Social inequalities in health among adolescents in a large southern European city.

BACKGROUND: Numerous health problems are initiated in childhood and adolescence. For example, obesity, which has increased significantly in recent years, often begins in early life. The objective of this study is to describe social inequalities in obesity and other health problems among adolescents, by sex. METHODS: Data were from a cross-sectional study conducted in a representative sample of 903 adolescents aged 12-16 years old, from secondary schools in Barcelona, Spain. Associations between socioeconomic indicators and health outcomes (perceived health status, and overweight and obesity) were examined through generalised estimating equation models. All analyses were stratified by sex. RESULTS: Boys were more likely to report very good perceived health status than girls (64.1% and 46.3%, respectively). Some of the less privileged socioeconomic position indicators were associated with the presence of overweight and obesity (prevalence ratio 2.41 for low family affluence scale in girls), and with a lower probability of reporting very good perceived health status among boys (prevalence ratio 0.75 for primary level of paternal education). CONCLUSIONS: This study suggests that there are social inequalities in perceived health status, overweight and obesity, measured by different socioeconomic indicators among the adolescent population of Barcelona, and that these inequalities were distributed differently among boys and girls. Gender differences in the impact of socioeconomic variables in health need to be considered in epidemiological and intervention studies.

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.

The geography of the highest mortality areas in Spain: a striking cluster in the southwestern region of the country.

AIMS: To determine the areas of Spain with the most increased mortality risk. METHODS: Age adjusted relative risk of death by gender was estimated in each of 2218 small areas of the country using a non-parametric empirical Bayes method. To determine areas with "significantly increased risk" a Poisson based score test was used. RESULTS: Mapping of the highest risk areas showed a striking geographical clustering in the southwestern region of the country. This region, comprising 8% of the Spanish population, accounts for about one third (2884 deaths) of the total excess mortality.

[Impact of smoking and alcohol consumption on mortality in the population of Barcelona [Spain]: 1983-1998]. / Impacto del tabaquismo y del consumo excesivo de alcohol en la mortalidad de la población de la ciudad de Barcelona: 1983-1998.

OBJECTIVES: To analyze the mortality attributable to smoking and alcohol consumption in the city of Barcelona from 1983 to 1998. METHODS: All deaths among residents of the city of Barcelona from 1983 to 1998 were included. Population data were obtained from the city inhabitants register. The mortality attributable to smoking and alcohol consumption was calculated by population attributable fractions using relative risks from previous studies in the US population. RESULTS: In 1998, 2,205 deaths were attributable to smoking, representing 13.8% of all deaths among the population aged 35 years or older and a decrease of 9.6% compared with deaths in 1983. From 1983 to 1998 there was an increase in smoking-attributable adjusted mortality rates for lung cancer (155.84/100,000 inhabitants in men and 9.39/100,000 in women in 1998) and chronic obstructive pulmonary disease (COPD) (95.89/100,000 in men and 11.29/ 100,000 in women in 1998). In 1998, deaths attributed to alcohol consumption accounted for 4.3% of total mortality, representing a reduction of 26% since 1983. Among men, the primary cause of alcohol-attributable mortality was liver cirrhosis (17.1%), although its relative importance decreased (accounting for 17.1% of alcohol-attributable mortality in 1998 compared with 24.3% in 1983). CONCLUSIONS: The mortality attributable to smoking and alcohol consumption decreased in the city of Barcelona during the study period. Smoking-attributable mortality from lung cancer and COPD increased in both sexes. Alcohol consumption-attributable mortality from liver cirrhosis decreased in men.

Social inequalities in perinatal mortality in a Southern European city.

The objective of this study was to describe and explain inequalities in perinatal mortality by educational level and occupational social class in Barcelona for the years 1993-1997. This was a case-control study. Cases were singleton perinatal deaths, controls were singleton live births obtained from a 2% random sample of births. The association among educational level, social class, other confounding and explanatory variables and perinatal mortality was studied through crude and adjusted odds ratios (OR) obtained by logistic regression. The study comprised 423 cases and 1032 controls. The model with mother's age and educational level showed that women with primary education had an OR of 1.75 (95% CI: 1.26-2.42), this association disappearing when explanatory variables were included. We also found inequalities by educational level in fetal mortality. These results point out the need to improve the living conditions, behavioural factors and also the management of pregnancy, labour and the health care of the newborn of these mothers with greater risk.

[Odds ratio or prevalence ratio? Their use in cross-sectional studies]. / ¿Odds ratio o razón de proporciones? Su utilización en estudios transversales.

BACKGROUND: The most commonly used measures of association in cross-sectional studies are the odds ratio (OR) and the prevalence ratio (PR). Some cross-sectional epidemiologic studies describe their results as OR but use the definition of PR. The main aim of this study was to describe and compare different calculation methods for PR described in literature using two situations (prevalence < 20% and prevalence > 20%). MATERIAL AND METHODS: A literature search was carried out to determine the most commonly used techniques for estimating the PR. The four most frequent methods were: 1) obtaining the OR using non-conditional logistic regression but using the correct definition; 2) using Breslow-Cox regression; 3) using a generalized linear model with logarithmic transformation and binomial family, and 4) using the conversion formula from OR into PR. The models found were replicated for both situations (prevalence less than 20% and greater than 20%) using real data from the 1994 Catalan Health Interview Survey. RESULTS: When prevalence was low, no substantial differences were observed in either the estimators or standard errors obtained using the four procedures. When prevalence was high, differences were found between estimators and confidence intervals although all the measures maintained statistical significance. CONCLUSION: All the methods have advantages and disadvantages. Individual researchers should decide which technique is the most appropriate for their data and should be consistent when using an estimator and interpreting it.

Role of individual and contextual effects in injury mortality: new evidence from small area analysis.

OBJECTIVE: To analyse the role of individual and contextual variables in injury mortality inequalities from a small area analysis perspective, looking at the data for the city of Barcelona (Spain) for 1992-98. SETTING: Barcelona (Spain). METHODS: All injury deaths in residents older than 19, which occurred in the period 1992-98 were included (n=4393). Age and sex specific mortality rates were calculated for each educational level and each cause of death (traffic injuries, falls, drug overdose, suicide, other injuries). The contextual variables included were the proportion of men unemployed, and the proportion of men in jail, in each neighbourhood. Multilevel Poisson regression models were fitted using data grouped by age, educational level, and neighbourhood for each sex. RESULTS: Death rates were higher in males, at the extremes of the age distribution (under 44 and over 74 years), and for lower educational levels. The results of the Poisson multilevel models indicate that inequalities by educational level follow a gradient, with higher risks for the population with no schooling, after having adjusted for the contextual variables of the neighbourhood. Such inequalities were more important in the youngest age group (20-34 years), as relative risk of 5.41 (95% confidence interval (CI) 3.9 to 7.4) for all injury causes in males and 4.38 (95% CI 2.3 to 8.4) in females. The highest relative risks were found for drug overdose. There was a contextual neighbourhood effect (the higher the deprivation, the higher the mortality) after having taken into account individual variables. CONCLUSION: The findings underscore the need to implement injury prevention strategies not only at the individual level taking into account socioeconomic position, but also at the neighbourhood level.

[Lung cancer mortality in Barcelona: evidence for an initial decline in men]. / Mortalidad por cáncer de pulmón: inicio de declive en los varones de Barcelona.

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.

Trends in young adult mortality in three European cities: Barcelona, Bologna and Munich, 1986-1995.

OBJECTIVE: In recent decades, in most European countries young adult mortality has risen, or at best has remained stable. The aim of this study was to describe trends in mortality attributable to the principal causes of death: AIDS, drug overdose, suicide and motor vehicle traffic accidents, among adults aged between 15 and 34 years in three European cities (Barcelona, Bologna and Munich), over the period 1986 to 1995. METHODS: The population studied consisted of all deaths that occurred between 1986 and 1995 among residents of Barcelona, Bologna and Munich aged from 15 to 34 years. Information about deaths was obtained from mortality registers. The study variables were sex, age, the underlying cause of death and year of death. Causes of death studied were: drug overdose, AIDS, suicide and motor vehicle traffic accidents. Age standardised mortality rates (direct adjustment) were obtained in all three cities for the age range 15-34. To investigate trends in mortality over the study period Poisson regression models were fitted, obtaining the average relative risk (RR) associated with a one year increment. RESULTS: Young adult mortality increased among men in Barcelona and Bologna (RR per year: 1.04, 95% confidence intervals (95%CI): 1.03, 1.06 in Barcelona and RR:1.03, 95%CI:1.01, 1.06 in Bologna) and among women in Barcelona (RR:1.02, 95%CI: 1.01, 1.04), with a change in the pattern of the main causes of death attributable to the increase in AIDS and drug overdose mortality. In Munich, the pattern did not change as much, suicides being the main cause of death during the 10 years studied, although they have been decreasing since 1988 (RR:0.92, 95%CI:0.88, 0.96 for men and 0.81, 95%CI: 0.75-0.87 for women). CONCLUSION: The increase in AIDS mortality observed in the three European cities in the mid-80s and mid-90s has yielded substantial changes in the pattern of the main causes of death at young ages in Barcelona and Bologna. Munich presented a more stable pattern, with suicide as the main cause of death.

Material deprivation and leading causes of death by gender: evidence from a nationwide small area study.

STUDY OBJECTIVE: To investigate the association between material deprivation and 10 leading causes of death by gender. DESIGN: Small area cross sectional ecological study using two dimensions of material deprivation (Index 1 and Index 2) drawn from 1991 census and cause specific mortality data aggregated for 1987-1995. SETTING: 2218 small areas in Spain. MAIN RESULTS: Strong detrimental associations of two deprivation indices were found with top six leading causes of death for men and top seven leading causes of death for women, except breast cancer. For men, the highest percentages of excess mortality (between 40% and 60%) were found for smoking and alcohol related causes of death such as lung cancer, chronic obstructive pulmonary diseases, and cirrhosis while for women the highest percentages of excess mortality (between 40% and 60%) were found for diet related causes such as diabetes and ischaemic heart disease. CONCLUSIONS: Health inequality is a widespread phenomenon in the majority of the top leading causes of deaths of the nation. Increasing levels of deprivation indices are associated with mortality risk differently by both cause and gender. Results suggest that deprivation effects mainly captured by Index 2 may manifest largely as unfavourable health behaviours leading to gender specific sets of causes of deaths. Findings of this study are consistent with the idea that material deprivation determines health inequality through both an increase of general susceptibility to ill health, leading to excess mortality in a wide range of causes, and a set of specific factors, resulting in an increased risk of death from a specific set of causes in each gender.

[Influence of social inequality, social unrest and extreme poverty on tuberculosis morbidity in the City of Barcelona]. / Influencia de las desigualdades sociales, la conflictividad social y la pobreza extrema sobre la morbilidad por tuberculosis en la ciudad de Barcelona.

BACKGROUND: The main purpose of this study was to analyse inequalities between tuberculosis/intravenous drug user and tuberculosis/not intravenous drug user among the different neighbourhoods of Barcelona and the relationship to socioeconomic indicators and social/material deprivation indicators throughout the 1990-1995 period. METHODS: An ecological study which included all cases of tuberculosis among residents of Barcelona, the analysis unit being the neighbourhood. Intravenous drug users within the 15-49 age range and non-intravenous drug users over age 14 were included. The mean annual incidence rate standardized by age was used. The social indicators considered were the inner city areas, unemployment, less than primary education, overcrowding, social unrest and extreme poverty. In the bivariate analysis, the relationship between tuberculosis incidence and the social indicators was studied by means of the Spearman correlation coefficient, and the multivariate analysis by means of the Poisson regression. RESULTS: The incidence rates were higher in the inner city neighbourhoods, followed by the newer outlying working class neighbourhoods in both groups studied, and in other older outlying districts for the non-users of intravenous drugs. Among the intravenous drug user group, the variables related to a greater risk of tuberculosis were: man (RR = 7.42, confidence interval at 95% ICI95%-: 6.16-8.93), age (RR = 61.51, CI95%: 34.64-109.20), unemployment (RR = 1.68, CI95%: 1.51-1.88), social unrest (RR = 1.29, CI 95%: 1.04-1.58), overcrowding (RR = 1.36, CI 95%: 1.19-1.55) and inner city areas (RR = 1.92, CI 95% 1.48-2.50). Among the male non-users of intravenous drugs, no interaction between unemployment and age was found. Neighbourhoods with extreme poverty and inner city neighbourhoods showed a higher risk of tuberculosis (RR = 1.11, CI 95% 1.08-1.135 and RR = 1.80, CI95%: 1.51-2.14). Among the female non-users of intravenous drugs, a relationship was found in those of lesser age (RR = 1.29, CI 95%: 1.05-1.57), unemployment (RR = 1.18, CI 95%: 1.09-1.26), extreme poverty (RR = 1.95, CI 95%: 1.56-2.45) and inner city areas (RR = 1.72, CI 95%: 1.35-2.19). CONCLUSION: Inequalities in tuberculosis are related to different social indicators such as unemployment and inner city areas. A difference exists between the two groups studied. Tuberculosis is related with social unrest and overcrowding among intravenous drug users and with extreme poverty among non-users of intravenous drugs.

Social inequalities in health related behaviours in Barcelona.

OBJECTIVE: This study describes social class inequalities in health related behaviours (tobacco and alcohol consumption, physical activity) among a sample of general population over 14 years old in Barcelona. DESIGN: Cross sectional study (Barcelona Health Interview Survey). SETTING: Barcelona city (Spain). PARTICIPANTS: A representative stratified sample of the non-institutionalised population resident in Barcelona was obtained. This study refers to the 4171 respondents aged over 14. DATA: Social class was obtained from a Spanish adaptation of the British Registrar General classification. In addition, sociodemographic variables such as family structure and employment status were used. As health related behaviours tobacco consumption, alcohol consumption, usual physical activity and leisure time physical activity were analysed. Age adjusted percentages were compared by social class. Multivariate analysis was performed using logistic regression models. MAIN RESULTS: Women in the upper social classes were more likely to smoke, the adjusted odds ratio (OR) for social class V in reference to social class I was 0.36 (95% confidence intervals (95%CI): 0.19, 0.67), while the opposite occurred among men although it was not statistically significant in multivariate analysis. Smoking cessation was more likely among men in the higher classes (OR for class V 0.41, 95%CI: 0.18, 0.90). Excessive alcohol consumption among men showed no differences between classes, while among women it was greater in the upper classes. Engaging in usual physical activity classified as "light or none" in men decreased with lowering social class (OR class IVa: 0.55 and OR class IVb: 0.47). Women of social classes IV and V were less likely to have two or more health risk behaviours (OR for class V 0.33, 95% CI: 0.18, 0.62). CONCLUSION: Health damaging behaviours are differentially distributed among social classes in Barcelona. Health policies should take into account these inequalities.

Inequalities in mortality by social class in men in Barcelona, Spain.

Most of the studies of inequalities in mortality carried out in Spain have been ecological, due to the difficulty of obtaining good quality socioeconomic information at individual level. The objective of this study was to describe inequalities in mortality by social class, based on occupation, among men residents of Barcelona in 1993. A representative sample was obtained of men residents of Barcelona who died during the year 1993, aged between 15 and 65 years. It was a retrospective interview given to relatives of the deceased, or other closely related persons. The variables analysed were: age, education level, underlying cause of death, and social class based on occupation (manual and non-manual workers). Rates, relative risks (RRs) and their 95% confidence intervals (95% CIs) are presented by age groups and cause of death. The main results show that among young people, the excess of mortality due to infectious diseases is notable (RR: 1.9; 95% CI: 1.6-2.2), and also due to external causes (RR: 2.1; 95% CI: 1.8-2.4) among manual workers with respect to non-manual workers, mainly due to AIDS and drug overdose. No significant differences were found in mortality due to tumours. For respiratory and cardiovascular causes, there is an increase in mortality in the less favoured social classes, as also occurs for mortality due to diseases of the digestive system, particularly among young manual workers, with an RR: 2.6 (95% CI: 1.5-3.6) compared to non-manual workers. This study shows that it is necessary to continue exploring inequalities in health, but above all it is necessary to implement efficient preventive measures addressed mainly at young people in situations of disadvantage, in order to avoid the excess of avoidable mortality which is found.

Trends in social class inequalities in health status, health-related behaviors, and health services utilization in a Southern European urban area (1983-1994).

BACKGROUND: The objective of this study was to describe the evolution of social class inequalities in Barcelona (Spain) residents in perceived health status, health-related behaviors, and utilization of health services between 1983 and 1994. METHODS: The information was obtained from the Health Interview Surveys conducted in 1983, 1986, 1992, and 1994 in Barcelona. In this study we included noninstitutionalized people ages >14 years. Social class was obtained from the Spanish adaptation of the British Registrar General classification. We studied health status, health-related behaviors, and health services utilization variables. Age-adjusted percentages and the relative index of inequality were obtained. RESULTS: Of the health status variables, having been confined to bed and acute restriction of activity in the 2 weeks prior to the interview showed an increase in inequalities by social class in 1994. The pattern of chronic conditions by social class in men did not change between 1983 and 1994. Women had a higher prevalence of chronic conditions and the inequalities among social classes had increased. In men there were no social class inequalities in smoking in 1983. In 1992 and 1994 smoking was more prevalent in men of social classes IV and V. In women, smoking was more prevalent in social classes I and II in 1983 than in social classes IV and V, something that had changed by 1994. Lack of usual physical activity in men was always more prevalent in social classes I and II, and this difference increased since more people of advantaged classes moved into inactivity. Health services utilization showed no inequalities in the years studied. CONCLUSION: The changing pattern according to social class of smoking and physical activity practice needs to be taken into account by policy-makers and public health workers.

[Exactness of the birth registry of Barcelona regarding birth weight and weeks of gestation]. / Exactitud del registro de nacimientos de Barcelona en el peso del recién nacido y las semanas de gestación.

OBJECTIVE: The aim of the study is to know the accuracy of the variables birth weight and gestational age in the Barcelona Birth Registry. Hospital medical records are used as gold standard. METHODS: A representative sample (n = 1,932) was selected from all the residents born in the city of Barcelona between 1st of May and 31st of December of 1996. The variables birth weight and gestational age were evaluated. Exhaustivity, sensitivity, specificity and predictive value for these variables were calculated. RESULTS: The Registry shows a high exhaustivity for the study variables. The lowest value of sensitivity corresponds to premature births (65.1%) and the lowest value of specificity to term births (63.9%). The predictive value positive was 77.5% for preterm births and 76.7% for term births. CONCLUSIONS: In general, exhaustivity and accuracy of the Barcelona Birth Registry are high, but sensitivity for preterm births in the Registry is lower. However, the corresponding maternal and child health indicators do not vary in an important manner.

[An evaluation of the impact of primary care reform on health]. / Evaluación del impacto de la reforma de la atención primaria sobre la salud.

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.

Social inequalities in perceived health and the use of health services in a southern European urban area.

People of lower social class have worse health and less access to health services and preventive care. This article describes social class inequalities in health status and use of services, both curative and preventive, in Barcelona, in a country with a national health service. The cross-sectional study uses information from the 1992 Barcelona Health Interview Survey. Social class was designated using an adaptation of the British Registrar General classification. The study variables measured health status, health services utilization, and preventive practices. Bivariate and multivariate analyses were used. Some 88 percent of men in social class I and 81 percent in class V had very good or good perceived health status. For women these figures were 85.2 and 57.6 percent, respectively. Chronic illness increased with lower social class. There were no social class differences in the frequency of physician visits during the two weeks prior to the interview among people with poor perceived health. Some 60.7 percent of women aged over 29 in social class I had periodic cervical smears, but only 32 percent of those in class V; the corresponding figures for mammography were 37.8 and 11.3 percent. The national health service has advantages in terms of access to health services, but more knowledge about the quality of these services is required. The study findings are sufficient to defend the undertaking of equitable health policies, especially in providing access to preventive care for the entire population.