Climate Change and Health in Urban Areas with a Mediterranean Climate: A Conceptual Framework with a Social and Climate Justice Approach

The consequences of climate change are becoming increasingly evident and highlight the important interdependence between the well-being of people and ecosystems. Although climate change is a global phenomenon, its causes and consequences vary dramatically across territories and population groups. Among settings particularly susceptible to health impacts from climate change are cities with a Mediterranean climate. Here, impacts will put additional pressure on already-stressed ecosystems and vulnerable economies and societies, increasing health inequalities. Therefore, this article presents and discusses a conceptual framework for understanding the complex relationship between climate change and health in the context of cities with Mediterranean climate from a social and climate justice approach. The different elements that integrate the conceptual framework are: (1) the determinants of climate change; (2) its environmental and social consequences; (3) its direct and indirect impacts on health; and (4) the role of mitigation and adaptation policies. The model places special emphasis on the associated social and health inequalities through (1) the recognition of the role of systems of privilege and oppression; (2) the distinction between structural and intermediate determinants of climate change at the root of health inequalities; (3) the role of individual and collective vulnerability in mediating the effects of climate change on health; and (4) the need to act from a climate justice perspective to reverse health inequities.

[A public health surveillance system applied to climate change for cities]

This paper makes a first proposal for a public health surveillance system for climate change in cities, and describes the process that led to its definition. After several years of monitoring different aspects related to climate change and its impact, the public health services of Barcelona made a preliminary proposal and gathered a working group of experts to discuss and review it. Four categories of components were defined: climate data, health impacts of climate change and its determinants, contributions of the city to mitigation (especially those with health co-benefits), and actions to reduce vulnerability to extreme events. They were broken in twelve components, with indicators for each. The proposal was further refined with subsequent reviews, and is being used by the city public health services involved in this field.

The blind men and the elephant: Systematic review of systematic reviews of cannabis use related health harms

Cannabis is the third most used psychoactive substance worldwide. The legal status of cannabis is changing in many Western countries, while we have very limited knowledge of the public health impact of cannabis-related harms. There is a need for a summary of the evidence of harms and risks attributed to cannabis use, in order to inform the definition of cannabis risky use. We have conducted a systematic review of systematic reviews, aiming to define cannabis-related harms. We included systematic reviews published until July 2018 from six different databases and following the PRISMA guidelines. To assess study quality we applied the AMSTAR 2 tool. A total of 44 systematic reviews, including 1,053 different studies, were eligible for inclusion. Harm was categorized in three dimensions: mental health, somatic harm and physical injury (including mortality). Evidence shows a clear association between cannabis use and psychosis, affective disorders, anxiety, sleep disorders, cognitive failures, respiratory adverse events, cancer, cardiovascular outcomes, and gastrointestinal disorders. Moreover, cannabis use is a risk factor for motor vehicle collision, suicidal behavior and partner and child violence. Cannabis use is a risk factor for several medical conditions and negative social consequences. There is still little data on the dose-dependency of these effects; evidence that is essential in order to define, from a public health perspective, what can be considered risky use of cannabis. This definition should be based on quantitative and qualitative criteria that informs and permits the evaluation of current approaches to a regulated cannabis market.

[Innovating the service management of public health: the experience of the Barcelona Public Health Agency (Spain)]

We describe the evolution of the organization of public health services in the city of Barcelona (Catalonia, Spain) until the creation of the Barcelona Public Health Agency. This Agency is a consortium created by the Barcelona City Council and the Government of Catalonia as the sole entity responsible for regional and local public health services in the city. The underlying logic for the Agency's design, as well as its mission, vision and value statements, strategy, services' portfolio, and the role of leadership in the process, are analyzed. Aspects related to the Agency's quality and communication plans, as well as the design of its processes, and its policy in terms of alliances for research and training in public health, are discussed. Finally, the main challenges for the future are described.

Chlorinated organic pesticides in marketed food: Barcelona, 2001-06

This paper reports concentration levels of 22 chlorinated organic compounds (both primary compounds and metabolites) in food marketed in the city of Barcelona (Catalonia, Spain) in 2001-06. Samples included meat products, fish and seafood, eggs, milk and dairy, vegetal oils, cereal products and derivates, vegetables, fresh fruits, dry fruits, spices, formula and baby food, tea and wine. Levels of chlorinated organic compounds were determined by gas chromatography with selective detectors: electron capture (ECD), flame photometric (FPD) and confirmation with mass-spectrometry. Chlorinated organic pesticides were detected in 7 of the 1,484 samples analyzed in the 2001-06 period (0.5%): 1 dairy product, 1 fruit, 1 olive oil and 4 vegetables. Specific pesticides detected are lindane and endosulfan alpha, beta or sulphate. A decrease in both the proportion of samples with detectable residues and in the variety of chlorinated pesticides found is visible when comparing these results with those of the previous 1989-2000 period. These results suggest the gradual disappearance of regulated chlorinated organic pesticides as a consequence of the growing worldwide implementation of current regulatory agreements.

Immunoquantitative measurement of soybean aeroallergen emissions at industrial sites

BACKGROUND

Asthma attacks and mortality due to inhalation of soybean antigens in Barcelona, Spain have been well documented. A new control scheme was adopted in the city to avoid the emission and dispersion of soybean dust into the atmosphere during unloading. We studied soybean allergen emission during unloading and at 3 industrial sites and compared the results obtained.

METHODS

Over a period of 31 months, 628 paired air samples from 3 plants (A, B, C) involved in soybean manipulation in Barcelona harbor were collected. Samples were analyzed by a radiometric competitive inhibition assay (RCIA) and the enzyme-linked immunosorbent assay (ELISA). A Bland-Altman plot was used to compare the soybean concentrations measured by each assay.

RESULTS

The median values for the 628 samples were 5535 U/m3 (range, 370-18,416,751) for the RCIA and 9955 U/m3 (range, 400-22,349,059) for the ELISA. Plant A had the lowest emission levels and the lowest Spearman rank correlation coefficient (0.409). The correlation coefficients were 0.747 and 0.794 for plants B and C. Soybean aeroallergen concentrations differed by plant. The highest variability in values was seen for plant A, which had the lowest allergen concentrations.

CONCLUSIONS

The competitive assays described are useful tools for the measurement of soybean allergen emission levels at industrial sites. These methods may be used to monitor unloading and the impact of environmental interventions.

Polycyclic aromatic hydrocarbons in food samples collected in Barcelona, Spain

This study reports on the concentrations of eight polycyclic aromatic hydrocarbons (PAHs) in food samples collected in the city of Barcelona (Catalonia, Spain) from 2003 to 2004. Food samples included meat products, fish (fresh and smoked), other seafood (cephalopods, crustaceans, and bivalves), vegetable oil, and tea. Concentrations of benz[a]anthracene, benzo[b]fluoranthene, benzo[k]fluoranthene, benzo[g,h,i]perylene, benzo[alpha]pyrene, benzo[e]pyrene, dibenz[a,h]anthracene, and indeno[1,2,3-c,d]pyrene were determined by reversed-phase high-performance liquid chromatography with fluorescence detection. PAHs were detected in most tea samples (94%), which had the highest concentration of total PAHs (mean concentration of 59 microg/kg). Other food groups with a high presence of PAHs were bivalves (present in 34% of the samples; mean value of 2.7 microg/kg) and meat products (present in 13% of the samples; mean value of 1.7 microg/kg). The PAHs detected most frequently were benzo[e]pyrene and benzo[b]fluoranthene. No sample had levels above current regulation standards. Nevertheless, the frequent presence of PAHs in bivalves, tea samples, and meat products, together with the fact that dietary sources are the main exposure to these carcinogenic compounds, suggests the need for some monitoring scheme to follow up on these trends.

[Changing epidemiology of smoking: Barcelona, 2000-2001]

CONTEXT

In recent years various initiatives of prevention and social changes have been carried out that should have an effect on epidemiology of smoking in our area. Their real effect is little known, however, because of methodological changes in the existing population surveys. In this work the data on smoking in the last city of Barcelona health survey (ESBA 2000-01) are analyzed, with reference to the cumulative information obtained along 18 years from the first survey in 1983.

METHOD

ESBA 2000-01 is an interview health survey carried out on a weighted sample with 10,030 people. Data relative to tobacco use are showed for people 15-year-old or older included in the survey, stratified by age, sex, and class. Consumption context variables are also showed, and the tobacco consumption quitting among people who have smoked is analyzed.

RESULTS

The proportion of daily smokers in the population over 14 years of age is 29 %, while that of former smokers is 21 % and 2.2 % in this population are occasional smokers. The prevalence is maximum in the 35-44 year-old group, and the prevalence is reduced drastically after this age. Stratified analysis by age, sex, and occupational category shows interesting differences among daily smokers. A strong gradient is observed according to occupational category in males. The situation is more complex in women. The typical smoker began when 17-year-old, and now consumes 16 cigarettes a day. Consumption is somewhat higher in males and is maximum in the 35-44 year-old group. Two-third of the smokers (65.7 %) want to quit smoking and more than one third (36 %) has attempted it along the last year. Almost half of smokers (48.1 %) have received advice to quit smoking from their physician. One of every four (24.9 %) smokers has been warned for smoking in some places. Almost half smokers are the only smoker in their home, and barely a third are the only smokers at work. The proportion of quitting increases with age in both sexes, and nowadays the differences in the probability of quitting smoking are few when the data are stratified by age groups.

CONCLUSIONS

These results show the changing pattern of tobacco epidemiology in Barcelona: smoking is no longer the main behavior in no age and sex group, and the only social group in which more than half of its members smoke are 25-44 year-old not qualified worker males. This situation has occurred because of two processes: an important proportion of early quitting (demonstrated even in young adults) and a decrease in the beginning of the habit. Real differences are not observed between males and females with regard to the probability of quitting smoking. These data correct recent estimates that could be influenced by methodological changes in the instruments used.

Epidemic soybean asthma and public health: new control systems and initial evaluation in Barcelona, 1996-98

OBJECTIVE

To evaluate the new measures adopted to control the risks from soybean unloading operations in the Port of Barcelona, after an episode of epidemic asthma in June 1996.

METHODS

After an initial cautionary suspension of all soybean unloading operations, they were subsequently resumed under restrictive criteria for time, flux, simultaneity, and meteorological conditions. Emission filtration systems based on either micro pore size filters or polytetrafluoroethylene membranes on tetratex filters showed promising results.

RESULTS

Allergen emission underwent a very important decrease to levels 95% to 98% lower. Emissions from the two plants with unloading operations are in the same order of magnitude as the processing plant that does not unload soybean. Allergen concentration levels presented fluctuations initially, but the new filters decreased mean values; despite increased unloading, allergen levels did not increase-mean allergen levels on unloading days (67 U/m(3)) and on days without unloading operations (63 U/m(3)) are similar. A panel of patients detected a cluster of increased symptoms during unloading operations on a day with suboptimal meteorological conditions and comparatively low allergen levels (225-415 U/m(3)). Since the June 1996 episode, no further asthma outbreak has been detected.

CONCLUSIONS

The evaluation shows the effectiveness of the new filters in the control of soybean dust emission. With a systematic control programme, industrial soybean operations may function near urban centres without public health risks. These data may be useful in the development of future standards for allergenic agents.

[Exposure to smoking during pregnancy: Barcelona (Spain) 1994-2001]

BACKGROUND

Exposure to smoking during pregnancy is an important risk factor for child health. In the last few decades, the prevalence of smoking among fertile women has increased in Spain.

OBJECTIVES

To assess fetal exposure to smoking in a representative sample of pregnant women and its trends.

METHODS

The prevalence of smoking and smoking cessation were analyzed in a representative sample of women who gave birth in the city of Barcelona, extracted from a population-based registry of birth defects. The sample consisted of 1,801 women and covered the period 1994 to 2001.

RESULTS

Among pregnant women, 43.4 % smoked before pregnancy, and 42.2 % of these quit. At the time of giving birth, 25.2 % of the women were smokers. Over the period studied the prevalence of smoking among pregnant women clearly decreased. Although the proportion of cessations showed no significant changes, fetal exposure to tobacco decreased.

CONCLUSIONS

The prevalence of smoking among pregnant women was high, although many quit during pregnancy. Over the period studied, fetal exposure to smoking decreased. There is a need for more systematic interventions.

Cambios en el consumo de tabaco en la población general en Barcelona, 1983–2000

OBJECTIVES

To analyze the prevalence trends for smoking and its determinants in the general population of Barcelona from 1983 to 2000.

DESIGN

Time series study.

SETTING

Health survey based on home interviews of a representative sample of the general population of Barcelona.

PARTICIPANTS

In the years 1983, 1992, and 2000 we interviewed 3134, 5004, and 10,000 persons, respectively.

MAIN OUTCOME MEASURES AND RESULTS

Between 1983 and 2000 daily tobacco use showed a steady tendency to decrease among men, with a prevalence that decreased from 54.6% to 38.3%, while in women, smoking increased between 1983 and 1992 (from 20.9% to 25.4%) but remained stable in 2000 (24.5%). The proportion of smokers who said they wanted to quit increased in both sexes from 1992 (54.2%) to 2000 (65.7%). During this period the proportion of smokers who said their doctor had advised them to quit increased from 36.1% to 48.1%. The trends for both sexes showed that consumption of tobacco products was greater among less privileged socioeconomic groups.

CONCLUSIONS

The results of this study confirm the decrease in the prevalence of daily consumption of tobacco products and the increase in smokers who would like to quit, in parallel with the increase in advice from physicians to quit. However, the trends among younger groups remained stable, a finding that makes it necessary to intensify efforts aimed at this population group.

[Trends in tobacco, alcohol and cannabis consumption among secondary school pupils in Barcelona, Spain (1987-1999)]

OBJECTIVE

To describe trends in tobacco, alcohol, and cannabis consumption among secondary school pupils in Barcelona between 1987 and 1999.

METHODS

Cross-sectional surveys administered to representative samples of pupils in the second year of secondary school between 1987 and 1999. The questionnaires were anonymous and self-completed. We present data from 5013 secondary school pupils from Barcelona who participated in one of the five surveys.

RESULTS

Regular smoking (daily and weekly) showed a uniform decrease between 1987 and 1996. The results of the last survey (1999) showed an increase over those the 1996 survey, ranging from 13.4% for regular smoking to 38.7% for experimental smoking. Between 1987 and 1999, the percentage of schoolchildren who reported drinking at least half a glass of alcohol at some time showed an overall decrease of 14.0%. No differences in sex were found in problematic alcohol consumption, while a higher proportion of girls (14.0%) than boys (10.5%) reported getting drunk at some time. Whereas in 1996, 6.9% of the population studied had smoked cannabis at some time, in 1999 this proportion was 7.3%, with no differences between sexes.

CONCLUSIONS

During the study period regular smoking increased, alcohol consumption decreased and cannabis consumption tended to level-off. Differences between boys and girls tended to disappear.

[Portfolio of services in a public health organization]

Health services in Spain are currently being improved. Definition of the services portfolio has been one of the elements in this process, from which public health services have been largely left out. In the present article public health services are examined from the perspective of the Public Health Agency of Barcelona. We propose a scheme to classify services into productive public health services, health care services, services that are intermediate products, support services, and liaison or coordinating services. Indicators of productivity, result, impact, and cost are explored, and a catalogue of services for a public health organization with a well defined population and area is proposed.

Prevalence of cigarette smoking by birth cohort among males and females in Spain, 1910-1990

We analysed the prevalence of cigarette smoking among subsequent birth cohorts of Spanish males and females. Data were drawn from the Spanish NHIS conducted in 1993 ( = 26 400), 1995 ( = 8300) and 1997 ( = 8300). From the original computer files, the three surveys were pooled to obtain a single sample. A total of 33 223 subjects (16 036 men and 17 187 women) born between 1900 and 1979, >/= 16 years old, were directly interviewed and with complete information on the history of smoking included for analysis. Based on each respondent's sex and calendar year of birth, the person was classified into a particular sex-birth cohort in the decades from 1900-09 to 1970-79. For each year from date of birth to date of survey, respondents were further classified as either cigarette smoker or nonsmoker. The prevalence of cigarette smoking among successive cohorts of Spanish men and women was estimated, with correction for excess mortality of smokers. In men, the peak in smoking was reached in the 1950-59 birth cohort (prevalence rate of 68% at ages 20-29), after increases during the previous calendar years. Smoking among women was rare until 1960. Female smoking prevalence rates increased progressively among subsequent cohorts until 1980. The age distribution of smoking prevalence in women in 1990 mimics that observed in men 40 years earlier. A substantial delay in the spread of the tobacco epidemic among men is apparent. In women, the delay in the initiation of the smoking epidemic ended with a quick diffusion of the habit.

[Smoking in Spain, 1945-1995. A retrospective analysis based on the Spanish National Health Interview Surveys]

BACKGROUND AND OBJECTIVE

To analyse trends in cigarette consumption in Spain between 1945 and 1995.

MATERIAL AND METHODS

Prevalence rates of daily cigarette smoking were derived from the individual information collected in the Spanish National Health Interview Surveys (1993, 1995 and 1997) for the period 1945-1995.

RESULTS

In males, the prevalence rate in 1945 was 42.4% (95% confidence interval [CI], 40,1-44,7%), increased till 59.1% in 1975 (95% CI, 58,0-60,2%), levelled-off during the decade 1975-1985, and decreased till 48.9% in 1995 (95% CI, 48,1-49,7%). In females, the prevalence rate of cigarette smoking was less than 5% till the 1970s, and it begun to steadily increase till the end of the study period (22,5%; 95% CI, 21,9-23,1%).

CONCLUSIONS

This analysis shows the different dynamics of the smoking epidemic among men and women in Spain.

[The tobacco industry's internal documents and smoking prevention in Spain]

A 1998 agreement between several states in the USA and the tobacco industry made millions of pages of internal documents available to the public. Many of these documents contain information that the industry would have preferred to keep confidential. Systematic review of these internal documents constitutes a valuable resource for international tobacco control, since they are available on the Internet and can be accessed from anywhere in the world. These documents provide relevant and useful information to antismoking activists and researchers. To facilitate their use, the present article presents the electronic archives of the tobacco industry's documents, describes methods for conducting searches, and identifies the documents with information on the industry's tactics for manipulating Spanish politics and society for its own commercial interests during the 1970s, 1980s, and 1990s.

De la perrera municipal al centro de acogida de animales de compañía de Barcelona

This article aims to present changes in public health policy and services related to pet dogs and cats in the city of Barcelona from 1983 to 2001. Initially the center's activity was limited to the custody and euthanasia of stray animals, serving not only the city but also the rest of the province. With the formulation of a city Plan for Pet Animals, the activities were redirected, concentrating on services within the city limits and stimulating adoption. Participation of both professional and humane organizations was sought, premises were renovated, responsible ownership of animals was promoted, controlled urban colonies of cats were established, and adoptions become the cornerstone of policy, centering the activity of the shelter toward its clients. Changes in the shelter's activity since 1998 reflects a clear decrease in the number of animals retained, as well as in the proportion subjected to euthanasia. This decrease may reflect an improvement in the problem of stray animals. These developments have also resulted in a positive change in the relationship with the media and animal welfare organizations.

[Smoking initiation: epidemiology, research, and behavioral sciences]

Becoming a regular smoker is a process that begins even before the first cigarette, and ends in lifelong physical and psychological dependence. Various psychological and behavioral factors contribute to this process. This article discusses smoking initiation from a comprehensive perspective, including the physiological and addictive effects of nicotine, and the personal and environmental factors that lead to smoking. Because smoking usually begins in adolescence, special emphasis is placed on this developmental stage and on the situations that encourage teenagers to smoke the first cigarette. Finally, this article analyzes the importance of the initiation process in the epidemiology and prevention of smoking. This approach may prove to be particularly useful to clinicians interested in interventions aimed to curb smoking.

[Halogenated by-products of chlorination in tap water]

OBJECTIVE

The presence of trihalomethanes in the water systems of several Spanish cities has been demonstrated. The aim of this study was to analyze trihalomethane concentrations in the water provided for human consumption in the city of Barcelona.

METHODS

We analyzed 151 water samples collected in 1998. The analyses were performed in the Public Health Laboratory of Barcelona using the purge-and-trap method and subsequent determination by gas chromatography and mass spectrometry. The results are presented according to the source of the water: the rivers of Llobregat or Ter, or a mixture of these.

RESULTS

Trihalomethane concentrations in the water from Ter were relatively low, with a predominance of chloroform and bromodichloromethane, while concentrations in the water from Llobregat were much higher, with a predominance of bromoform and dibromochloromethane. Mixed water showed intermediate concentrations. The total concentrations reached in the water from Llobregat were above 100 microg/l.

CONCLUSIONS

The results show the need to continue reducing organic pollution and halogenated compounds in the water used for human consumption in Barcelona.

[Lung cancer mortality in Barcelona: evidence for an initial decline in men]

BACKGROUND

Tobacco use in Spain is still high, with many smoking related deaths. However, a decrease in smoking prevalence in men has been observed in recent years, with a stabilisation or an increase among women. This paper studies the evolution of cancer mortality in Barcelona city (Catalonia, Spain) according to age and sex over the period 1984-1998.

SUBJECTS AND METHOD

The evolution of annual mortality by age and sex was calculated. Specific mortality rates were estimated by age and sex strata; crude and standardized death rates for each year were also determined. Finally, for the 35-64 years population, specific mortality rates were estimated for each 5-year period (1984-1988, 1989-1993, and 1994-1998).

RESULTS

Mortality rates do not change for men aged 35-39, 50-54 and 55-59 years. There was a decrease in lung cancer mortality rates in the 1994-1998 period compared to the first period for those men in the 60-64 years group. In men in the 40-44 and 45-49 years groups, rates increased in the second and stabilize in the last period. Global rates in men in the 35-64 years group, both crude and adjusted, were in the first and last 5-year periods. Among women, rates are much lower, although there was a significant increase in the 35-39 and 45-49 years groups. Crude and adjusted rates in all women aged 35 to 64 years displayed an increase in the last 5-year period.

CONCLUSIONS

These results show that in Barcelona the decrease in smoking prevalence among males is now leading to an initial decrease in lung cancer mortality. The turning point seems to be in the period 1989-1993. On the contrary, there is a clear increase among young women, although the rates are still much lower.

The price of cigarettes in the European Union

BACKGROUND

A major factor influencing tobacco use is its price. Fiscal policies on tobacco are a key ingredient of any comprehensive control strategy, as they can be used to raise prices. The European Union (EU) developed directives to ensure some harmonisation of the fiscal pressure on tobacco across its member states.

OBJECTIVES

To provide a simple comparison of tobacco prices in the EU, adjusting for the purchasing power of each currency.

DESIGN

For price comparisons, a 20 units pack of Marlboro was the reference product, and data refer to April 2000. Purchasing power parities (PPP) for each member state currency have been compiled. These are currency conversion rates, which convert to a common currency and equalise the purchasing power of different currencies.

MAIN OUTCOME MEASURES

Nominal prices of a Marlboro pack for each member state, and a price index, estimated taking as reference the EU mean. Adjusted prices and an adjusted price index have been estimated using PPP.

RESULTS

Nominal prices show wide variation, with the cheapest pack in Portugal (59) and the most expensive in the UK (196); the range of variation is three-fold. However, PPP adjusted prices reveal a different distribution. In three countries adjusted prices are outliers, but all other countries make two clusters, one around the average EU index of 100, the other around a lower value of 85.

CONCLUSIONS

These results suggest that fiscal harmonisation policies in the EU do not have an even effect at reducing availability by its impact in price.

[Evidence-based tuberculosis control: a public health approach]

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. One of the differential traits of the practice of public health when compared to clinical medicine is that it does not concentrate in individual patients, but rather in the health problems of the population in a given time. In public health interventions, besides the importance of efficacy, aspects related to the process of implementation become also crucial. This paper develops some principles for evidence-based public health, which are then applied to a given problem: tuberculosis control in our context. Tuberculosis control poses challenges which go beyond clinical practice, and require a collective organized effort. This is precisely what makes it a public health issue and not only a clinical problem, as it requires not only health care dimensions but also public health dimensions, which require policies that are feasible, have high efficacy, and a moderate cost. To illustrate the problem and the results of public health policies, available data and indicators are used, with special reference to the authors experience in the program for the prevention and control of tuberculosis in Barcelona (Catalonia, Spain).

[Coping with the toll of heroin: 10 years of the Barcelona Action Plan on Drugs, Spain]

INTRODUCTION

The epidemic of heroin use began in Barcelona, as in the rest of Spain, in the late 70's, to reach its peak by the end of the 80's. In a first period, responsible officers experimented difficulties to define the specific objectives of opiate control policies. This paper reviews the effects of the adoption of an explicit policy on drug dependence grounded on a wide consensus in the City of Barcelona (Catalonia, Spain).

SUBJECTS AND METHODS

Over a period of twelve years, from 1986 to 1997, both demand and offer of care and harm reduction services were analyzed, as well as the evolution of the adverse effects of drug use, such as mortality from acute adverse drug reaction, human immunodeficiency virus (HIV) infection, aids incidence, and incidence of tuberculosis. Data for city residents was compared through four different stages in this period.

RESULTS

Despite the lack of data in initial years, relevant changes are apparent. Treatment offer changes clearly, with significant increases in initial treatment, coverage of methadone maintenance programmes, and sterile syringes distribution. Therapeutic compliance of tuberculous intravenous drug users IVDU and risk of HIV infection improve. Emergency service use linked to heroin, overdose, or withdrawal syndrome decreases. Mortality rates decline, although this decline does not reach statistical significance.

DISCUSSION

Service offer shows a clear increase, reflected in treatment initiation, while harm reduction services expand. With the development of this process, outcome indicators change, both reflecting changes in the toll of the heroin epidemic (cases of tuberculosis and aids among IVDUs, HIV infection). and changes in a more comprehensive care (better treatment compliance of IVDUs with tuberculosis). There is a lower distortion of emergency services. These changes occur although the predominance of white heroin in Barcelona favors parenteral use.

[An evaluation of the impact of primary care reform on health]

OBJECTIVE

Evaluation of the impact of the reform of primary health care services on the population health.

DESIGN

Comparative analysis of mortality rates for the 1984-96 period in three zones of homogeneous socioeconomic level, assessing the effect of the differential development of the reform of public primary health care services.

SETTING

The study is restricted to the 23 health areas with lower socioeconomic status in the city of Barcelona (443092 inhabitants).

MEASUREMENTS AND MAIN RESULTS

The study areas are categorized in three groups, according to the sequence of the reform: reformed between 1984 and 1989, RAP1 zone, reformed between 1990 and 1991, RAP2 zone, and those still served by the old scheme in 1992, NORAP zone. General mortality rates are analyzed, and also mortality rates by those avoidable conditions. Significant differences among the three zones are initially visible. The mortality decline is 13.6% in the RAP1 zone and 10.3% in the NORAP zone, so that the decline in the RAP1 zone is 32% greater than in the NORAP zone. At the end of the study, mortality due to stroke and hypertension is lower in the RAP zones than in the NORAP zone. Perinatal mortality shows a clear decline in the three zones. No relevant changes are seen for tuberculosis or cervical cancer. Lung cancer mortality increases except in RAP1 zone where it declines, to the point that the excess mortality from that cause estimated by comparison with the NORAP zone in the initial phase of the study vanishes. Death rates from cirrhosis and motor vehicle accident decline in all zones.

CONCLUSIONS

There is a clear association between the process of reform of primary care and the decrease in general mortality in these zones of low socioeconomic level. These results suggest that the reform of primary health care services in Spain may have a significant impact in the mortality of the population of lower socioeconomic level. The study highlight the cost in health and human lives of maintaining obsolete and overburdened services for some segments of the population, and justify the need and urgency of completing the process of reform initiated in 1984 and still unfinished in 1999.

[Preventive behaviors for the sexual transmission of AIDS, other infections, and pregnancy in high-school students]

OBJECTIVES

To describe preventive behaviors and behavioral intentions related to AIDS sexual transmission, other sexually transmitted diseases and unwanted pregnancies among 10th grade Barcelona students.

DESIGN

Cross-sectional study. Stratified random sample from Barcelona secondary schools in 1996.

SETTING

Secondary schools.

PARTICIPANTS

981 students at 35 10th grade classrooms.

MAIN RESULTS

82% of the students are 15-16 years old. 58% are girls. 16% have had sexual intercourse (boys 18% and girls 14%); among those, 43% of males and 30% of females have had only once sexual intercourse. 78% use always or almost always a condom. 22% of boys and 44% of girls have refused at least an opportunity of unprotected intercourse. Boys feel more confident to buy, carry on and use a condom, however girls feel more confident in convincing their partner and refusing unprotected sex. Among those with sexual experience, partner opinion predicts condom use (boys OR = 30.8 and girls OR = 8.8), as well as partner use (boys OR = 14.2 and girls OR = 15.4). Intention to use condoms with a regular partner is related to the perception of youth normative behaviors (boys OR = 10.9 and girls OR = 4.4) and friends opinion (boys OR = 6.2 and girls OR = 5.4). Condom use with a non regular partner is related also to the perception that its use avoids infections and unwanted pregnancies (boys OR = 9.9 and girls OR = 8.0). Intention to refuse unprotected sex relates, in both genders, to youth normative behaviors and self-efficacy to refuse unprotected intercourse.

CONCLUSIONS

16% of the 10th grade students have had a sexual intercourse. Only half part of them use always condom, although it is the contraceptive method more frequently used. Condom use relates mainly to partners opinions and their current use. Intentions to use condoms are associated also to friends opinion and youth social norm perception. Intention to use a condom with non regular partners aims avoiding diseases and unwanted pregnancies.

A small area analysis estimating the prevalence of addiction to opioids in Barcelona, 1993

STUDY OBJECTIVE

To determine the distribution of opioid use prevalence in small areas and its relation with socioeconomic indicators.

DESIGN

Capture-recapture was applied using data from the Barcelona Drug Information System for 1993 (treatment demands, hospital emergency room visits, deaths from heroin acute adverse reaction and pre-trial prison admissions). To avoid dependence between sources, a log-linear regression model with interactions was fitted. For small neighbourhoods, where capture-recapture estimates were not obtainable, the Heroin Problem Index (HPI) was used to predict prevalence rates from a regression model. The correlation between estimated opioid use prevalence by neighbourhoods and their socioeconomic level was computed.

MAIN RESULTS

The city's estimated prevalence was 12.9 opioid addicts per 1000 inhabitants aged 15 to 44 years (95% CI: 10.1, 17.2), which represents 9176 persons. The highest rate was found in the inner city neighbourhood. Comparing rates obtained for each neighbourhood with their unemployment rates, a high correlation coefficient was obtained (r = 0.80, p < 0.001).

CONCLUSION

The main contribution of this study is that of combining capture-recapture with the HPI to produce small area prevalence estimates, which would not have been possible using only one method. Areas with higher socioeconomic status showed proportionally low addiction prevalences, but in depressed areas, prevalences varied widely.

[Trends in smoking among school children: Barcelona, 1987-1996]

OBJECTIVE

Despite the growth of aids and of other causes of premature death, smoking is the main single cause of avoidable mortality in Spain. Given the addictive nature of tobacco and the difficulties experienced by many smokers to quit, the primary prevention of smoking is crucial. In recent years several initiatives have been developed to this end. The objective of this paper is to monitor smoking among schoolchildren by repeated surveys over a decade, to ascertain the impact of current interventions and to reorient them according to evidence.

DESIGN

Cross sectional surveys over a decade, from 1987 to 1996, while several smoking prevention efforts were developed. Survey instruments were similar self administered and anonymous questionnaires. SITE: Schools in Barcelona (Catalonia, Spain).

PARTICIPANTS

Around 1000 participants in each survey were selected through representative samples of 8th grade students (predominantly 13-14 years old), stratified by school type and size in each round.

MAIN RESULTS

Ever smoking declined, specially for boys (global decline 12.4%, p = 0.05). There is a clear and steady decline, statistically significant, in the proportion smoking in the month prior to the survey (global decline 50.5%, p < 0.0001). The proportion of regular smokers declines from 1987 to 1994, and then is stabilized (global decline 23%, p < 0.05). The proportion of daily smokers fluctuates, but globally it is the lowest of the decade in 1996. No changes are visible in the proportion who declare buying tobacco for personal use.

DISCUSSION

From 1987 to 1996 several smoking indicators show a decline among 8th grade schoolchildren in Barcelona, Spain. The pattern suggests a decline in global smoking experimentation and in the intensity of experimentation, with a small reduction in the prevalence of regular use, while the small proportion of daily smokers at this young age does not change.

Age at starting smoking and number of cigarettes smoked in Catalonia, Spain

BACKGROUND

Few studies have investigated the association between age at starting smoking and the average number of cigarettes smoked per day in adulthood. To provide further evidence on this issue, we analyzed data from the Catalan Health Interview Survey (CHIS).

METHODS

The CHIS was conducted in 1994 on a randomly selected sample (N = 15,000) of the population of Catalonia, Spain. A total of 4,897 current or exsmokers (3,276 males and 1,621 females) were included for analysis. Age-standardized proportions of subjects smoking <15, 15-24, and >/=25 cigarettes/day, age-standardized mean number of cigarettes smoked per day, and multivariate odds ratios (OR) of being a heavy smoker (>/=25 cigarettes/day) according to age at starting smoking (<15, 15-17, 18-19, >/=20 years) were computed.

RESULTS

Men who started smoking before the age of 15 smoked on average 5.5 cigarettes more than those who started at age 19 or over. Women who started smoking early in life smoked, on average, 6.8 cigarettes/day more than women who started later. The proportion of smokers of <15 cigarettes/day was higher among subjects who started smoking later. Both for males and for females, the OR of being a heavy smoker significantly increased with decreasing age at starting smoking (OR = 2.4 for males and 4.5 for females who started at age <15 versus >/=20 years). The level of education did not modify the relationship in males, whereas the association with age at starting was only apparent for more educated women.

CONCLUSIONS

This study confirms that age at starting smoking is inversely and strongly associated to the number of cigarettes smoked per day. Thus, actions aimed at the prevention or delay of smoking onset among adolescents would have an important beneficial effect.

Tuberculosis infection and disease among schoolchildren: the influence of the HIV epidemic and of other factors

BACKGROUND

The HIV/AIDS epidemic has caused an excess of tuberculosis cases in Spain and in other countries, but its impact on tuberculosis infection is less well understood. This study presents a massive screening undertaken to estimate the prevalence of tuberculous infection in a cohort of primary school entrants. The evolution of the risk of infection is studied by comparison with previous data in the same population.

METHODS

Tuberculin skin test screening with 2TU of PPD RT 23 of first grade students in the primary schools of Barcelona, in the 1994-95 school year (cohort born in 1988). Information was also sought from families of unscreened children. Contacts of PPD+ children were traced to locate index cases. The results were also linked to the case registry of the tuberculosis control programme.

RESULTS

The prevalence of tuberculin reactors free of BCG vaccination among the 11,080 schoolchildren screened belonging to the 1988 cohort was 0.76%. A 3% annual decline in the annual risk of infection is estimated by comparison with previous data. The identification of 24 cases with a previous history of tuberculosis disease and of 13 cases with active disease diagnosed after the screening was possible by the follow up of these tuberculin positive children and of the information provided by families of unscreened pupils. The screening detected 1.5 new cases of tuberculosis per 1000 tuberculin tests performed. Tuberculosis infection could be traced to HIV infected tuberculosis cases for at least 6% of the positive schoolchildren.

CONCLUSIONS

The decline of the annual risk of infection continues in Barcelona, although at a slower pace than before the HIV/AIDS epidemic, probably attributable to the influence of injecting drug users with smear positive tuberculosis and HIV/AIDS.

[Haemophilus influenzae type b invasive disease and meningococcal disease: incidence and characteristics in Barcelona, 1994-1995. Work Group IMS-IUSPC for Surveillance and Control of Meningitis]

BACKGROUND

The purpose of the study is to estimate the incidence of Haemophilus influenzae type b invasive disease (HibID) and meningococcal disease (MD) in Barcelona (Catalonia, Spain) for the years 1994-1995.

MATERIAL AND METHODS

Data were obtained from the nominal registry of the surveillance system for reportable transmissible diseases of the Barcelona City Health Department, combining the reporting system with active surveillance, including microbiological reports and the review of hospital discharge registries to ensure completeness.

RESULTS

During this two-years period there were 17 cases of HibID (12 meningitis), and for 12 cases there was a laboratory confirmation. The annual incidence rate can be estimated at 15.4 cases of HibID for 100,000 children below 5 years of age, and 4.5 cases for 100,000 children below 15 years. The annual incidence rates for Hib meningitis were 3.2 for 100,000 below 15 years. There were 60 cases of MD, and for 33 there was a laboratory confirmation, with a majority of serogroup B. The annual incidence rate of MD can be estimated at 32.6 cases for 100,000 below 5 years and 16 cases for 100,000 below 15 years. The incidence rate of meningococcal meningitis is at least 5.9 cases for 100,000 below 15 years of age.

CONCLUSIONS

These results confirm the relatively low incidence of Hib meningitis in Barcelona, Spain, while the Hib vaccine was not in systematic use, much lower than the incidence of MD. The incidence rates are similar to all other population-based studies in Spain, except for the Basque Country study.

[Women and tobacco in the European Union]

Over the last decades, the prevalence of smoking in the European Union has followed different trends by sex. While the prevalence has declined for men, it has increased or is stable for women. In some countries where these changes took place earlier, the prevalence of smoking is now higher among women than among men. This document provides quantitative data for these trends in the European Union, with special reference to the situation in Spain. In 1995 there were 60 million men and 42 million women smokers in the European Union. Up to 48% of female smokers used light cigarettes, that is 20 million women. There are documents from the tobacco industry showing that the goal of the promotion of light cigarettes is to reassure their clients and to keep as smokers those concerned about their health who are considering the possibility of quitting. There is evidence confirming that this policy is successful, and that the misconceptions of smokers about light cigarettes deter them from quitting. There is evidence on the role of smoking in weight control. Women are more concerned than men about their weight, and for young women body image is very relevant. Young girls often have the perception that they are overweight. Although fear of being overweight is more common than actual overweight, the evidence suggests that being afraid of gaining weight plays a role in keeping women as smokers, and that young girls begin smoking taking into consideration weight issues. The advice on how to maintain weight should be included in any smoking cessation program for women. Any preventive action for teen age smokers should include weight control issues.

[Health-related behaviors in secondary-school students: sexual relations and tobacco, alcohol and cannabis consumption]

BACKGROUND AND OBJECTIVES

The main premature mortality causes among youngsters are related to risk behaviors, usually initiated in adolescence. The study objective is to describe substance use and sexual behaviours among 10th-grade Barcelona students in 1996 (last year of compulsory education), as well as the interrelations between these variables and several sociodemographic variables.

METHODS

Cross sectional study. Random sample including 35 10th grade classrooms (958 students whose mean age is 15.8 years old) stratified by academic or vocational studies, public or private school, school neighbourhood socioeconomical level and school size. Measurement instrument is a previously validated questionnaire. Tobacco, alcohol, and cannabis consumption, sexual intercourse as well as gender, age, weekly available money, parental instruction and type of studies are studied. Bivariate chi 2 analysis and multivariate gender specific log-linear model are performed.

RESULTS

27% of the students smoke daily and 31% drink alcohol weekly. 15% have had sexual intercourse, and among those 79% use always or almost always condoms. Among girls tobacco consumption is related to alcohol (OR = 4.2), to cannabis (OR = 5.9) and sexual intercourse (OR = 3.9), and, less strongly, with age, available money and vocational studies. Alcohol is associated with tobacco and cannabis use (OR = 4.2). Having had sexual intercourse is related to tobacco use, age (OR = 3.4), vocational studies (OR = 2.4) and cannabis experience (OR = 2.8). Among boys tobacco consumption is related to alcohol, (OR = 2.7), to cannabis (OR = 7.6) and sexual intercourse (OR = 4.4), and, less strongly, to available money and type of studies. Alcohol consumption is associated with tobacco and cannabis use (OR = 5.5). Sexual intercourse is related to tobacco use and age (OR = 2.5).

DISCUSSION

Risk behaviors among final year secondary school students are strongly and significantly interrelated, both among boys and among girls, and are more frequent among older students, those with more money available and those in vocational curricula.

[Smoking and school children: context, opinions and behavior]

BACKGROUND

This paper studies smoking epidemiology in school-age students.

MATERIAL AND METHODS

A cross-sectional survey of 8th grade students (13-14 years-old) in the schools of Barcelona (Catalonia, Spain) in 1987, 1992 and 1994.

RESULTS

The perception of smoking in the students environment has decreased. The proportion of regular smokers decreases, from 12.6% in 1987 to 9.5% in 1994 (p < 0.05) (an annual decrease of 3.5%) although the proportion who experiment with tobacco remains table.

CONCLUSIONS

There is a decrease in the prevalence of regular smoking in the school-age population (13-14 years-old) in Barcelona (Spain).

[Smoking initiation in students: cross-sectional and longitudinal study of predictive factors]

BACKGROUND

This study examines the evolution of tobacco use among schoolchildren in sixth and seventh grades in Barcelona (11-13 years) and identifies smoking risk factors through cross-sectional and follow-up analysis. POBLATION AND METHODS: The cohort consists of 1,003 students attending 13 schools who served as control units for a study assessing the effects of a school-based addictive substances prevention program. Participants answered the same questionnaire in 1990 and 1991. Risk factors for the experimentation and for regular smoking are studied through cross-sectional and prospective studies.

RESULT

In a year, smokers increase from 9.7% to 18.9% and regular smokers rise from 1.1% to 5.5%. The initial cross-sectional analysis finds stronger associations than the follow-up one. Some variables loose their significance in the longitudinal analysis. Among non-smokers, the strongest predictors to emerge are intention to smoke, the belief that smoking is fun, peers, siblings and mother consumption, and being male; however girls appear to consolidate the consumption more than boys among the cohort of triers.

CONCLUSIONS

Tobacco use prevalences are consistent with other studies developed in our city. Social environment emerges as an important predictor; friends, siblings and mothers tobacco use and gender are the main risk factors.