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After discussing the comparative effectiveness of different measures of dispersion used as indices of inequality, the Weighted Coefficient of Variation is proposed as an appropriate indicator of geographical inequality attending infant death. Furthermore, this paper proposes a methodology based on simple linear regression to be employed for the purposes of assessing the percentage of the observed change in said inequality over any given period, as is required by the terms of Target 1 of the WHO policy document 'Health for All by the Year 2000'. To this end, trends in Infant, Neonatal, Postneonatal and Perinatal Mortality in Spain for the period 1975-1986 have been analysed. For the 12 years examined, the Average Spanish Rate for these four indicators fell by over 50%. We observed a statistically significant decrease (34.8%) in geographical inequalities in the case of Postneonatal Mortality. However for the same period, geographical inequalities in Perinatal Mortality showed an important and significant rise (79.33%). It is suggested that, where Spain is concerned, it is Perinatal Mortality which should be assigned priority status for monitoring purposes. A plan of action should be drawn up, duly targeted at reducing geographical inequalities in health services, in the mother-and-child care sector above all.

Miguel Angel Luque-Fernandez,1– 3 Daniel Redondo-Sánchez,1,2 Miguel Rodríguez-Barranco,1,2,4 Yoe-Ling Chang-Chan,1,4 Elena Salamanca-Fernández,1,2 Olivier Núñez,2,5 Pablo Fernandez-Navarro,2,5 Marina Pollán,2,5 María-José Sánchez1,2,4,6 1Instituto de Investigación Biosanitaria de Granada, Non-Communicable Disease and Cancer Epidemiology Group, ibs.GRANADA, University of Granada, Granada, Spain; 2Biomedical Network Research Centers of Epidemiology and Public Health (CIBERESP), Madrid, Spain; 3London School of Hygiene and Tropical Medicine, Non-Communicable Disease Epidemiology, London, UK; 4Andalusian School of Public Health, Granada, Spain; 5National Centre of Epidemiology, Health Institute Carlos III (CNE-ISCIII), Madrid, Spain; 6Department of Preventive Medicine and Public Health, University of Granada, Granada, SpainCorrespondence: Miguel Angel Luque-FernandezAndalusian School of Public Health, Cuesta Del Observatorio, 4, Granada 18080, SpainEmail miguel-angel.luque@lshtm.ac.ukBackground: Colorectal cancer (CRC) is the most frequently diagnosed cancer in Spain. Socioeconomic inequalities in cancer survival are not documented in Spain. We aim to study the association of socioeconomic inequalities with overall mortality and survival among CRC patients in southern Spain.Methods: We conducted a multilevel population-based cohort study, including CRC cases for the period 2011– 2013. The study time-to-event outcome was death, and the primary exposure was CRC patients’ socioeconomic status assessed by the Spanish deprivation index at the census tract level. We used a mixed-effects flexible hazard model, including census tract as a random intercept, to derive overall survival estimates by deprivation.Results: Among 3589 CRC patients and 12,148 person-years at risk (pyr), 964 patients died before the end of the follow-up. Mortality by deprivation showed the highest mortality rate for the most deprived group (96.2 per 1000 pyr, 95% CI: 84.0– 110.2). After adjusting for sex, age, cancer stage, and the area of residence, the most deprived had a 60% higher excess mortality risk than the less deprived group (excess mortality risk ratio: 1.6, 95% CI: 1.1– 2.3).Conclusions: We found a consistent association between deprivation and CRC excess mortality and survival. The reasons behind these inequalities need further investigation in order to improve equality cancer outcomes in all social groups.Keywords: socioeconomic inequalities, colorectal cancer, survival, population-based epidemiology, epidemiological methods, multilevel

Abstract Background Measurement of obesity using self-reported anthropometric data usually involves underestimation of weight and/or overestimation of height. The dual aim of this study was, first, to ascertain and assess the validity of new cut-off points, for both overweight and obesity, using self-reported Body Mass Index furnished by women participants in breast cancer screening programmes, and second, to estimate and validate a predictive model that allows recalculate individual BMI based on self-reported data. Methods The study covered 2927 women enrolled at 7 breast cancer screening centres. At each centre, women were randomly selected in 2 samples, in a ratio of 2:1. The larger sample (n = 1951) was used to compare the values of measured and self-reported weight and height, to ascertain new overweight and obesity cut-off points with self-reported data, using ROC curves, and to estimate a predictive model of real BMI using a regression model. The second sample (n = 976) was used to validate the proposed cut-off points and the predictive model. Results Whereas reported prevalence of obesity was 19.8%, measured prevalence was 28.2%. The sensitivity and specificity of this classification would be maximised if the new cut-off points were 24.30 kg/m2 for overweight and 28.39 kg/m2 for obesity. The probability of classifying women correctly in their real weight categories on the basis of these points was 82.5% in the validation sample. Sensitivity and specificity for determining obesity using the new cut-off point in the validation sample were 90.0% and 92.3% respectively. The predictive model for real BMI included the self-reported BMI, age and educational level (university studies vs lower levels of education). This model succeeded in correctly classifying 90.5% of women according to BMI categories, but its performance was similar to that obtained with the new cut-off points. Conclusions Quantification of self-reported obesity entails a considerable underestimation of this problem, thereby questioning its validity. The new cut-off points established in this study and the predictive equation both allow for more accurate estimation of these prevalences.

Abstract Background Breast cancer is one of the oncological diseases in which health-related quality of life (HRQL) has been most studied. This is mainly due to its high incidence and survival. This paper seeks to: review published research into HRQL among women with breast cancer in Spain; analyse the characteristics of these studies; and describe the instruments used and main results reported. Methods The databases consulted were MEDLINE, EMBASE, PsycINFO, Dialnet, IBECS, CUIDEN, ISOC and LILACS. The inclusion criteria required studies to: 1) include Spanish patients, and a breakdown of results where other types of tumours and/or women from other countries were also included; and, 2) furnish original data and measure HRQL using a purpose-designed questionnaire. The methodological quality of studies was assessed. Results Spain ranked midway in the European Union in terms of the number of studies conducted on the HRQL of breast cancer patients. Of the total of 133 papers published from 1993 to 2009, 25 met the inclusion criteria. Among them, only 12 were considered as having good or excellent quality. A total of 2236 women participated in the studies analysed. In descending order of frequency, the questionnaires used were the EORTC, FACT-B, QL-CA-Afex, SF-12, FLIC, RSCL and CCV. Five papers focused on validation or adaptation of questionnaires. Most papers examined HRQL in terms of type of treatment. Few differences were detected by type of chemotherapy, with the single exception of worse results among younger women treated with radiotherapy. In the short term, better results were reported for all HRQL components by women undergoing conservative rather than radical surgery. Presence of lymphedema was associated with worse HRQL. Three studies assessed differences in HRQL by patients' psychological traits. Psychosocial disorder and level of depression and anxiety, regardless of treatment or disease stage, worsened HRQL. In addition, there was a positive effect among patients who reported having a "fighting spirit" and using "denial" as a defence mechanism. One study found that breast cancer patients scored worse than did healthy women on almost all SF-12 scales. Conclusion Research into health-related quality of life of breast-cancer patients is a little developed field in Spain.

Abstract Background Asturias, an Autonomous Region in Northern Spain with a large industrial area, registers high lung cancer incidence and mortality. While this excess risk of lung cancer might be partially attributable to smoking habit and occupational exposure, the role of industrial and urban pollution also needs to be assessed. The objective was to ascertain the possible effect of air pollution, both urban and industrial, on lung cancer risk in Asturias. Methods This was a hospital-based case-control study covering 626 lung cancer patients and 626 controls recruited in Asturias and matched by ethnicity, hospital, age, and sex. Distances from the respective participants' residential locations to industrial facilities and city centers were computed. Using logistic regression, odds ratios (ORs) and 95% confidence intervals (95%CIs) for categories of distance to urban and industrial pollution sources were calculated, with adjustment for sex, age, hospital area, tobacco consumption, family history of cancer, and occupation. Results Whereas individuals living near industries displayed an excess risk of lung cancer (OR = 1.49; 95%CI = 0.93-2.39), which attained statistical significance for small cell carcinomas (OR = 2.23; 95%CI = 1.01-4.92), residents in urban areas showed a statistically significant increased risk for adenocarcinoma (OR = 1.92; 95%CI = 1.09-3.38). In the Gijon health area, residents in the urban area registered a statistically significant increased risk of lung cancer (OR = 2.17; 95%CI = 1.25-3.76), whereas in the Aviles health area, no differences in risk were found by area of exposure. Conclusions This study provides further evidence that air pollution is a moderate risk factor for lung cancer.

Abstract Background Increased mammographic breast density is a moderate risk factor for breast cancer. Different scales have been proposed for classifying mammographic density. This study sought to assess intra-rater agreement for the most widely used scales (Wolfe, Tabár, BI-RADS and Boyd) and compare them in terms of classifying mammograms as high- or low-density. Methods The study covered 3572 mammograms drawn from women included in the DDM-Spain study, carried-out in seven Spanish Autonomous Regions. Each mammogram was read by an expert radiologist and classified using the Wolfe, Tabár, BI-RADS and Boyd scales. In addition, 375 mammograms randomly selected were read a second time to estimate intra-rater agreement for each scale using the kappa statistic. Owing to the ordinal nature of the scales, weighted kappa was computed. The entire set of mammograms (3572) was used to calculate agreement among the different scales in classifying high/low-density patterns, with the kappa statistic being computed on a pair-wise basis. High density was defined as follows: percentage of dense tissue greater than 50% for the Boyd, "heterogeneously dense and extremely dense" categories for the BI-RADS, categories P2 and DY for the Wolfe, and categories IV and V for the Tabár scales. Results There was good agreement between the first and second reading, with weighted kappa values of 0.84 for Wolfe, 0.71 for Tabár, 0.90 for BI-RADS, and 0.92 for Boyd scale. Furthermore, there was substantial agreement among the different scales in classifying high- versus low-density patterns. Agreement was almost perfect between the quantitative scales, Boyd and BI-RADS, and good for those based on the observed pattern, i.e., Tabár and Wolfe (kappa 0.81). Agreement was lower when comparing a pattern-based (Wolfe or Tabár) versus a quantitative-based (BI-RADS or Boyd) scale. Moreover, the Wolfe and Tabár scales classified more mammograms in the high-risk group, 46.61 and 37.32% respectively, while this percentage was lower for the quantitative scales (21.89% for BI-RADS and 21.86% for Boyd). Conclusions Visual scales of mammographic density show a high reproducibility when appropriate training is provided. Their ability to distinguish between high and low risk render them useful for routine use by breast cancer screening programs. Quantitative-based scales are more specific than pattern-based scales in classifying populations in the high-risk group.

Abstract Background While the timing of reproductive events varies across populations, a downward trend in age at menarche has nevertheless been reported in most of the developed world over the past century. Given the impact of change in age at menarche on health conditions, this study sought to examine secular trends in age at menarche among women living in Navarre (Northern Spain) who participated in a population-based breast cancer screening programme. Methods The study was based on 110545 women born from 1925 to 1962. Trends were tested using a linear regression model, in which year of birth was entered continuously as the predictor and age at menarche (years) as the response variable, using size of town and region of birth as covariates. Results Among women born in Navarre between 1925 and 1962, age at menarche declined steadily from an average of 13.72 years in the 1925-1929 birth-cohorts to 12.83 years in the 1958-1962 birth-cohorts. Controlling for size of town or city of birth, age at menarche declined by an average of 0.132 years every 5 years over the period 1925-1962. This decline was greater in women born in rural versus urban settings. Trends were also different among regions of birth. Conclusion We report a population-based study showing a downward trend in age of onset of menarche among Spanish women born in the period 1925-1962, something that is more pronounced among women born in rural settings and varies geographically.

Abstract Background Gastric cancer is the second leading cause of oncologic death worldwide. One of the most noteworthy characteristics of this tumor's epidemiology is the marked decline reported in its incidence and mortality in almost every part of the globe in recent decades. This study sought to describe gastric cancer mortality time trends in Spain's regions for both sexes. Methods Mortality data for the period 1976 through 2005 were obtained from the Spanish National Statistics Institute. Cases were identified using the International Classification of Diseases 9th and 10th revision (codes 151 and C16, respectively). Crude and standardized mortality rates were calculated by geographic area, sex, and five-year period. Joinpoint regression analyses were performed to ascertain whether changes in gastric cancer mortality trends had occurred, and to estimate the annual percent change by sex and geographic area. Results Gastric cancer mortality decreased across the study period, with the downward trend being most pronounced in women and in certain regions situated in the interior and north of mainland Spain. Across the study period, there was an overall decrease of 2.90% per annum among men and 3.65% per annum among women. Generally, regions in which the rate of decline was sharpest were those that had initially registered the highest rates. However, the rate of decline was not constant throughout the study period: joinpoint analysis detected a shift in trend for both sexes in the early 1980s. Conclusion Gastric cancer mortality displayed in both sexes a downward trend during the study period, both nationally and regionally. The different trend in rates in the respective geographic areas translated as greater regional homogeneity in gastric cancer mortality by the end of the study period. In contrast, rates in women fell more than did those in men. The increasing differences between the sexes could indicate that some risk factors may be modifying the sex-specific pattern of this tumor.

Abstract Background Gastric cancer is decreasing in most countries. While socioeconomic development is the main factor to which this decline has been attributed, enormous differences among countries and within regions are still observed, with the main contributing factors remaining elusive. This study describes the geographic distribution of gastric cancer mortality at a municipal level in Spain, from 1994-2003. Methods Smoothed relative risks of stomach cancer mortality were obtained, using the Besag-York-Molliè autoregressive spatial model. Maps depicting relative risk (RR) estimates and posterior probabilities of RR being greater than 1 were plotted. Results From 1994-2003, 62184 gastric cancer deaths were registered in Spain (7 percent of all deaths due to malignant tumors). The geographic pattern was similar for both sexes. RRs displayed a south-north and coast-inland gradient, with lower risks being observed in Andalusia, the Mediterranean coastline, the Balearic and Canary Islands and the Cantabrian seaboard. The highest risk was concentrated along the west coast of Galicia, broad areas of the Castile & Leon Autonomous community, the province of Cáceres in Extremadura, Lleida and other areas of Catalonia. Conclusion In Spain, risk of gastric cancer mortality displays a striking geographic distribution. With some differences, this persistent and unique pattern is similar across the sexes, suggesting the implication of environmental exposures from sources, such as diet or ground water, which could affect both sexes and delimited geographic areas. Also, the higher sex-ratios found in some areas with high risk of smoking-related cancer mortality in males support the role of tobacco in gastric cancer etiology.

Abstract Background The impact of obesity on health-related quality of life (HRQL) has been little explored in rural areas. The goal of this study is to ascertain the association between obesity and HRQL among Spanish women living in a rural area, and the influence of their educational level. Methods Cross-sectional study with personal interview of 1298 women (aged 18 to 60) randomly selected from the electoral rolls of 14 towns in Galicia, a region in the north-west of Spain. HRQL was assessed using the SF-36 questionnaire. The association between body mass index (BMI) and suboptimal scores in the different HRQL dimensions was summarised using odds ratios (ORs), obtained from multivariate logistic regression models. Separate analyses were conducted for women who had finished their education younger than 16 years old and women with secondary education to assess differences in the relationship between BMI and HRQL according to educational level. Results Among women with primary or lower education, obesity was associated with a higher prevalence of suboptimal values in the following dimensions: Physical functioning (OR: 1.97; 95%CI: 1.22–3.18); Role-physical (OR: 1.81; 95%CI: 1.04–3.14); General health (OR: 1.76; 95%CI: 1.10–2.81); and Role-emotional (OR: 2.52; 95%CI: 1.27–5.03). In women with higher education, physical functioning was the only dimension associated with obesity (OR: 2.02: 95%CI 0.83–4.97). Conclusion The impact of obesity on women's HRQL is greater among those with a lower educational level. This group registered higher prevalence of obesity and poorer self-perceived health.

Abstract Background Non-Hodgkin's lymphomas (NHLs) have been linked to proximity to industrial areas, but evidence regarding the health risk posed by residence near pollutant industries is very limited. The European Pollutant Emission Register (EPER) is a public register that furnishes valuable information on industries that release pollutants to air and water, along with their geographical location. This study sought to explore the relationship between NHL mortality in small areas in Spain and environmental exposure to pollutant emissions from EPER-registered industries, using three Poisson-regression-based mathematical models. Methods Observed cases were drawn from mortality registries in Spain for the period 1994–2003. Industries were grouped into the following sectors: energy; metal; mineral; organic chemicals; waste; paper; food; and use of solvents. Populations having an industry within a radius of 1, 1.5, or 2 kilometres from the municipal centroid were deemed to be exposed. Municipalities outside those radii were considered as reference populations. The relative risks (RRs) associated with proximity to pollutant industries were estimated using the following methods: Poisson Regression; mixed Poisson model with random provincial effect; and spatial autoregressive modelling (BYM model). Results Only proximity of paper industries to population centres (>2 km) could be associated with a greater risk of NHL mortality (mixed model: RR:1.24, 95% CI:1.09–1.42; BYM model: RR:1.21, 95% CI:1.01–1.45; Poisson model: RR:1.16, 95% CI:1.06–1.27). Spatial models yielded higher estimates. Conclusion The reported association between exposure to air pollution from the paper, pulp and board industry and NHL mortality is independent of the model used. Inclusion of spatial random effects terms in the risk estimate improves the study of associations between environmental exposures and mortality. The EPER could be of great utility when studying the effects of industrial pollution on the health of the population.

Abstract Background Since the second half of the 1990s, kidney cancer mortality has tended to stabilize and decline in many European countries, due to the decrease in the prevalence of smokers. Nevertheless, incidence of kidney cancer is rising across the sexes in some of these countries, a trend which may possibly reflect the fact that improvements in diagnostic techniques are being outweighed by the increased prevalence of some of this tumor's risk factors. This study sought to: examine the geographic pattern of kidney cancer mortality in Spain; suggest possible hypotheses that would help explain these patterns; and enhance existing knowledge about the large proportion of kidney tumors whose cause remains unknown. Methods Smoothed municipal relative risks (RRs) for kidney cancer mortality were calculated in men and women, using the conditional autoregressive model proposed by Besag, York and Molliè. Maps were plotted depicting smoothed relative risk estimates, and the distribution of the posterior probability of RR>1 by sex. Results Municipal maps displayed a marked geographic pattern, with excess mortality in both sexes, mainly in towns along the Bay of Biscay, including areas of Asturias, the Basque Country and, to a lesser extent, Cantabria. Among women, the geographic pattern was strikingly singular, not in evidence for any other tumors, and marked by excess risk in towns situated in the Salamanca area and Extremaduran Autonomous Region. This difference would lead one to postulate the existence of different exposures of environmental origin in the various regions. Conclusion The reasons for this pattern of distribution are not clear, and it would thus be of interest if the effect of industrial emissions on this disease could be studied. The excess mortality observed among women in towns situated in areas with a high degree of natural radiation could reflect the influence of exposures which derive from the geologic composition of the terrain and then become manifest through the agency of drinking water.

Abstract Background Spain was the country that registered the greatest increases in ovarian cancer mortality in Europe. This study describes the municipal distribution of ovarian cancer mortality in Spain using spatial models for small-area analysis. Methods Smoothed relative risks of ovarian cancer mortality were obtained, using the Besag, York and Molliè autoregressive spatial model. Standardised mortality ratios, smoothed relative risks, and distribution of the posterior probability of relative risks being greater than 1 were depicted on municipal maps. Results During the study period (1989–1998), 13,869 ovarian cancer deaths were registered in 2,718 Spanish towns, accounting for 4% of all cancer-related deaths among women. The highest relative risks were mainly concentrated in three areas, i.e., the interior of Barcelona and Gerona (north-east Spain), the north of Lugo and Asturias (north-west Spain) and along the Seville-Huelva boundary (in the south-west). Eivissa (Balearic Islands) and El Hierro (Canary Islands) also registered increased risks. Conclusion Well established ovarian cancer risk factors might not contribute significantly to the municipal distribution of ovarian cancer mortality. Environmental and occupational exposures possibly linked to this pattern and prevalent in specific regions, are discussed in this paper. Small-area geographical studies are effective instruments for detecting risk areas that may otherwise remain concealed on a more reduced scale.

Abstract Background This study sought to ascertain whether there might be excess lung cancer mortality among the population residing in the vicinity of Spanish paper and board industries which report their emissions to the European Pollutant Emission Register (EPER). Methods This was an ecological study that modelled the Standardised Mortality Ratio (SMR) for lung cancer in 8073 Spanish towns over the period 1994–2003. Population exposure to industrial pollution was estimated on the basis of distance from town of residence to pollution source. An exploratory, near-versus-far analysis was conducted, using mixed Poisson regression models and an analysis of the effect of municipal proximity within a 50-kilometre radius of each of the 18 installations. Results Results varied for the different facilities. In two instances there was an increasing mortality gradient with proximity to the installation, though this was exclusively observed among men. Conclusion The study of cancer mortality in areas surrounding pollutant foci is a useful tool for environmental surveillance, and serves to highlight areas of interest susceptible to being investigated by ad hoc studies. Despite present limitations, recognition is therefore due to the advance represented by publication of the EPER and the study of pollutant foci.

Abstract Background Cutaneous melanoma (CM) is a cancer usually associated with high socio-economic level in the literature. Few studies have, however, assessed this relationship by gender and site or the association between CM and rurality. Methods A major-sized historical occupational Swedish cohort comprising 2,992,166 workers was used to estimate relative risk of cutaneous melanoma, broken down by gender and anatomical site, for occupational sectors (as a proxy of socio-economic class) and rurality. To this end, Poisson models were fitted for each site in men and women, including occupational sector and town size, with adjustment for age, period of diagnosis and geographical area as possible confounding factors. Results White collar workers presented a marked increased of risk in men in all melanoma cases, as well as in trunk, upper and lower limbs. This pattern was less clear for women, in which some heterogeneity appeared, as low risks in lower socioeconomic sectors in trunk, or risk excesses in white collar workers in lower limbs did not achieve statistical significance. Males also showed significant differences in risk by rural/urban distribution, but in women this association was limited to CM of lower limb. Risk of CM of head/neck did not vary by occupational sector or town size, thus depicting a specific epidemiological profile, which proved common to both sexes. Conclusion While differences in risk between men and women could suggest greater homogeneity in UV-exposure behaviour among women, the uniform risk pattern in head and neck melanoma, present in both sexes, might support the coexistence of different aetiological pathways, related to anatomical site.

Abstract Background The European Pollutant Emission Register in Spain (EPER-Spain) is a public inventory of pollutant industries created by decision of the European Union. The location of these industries is geocoded and the first published data correspond to 2001. Publication of these data will allow for quantification of the effect of proximity to one or more such plant on cancer and all-cause mortality observed in nearby towns. However, as errors have been detected in the geocoding of many of the pollutant foci shown in the EPER, it was decided that a validation study should be conducted into the accuracy of these co-ordinates. EPER-Spain geographic co-ordinates were drawn from the European Environment Agency (EEA) server and the Spanish Ministry of the Environment (MOE). The Farm Plot Geographic Information System (Sistema de Información Geográfica de Parcelas Agrícolas) (SIGPAC) enables orthophotos (digitalized aerial images) of any territorial point across Spain to be obtained. Through a search of co-ordinates in the SIGPAC, all the industrial foci (except farms) were located. The quality criteria used to ascertain possible errors in industrial location were high, medium and low quality, where industries were situated at a distance of less than 500 metres, more than 500 metres but less than 1 kilometre, and more than 1 kilometre from their real locations, respectively. Results Insofar as initial registry quality was concerned, 84% of industrial complexes were inaccurately positioned (low quality) according to EEA data versus 60% for Spanish MOE data. The distribution of the distances between the original and corrected co-ordinates for each of the industries on the registry revealed that the median error was 2.55 kilometres for Spain overall (according to EEA data). The Autonomous Regions that displayed most errors in industrial geocoding were Murcia, Canary Islands, Andalusia and Madrid. Correct co-ordinates were successfully allocated to 100% of EPER-Spain industries. Conclusion Knowing the exact location of pollutant foci is vital to obtain reliable and valid conclusions in any study where distance to the focus is a decisive factor, as in the case of the consequences of industrial pollution on the health of neighbouring populations.

Abstract Background In 2002 the oil-tanker Prestige sank off the Galician coast. This study analyzes the effect of this accident on health-related quality of life (HRQoL) and mental health in the affected population. Methods Using random sampling stratified by age and sex, 2700 residents were selected from 7 coastal and 7 inland Galician towns. Two exposure criteria were considered: a) residential exposure, i.e., coast versus interior; and b) individual exposure-unaffected, slightly affected, or seriously affected-according to degree of personal affectation. SF-36, GHQ-28, HADS and GADS questionnaires were used to assess HRQoL and mental health. Association of exposure with suboptimal scores was summarized using adjusted odds ratios (OR) obtained from logistic regression. Results For residential exposure, the SF-36 showed coastal residents as having a lower likelihood of registering suboptimal HRQoL values in physical functioning (OR:0.69; 95%CI:0.54–0.89) and bodily pain (OR:0.74; 95%CI:0.62–0.91), and a higher frequency of suboptimal scores in mental health (OR:1.28; 95%CI:1.02–1.58). None of the dimensions of the other questionnaires displayed statistically significant differences. For individual exposure, no substantial differences were observed, though the SF-36 physical functioning dimension rose (showed better scores) with level of exposure (91.51 unaffected, 93.86 slightly affected, 95.28 seriously affected, p < 0.001). Conclusion Almost one and a half years after the accident, worse HRQoL and mental health levels were not in evidence among subjects exposed to the oil-spill. Nevertheless, some of the scales suggest the possibility of slight impact on the mental health of residents in the affected areas.

Abstract Background Spain has one of the lowest rates of breast cancer in Europe, though estimated incidence has risen substantially in recent decades. Some years ago, the Spanish Cancer Mortality Atlas showed Spain as having a heterogeneous distribution of breast cancer mortality at a provincial level. This paper describes the municipal distribution of breast cancer mortality in Spain and its relationship with socio-economic indicators. Methods Breast cancer mortality was modelled using the Besag-York-Molliè autoregressive spatial model, including socio-economic level, rurality and percentage of population over 64 years of age as surrogates of reproductive and lifestyle risk factors. Municipal relative risks (RRs) were independently estimated for women aged under 50 years and for those aged 50 years and over. Maps were plotted depicting smoothed RR estimates and the distribution of the posterior probability of RR>1. Results In women aged 50 years and over, mortality increased with socio-economic level, and was lower in rural areas and municipalities with higher proportion of old persons. Among women aged under 50 years, rurality was the only statistically significant explanatory variable. For women older than 49 years, the highest relative risks were mainly registered for municipalities located in the Canary Islands, Balearic Islands, the Mediterranean coast of Catalonia and Valencia, plus others around the Ebro River. In premenopausal women, the pattern was similar but tended to be more homogeneous. In mainland Spain, a group of municipalities with high RRs were located in Andalusia, near the left bank of the Guadalquivir River. Conclusion As previously observed in other contexts, mortality rates are positively related with socio-economic status and negatively associated with rurality and the presence of a higher proportion of people over age 64 years. Taken together, these variables represent the influence of lifestyle factors which have determined the increase in breast cancer frequency over recent decades. The results for the younger group of women suggest an attenuation of the socio-economic gradient in breast cancer mortality in Spain. The geographical variation essentially suggests the influence of other environmental variables, yet the descriptive nature of this study does not allow for the main determinants to be established.

Abstract Background Toxic substances released into the environment (to both air and water) by many types of industries might be related with the occurrence of some malignant tumours and other diseases. The publication of the EPER (European Pollutant Emission Register) Spanish data allows to investigate the presence of geographical mortality patterns related to industrial pollution. The aim of this paper is to describe industrial air and water pollution in Spain in 2001, broken down by activity group and specific pollutant, and to plot maps depicting emissions of carcinogenic substances. Methods All information on industrial pollution discharge in 2001 was drawn from EPER-Spain public records provided by the European Commission server. We described the distribution of the number of industries and amounts discharged for each pollutant, as well as emission by pollutant group and the industrial activities associated with each pollutant. Maps of Spain were drawn up, with UTM coordinates being used to plot pollutant foci, and circles with an area proportional to the emission to depict pollution emission values. Results The EPER-Spain contained information on 1,437 industrial installations. The industrial plants that discharge pollutant substances into air and water above the pollutant-specific EPER threshold were mainly situated in the Autonomous Regions of Aragon, Andalusia and Catalonia and in Catalonia, the Basque Country and Andalusia respectively. Pollution released in 2001 into air approached 158 million Mt. Emissions into water were over 8 million Mt. Conclusion A few single industrial plants are responsible for the highest percentage of emissions, thus rendering monitoring of their possible health impact on the surrounding population that much simpler. Among European countries Spain is the leading polluter in almost one third of all EPER-registered pollutant substances released into the air and ranks among the top three leading polluters in two-thirds of all such substances. Information obtained through publication of EPER data means that the possible consequences of reported pollutant foci on the health of neighbouring populations can now be studied.

Abstract Background Oesophageal carcinoma is one of the most common cancers worldwide. Its incidence and mortality rates show a wide geographical variation at a world and regional level. Geographic mapping of age-standardized, cause-specific death rates at a municipal level could be a helpful and powerful tool for providing clues leading to a better understanding of its aetiology. Methods This study sought to describe the geographic distribution of oesophageal cancer mortality for Spain's 8077 towns, using the autoregressive spatial model proposed by Besag, York and Mollié. Maps were plotted, depicting standardised mortality ratios, smoothed relative risk (RR) estimates, and the spatial pattern of the posterior probability of RR being greater than 1. Results Important differences associated with area of residence were observed in risk of dying from oesophageal cancer in Spain during the study period (1989–1998). Among men, excess risk appeared across the north of the country, along a band spanning the length of the Cantabrian coastline, Navarre, the north of Castile & León and the north-west of La Rioja. Excess risk was likewise observed in the provinces of Cadiz and part of Seville in Andalusia, the islands of Tenerife and Gran Canaria, and some towns in the Barcelona and Gerona areas. Among women, there was a noteworthy absence of risk along the mid-section of the Cantabrian seaboard, and increases in mortality, not observed for men, in the west of Extremadura and south-east of Andalusia. Conclusion These major gender- and area-related geographical differences in risk would seem to reflect differences in the prevalence of some well-established and modifiable risk factors, including smoking, alcohol consumption, obesity and diet. In addition, excess risks were in evidence for both sexes in some areas, possibly suggesting the implication of certain local environmental or socio-cultural factors. From a public health standpoint, small-area studies could be very useful for identifying locations where epidemiological research and intervention measures ought to receive priority, given the potential for reducing risk in certain places.

Abstract Background Thyroid cancer is a tumor with a low but growing incidence in Spain. This study sought to depict its spatial municipal mortality pattern, using the classic model proposed by Besag, York and Mollié. Methods It was possible to compile and ascertain the posterior distribution of relative risk on the basis of a single Bayesian spatial model covering all of Spain's 8077 municipal areas. Maps were plotted depicting standardized mortality ratios, smoothed relative risk (RR) estimates, and the posterior probability that RR > 1. Results From 1989 to 1998 a total of 2,538 thyroid cancer deaths were registered in 1,041 municipalities. The highest relative risks were mostly situated in the Canary Islands, the province of Lugo, the east of La Coruña (Corunna) and western areas of Asturias and Orense. Conclusion The observed mortality pattern coincides with areas in Spain where goiter has been declared endemic. The higher frequency in these same areas of undifferentiated, more aggressive carcinomas could be reflected in the mortality figures. Other unknown genetic or environmental factors could also play a role in the etiology of this tumor.

Abstract Background Spain shows the highest bladder cancer incidence rates in men among European countries. The most important risk factors are tobacco smoking and occupational exposure to a range of different chemical substances, such as aromatic amines. Methods This paper describes the municipal distribution of bladder cancer mortality and attempts to "adjust" this spatial pattern for the prevalence of smokers, using the autoregressive spatial model proposed by Besag, York and Molliè, with relative risk of lung cancer mortality as a surrogate. Results It has been possible to compile and ascertain the posterior distribution of relative risk for bladder cancer adjusted for lung cancer mortality, on the basis of a single Bayesian spatial model covering all of Spain's 8077 towns. Maps were plotted depicting smoothed relative risk (RR) estimates, and the distribution of the posterior probability of RR>1 by sex. Towns that registered the highest relative risks for both sexes were mostly located in the Provinces of Cadiz, Seville, Huelva, Barcelona and Almería. The highest-risk area in Barcelona Province corresponded to very specific municipal areas in the Bages district, e.g., Suría, Sallent, Balsareny, Manresa and Cardona. Conclusion Mining/industrial pollution and the risk entailed in certain occupational exposures could in part be dictating the pattern of municipal bladder cancer mortality in Spain. Population exposure to arsenic is a matter that calls for attention. It would be of great interest if the relationship between the chemical quality of drinking water and the frequency of bladder cancer could be studied.

Abstract Background This paper examines the association between use of protective devices, frequency of acute health problems and health-protection information received by participants engaged in the Prestige oil spill clean-up in Asturias and Cantabria, Spain. Methods We studied 133 seamen, 135 bird cleaners, 266 volunteers and 265 paid workers selected by random sampling, stratified by type of worker and number of working days. Information was collected by telephone interview conducted in June 2003. The association of interest was summarized, using odds ratios (OR) obtained from logistic regression. Results Health-protection briefing was associated with use of protective devices and clothing. Uninformed subjects registered a significant excess risk of itchy eyes (OR:2.89; 95%CI:1.21–6.90), nausea/vomiting/dizziness (OR:2.25; 95%CI:1.17–4.32) and throat and respiratory problems (OR:2.30; 95%CI:1.15–4.61). There was a noteworthy significant excess risk of headaches (OR:3.86: 95%CI:1.74–8.54) and respiratory problems (OR:2.43; 95%CI:1.02–5.79) among uninformed paid workers. Seamen, the group most exposed to the fuel-oil, were the worst informed and registered the highest frequency of toxicological problems. Conclusion Proper health-protection briefing was associated with greater use of protective devices and lower frequency of health problems. Among seamen, however, the results indicate poorer dissemination of information and the need of specific guidelines for removing fuel-oil at sea.

The article focuses on occupational diseases related to chemical industries. Exposure to mercury was associated with a global excess of risk also present in head and neck and thorax, which reflects the high risk of cutaneous melanoma in dentists, as this was the only exposed job in the job exposure matrix. Marginally significant high risk estimators were also found for exposure to lead. However, the most relevant result was the high relative risk in workers possibly exposed to short term high exposure peaks of pesticides.