Socioeconomic disparities in diet and physical activity in children: evidence from well-child visit electronic health records in the Canary Islands, Spain

BACKGROUND

Diet and physical activity (PA) in childhood are heavily influenced by the living environment. While diet quality follows a socioeconomic pattern, limited evidence is available in relation to PA in children. We assessed the effect of socioeconomic status at the individual (SES) and neighbourhood (NSES) levels on diet and PA among children from the general population of the Canary Islands, Spain.

METHODS

In this cross-sectional study, patients aged 6-14 years from the Canary Health Service in 2018 were included (n=89 953). Diet and PA surveys from the electronic health records of the well-child visit programme were used. A healthy habits (HH) score was defined to assess the level of adherence to the dietary and leisure time PA guidelines. We modelled the association between the HH score, SES and NSES using a stepwise multilevel linear regression analysis, differentiating between specific and general contextual observational effects.

RESULTS

A strong positive association between SES and the HH score was found, as children living in more affluent families were more likely to follow a healthy diet and being physically active. Differences in the HH score between geographical areas were of minor relevance (variance partition coefficient=1.8%) and the general contextual effects were not substantially mediated by NSES (proportional change in variance=3.5%). However, the HH score was significantly lower in children from areas with a higher percentage of annual incomes below the €18 000 threshold.

CONCLUSION

HH followed a socioeconomic gradient at the individual and the neighbourhood level. In the study population, the geographical component of the inequalities found were low.

How has the strict lockdown during the SARS-COV-2 outbreak changed the diet of Spaniards?

Purpose

We investigate the impact of a specific macroeconomic shock that occurred as a response to the SARS-COV-2 outbreak, namely the strict lockdown imposed in Spain on the March 14, 2020.

Methods

We use fortnightly purchase data relating to over 50,000 households from a supermarket chain in Catalonia from March to June in 2019 and 2020. Using a panel data approach, we analyse the impact of the lockdown on the caloric content, sugar composition, and alcohol content in beverages and food purchases bought before and after lockdown. We corrected our results to take into account the likelihood of stockpiling.

Results

The lockdown is related to an increase in unhealthy beverage and food purchases. We find heterogeneous effects across groups of the sample based on cardholder characteristics. Families with children or babies and those in the upper two income quintiles had the unhealthiest changes. As the lockdown went through phases of relaxation, households made better food decisions but maintained unhealthy beverage choices.

Conclusions

The very restrictive lockdown negatively impacted the characteristics of food and beverage purchases made by Spaniards. However, we are unsure whether there was substitution to restaurant and bar visits. Additional work to find out whether there were permanent changes in purchasing behaviour after lockdown ended is needed in the future.

How do consumers respond to "sin taxes"? New evidence from a tax on sugary drinks

It is unclear what the effects of taxes on sugar sweetened beverages (SSBs) are on consumer behaviour and which consumers may be affected the most. We evaluate the effect of the SSB tax introduced in Catalonia (but not in the rest of Spain) in May 2017 using loyalty card data of monthly purchases by 884,843 households from May 2016 to April 2018. Using a Difference-in-Differences approach, we study the SSB tax effect on the purchased quantity of beverages and sugar. Our results suggest a reduction in purchases of taxed beverages and a small increase in purchases of untaxed beverages. Households have substituted taxed beverages with their lower sugar (untaxed) counterparts. This has led to a 2.2% overall reduction in sugar purchases from beverages. Our study implies that although sin taxes moderately change consumer behaviour, a combination of different policies would be required to tackle obesity.

Preferences of Patients With HR+ and HER2- Breast Cancer Regarding Hormonal and Targeted Therapies in the First Line of Their Metastatic Stage: A Discrete Choice Experiment

OBJECTIVE

Some hormonal and targeted treatment options are available in the first line of metastatic HR+ & HER2- breast cancer. This study aimed to quantify the preferences of Iranian breast cancer patients regarding the levels of attributes of hypothetical treatment options.

METHODS

The discrete choice experiment included 16 orthogonally designed scenarios. A novel method (named "the World Cup") was used to offer the scenarios to the respondents. Each choice task had 2 hypothetical treatments. A conditional logit regression model was used to obtain preference estimates, based on an expected utility model without interactions between attributes.

RESULTS

A total of 78 patients with breast cancer participated in the survey. The effectiveness was the main concern of the patient, which was followed by monthly cost. Participant patients significantly preferred to avoid adverse events; preference dummy-coded estimates were reported.

CONCLUSION

Followed by the effectiveness and cost, the risk of neutropenia, stomatitis, and arthralgia was least prioritized by the respondents. The estimation for the levels of the attribute "administration mode" is not significant (P = .690). Patients with breast cancer were willing to pay significant amounts to gain the benefit of the treatments and showed a significant willingness to accept to avoid the adverse events of the treatments.

Review of medical professional organizations in developed countries: problems of decentralized membership registers

This article provides a critical review of international experiences regarding the professional organization of physicians and the registration of doctors in developed countries. The problems faced by professional medical organizations in the EU-15 countries, Japan, the United States and Canada, are examined. Medical professional groups differ in several dimensions, including obligatory registration versus voluntary membership or types of registration (centralized, indirect, or delegated). The centralization-decentralization axis is a key aspect for the analysis. While decentralized systems are better able to adapt to the idiosyncrasy of a particular region, decentralization is identified as a source of potential problems in the organization of medical doctors. Some of these problems (discrepancies in positions on health matters, problems with the reliability of statistical information on medical demography at national level, deficient mechanisms for the control of doctors who have lost their licenses) might have consequences for the quality of the health care system.

Allocation of Residency Training Positions in Spain: Contextual Effects on Specialty Preferences

In Spain's 'MIR' system, medical school graduates are ranked by their performance on a national exam and then sequentially choose from the available residency training positions. We took advantage of a unique survey of participants in the 2012 annual MIR cycle to analyze preferences under two different choice scenarios: the residency program actually chosen by each participant when it came her turn (the 'real') and the program that she would have chosen if all residency training programs had been available (the 'counterfactual'). Utilizing conditional logit models with random coefficients, we found significant differences in medical graduates' preferences between the two scenarios, particularly with respect to three specialty attributes: work hours/lifestyle, prestige among colleagues, and annual remuneration. In the counterfactual world, these attributes were valued preferentially by those nearer to the top, while in the real world, they were valued preferentially by graduates nearer to the bottom of the national ranking. Medical graduates' specialty preferences, which we conclude, are not intrinsically stable but depend critically on the 'rules of the game'. The MIR assignment system, by restricting choice, effectively creates an externality in which those at the bottom, who have fewer choices, want what those at the top already have. Copyright © 2016 John Wiley & Sons, Ltd.

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

This paper reviews economic and medical research publications to determine the extent to which the measures applied in Spain to control public health spending following the economic and financial crisis that began in 2008 have affected healthcare utilization, health and fairness within the public healthcare system. The majority of the studies examined focus on the most controversial cutbacks that came into force in mid-2012. The conclusions drawn, in general, are inconclusive. The consequences of this new policy of healthcare austerity are apparent in terms of access to the system, but no systematic effects on the health of the general population are reported. Studies based on indicators of premature mortality, avoidable mortality or self-perceived health have not found clear negative effects of the crisis on public health. The increased demands for co-payment provoked a short-term cutback in the consumption of medicines, but this effect faded after 12-18 months. No deterioration in the health of immigrants after the onset of the crisis was unambiguously detected. The impact of the recession on the general population in terms of diseases associated with mental health is well documented; however, the high levels of unemployment are identified as direct causes. Therefore, social policies rather than measures affecting the healthcare system would be primarily responsible. In addition, some health problems have a clear social dimension, which seems to have become more acute during the crisis, affecting in particular the most vulnerable population groups and the most disadvantaged social classes, thus widening the inequality gap.

Estimating direct effects of parental occupation on Spaniards' health by birth cohort

Background

Social health inequalities in adult population are partly due to socioeconomic circumstances in childhood. A better understanding of how those circumstances affect health during adulthood may improve the opportunities for reducing health disparities. The objective of this study is to investigate the effect of parental socioeconomic status, which is proxied by occupation, on adult Spaniards’ health by birth cohort. The analysis will allow checking not only the direct impact of parental occupation on their offspring’s health, but also whether inherited inequality has been reduced over time.

Methods

We use data from the Bank of Spain’s Survey of Household Finances on Spanish households from 2002 to 2008. Sequential models were used to estimate the influence of the father’s and mother’s occupation on their offspring’s health, trying to disentangle direct from indirect effects. With a sample of 26,832 persons we consider effects for four different cohorts by birth periods ranging from 1916 to 1981.

Results

The results show that parental occupation has a significant direct impact on individuals’ health (p < 0.01). The effect of father’s occupation exceeds that of mother’s. For those born before 1936, the probability of reporting a good health status ranges from 0.31 (95% confidence interval (CI) 0.14–0.48), when fathers were classified as unskilled elementary workers, to 0.98 (95% CI 0.98–0.99) when they were managers or mid-level professionals. For those born during the period 1959–1975, those probabilities are 0.49 (95% CI 0.39–0.59) and 0.97 (95% CI 0.96–0.98), respectively. Therefore, health inequalities linked to parental socioeconomic status have been noticeably reduced, although discrimination against unskilled workers persists over time.

Conclusions

Great progress has been made in the health area during the twentieth century, so that the impact of parental socioeconomic status on individuals’ health has been significantly tempered for those at the bottom of the social scale. However, more efforts focused on the improvement of living conditions for most socioeconomically disadvantaged are needed in order to further reduce social inequalities in health.

The influence of the economic crisis on the association between unemployment and health: an empirical analysis for Spain

OBJECTIVES

To estimate the impact of (particularly long-term) unemployment on the overall and mental health of the Spanish working-age population and to check whether the effects of unemployment on health have increased or been tempered as a consequence of the economic crisis.

METHODS

We apply a matching technique to cross-sectional microdata from the Spanish Health Survey for the years 2006 and 2011-2012 to estimate the average treatment effect of unemployment on self-assessed health (SAH) in the last year, mental problems in the last year and on the mental health risk in the short term. We also use a differences-in-differences estimation method between the two periods to check if the impact of unemployment on health depends on the economic context.

RESULTS

Unemployment has a significant negative impact on both SAH and mental health. This impact is particularly high for the long-term unemployed. With respect to the impact on mental health, negative effects significantly worsen with the economic crisis. For the full model, the changes in effects of long-term unemployment on mental problems and mental health risk are, respectively, 0.35 (CI 0.19-0.50) and 0.20 (CI 0.07-0.34).

CONCLUSIONS

Anxiety and stress about the future associated with unemployment could have a large impact on individuals' health. It may be necessary to prevent health deterioration in vulnerable groups such as the unemployed, and also to monitor specific health risks that arise in recessions, such as psychological problems.

Paying for formerly free medicines in Spain after 1 year of co-payment: changes in the number of dispensed prescriptions

BACKGROUND

After more than three decades of free medicines for the elderly in Spain, in the context of heavy austerity reforms of public financing, a set of cost-sharing reforms on pharmaceutical prescriptions with regional variants have been established in Spain since July 2012.

OBJECTIVE

The purpose of this analysis is to present the first attempt to provide accurate estimates of the overall impact at the regional level of these cost-sharing reforms.

METHODS

We estimated the impact of the reforms on the quantity of dispensed medicines during the first 14 months. We estimated 17 autoregressive integrated moving average (ARIMA) time series models of the monthly number of prescriptions dispensed in pharmacies for the period January 2003-May 2012 in each one of the 17 regions (Autonomous Communities) of Spain. We calculated dynamic forecasts for the horizon June 2012-July 2013 in order to estimate the counterfactual (number of prescriptions that would had been observed without the intervention), and we estimated the impact of cost-sharing changes as the difference between the observed number of accumulated prescriptions at 3, 6, 12, and 14 months and the number predicted by our time-series models (in percentages).

RESULTS

During the last decade the number of dispensed prescriptions has experienced rapid and continuous increases. In the first 14 months after the co-payment reform, the total number of prescriptions decreased dramatically, by more than 20% in Catalunya, Valencia, and Galicia, by more than 15% in nine other regions, and by more than 10% in 15 of the 17 Spanish regions. The results of our model suggest that the new co-payment caused an abrupt shift in the mean level of the time series. No shift in trend has been detected; the previous positive trend remains unchanged in most of the Autonomous Communities.

CONCLUSION

After decades of unsuccessfully trying to reduce drug spending in the Spanish National Health System through actions on prices and on prescribers, the co-payment established in mid-2012 led to a dramatic reduction in the use of drugs. The health effects of this reduction are not known.

Medical societies' recommendations for immunization with Human Papillomavirus vaccine and disclosure of conflicts of interests

OBJECTIVE

To review the recommendations on Human Papillomavirus (HPV) vaccination issued by different medical societies, as well as disclosures of any conflict of interests regarding such recommendations.

METHODS

The search for recommendations was mainly conducted through the Internet, together with a bibliography search on Pubmed (November 2008). The countries were selected to encompass a broad range of healthcare systems and income levels.

RESULTS

In all, 18 documents were identified: 4 from the U.S., 5 from Canada, and 1 from France (all 10 in favor of recommending vaccination), 5 from Spain (3 in favor of vaccination and 2 recommending no vaccination until further evidence of the vaccine effectiveness to prevent cervical cancer becomes available), 2 from Argentina (one in favor of vaccination and another pointing to the missing information on the vaccine's cost-effectiveness), and 1 from Chile (recommending no vaccination until more information becomes available). Only two documents disclose specific conflicts of interests for authors (American Cancer Society and Chilean Working Group on HPV). One of the Canadian documents did not include any conflict of interest statement, although Merck and GSK are listed among the sponsors.

CONCLUSIONS

Disclosure of conflicts of interest in documents where medical societies issue recommendations on HPV vaccination is very unusual. However, lack of disclosure is more frequent (near twice) when recommendations are in favor of the vaccination.