Weighing social and economic determinants related to inequalities in mortality

[Health inequalities as a political priority in Barcelona]

There is a wealth of information and research on health inequalities in Barcelona, but this issue has not been clearly prioritised on the political agenda. The arrival in government of a new left-wing party (Barcelona en Comú) in 2015, gave an important boost to the political agenda to reduce inequalities and health inequalities. The aim of this review is to describe the progress made in relation to health inequalities in these four years and especially in the areas involving public health. With respect to evidence and communication on health inequalities, the progress made is presented in the Barcelona annual health report and the creation of the Observatory on Health, Inequalities and Impacts of Municipal Policies. The policies presented refer to different municipal strategies, the Health Plan, the promotion of the Barcelona Health in the Neighbourhoods programme and the Plan for Tackling Inequalities in the Barcelona Public Health Agency. The combination of political will, technical capacity and the drive of citizens have facilitated progress in the city of Barcelona in policies to reduce social inequalities in health.

The Experience of Implementing Urban HEART Barcelona: a Tool for Action

Urban Health Equity Assessment and Response Tool (HEART) is a tool developed by the World Health Organization whose objective is to provide evidence on urban health inequalities so as to help to decide the best interventions aimed to promote urban health equity. The aim of this paper is to describe the experience of implementing Urban HEART in Barcelona city, both the adaptation of Urban HEART to the city of Barcelona, its use as a means of identifying and monitoring health inequalities among city neighbourhoods, and the difficulties and barriers encountered throughout the process. Although ASPB public health technicians participated in the Urban HEART Advisory Group, had large experience in health inequalities analysis and research and showed interest in implementing the tool, it was not until 2015, when the city council was governed by a new left-wing party for which reducing health inequalities was a priority that Urban HEART could be used. A provisional matrix was developed, including both health and health determinant indicators, which allowed to show how some neighbourhoods in the city systematically fare worse for most of the indicators while others systematically fare better. It also allowed to identify 18 neighbourhoods-those which fared worse in most indicators-which were considered a priority for intervention, which entered the Health in the Barcelona Neighbourhoods programme and the Neighbourhoods Plan. This provisional version was reviewed and improved by the Urban HEART Barcelona Working Group. Technicians with experience in public health and/or in indicator and database management were asked to indicate suitability and relevance from a list of potential indicators. The definitive Urban HEART Barcelona version included 15 indicators from the five Urban HEART domains and improved the previous version in several requirements. Several barriers were encountered, such as having to estimate indicators in scarcely populated areas or finding adequate indicators for the physical context domain. In conclusion, the Urban HEART tool allowed to identify urban inequalities in the city of Barcelona and to include health inequalities in the public debate. It also allowed to reinforce the community health programme Health in the Barcelona Neighbourhoods as well as other city programmes aimed at reducing health inequalities. A strong political will is essential to place health inequalities in the political agenda and implement policies to tackle them.

Economic Conditions and Drug and Opioid Overdose Deaths

We examine the effects of state-level economic conditions including unemployment rates, median house price, median household income, insurance coverage, and annual and weekly work time on deaths on drug overdose deaths including from opioids and prescription opioids between 1999 and 2014. We employ difference-in-differences estimation controlling for state and year fixed effects, state-specific time trends, and demographic characteristics. Drug overdose deaths significantly declined with higher house prices, an effect driven by reduction in prescription-opioid mortality, by nearly 0.17 deaths per 100,000 (~4%) with a $10,000 increase in median house price. House price effects were more pronounced and only significant among males, non-Hispanic Whites, and individuals younger 45 years. Other economic indicators had insignificant effects. Our findings suggest that economic downturns that substantially reduce house prices such as the Great Recession can increase opioid-related deaths, suggesting that efforts to control access to such drugs should especially intensify during these periods.

Recent immigration and adverse pregnancy outcomes in an urban setting in Spain

To describe social and economic inequalities in non-fatal pregnancy outcomes (low birth weight, preterm birth and small for gestational age births) in the neighbourhoods of the city of Barcelona (Spain), according to maternal age and maternal country of origin, between 1991 and 2005. A cross-sectional ecological study was carried out using the 38 neighbourhoods of Barcelona as the unit of analysis. The study population comprises the 192,921 live births to resident women aged 12-49 residing from 1991 to 2005. Information was gathered from births registry. Prevalence of low birth-weight, preterm birth and small for gestational age, was calculated for each of the 38 neighbourhoods of mothers' residence, stratifying results by maternal age and country of origin. The indicator of neighbourhood socio-economic level was the unemployment rate. Quartile maps along with Spearman correlation coefficients and linear regression were performed between indicators. The present study reports socio-economic inequalities in pregnancy outcomes among neighbourhoods in Barcelona (Spain): the more disadvantaged neighbourhoods have worse pregnancy outcomes (low birth weight, preterm birth and small for gestational age births) in all women age groups. These inequalities do not exist among immigrant women, and some groups of foreign mothers even have lower rates of low birth weight, preterm birth, and small for gestational age births than autochthonous women. The existing inequalities suggest that policy efforts to reduce these inequalities are not entirely successful and should focus on improving pregnancy and delivery care in less privileged women in a country with universal access to health care.

Socio-economic inequalities in mortality due to injuries in small areas of ten cities in Spain (MEDEA Project)

OBJECTIVES

To analyse socio-economic inequalities in mortality due to injuries among census tracts of ten Spanish cities by sex and age in the period 1996-2003.

METHODS

This is a cross-sectional ecological study where the units of analysis are census tracts. The study population consisted of people residing in the cities during the period 1996-2003. For each census tract we obtained an index of socio-economic deprivation, and estimated standardized mortality ratios using hierarchical Bayesian models which take into account the spatial structure of the data.

RESULTS

In the majority of the cities, the geographical pattern of total mortality from injuries is similar to that of the socio-economic deprivation index. There is an association between mortality due to injuries and the deprivation index in the majority of the cities which is more important among men and among those younger than 45 years. In these groups, traffic injuries and overdoses are the causes most often associated with deprivation in the cities. The percentage of excess mortality from injuries related to socio-economic deprivation is higher than 20% in the majority of the cities, the cause with the highest percentage being drug overdose.

CONCLUSIONS

In most cities, there are socio-economic inequalities in mortality due to overdose and traffic injuries. In contrast, few cities have found association between suicide mortality and deprivation. Finally, no association was found between deprivation and deaths due to falls. Inequalities are higher in men and those under 45 years of age. These results highlight the importance of intra-urban inequalities in mortality due to injuries.

Gender, socio-economic variables and target organ damage in new-diagnosed hypertensive patients

The aim of the study as to ascertain whether gender and socio-economic variables can explain differences in the degree of severity of hypertension (HT) at the time of diagnosis. Patients were recently diagnosed and never-treated hypertensives, seen in primary care sites and aged 15-75. This study also included a cohort of normotensive patients. All individuals were invited to respond a questionnaire to collect socio-demographic and socio-economic data. Target organ damage (TOD) is considered a marker of severity. Three hundred and eighty-eight individuals responded to the questionnaire, 277 hypertensive, 111 normotensive. In an ordered probit model, the odds ratio of presenting with more than one TOD were: Aged >67 (OR=1.22; 1.06-1.38), being a smoker (OR=1.21; 1.02-1.40) or ex-smoker (OR=2.89; 1.27-4.51), primary school education (OR=2.17; 1.47-2.87), being male (OR=0.75; 0.59-0.90), being an agricultural worker (OR=0.03; 0.00-0.05) or a salaried professional (OR=0.96; 0.94-0.99). The results show differences in the severity of the HT in the initial assessment of the patient according to gender or other socio-economic variables. It is particularly important at the time of carrying out the diagnosis and the HT assessment.

Preventable avoidable mortality: evolution of socioeconomic inequalities in urban areas in Spain, 1996-2003

This study describes the inequalities in preventable avoidable mortality in relation to socioeconomic levels and analyses their evolution during the period 1996-2003 in the cities of Alicante, Castellon and Valencia. Four causes of preventable avoidable mortality were analysed according to sex: malignant tumour of the trachea, bronchus and lung, cirrhosis and other chronic diseases of the liver, motor vehicle accidents and AIDS, which had caused the death of non-institutionalised residents in the three cities during the period 1996-2003. The different census tracts were grouped into three socioeconomic levels. In general, socioeconomic inequalities in preventable avoidable mortality remain constant in time, except the ones caused by AIDS in Valencia, where they increase for men. Some census tracts in the three cities where the study was carried out were found to have significantly higher preventable mortality rates, and therefore require intervention.

[Utility of an information system for primary care]

OBJECTIVE

To know the usefulness and applicability of an information system for basic health areas put into operation 16 years ago.

DESIGN

Descriptive study of selected indicators registered in 1994 and 2004.

SETTING

Basic health areas of Barcelona, Spain.

PARTICIPANTS

Population living in Barcelona, Spain, during 1994 and 2004.

MEASUREMENTS

The following indicators were described, and standardized taking the Barcelona 2004 population as reference: proportion of foreign population, proportion of unemployment, number of mothers less than 20 years old, AIDS incidence rate, tuberculosis incidence rate, and traffic accident, ischaemic disease, lung cancer (for men), breast cancer (for women), and total mortality rates. Results were presented for one basic health area, its corresponding district, and Barcelona. Moreover, users of the information system were interviewed about their level of knowledge, and the adequacy, usefulness, and limitations of the system.

RESULTS

Disaggregated annual information allows comparing indicators between different fields and years. The information system was found useful to users to describe the level of health of the community and to design preventive interventions.

CONCLUSIONS

Although some of the indicators did not show the desired level of accuracy, the information system for basic health areas showed to be useful to know the level of health of the population assigned to primary healthcare teams.

Somatic health among heroin addicts before and during opioid maintenance treatment: a retrospective cohort study

Background

The long-term impact of opioid maintenance treatment (OMT) on morbidity and health care utilization among heroin addicts has been insufficiently studied. The objective of this study was to investigate whether health care utilization due to somatic disease decreased during OMT, and if so, whether the reduction included all kinds of diseases and whether a reduction was related to abstinence from drug use.

Methods

Cohort study with retrospective registration of somatic disease incidents (health problems, acute or sub-acute, or acute problems related to chronic disease, resulting in a health care contact). Medical record data were collected from hospitals, Outpatients' Departments, emergency wards and from general practitioners (GPs) and prospective data on substance use during OMT were available from 2001 onwards. The observation period was five years before and up to five years during OMT. The cohort consisted of 35 out of 40 patients who received OMT between April 1999 and January 2005 in a Norwegian district town. Statistical significance concerning changes in number of incidents and inpatient and outpatient days during OMT compared with the pre OMT period was calculated according to Wilcoxon signed rank test. Significance concerning pre/during OMT changes in disease incidents by relation to the type of health service contacts, as well as the impact of ongoing substance use during OMT on the volume of contacts, was calculated according to Pearson chi-square and Fisher's exact tests.

Results

278 disease incidents were registered. There was a reduction in all incidents by 35% (p = 0.004), in substance-related incidents by 62% (p < 0.001) and in injection-related incidents by 70% (p < 0.001). There was an insignificant reduction in non-fatal overdose incidents by 44% (p = 0.127) and an insignificant increase in non-substance-related incidents by 13% (p = 0.741). Inpatient and outpatient days were reduced by 76% (p = 0.003) and 46% (p = 0.060), respectively. The disease incidents were less often drug-related during OMT (p < 0.001). Patients experienced a reduction in substance-related disease incidents regardless of ongoing substance use, however there was a trend towards greater reductions in those without ongoing abuse.

Conclusion

Although as few as 35 patients were included, this study demonstrates a significant reduction in health care utilization due to somatic disease incidents during OMT. The reduction was most pronounced for incidents related to substance use and injection. Inpatient and outpatient days were reduced. Most probably these findings reflect somatic health improvement among heroin addicts during OMT.

Identifying health disparities across the tobacco continuum

AIMS

Few frameworks have addressed work-force diversity, inequities and inequalities as part of a comprehensive approach to eliminating tobacco-related health disparities. This paper summarizes the literature and describes the known disparities that exist along the tobacco disease continuum for minority racial and ethnic groups, those living in poverty, those with low education and blue-collar and service workers. The paper also discusses how work-force diversity, inequities in research practice and knowledge allocation and inequalities in access to and quality of health care are fundamental to addressing disparities in health.

METHODS

We examined the available scientific literature and existing public health reports to identify disparities across the tobacco disease continuum by minority racial/ethnic group, poverty status, education level and occupation.

FINDINGS

Results indicate that differences in risk indicators along the tobacco disease continuum do not explain fully tobacco-related cancer consequences among some minority racial/ethnic groups, particularly among the aggregate groups, blacks/African Americans and American Indians/Alaska Natives. The lack of within-race/ethnic group data and its interactions with socio-economic factors across the life-span contribute to the inconsistency we observe in the disease causal paradigm.

CONCLUSIONS

More comprehensive models are needed to understand the relationships among disparities, social context, diversity, inequalities and inequities. A systematic approach will also help researchers, practitioners, advocates and policy makers determine critical points for interventions, the types of studies and programs needed and integrative approaches needed to eliminate tobacco-related disparities.

Individual and community-level effects in the socioeconomic inequalities of AIDS-related mortality in an urban area of southern Europe

OBJECTIVE

To study socioeconomic inequalities in AIDS mortality in Barcelona, Spain, during the periods 1991-6 (before highly active antiretroviral therapy (HAART)) and 1997-2001 (post-HAART) taking into account individual as well as community effects of socioeconomic level.

DESIGN

Cross-sectional design.

SETTING

Barcelona, Spain.

PARTICIPANTS

All residents aged > or =20 years. All AIDS-related deaths occurring between 1991 and 2001 were studied. The individual variables analysed were age, sex, educational level, neighbourhood of residence and HIV transmission group. Male unemployment was used as the community-level indicator of neighbourhood deprivation. Multilevel Poisson regression models were fitted to estimate the relationship between AIDS mortality and the individual- and community-level variables.

RESULTS

At the individual level, AIDS mortality relative risks (RR) were higher among intravenous drug users (IDUs) with lower educational level in both periods. For the younger population, the RR of AIDS-related mortality associated with having little education compared with having a primary education or more was 4.7 (95% CI 3.6 to 6.1) in men and 5.2 (95%CI 3.6 to 7.7) in women in the pre-HAART period, and 4.7 (95% CI 2.7 to 8.1) in men and 4.5 (95% CI 1.4 to 14.1) in women in the post-HAART period. At the community level, an area effect in AIDS mortality was found, which was more important in neighbourhoods having high deprivation in both periods, although the effect was most important in the post-HAART period.

CONCLUSIONS

This study has shown inequalities in AIDS mortality in terms of both individual variables and a community-level variable in the pre-HAART as well as in the post-HAART period. These socioeconomic inequalities of AIDS mortality must be considered when prevention and treatment strategies are implemented.

Effect of education on overall and cause-specific mortality in injecting drug users, according to HIV and introduction of HAART

BACKGROUND

We assessed the impact of education on long-term overall and cause-specific mortality among 6575 injecting drug users (IDUs) according to HIV status and introduction of highly active antiretroviral therapy (HAART).

METHODS

Community-based cohort study of IDUs recruited in three AIDS prevention centres (1987-1996). Causes of death were ascertained in clinical centres and Mortality Registry and classified as AIDS, drug use related, injuries, or liver diseases. Poisson regression models including education and calendar period interaction and adjusted by sex, age, and HIV were used.

RESULTS

In 73 901 person-years of follow-up, there were 1493 deaths (20.2/1000 person-years): 761 related to AIDS, 234 to drug use, 179 to injuries, and 93 to liver diseases. IDUs with university studies had a lower risk of death (RR 0.52; 95% CI 0.36-0.77) than those without studies: this difference was higher after (RR 0.45; 95% CI 0.25-0.80) than before 1997 (RR 0.68; 95% CI 0.41-1.13). Compared to before 1997, while decreases in the risk of AIDS mortality were seen during 1997-2004 for both lower (RR 0.49; 95% CI 0.41-0.58) and higher (RR 0.33; 95% CI 0.23-0.48) educated, only those higher educated experienced a reduction in drug-use mortality (RR 0.54; 95% CI 0.28-1.05) and death from injuries (RR 0.52; 95% CI 0.23-1.21).

CONCLUSIONS

Independently of HIV status, lower education predicts a higher risk of death in IDUs and its impact is stronger after 1997. Education has a protective effect on most causes of death and it cannot be entirely attributable to the access or use of HAART.

Mortality and socioeconomic deprivation in census tracts of an urban setting in southern Europe

In southern European cities, research on deprivation and mortality inequalities using small-area analysis is recent. In many countries, the census tract (CT) is the smallest territorial unit for which population data are available. The aim of this study was to examine the association between mortality from all causes and socioeconomic deprivation in CTs in Barcelona (Spain). A cross-sectional ecologic study was carried out using mortality data for 1987-1995 and 1991 census variables. Mortality data were obtained from death certificates. Socioeconomic deprivation indicators were drawn from the census and included unemployment, inadequate education, and low social class. They were correlated, and a deprivation index was elaborated with them. The analysis was descriptive, and multivariate Poisson regression models were adjusted. The most deprived CTs tend to present higher mortality (49.7% of CT in the quartile associated with greatest deprivation were included in the top male mortality quartile and 40.4% in the top female mortality quartile), whereas the less deprived ones present lower mortality. For male mortality, the risk of dying among those in the quartile representing most deprivation is from 25 to 29% higher (depending on the indicator chosen) than the least deprived quartile, and for women, it is from 12 to 14% higher. We concluded that the mortality from all causes in the CT of a southern European city has shown a clear positive association with a variety of socioeconomic deprivation indicators drawn from the census. Studies of this nature may help to orient more specific studies in which CTs are grouped together as a function of particular population and/or health characteristics.