929) and in 2016 (N = 1751). A multidimensional environment index, with data of both built and socioeconomic nature collected at the statistical section level (areas comprised 300 dwellers) in the 2011 census, was used to characterize neighbourhoods.

RESULTS

Overall, the proportion of children who are overweight or obese living in the socioeconomically vulnerable areas decreased in 2016. Families living in the latter areas stopped buying some food items, started to buy cheaper food items, cooked more meals at home and ate less in restaurants. In 2016, the risk for overweight and obesity increased in children who lived in the least advantageous areas. Living in areas with high socioeconomic status or most advantageous areas no longer represented a decreased risk of being overweight or obese in children in 2016 as it did in 2009.

CONCLUSIONS

This study suggests that the economic crisis enhanced the social inequalities regarding childhood obesity. These results aid the development of evidence-based strategies to lessen the social inequities in health outcomes created by the crisis.

Big data-based analysis to characterise and identify variations in the type of Primary Care visits before and during COVID in Catalonia

Background

The COVID-19 pandemic has turned the care model of health systems around the world upside down, causing the abrupt cancellation of face-to-face visits and redirection of the model toward telemedicine. Digital transformation boosts information systems—the more robust they are, the easier it is to monitor the health care system in a highly complex state and allow for more agile and reliable analysis.

Objective

The purpose of this study was to analyze diagnoses from primary care visits and distinguish between those that had higher and lower variations, relative to the 2019 and 2020 periods (roughly before and during COVID-19), to identify clinical profiles that may have been most impaired from the least-used diagnostic codes for visits during the pandemic.

Methods

We used a database from the Primary Care Services Information Technologies Information System of Catalonia. We analyzed the register of visits (n=2,824,185) and their International Classification of Diseases (ICD-10) diagnostic codes (n=3,921,974; mean 1.38 per visit), as approximations of the reasons for consultations, at 3 different grouping levels. The data were represented by a term frequency matrix and analyzed recursively in different partitions aggregated according to date.

Results

The increase in non–face-to-face visits (+267%) did not counterbalance the decrease in face-to-face visits (–47%), with an overall reduction in the total number of visits of 1.36%, despite the notable increase in nursing visits (10.54%). The largest increases in 2020 were visits with diagnoses related to COVID-19 (ICD-10 codes Z20-Z29: 2.540%), along with codes related to economic and housing problems (ICD-10 codes Z55-Z65: 44.40%). Visits with most of the other diagnostic codes decreased in 2020 relative to those in 2019. The largest reductions were chronic pathologies such as arterial hypertension (ICD-10 codes I10-I16: –32.73%) or diabetes (ICD-10 codes E08-E13: –21.13%), but also obesity (E65-E68: –48.58%) and bodily injuries (ICD-10 code T14: –33.70%). Visits with mental health–related diagnostic codes decreased, but the decrease was less than the average decrease. There was a decrease in consultations—for children, adolescents, and adults—for respiratory infections (ICD-10 codes J00-J06: –40.96%). The results show large year-on-year variations (in absolute terms, an average of 12%), which is representative of the strong shock to the health system.

Conclusions

The disruption in the primary care model in Catalonia has led to an explosive increase in the number of non–face-to-face visits. There has been a reduction in the number of visits for diagnoses related to chronic pathologies, respiratory infections, obesity, and bodily injuries. Instead, visits for diagnoses related to socioeconomic and housing problems have increased, which emphasizes the importance of social determinants of health in the context of this pandemic. Big data analytics with routine care data yield findings that are consistent with those derived from intuition in everyday clinical practice and can help inform decision making by health planners in order to use the next few years to focus on the least-treated diseases during the COVID-19 pandemic.

Trends and equity in the use of health services in Spain and Germany around austerity in Europe

Background

Following the 2008 economic crisis many countries implemented austerity policies, including reducing public spending on health services. This paper evaluates the trends and equity in the use of health services during and after that period in Spain – a country with austerity policies – and in Germany – a country without restriction on healthcare spending.

Methods

Data from several National Surveys in Spain and several waves of the Socio-Economic Panel in Germany, carried out between 2009 and 2017, were used. The dependent variables were number of doctor’s consultations and whether or not a hospital admission occurred. The measure of socioeconomic position was education. In each year, the estimates were made for people with and without pre-existing health problems. First, the average number of doctor’s consultations and the percentage of respondents who had had been hospitalized were calculated. Second, the relationship between education and use of those health services was estimated by calculating the difference in consultations using covariance analysis – in the case of number of consultations – and by calculating the percentage ratio using binomial regression – in the case of hospitalization.

Results

The annual mean number of consultations went down in both countries. In Spain the average was 14.2 in 2009 and 10.4 in 2017 for patients with chronic conditions; 16.6 and 13.5 for those with a mental illness; and 6.4 and 5.9 for those without a defined illness. In Germany, the averages were 13.8 (2009) and 12.9 (2017) for the chronic group; 21.1 and 17.0 for mental illness; and 8.7 and 7.5 with no defined illness. The hospitalization frequency also decreased in both countries. The majority of the analyses presented no significant differences in relation to education.

Conclusion

In both Spain and Germany, service use decreased between 2009 and 2017. In the first few years, this reduction coincided with a period of austerity in Spain. In general, we did not find socioeconomic differences in health service use.

Socioeconomic inequalities in self-assessed health and mental health in Barcelona, 2001-2016

OBJECTIVE

Previous research has found persistent socioeconomic inequalities in health outcomes at the national level, with different patterns after the economic crisis. However, inequalities in urban areas are also important. This study analyses socioeconomic inequalities in self-assessed health and mental health in the city of Barcelona.

METHOD

Repeated cross-sectional design using quinquennial data from the Barcelona Health Surveys carried out in 2001, 2006, 2011 and 2016 for the population older than 22 years. Robust Poisson regressions models were used to compute socioeconomic gradients and relative (RII) and slope indexes of inequality (SII) by occupational social class, with stratification by sex. RII and SII were also obtained with further adjustment by employment situation.

RESULTS

A consistent socioeconomic gradient was found for all years except for 2011. Relative and absolute inequalities followed a V-shape, showing a drop during the economic crisis but widening thereafter to recover pre-crisis figures for self-assessed health and widening for mental health, in both relative and absolute terms in 2016. Adjustment for employment situation reduces inequalities but a large part of these inequalities remains, with variability across years.

CONCLUSIONS

The lasting effects of the 2008 economic crisis and the austerity programmes imposed since then may have contributed to the persistence of socioeconomic inequalities in self-assessed health and the widening of those for mental health.

Inequalities in the long-term impact of the economic recession on preventive healthcare use and health-related lifestyle in Spain (2006-2017)

Study of the long-term impact of economic recession on lifestyle according to socioeconomic groups is scarce. This study examines health-related lifestyle and preventive medical attendance in different socioeconomic groups in the Spanish adult population (18-64 years of age) before, during and after an economic recession. Data were collected from three waves of the Spanish National Health Survey (2006, 2012 and 2017). Self-perceived health, health-related lifestyle and common preventive medical attendance were evaluated by means of multivariate logistic models. The increase in good self-perceived health in 2006-2012 was 7.1%, 6.9% and 8.3% for the high, middle and low group, respectively, and 5.2%, 5.9% and 7.9% for the high, middle and low group, respectively, in 2006-2017. In 2006-2012 and 2006-2017, the gap increased between people of the high and low groups in smoking prevalence (2.8%-4.7%), physical activity (2.0%-4.0%), daily fruit (1.0%-6.3%) and vegetable intake (2.5%-6.1%). The probability of women´s gynaecological attendance increased statistically significant for cytology in three groups in 2006-2012 and 2006-2017 (OR = 1.35, 95% CI = 1.08-1.67; OR = 1.42, 95% CI = 1.18-1.7; OR = 1.34, 95% CI = 1.21-1.47 for the high, middle and low groups, respectively, in 2006-2012 and OR = 1.34, 95% CI = 1.08-1.67; OR = 1.62, 95% CI = 1.35-1.95; OR = 1.51, 95% CI = 1.37-1.66 for the high, middle and low groups, respectively, in 2006-2017), but not for mammography. This study reveals long-term socioeconomic inequalities in lifestyle behaviours after the economic recession. Health policies must be emphasised in these population subgroups and in more disadvantaged populations.

Autonomy, power dynamics and antibiotic use in primary healthcare: A qualitative study

Antibiotic resistance is a global health concern. Although numerous strategies have tried to reduce inadequate antibiotic prescribing, antibiotics are still prescribed in 60% of acute lower respiratory tract infections (ALRTIs) cases in Catalonia (Spain). This study aims to explore service users' experiences of ALRTIs, the quality and access to healthcare services, and health education. Selective purposive sampling was carried out, based on a prior definition of participant characteristics. These were sex, age, ethnicity, date of the last ALRTI, number of ALRTIs in the last year, and treatments received. Participants with a previous diagnosis of ALRTIs were recruited from three primary health care centres in Barcelona and one in Tarragona. Twenty-nine interviews were conducted between April and June 2019. A content thematic analysis was performed. Three themes were identified: 1) risk perceptions and help-seeking; 2) treatment preferences and antibiotic use; and 3) relationship dynamics and communication with healthcare professionals. Accounts of service users' sense of autonomy towards their health and power dynamics within the healthcare system were apparent. Supporting service users to become reliable, subjective and agentic experts of their health and bodies could help them to voice their healthcare agendas. Power structures embedded within healthcare, political and economic institutions should be challenged so that healthcare services can be co-developed (with service users) and based on service users' autonomy and horizontal relationships. Special consideration should be paid to the intersection of social vulnerabilities. A concordance approach to prescribing could be key to improve the responsible use of antibiotics and to contribute to the prevention of AMR in primary healthcare. The marketisation of health, and the increased demands of private healthcare in Spain due to the financial pressures on public healthcare as a consequence of the financial crisis of 2008 and the COVID-19 pandemic, are a risk for promoting adequate antibiotic prescribing and use. Trial registration The ISAAC-CAT study has been registered in the NCT registry, ID: NCT03931577.

Income-related inequalities in unmet dental care needs in Spain: traces left by the Great Recession

BACKGROUND

Dental health is an important component of general health. Socioeconomic inequalities in unmet dental care needs have been identified in the literature, but some knowledge gaps persist. This paper tries to identify the determinants of income-related inequality in unmet need for dental care and the reasons for its recent evolution in Spain, and it inquires about the traces left by the Great Recession.

METHODS

Data from the EU-SILC forming a decade (2007-2017) were used. Income-related inequalities for three years were measured by calculating corrected concentration indices (CCI), which were further decomposed in order to compute the contribution of different factors to inequality. An Oaxaca-type decomposition approach was also used to analyze the origin of changes over time. Men and women were analyzed separately.

RESULTS

Pro-rich inequality in unmet dental care needs significantly increased over time (CCI 2007: - 0.0272 and - 0.0334 for males and females, respectively; CCI 2017: - 0.0704 and - 0.0776; p < 0.001). Inequality showed a clear "pro-cycle" pattern, growing during the Great Recession and starting to decrease just after the economic recovery began. Gender differences only were significant for 2009 (p = 0.004) and 2014 (p = 0.063). Income was the main determinant of inequality and of its variation along time -particularly for women-, followed by far by unemployment -particularly for men-; the contributions of both were mainly due to changes in elasticites.

CONCLUSIONS

The Great Recession left its trace in form of a higher inequality in the access to dental care. Also, unmet need for dental care, as well as its inequality, became more sensitive to the ability to pay and to unemployment along recent years. To broaden public coverage of dental care for vulnerable groups, such as low-income/unemployed people with high oral health needs, would help to prevent further growth of inequality.

Trends, Coverage and Influencing Determinants of Influenza Vaccination in the Elderly: A Population-Based National Survey in Spain (2006-2017)

Influenza is a significant public health problem and the elderly are at a greater risk of contracting the disease. The vaccination coverage of the elderly is below the Spanish target of 65% for each influenza season. The aims of this study were to report the coverage of influenza vaccination in Spain among the population aged ≥65 years and high-risk groups for suffering chronic diseases, to analyze the time trends from 2006 to 2017 and to identify the factors which affect vaccination coverage. A nationwide cross-sectional study was conducted including 20,753 non-institutionalized individuals aged ≥65 years who had participated in the Spanish National Health Surveys in 2006, 2011/2012, and 2017. Sociodemographic, health-related variables, and influenza vaccination data were used. A logistic regression analysis was performed to determine the variables associated with influenza vaccination. Influenza vaccination coverage was 60%. By chronic condition, older people with high cholesterol levels and cancer had the lowest vaccination coverage (62.41% and 60.73%, respectively). This coverage declined from 2006 to 2017 in both groups. Higher influenza vaccination was associated with males, Spanish nationality, normal social support perceived, polypharmacy, worse perceived health, participation in other preventive measures, and increasing age and the number of chronic diseases.

Differences in physical and psychological health in patients with chronic low back pain: a national survey in general Spanish population

PURPOSE

To estimate the prevalence of diagnosed and undiagnosed chronic low back pain (CLBP-D and CLBP-UD, respectively) in the general adult population in Spain and to compare the characteristics of these two groups with subjects without CLBP symptoms (No-CLBP). To establish CLBP-D patient sub-groups according to their self-perceived health status, mental health, level of pain and the impact of their pain on daily activities.

METHODS

Data were obtained from the National Health Survey of Spain 2017 with a sample of 23,089 adults. Three groups were defined: CLBP-D, CLBP-UD and No-CLBP. In the CLBP-D group, a cluster analysis was performed to identify sub-groups. A multinomial regression model was constructed to determine the factors associated with each of the sub-groups identified.

RESULTS

The prevalence of CLBP-D was 22% (95% CI 21.5-22.5) and that of CLBP-UD was 1.4% (95% CI 1.2-1.5). CLBP-D was more common in middle-aged females with a low educational level. They have a worse perceived health status, report more comorbidities, have worse mental health and more limitations in comparison with the populations without CLBP and with CLBP-UD. Three sub-groups of CLBP-D subjects were identified. Women and older subjects with a lower educational level, more occupational stress, less social support and with more physical limitations were the most likely subjects to be included in the group worst-affected.

CONCLUSIONS

There is a high prevalence of CLBP among the adult population in Spain. Occupational stress and a lack of social support are common factors among subjects' worst-affected of CLBP-D and identifying the subjects with these risks is therefore a recommended strategy for improving the healthcare provided to CLBP patients.

Prevalence and Determinants of Antibiotic Consumption in the Elderly during 2006-2017

Elderly people are a particularly important population with regard to antibiotic overuse, using around 50% more antibiotics per capita than younger adults. The aim of this study was to analyze the prevalence, associated factors and evolution over time of antibiotic consumption among the Spanish population aged ≥ 65 years from 2006 to 2017. A descriptive cross-sectional study was conducted using data from the Spanish National Health Survey in 2006, 2011/2012 and 2017, and from the European Health Survey in Spain in 2009 and 2014. The sample consisted of 26,891 non-institutionalized individuals ≥ 65 years. Antibiotic consumption was the dependent variable, and sociodemographic variables, lifestyle habits and health status were analyzed using a logistic regression model. The prevalence of antibiotic consumption was 4.94%, with a marked increase from 2006 (4.64%) to 2017 (5.81%) (p < 0.0001). Higher antibiotic consumption was associated with poor or very poor self-perceived health status, no polypharmacy and not having been in hospital during the previous twelve months, while a lower consumption was linked to being limited but not severely due to a health problem and not being at all limited.

[Assessment of the consensus document on food in educational centres to evaluate school menus]

OBJECTIVE

To explore the applicability of the Consensus Document on School Food Programmes in Educational Centres (DCSECE) to evaluate the adaptation of school menus to healthy eating recommendations.

METHOD

Transversal study that analyzes monthly school menus from 28 early-childhood education and primary education centres in Andalusia and Canary Islands (Spain). Data were collected using an ad-hoc protocol based on the DCSECE recommendations and divided into food categories and subcategories. We studied the weekly menu offering of each of the foods by category and subcategory and compared them to the DCSECE recommendations.

RESULTS

The majority of the schools offered better meals than as specified by the recommendations, in terms of vegetables, other garnishes and other deserts. They offered poorer quality meals in the categories of rice, pasta, prepared foods and salads, and had an equivalent offering in terms of pulses, meats, fish and eggs. By subcategory, we observed the predominance of cooked vegetables in the vegetable category as compared to salads, and the predominance of processed meats in the meats category.

CONCLUSIONS

The DCSECE could be a useful instrument for evaluating the nutritional offering of school menus. However, there is a need for greater specificity in the recommendations, in order to identify whether these menus adhere to healthy eating recommendations.

Austerity, healthcare provision, and health outcomes in Spain

The recession that started in the United States in December 2007 has had a significant impact on the Spanish economy through a large increase in the unemployment rate and a long recession which led to tough austerity measures imposed on public finances. Taking advantage of this quasi-natural experiment, we use data from the Spanish Ministry of Health from 1996 to 2015 to provide novel causal evidence on the short-term impact of changes in healthcare provision and regulations on health outcomes. The fact that regional governments have discretionary powers in deciding healthcare budgets and that austerity measures have not been implemented uniformly across Spain helps isolate the impact of these policy changes on health indicators of the Spanish population. Using Ruhm's (Q J Econ 115(2):617-650, 2000) fixed effects model, we find that medical staff and hospital bed reductions account for a significant increase in mortality rates from circulatory diseases and external causes, but not from other causes of death. Similarly, mortality rates do not seem to be robustly affected by the 2012 changes in retirees' pharmaceutical co-payments and access restrictions for illegal immigrants. Our results are robust to changes in model specification and sample selection and are primarily driven by accidental and emergency deaths rather than in-hospital mortality, which suggests a larger role for decreases in accessibility rather than decreases in healthcare quality as impact channels.

The Impact of Business Cycle on Health Financing: Subsidized, Voluntary and Out-of-Pocket Health Spending

Diverse types of healthcare systems in countries offer opportunities to explore the heterogeneous sources of health financing. This paper widely explores the effect of the business cycle on subsidized, voluntary and out-of-pocket health spending in 34 countries with different types of healthcare systems, by the methodology of hierarchical linear modeling (HLM). We use a panel of annual data during the years from 2000 to 2016. It further examines the business cycle-health financing mechanism by inquiring into the mediating effect of external conditions and innovative health financing, based on the structural equation modeling (SEM). The empirical results reveal that the business cycle harms subsidized spending, whereas its effect on voluntary and protective health spending is positive. Results related to the SEM indicate that the mediating effect of external conditions on the relationship between the business cycle and health financing is negative. However, we find that the business cycle plays a positive effect on health financing through innovative health financing channels. Thus, designing and implementing efforts to shift innovative health financing have substantial effects on the sustainability of healthcare systems.

Effect of the Financial Crisis on Socioeconomic Inequalities in Mortality in Small Areas in Seven Spanish Cities

Background: The aim of this study was to analyze the trend in socioeconomic inequalities in mortality in small areas due to several specific causes before (2001–2004, 2005–2008) and during (2009–2012) the economic crisis in seven Spanish cities. Methods: This ecological study of trends, with census tracts as the areas of analysis, was based on three periods. Several causes of death were studied. A socioeconomic deprivation index was calculated for each census tract. For each small area, we estimated standardized mortality ratios, and controlled for their variability using Bayesian models (sSMR). We also estimated the relative risk of mortality according to deprivation in the different cities, periods, and sexes. Results: In general, a similar geographical pattern was found for the socioeconomic deprivation index and sSMR. For men, there was an association in all cities between the deprivation index and all-cause mortality that remained stable over the three periods. For women, there was an association in Barcelona, Granada, and Sevilla between the deprivation index and all-cause mortality in the third period. Patterns by causes of death were more heterogeneous. Conclusions: After the start of the financial crisis, socioeconomic inequalities in total mortality in small areas of Spanish cities remained stable in most cities, although several causes of death showed a different pattern.

Chronic obstructive pulmonary disease (COPD) in Spain and the different aspects of its social impact: a multidisciplinary opinion document

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent diseases in the World, and one of the most important causes of mortality and morbidity. In adults 40 years and older, it affects more than 10% of the population and has enormous personal, family and social burden. Tobacco smoking is its main cause, but not the only one, and there is probably a genetic predisposition that increases the risk in some patients. The paradigm of this disease is changing in Spain, with an increase of women that has occurred in recent years. Many of the physio pathological mechanisms of this condition are well known, but the psychological alterations to which it leads, the impact of COPD on relatives and caregivers, the limitation of daily life observed in these patients, and the economic and societal burden that they represent for the health system, are not so well-known. A major problem is the high under-diagnosis, mainly due to difficulties for obtaining, in a systematic way, spirometries in hospitals and health-care centers. For this reason, the Fundación de Ciencias de la Salud and the Spanish National Network Center for Research in Respiratory Diseases (CIBERES) have brought together experts in COPD, patients and their organizations, clinical psychologists, experts in health economics, nurses and journalists to obtain their opinion about COPD in Spain. They also discussed the scientific bibliometrics on COPD that is being carried out from the CIBERES and speculated on the future of this condition. The format of the meeting consisted in the discussion of a series of questions that were addressed by different speakers and discussed until a consensus conclusion was reached.

The use of health care services in the Great Recession: evaluating inequalities in the Spanish context

OBJECTIVE

To analyse the effect of the Great Recession (2008) on primary care (PC) and secondary care (SC) inequalities in Spain.

METHOD

Repeated cross-sectional study using Spanish Health Surveys from 2001 to 2017 (n=139,566). Prevalence of PC and SC utilization were calculated standardized by age. Chi square tests for trend were conducted to explore the evolution. We performed logistic regression analyses adjusted by the Andersen's model of demand for care to explore inequalities prior to, during and following the recession. All the analyses were stratified by sex.

RESULTS

Healthcare use trends changed from a rapid increase in the pre-recession period to a plateau during the recession and a decrease in the post-recession period. Healthcare use was higher in women (PC: 15.8% to 32.5%; SC: 8.2% to 16.2%) than in men (PC: 11.3% to 24.1%; SC: 5.4% to 11.6%) and the gender gap increased. During the recession the likelihood of PC use was higher in disadvantaged groups, while SC had greater usage amongst more advantaged social groups. Inequalities in SC use increased during the recession and could not be attributed to factors of need.

CONCLUSIONS

Healthcare use trends changed as a result of the recession. There are socioeconomic inequalities in the use of PC and SC in Spain, which increased in secondary care, during the recession and in the post-recession period. It is necessary to take into account socioeconomic determinants in health planning, in order to achieve equity in healthcare services.

Financial Catastrophism Inherent with Out-of-Pocket Payments in Long Term Care for Households: A Latent Impoverishment

Background: Out-of-pocket (OOP) payments are configured as an important source of financing long-term care (LTC). However, very few studies have analyzed the risk of impoverishment and catastrophic effects of OOP in LTC. To estimate the contribution of users to the financing of LTC and to analyze the economic consequences for households in terms of impoverishment and catastrophism after financial crisis in Spain.

METHODS

The database that was used is the 2008 Spanish Disability and Dependency Survey, projected to 2012. We analyze the OOP payments effect associated to the impoverishment of households comparing volume and financial situation before and after OOP payment. At the same time, the extent to which OOP payment had led to catastrophism was analyzed using different thresholds.

RESULTS

The results show that contribution of dependent people to the financing of the services they receive exceeds by 50% the costs of these services. This expenditure entails an increase in the number of households that live below the poverty. In terms of catastrophism, more than 80% of households dedicate more than 10% of their income to dependency OOP payments. In annual terms, the catastrophe gap generated by devoting more than 10% of the household income to dependent care OOP payment reached €3955, 1 million (0.38% of GDP).

CONCLUSION

This article informs about consequences of OOP in LCT and supplements previous research that focus on health. Our results should serve to develop strategic for protection against the financial risk resulting from facing the costs of a situation of dependence.

[Impact of Great Recession on mental health in Spain. SESPAS Report 2020]

The objective of this article is to identify the effects of the Great Recession on the mental health of people residing in Spain. After presenting a conceptual framework on the mechanisms through which economic crises affect mental health, we describe the main results of 45 papers identified in our search. Studies indicate a worsening of mental health in Spain in the years of economic crisis, especially in men. Working conditions (unemployment, low wages, instability, precariousness) emerge as one of the main channels through which mental health is put at risk or deteriorates. This deterioration occurs with intensity in particularly vulnerable groups, such as immigrant population and families with economic burdens. In the case of suicides, the results were inconclusive. Regarding the use of health care services, an increase in the consumption of certain drugs seems to be identified, although the conclusions of all the studies are not coincidental. Social inequalities in mental health do not seem to have remitted. We conclude that Spain needs to improve information systems to a better understanding of the health effects of economic crises. In terms of public policies, together with the reinforcement of health services aimed at addressing mental health problems, an income guarantee network for people in vulnerable situations should be promoted, as well as the development of policies aimed at the labour market.

Stable socioeconomic inequalities in ischaemic heart disease mortality during the economic crisis: a time trend analysis in 2 Spanish settings

Background

Prior studies have identified a decrease in ischaemic heart disease mortality during the recent economic recession. The Spanish population was severely affected by the Great Recession, however, there is little evidence on its effects on socioeconomic inequalities in ischaemic heart disease mortality. This study examines trends in socioeconomic inequalities in mortality due to ischaemic heart disease (IHD).

Methods

We used linked census records with mortality registers available from the Basque Country and Barcelona city for population above 25 years, between 2001 and 04, the accelerated economic growth period of 2005–08, and 2009–12, with the last period coinciding with the Great Recession. Applying Poisson models, we calculated relative and absolute indexes of inequalities by education level for each period, age group, gender, and site.

Results

We found moderate age-adjusted inequalities in IHD with a gradient of increasing rates through less educational level, but no significant evidence of increasing trends in socioeconomic inequalities in IHD mortality, rather an inverted U-shape time trend in some groups below 75 years in relative inequalities. Absolute inequalities decrease in the last period except for women from 50 to 64 years.

Conclusions

This study shows that the economic crisis has not increased socioeconomic inequalities in IHD mortality in two geographical settings in Spain.

Mortality in Spain in the Context of the Economic Crisis and Austerity Policies

Objectives. To analyze the mortality trend in Spain before, during, and after the economic crisis and austerity policies. Methods. We calculated age-standardized annual mortality rates in 2001 through 2016 and estimated linear trends in mortality rates during 4 periods (2001-2007, 2008-2010, 2011-2013, and 2014-2016) using the annual percentage change (APC). Results. All-cause mortality rate decreased during the period 2001 to 2016, although we found increases over the previous year. After adjusting for increased influenza activity (P = .743) and heat waves (P = .473), we found the greatest declines during the economic crisis (2008-2010) and the smallest in the period 2014 to 2016, in which the APC in mortality rates was -2.9 and -0.6, respectively. The APC before the crisis (2001-2007) and during austerity (2011-2013) was -2.0 and -2.2, respectively. We observed similar results in mortality from cardiovascular, respiratory, and digestive diseases and motor vehicle accidents. Mortality from cancer showed the smallest decline during the crisis and the austerity period, whereas suicide increased in the period 2011 to 2013. Conclusions. Lifestyle changes could explain the decline in mortality during the economic crisis. Increased influenza activity and the 2015 heat wave may prevent identifying a possible delayed effect of austerity policies in the slowing down of mortality decline in the period 2014 to 2016.

Mortality in working-age population during the Great Recession and austerity in Spain

OBJECTIVE

To analyze the mortality trend in Spain before, during and after the economic crisis and austerity policies in the working-age population.

METHODS

From 2005 to 2016 we calculated the annual all-cause mortality rate and the annual mortality rate from the main causes of death in the population aged 15 to 64. We also estimated the linear trends in mortality rates during four time intervals-2005-2007 (before crisis), 2008-2010 (first part of the crisis), 2011-2013 (second part of the crisis and implementation of austerity policies) and 2014-2016 (after the crisis)- by the annual percentage change (APC).

RESULTS

The all-cause mortality rate in men and women showed the greatest decline in 2008-2010 and the smallest decline in 2014-2016. The decline in 2011-2013 was higher than in 2014-2016. The APCs in 2005-2007, 2008-2010, 2011-2013 and 2014-2016 were -2.8, -4.1, -3.0 and -1.5 in men and -1.0. -2.1, -1.1 and -0.6 in women, respectively, although the APC in 2014-2016 in women was not significant. In 2014-2016, cancer mortality showed the largest decrease, mortality from cardiovascular diseases (men), respiratory diseases and traffic accidents reversed and showed an upward trend, and the downward trend in mortality from infectious diseases and digestive diseases was equal to or greater than that observed before the crisis.

CONCLUSION

The decline in all-cause mortality in the working-age population during the economic crisis and the introduction of austerity measures was greater than that observed before and after the economic crisis. The slowing of the decline after the crisis was due to the reversal of the trend in mortality from cardiovascular and respiratory diseases.

Solidarity against healthcare access restrictions on undocumented immigrants in Spain: the REDER case study

Background

In the context of public expenditure reduction and cuts, in 2012, the Spanish government approved the RDL 16/2012, which significantly affected the core values of the national health system. The measure particularly affected undocumented immigrants over 18 years of age, excluding them from accessing the full range of healthcare services in Spain, except for emergency care. In 2014, Red de Denuncia y Resistencia al RDL 16/2012 (REDER) was created as a public awareness and resistance network to defend universal access to healthcare and to stop its infringement. This study aims to analyse the social impact of REDER as a solidarity movement in response to the exclusion of undocumented immigrants from their universal right to health.

Methods

Qualitative research methodologies were used for the research. Data were collected between November 2017 and December 2017, using eight semi-structured interviews with key informants from the main REDER stakeholders. Additionally, key publications, documents, and presentations of researchers and experts in the field were analysed. For data analysis, a framework extracted from the literature on exclusionary and transformative dimensions of solidarity was used to identify barriers and drivers in REDER’s intervention.

Results

From its creation to the present, REDER has been able to achieve many of its objectives to defend the right to medical care of groups in irregular situations, contributing to the identification of 4,755 cases of discrimination in healthcare access and helping solve over 90% of these cases by delivering either healthcare assistance or administrative support. REDER has also played an important role in: stimulating social activation and empowering citizens to claim their fundamental rights, organising actions against restrictions on accessibility and creating synergies to restore universal healthcare coverage.

Conclusions

REDER has been shown to be effective in leading the defence of universal healthcare rights, and some achievements in the years following 2012 could be directly attributed to the work done by the network, such as the elimination of legal requirements to obtain health cards or the reduction of the minimum time required to access healthcare. Despite context particularities, the initiatives and main actions of this network may be implemented in other settings that are facing similar limitations to healthcare access, in order to address injustices and promote solidarity.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0971-9) contains supplementary material, which is available to authorized users.

Austerity Policies and Mortality Rates in European Countries, 2011-2015

OBJECTIVES

To assess time trends in mortality rates in European countries for the period 2011 to 2015 by level of austerity measures imposed by governments in response to the economic and financial crisis.

METHODS

We analyzed standardized mortality rates (SMRs) for 2011 through 2015 in 15 European countries based on Eurostat data ( http://ec.europa.eu/eurostat/data/database ). We used the Cyclically Adjusted Primary Balance (CAPB) in terciles as an independent variable to represent the level of austerity adopted in each country. We conducted a longitudinal analysis of panel data using generalized estimating equation models of SMR. We included interaction terms to assess the influence of time period and level of austerity.

RESULTS

SMRs generally declined in the study period, except in the last year of the study. In 2015, compared with countries in the low-austerity group, countries with intermediate austerity had excess mortality of 40.2 per 100 000 per year and those with high austerity had excess mortality of 31.22 per 100 000 per year.

CONCLUSIONS

The results suggest a negative effect on mortality in those countries that apply a higher level of austerity.

The Right to healthcare and fiscal austerity: the Brazilian case from an international perspective

The article analyzes the implications of the austerity policy in Brazil on the guarantee of universal social rights, focusing on the financing of the Unified Health System (SUS) and the right to health. The effects of the Brazilian austerity policy are analyzed in an international perspective, based on evidence produced in different contexts, identified from a literature review, in order to base the arguments developed in the article. Information on the fiscal austerity measures being implemented in Brazil is presented and its likely impacts on social protection in the country are analyzed in a context of significant economic recession. The austerity policy adopted in Brazil is not universal, since it does not affect all Brazilian society equally, nor does it have temporary effects, since it is not focused on reducing the momentary imbalance in public accounts. Its main objective is to promote the reduction of the size of the Brazilian State. Finally, we show alternative paths to the fiscal austerity policy that has been used to tackle the economic crisis. The authors argue by a national development project that is necessarily linked to social protection for the universe of citizens and based on values of solidarity.

Framing the Shades of Sustainability in Health Care: Pitfalls and Perspectives from Western EU Countries

Sustainability is momentous for the appropriate functioning of health care systems. In fact, health and sustainability are two strictly related values, which could not be separately sought. While studies discussing the contextualization of this issue with respect to the distinguishing attributes of health care systems are rapidly blooming, there is still little agreement about what is ultimately meant by sustainability in the health care arena. On the one hand, attention is primarily focused on the proper use of available financial resources; on the other hand, people engagement and empowerment are gradually arising as a crucial step to enhance the viability of the health care system. This paper tries to identify, from a conceptual point of view inspired by the European integrative movement, the different shades of sustainability in health care and proposes a recipe to strengthen the long-term viability of health care organizations. The balanced mix of financial, economic, political, and social sustainability is compelling to increase the ability of health care organizations to create meaningful value for the population served. However, the focus on a single dimension of sustainability is thought to engender several side effects, which compromise the capability of health care organizations to guarantee health gains at the individual and collective levels. From this standpoint, further conceptual and practical developments are envisioned, paving the way for a full-fledged understanding of sustainability in the health care environment.

Health Services Access Inequalities Between Native and Immigrant in a Southern European Region

With the economic crisis in Spain, austerity measures were applied. However, it is unknown how these measures have affected the pattern of use of health services for the immigrant population. Thus, the objective of this study was to examine the inequalities in access to different levels of health care services according to place of birth. We used data from the 2014 Foreign Immigrant Population Survey (n = 1,908) and the Basque Health Survey 2013 for the native population (n = 4,232) for adults aged 16-59 years residing in the Basque Country, Spain. Log-binomial regression was used to quantify the association between country of origin and use of different levels of care in men and in women. We found a higher probability of using general practitioner (GP) services in immigrant women (PR: 1.19; 95% CI: 1.12-1.26) and men (PR: 1.11; 95% CI: 1.01-1.23) than in natives. This was also true for emergency services with immigrant women (PR: 1.97; 95% CI: 1.43-2.69) and men (PR: 1.50; 95% CI: 1.01-2.25). However, for specialized medicine services, there was no association. This study suggests the importance of guaranteeing access to health care to the entire population. Hence policies to eliminate barriers to health care are essential to ensure health for all.

Career Ambition as a Way of Understanding the Relation Between Locus of Control and Self-Perceived Employability Among Psychology Students

Employability is one of the core concepts for the future career. Students' self-perceived employability is the concept that connects students' present context of education with their future professional engagement. Students' self-perceived employability is defined as the capacity to gain and keep employment in line with their future qualification level. Locus of control is a concept that explains where the person situates the causation of various life events. It is found that internal locus of control was related to different aspects of career success. Career ambition is regarded as a proxy for students' future career success. Both internal locus of control and ambition lead to proactive behaviors that are relevant for employability and consequently result in securing a sustainable job. The aim of this mixed-method study was to investigate the relations among locus of control, ambition and students' self-perceived employability. Firstly, we tested mediating role of career ambition in relation of internal locus of control and students' self-perceived employability, then we turned to qualitative analysis of students' career self-SWOT analyses in order to deepen and enrich quantitative findings. The sample consisted of 124 undergraduate psychology students that filled out Levenson's Internality subscale from IPC locus of control scale, Rothwell et al. (2008) Ambition subscale, and three items extracted from the Self-perceived employability subscale. Majority of the survey participants (N = 100) filled out personal career SWOT analysis. The mediation analysis showed that career ambition had a mediating role in the relation between the locus of control and employability. Students perceived personal capabilities and ambition as internal strengths and lack of ambition as a major internal weakness. As external opportunities students perceived various chances for developing professional skills, whereas as external threats they perceived limited opportunities in job market. In order to support university students to develop employability and future career success, university curricula should support developing future work skills that, in addition to functional competences and personal resources, entail career ambition, ways of utilizing external opportunities and dealing with job market threats.

Crisis, austeridad y áreas rurales: estudio cualitativo de las percepciones sobre los impactos en el sistema sanitario y la salud en Navarra, España

Resumen La crisis financiera ha impulsado severas medidas de austeridad al sistema español de atención a la salud, entre las que se destacan la reducción del gasto público, la modificación del principio básico de cobertura universal, el copago y las reformas laborales. En este artículo se presentan los resultados de un estudio cualitativo sobre la percepción del personal sanitario y de la población de los impactos de la crisis en el sistema sanitario y de la salud en las áreas rurales. Se consideró la metodología cualitativa como la opción idónea para el estudio de un fenómeno complejo, en el que se buscó profundidad en su comprensión, teniendo en cuenta los significados y el contexto. El estudio se realizó en tres valles del Pirineo navarro. Se llevaron a cabo 22 entrevistas semiestructuradas a informantes clave y de perfiles no expertos, que fueron analizadas según el análisis sociológico del discurso. La desigual accesibilidad a los servicios de salud por parte de la población rural fue el factor identificado de forma unánime como la mayor amenaza y desafío para estos territorios. Una desigualdad que se consideró agravada en la población más envejecida. Las personas entrevistadas no refirieron un impacto negativo en la calidad del servicio de atención primaria, sino que lo localizaron en el entorno urbano y en la asistencia especializada. Los impactos diferenciados de las políticas en las zonas rurales exigen más investigación atendiendo a sus particularidades y de esta forma comprender el impacto específico de la crisis en estos territorios.

Real and predicted mortality under health spending constraints in Italy: a time trend analysis through artificial neural networks

BACKGROUND

After 2008 global economic crisis, Italian governments progressively reduced public healthcare financing. Describing the time trend of health outcomes and health expenditure may be helpful for policy makers during the resources' allocation decision making process. The aim of this paper is to analyze the trend of mortality and health spending in Italy and to investigate their correlation in consideration of the funding constraints experienced by the Italian national health system (SSN).

METHODS

We conducted a 20-year time-series study. Secondary data has been extracted from a national, institution based and publicly accessible retrospective database periodically released by the Italian Institute of Statistics. Age standardized all-cause mortality rate (MR) and health spending (Directly Provided Services - DPS, Agreed-Upon Services - TAUS, and private expenditure) were reviewed. Time trend analysis (1995-2014) through OLS and Multilayer Feed-forward Neural Networks (MFNN) models to forecast mortality and spending trend was performed. The association between healthcare expenditure and MR was analyzed through a fixed effect regression model. We then repeated MFNN time trend forecasting analyses on mortality by adding the spending item resulted significantly related with MR in the fixed effect analyses.

RESULTS

DPS and TAUS decreased since 2011. There was a mismatch in mortality rates between real and predicted values. DPS resulted significantly associated to mortality (p < 0.05). In repeated mortality forecasting analysis, predicted MR was found to be lower when considering the pre-constraints health spending trend.

CONCLUSIONS

Between 2011 and 2014, Italian public health spending items showed a reduction when compared to prior years. Spending on services directly provided free of charge appears to be the financial driving force of the Italian public health system. The overall mortality was found to be higher than the predicted trend and this scenario may be partially attributable to the healthcare funding constraints experienced by the SSN.

Austerity Policies and Mortality in Spain After the Financial Crisis of 2008

OBJECTIVES

To analyze mortality in Spain and the United States before and after these countries implemented divergent policies in response to the financial crisis of 2008.

METHODS

We examined mortality statistics in both countries in the years 2000 to 2015. Spain started austerity policies in 2010. We compared differences in mortality ratios, on the basis of trends and effect size analysis.

RESULTS

During 2000 to 2010, overall mortality rates (r = 0.98; P < .001; Cohen's d = -0.228) decreased in both countries. In 2011, this trend changed abruptly in Spain, where observed mortality surpassed expected mortality by 29% in 2011 and by 41% in 2015. By contrast, observed mortality surpassed expected mortality in the United States by only 8% in 2015. As the mortality statistics diverged, the effect size greatly increased (d = 7.531). During this 5-year period, there were 505 559 more deaths in Spain than the expected number, while in the United States the difference was 431 501 more deaths despite the 7-fold larger population in the United States compared with Spain.

CONCLUSIONS

The marked excess mortality in 2011 to 2015 in Spain is attributable to austerity policies.

Effect of the economic crisis on the use of health and home care services among elderly Spanish diabetes patients

AIMS

To describe the utilization of health and home care services among older people (≥65 years) with diabetes during the economic crisis; to identify the factors associated with changes in the utilization of these services; and to study the time trends (2009-2014).

METHODS

We used the European Health Interview Surveys for Spain (EEHSS) for 2009/10 and 2014. The dependent variables included self-reported hospitalizations; general practitioner (GP) visits; 'other healthcare services' (OHS) used; and home care services (HCS) used.

RESULTS

We identified 6026 and 6020 diabetic patients (EEHSS2009 and EEHSS2014, respectively). A significant decrease in the number of GP visits (OR 0.94; 95% CI 0.91-0.98) and the use of HCS (OR 0.95; 95% CI 0.91-0.99) was found; however, we found an increase in the use of OHS (OR 1.06; 95% CI 1.02-1.10). Multivariate models showed that factors associated with an increased use included chronic conditions, worse self-rated health, pain and mental disorders. Physical activity was a strong predictor of lower hospitalizations and HCS use. Female gender was associated with significantly lower hospitalizations and a higher use of OHC and HCS.

CONCLUSION

We found a decrease in the number of GP visits and the use of HCS among elderly diabetic adults; however, we also observed an increase in the use of OHS, which may partly explain this decrease in the figures. Significant differences in the use of health services were found according to gender. The effect of the economic crisis, if any, seems to have had a small magnitude.

The Effects of Organizational Justice on Positive Organizational Behavior: Evidence from a Large-Sample Survey and a Situational Experiment

Employees' positive organizational behavior (POB) is not only to promote organizational function but also improve individual and organizational performance. As an important concept in organizational research, organizational justice is thought to be a universal predictor of employee and organizational outcomes. The current set of two studies examined the effects of organizational justice (OJ) on POB of employees with two different studies, a large-sample survey and a situational experiment. In study 1, a total of 2,566 employees from 45 manufacturing enterprises completed paper-and-pencil questionnaires assessing organizational justice (OJ) and positive organizational behavior (POB) of employees. In study 2, 747 employees were randomly sampled to participate in the situational experiment with 2 × 2 between-subjects design. They were asked to read one of the four situational stories and to image that this situation happen to the person in the story or them, and then they were asked to imagine how the person in the story or they would have felt and what the person or they subsequently would have done. The results of study 1 suggested that OJ was correlated with POB of employees and OJ is a positive predictor of POB. The results of study 2 suggested that OJ had significant effects on POB and negative organizational behavior (NOB). Procedural justice accounted for significantly more variance than distributive justice in POB of employees. Distributive justice and procedural justice have different influences on POB and NOB in terms of effectiveness and direction. The effect of OJ on POB was greater than that of NOB. In addition, path analysis indicated that the direct effect of OJ on POB was smaller than its indirect effect. Thus, many intermediary effects could possibly be between them.

Health Expenditure and All-Cause Mortality in the 'Galaxy' of Italian Regional Healthcare Systems: A 15-Year Panel Data Analysis

BACKGROUND

The sustainability of healthcare systems is a topic of major interest. During periods of economic instability, policy makers typically reallocate resources and execute linear cuts in different areas of public spending, including healthcare.

OBJECTIVES

The aim of this paper was to examine whether and how per capita public healthcare expenditure (PHE) in the Italian regions was related to the all-cause mortality rate (MR) between 1999 and 2013 and to determine which expenditure item most affected mortality in the short and very short term.

METHODS

We conducted a pooled cross-sectional time series study. Secondary data were extracted from 'Health for All', a database released periodically by the Italian National Institute of Statistics. PHE is subdivided into directly provided services (DPS), pharmaceutical care, general practitioner care, specialist medical care, privately delivered hospital care, other privately delivered medical services, and psychiatric support and rehabilitation. We used a fixed-effects regression to assess the effects of PHE items on the MR after controlling for a number of socioeconomic and supply variables.

RESULTS

Higher spending on DPS was associated with a lower MR. Other expenditure variables were not significantly associated with the MR.

CONCLUSIONS

The results highlight the importance of medical services and goods provided directly by public services (i.e. hospital-based general and specialized wards and offices, emergency departments, etc.). DPS represents the driving force of the system and should be considered a determinant of the health of the Italian population. Our results suggest that the context and financing methods of a healthcare system should be carefully analysed before linear cuts are made or resources are reallocated.

Work Engagement in Serbia: Psychometric Properties of the Serbian Version of the Utrecht Work Engagement Scale (UWES)

Work engagement is defined as a positive, affective-motivational state of work-related well-being characterized by vigor, dedication and absorption. The Utrecht Work Engagement Scale (UWES) is the most frequently used measure of work engagement. The aim of this study was to analyze the psychometric properties of the Serbian versions of the UWES-17 and UWES-9. The sample consisted of 860 employees from a number of organizations and jobs across Serbia. Based on the UWES-17 findings, the data confirm both the three-factor and one-factor solutions by giving a slight advantage to the three-factor solution. As for the UWES-9, based on the PCFA and CFA, the one-factor solution was obtained as the preferred one. Taking into account the UWES-9 reliability and correlation patterns of its subscales with other well-being variables, both one- and three-factor solutions of the UWES-9 are suggested for future research. Serbian versions of both the UWES-17 and UWES-9 have satisfactory psychometric properties with high reliability, factorial structure in line with the theoretical model, and good predictive validity. The study contributes to enhanced understanding of work engagement by offering an insight from the Serbian cultural and economic context, significantly different from the UWES originating setting. There is still a need for exploring how employees from Serbia conceptualize work engagement, as well as for further, more stringent investigating of the cultural invariance of the UWES factorial structure.