Monitoring health inequalities in Barcelona

In Spain, the Public Health Law approved in 2011 foresees the creation of a Surveillance System on Social Determinants of Health and Equity. However, although information on health inequalities has been reported in technical reports and scientific articles before, it is not until now with the change of the Spanish government the political will to set up the more strategic surveillance system approved and foreseen in 2011 is there.

The change of government in some cities can be an opportunity to advance in the surveillance of health inequalities and policies to tackle them. In Barcelona, for instance, there is a wealth of information and research on health inequalities, but in the past health inequalities was not clearly prioritised on the political agenda. Hence, although health inequalities have been presented in many reports, a monitoring and surveillance system has not been available nor a prioritised task. This has now changed and as part of Spain's engagement in the Joint Action Health Equity Europe project (JAHEE) a system for Monitoring Health Inequalities in the city of Barcelona is being established. During the course of the JAHEE project the objectives of the system and target populations will be defined, sources of information and indicators identified, dissemination and evaluation structures set up before finally, in the next step, the system is to be implemented. The ambition is that the new monitoring system on health inequalities set up in Barcelona in its final form, will make out a part of the information systems of the Public Health Observatory of the city of Barcelona.

In this presentation, we will learn more about the establishment, the content and the experiences gained while setting up the new monitoring system on health inequalities in Barcelona - from defining the objective of the system to implementing it.

CYP11A1 expression in bone is associated with aromatase inhibitor-related bone loss

Aromatase inhibitors (AIs) used as adjuvant therapy in postmenopausal women with hormone receptor-positive breast cancer cause diverse musculoskeletal side effects that include bone loss and its associated fracture. About half of the 391 patients treated with AIs in the Barcelona-Aromatase induced bone loss in early breast cancer cohort suffered a significant bone loss at lumbar spine (LS) and/or femoral neck (FN) after 2 years on AI-treatment. In contrast, up to one-third (19.6% LS, 38.6% FN) showed no decline or even increased bone density. The present study aimed to determine the genetic basis for this variability. SNPs in candidate genes involved in vitamin D and estrogen hormone-response pathways (CYP11A1, CYP17A1, HSD3B2, HSD17B3, CYP19A1, CYP2C19, CYP2C9, ESR1, DHCR7, GC, CYP2R1, CYP27B1, VDR and CYP24A1) were genotyped for association analysis with AI-related bone loss (AIBL). After multiple testing correction, 3 tag-SNPs (rs4077581, s11632698 and rs900798) located in the CYP11A1 gene were significantly associated (P<0.005) with FN AIBL at 2 years of treatment. Next, CYP11A1 expression in human fresh bone tissue and primary osteoblasts was demonstrated by RT-PCR. Both common isoforms of human cholesterol side-chain cleavage enzyme (encoded by CYP11A1 gene) were detected in osteoblasts by western blot. In conclusion, the genetic association of CYP11A1 gene with AIBL and its expression in bone tissue reveals a potential local function of this enzyme in bone metabolism regulation, offering a new vision of the steroidogenic ability of this tissue and new understanding of AI-induced bone loss.

Substance use among road traffic casualties admitted to emergency departments

OBJECTIVE

To describe the prevalence of recent psychoactive substance use and associated factors among road traffic casualties admitted to emergency departments.

METHODS

A cross-sectional study was carried out, including adults injured in road traffic crashes admitted to the emergency department (ED) of eight hospitals in Catalonia (Spain), during three cross-sections, each of 4 days duration (2005-2006). Information sources were an interview, an oral fluid specimen and the patient's clinical record. Dependent variables were presence of alcohol, cannabis, cocaine, ecstasy, opiates or benzodiazepines. Independent variables were socioeconomic characteristics and circumstances of the injuries and admission. Prevalence and exact 95% confidence intervals were estimated for men and women. Bivariate analyses and multivariate binomial regression modelling were carried out to study factors associated with substance use in male drivers and pedestrians.

RESULTS

The prevalence of substance use was higher in men (n = 226) than in women (n = 161) for any substance (34.4% and 16.2%), any illegal substance (19.3% and 7.6%), alcohol (18.5% and 9.2%) and cannabis (17.0% and 3.8%), respectively. In male drivers and pedestrians, alcohol use was associated with being in the 25-30-year age group, being injured at night and the weekend, and arriving at the ED by ambulance; cannabis use was only associated with being in the 18-30-year age group.

CONCLUSIONS

A high prevalence of recent psychoactive substance use, especially alcohol, cannabis and cocaine, was observed in all age groups. The results indicate the need to screen for substance use and to give simple advice to casualties at EDs.

Socioeconomic inequalities in diabetes mellitus across Europe at the beginning of the 21st century

AIMS/HYPOTHESIS

The aim of this study was to determine and quantify socioeconomic position (SEP) inequalities in diabetes mellitus in different areas of Europe, at the turn of the century, for men and women.

METHODS

We analysed data from ten representative national health surveys and 13 mortality registers. For national health surveys the dependent variable was the presence of diabetes by self-report and for mortality registers it was death from diabetes. Educational level (SEP), age and sex were independent variables, and age-adjusted prevalence ratios (PRs) and risk ratios (RRs) were calculated.

RESULTS

In the overall study population, low SEP was related to a higher prevalence of diabetes, for example men who attained a level of education equivalent to lower secondary school or less had a PR of 1.6 (95% CI 1.4-1.9) compared with those who attained tertiary level education, whereas the corresponding value in women was 2.2 (95% CI 1.9-2.7). Moreover, in all countries, having a disadvantaged SEP is related to a higher rate of mortality from diabetes and a linear relationship is observed. Eastern European countries have higher relative inequalities in mortality by SEP. According to our data, the RR of dying from diabetes for women with low a SEP is 3.4 (95% CI 2.6-4.6), while in men it is 2.0 (95% CI 1.7-2.4).

CONCLUSIONS/INTERPRETATION

In Europe, educational attainment and diabetes are inversely related, in terms of both morbidity and mortality rates. This underlines the importance of targeting interventions towards low SEP groups. Access and use of healthcare services by people with diabetes also need to be improved.

Trends in socioeconomic mortality inequalities in a southern European urban setting at the turn of the 21st century

OBJECTIVE

To analyse trends in mortality inequalities by educational level for main causes of death among men and women in Barcelona, Spain, at the turn of the 21st century (1992-2003).

METHODS

The population of reference was all Barcelona residents older than 19 years. All deaths between 1992-2003 were included. Educational level was obtained through record linkage between the mortality register and the municipal census of Barcelona city. Variables studied were age, sex, educational level, period of death (four periods of 3 years) and cause of death. Age-standardised mortality rates for each educational level, sex and period were calculated. Poisson regression models were fitted to obtain relative index of inequality (RII) for educational level, adjusted for age for the time-periods.

RESULTS

RII for all causes of death was constant (around 1.5), but rate differences were higher in 1995-7 (715.6 per 100,000 in men and 352.8 in women) than in other periods and tended to decrease in men over the periods. Analysis of inequality trends by specific causes of death shows a stable trend for the majority of causes, with higher mortality among those with less education for all causes of death except lung cancer and breast cancer among women having RII below 1.

CONCLUSIONS

Relative inequalities in total mortality by sex in Barcelona did not change during the 12 years studied, whereas absolute inequalities tended to decrease in men. Our study fills an important gap in southern Europe and Spanish literature on trends during this period.