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PurposeEntrepreneurship requires the attitudes and capabilities needed to begin new and innovative projects able to create positive impacts in the economy of a society. Given that it forms the basis from which new companies, products and innovations emerge, it is a very relevant term in business. With the aim of strengthening these capabilities, many universities are incorporating new educational strategies into their curricula to boost entrepreneurial intention and business skills among their students. This study aims to determine the factors that intervene in the entrepreneurial spirit of students in Spanish universities by examining areas of study, different personal and contextual characteristics, and the type of training students receive in entrepreneurship.Design/methodology/approachData collected from 33,182 students in 77 Spanish universities in the 2018 edition of the Global University Entrepreneurial Spirit Students' Survey (GUESSS) is examined in an exhaustive univariate and bivariate descriptive and inferential analysis. Furthermore, the relationship between the entrepreneurial index and the different explicative variables is modelled, and a basic random effect for the area of study is introduced to detect differences at this level.FindingsEconomics, engineering and health sciences presented higher than average entrepreneurial indices. Regarding the type of training, only voluntary education in entrepreneurship influenced entrepreneurial spirit, albeit not equally in all areas of study.Originality/valueThis study’s results can help universities to incorporate new educational strategies into their curricula to boost entrepreneurial intention and business skills among students by focusing resources where they are most efficient.

Additional file 1: Table S1. Prevalence of SH according to the study covariates of the “Sexual Violence among Young People” survey administered to the Spanish population aged 18–35 years.

Background There are many studies that address the issue of gender-based violence, but few analyse the police-reported cases. It is as important to analyse the temporal and geographic distribution of these incidents as it is the sociodemographic profile of the accuser. To this effect, the present study aims to analyse the sociodemographic profile of the victims of the particular case of domestic violence that report the incident to the police and to evaluate the spatial–temporal distribution of these reports. Methods Using the data from a database containing the police-reported incidents of domestic violence in Girona in the period 2012–2018, the risk of a police-reported incident was estimated by adjusting the two-part Hurdle model. Results The risk of reporting incidents of domestic violence to the police is higher in the less deprived areas of the city, and the spatial distribution of these police reports corroborate this finding. Nevertheless, those areas with the greatest socio-economic deprivation were also the ones where there were less police reports filed. Also the prediction of less police reports in the census tract with the highest percentage of the population with an insufficient educational level coincides with the largest number of police reports made by women with a medium and university level education (56.1%) compared with 9.5% of police reports made by women with insufficient schooling. Conclusions These results can be useful for social protection services to design policies specifically aimed at women residing in those areas with the highest risk. Moreover, the use of spatial statistical techniques together with geographic information systems tools is a good strategy to analyse domestic violence and other types of offences because they not only allow to graphically identify the spatial distribution, but it is also a good tool to identify problems related to this type of offence.

In this paper we present the results of a research about the relationship betwen the social economic characteristics of the students and their academiec achievement at university level. The sample was formed with students of business administration from the business schools of Girona and Sabadell. The results show that the students can be classified in three social economic categories: low middle and high. They also show that the academic achieveent can not be associated to any dermined category. This can be explained by the fact that the educational system has alread done a selection in previous levels of studies En aquest treball es presenten els principals resultats d'una investigació sobre la relació entre les característiques socioeconòmiques i el rendiment acadèmic dels estudiants a nivell universitari. La mostra esta formada per estudiants de les diplomatures en Ciències Empresarials de Girona i Sabadell. Els resultats mostren que els estudiants es poden classificar en tres categories socials: baixa, mitjana i alta. També mostren que el rendiment acadèmic no es pot associar a una categoria determinada. Això és explicable pel fet que el sistema educatiu ja ha realitzat la selecció en els nivells previs als estudis superiors

Background In this study we propose improvements to the method of elaborating deprivation indexes. First, in the selection of the variables, we incorporated a wider range of both objective and subjective measures. Second, in the statistical methodology, we used a distance indicator instead of the standard aggregating method principal component analysis. Third, we propose another methodological improvement, which consists in the use of a more robust statistical method to assess the relationship between deprivation and health responses in ecological regressions. Methods We conducted an ecological small-area analysis based on the residents of the Metropolitan region of Barcelona in the period 1994–2007. Standardized mortality rates, stratified by sex, were studied for four mortality causes: tumor of the bronquial, lung and trachea, diabetes mellitus type II, breast cancer, and prostate cancer. Socioeconomic conditions were summarized using a deprivation index. Sixteen socio-demographic variables available in the Spanish Census of Population and Housing were included. The deprivation index was constructed by aggregating the above-mentioned variables using the distance indicator, DP2. For the estimation of the ecological regression we used hierarchical Bayesian models with some improvements. Results At greater deprivation, there is an increased risk of dying from diabetes for both sexes and of dying from lung cancer for men. On the other hand, at greater deprivation, there is a decreased risk of dying from breast cancer and lung cancer for women. We did not find a clear relationship in the case of prostate cancer (presenting an increased risk but only in the second quintile of deprivation). Conclusions We believe our results were obtained using a more robust methodology. First off, we have built a better index that allows us to directly collect the variability of contextual variables without having to use arbitrary weights. Secondly, we have solved two major problems that are present in spatial ecological regressions, i.e. those that use spatial data and, consequently, perform a spatial adjustment in order to obtain consistent estimators.

Our main objective was to evaluate the fundamental biases detected in studies assessing the effects the Great Recession had on health for the case of Spain. As secondary objectives we presented methods to control these biases and to discuss the results of the studies in question if they had controlled for them. Methods: We carried out a systematic review of the literature published up to June 2018. We evaluated the biases that could have happened in all the eligible studies. Results: From the review, we finally selected 53 studies. Of the studies we reviewed, 60.38% or 32 out of 53, were evaluated as having a high risk of bias. The main biases our review revealed were problems with evaluation, time bias, lack of control of unobserved confounding, and non-exogeneity when defining the onset of the Great Recession. Conclusions: The results from the studies that controlled the biases were quite consistent. Summing up, the studies reviewed found that the Great Recession increased the risk of declaring poor self-rated health and the deterioration of mental health. Both the mortality rate and the suicide rate may well have increased after the Great Recession, probably after a three- to four-year delay This work was partly supported by the CIBER of Epidemiology and Public Health (CIBERESP) through the strategic subprogram ‘Crisis and Health’ and by the University of Girona through the programs MPCUdG2016/69 and GDRCompetUdG2017

Although psychotropic drugs are used to treat mental health disorders, little evidence analyses the effects the 2008 economic downturn had on psychotropic drug consumption in the case of Spain. We analyse these effects, considering both gender and employment situation. Participants We used the microdata from the face-to-face cross-sectional population-based Spanish National Health Survey for two periods: 2006–2007 (n=28 954) and 2011–2012 (n=20 509). Our samples included adults (>15 years old). Methods The response variables are consumption (or not) of antidepressants or sedatives and the explanatory variables are the year of the survey, gender and employment status. Covariates are mental health problems, mental health index General Health Questionnaire (GHQ-12) and self-reported health outcome variables such as self-rated health, chronic diseases, smoking behaviour, sleeping hours, body mass index, physical activity in the workplace, medical visits during the past year, age, region of residence (autonomous communities), educational level, marital status and social class of the reference person. Finally, we include interactions between time period, gender and employment status. We specify random effects logistic regressions and use Bayesian methods for the inference. Results The economic crisis did not significantly change the probability of taking antidepressant drugs (OR=0.56, 95% CI 0.18 to 2.56) nor sedatives (OR=1.21, 95% CI 0.26 to 5.49). In general, the probability of consuming antidepressants among men and women decreases, but there are differences depending on employment status. The probability of consuming sedatives also depends on the employment status. Conclusions While the year of the financial crisis is not associated with the consumption of antidepressants nor sedatives, it has widened the gap in consumption differences between men and women. Although antidepressant use dropped, the difference in consumption levels between men and women grew significantly among the retired, and in the case of sedatives, risk of women taking sedatives increased in all groups except students. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial

The response to antihypertensive drugs is predictable. The absence of precise prescription recommendations to treat arterial hypertension (HT) lead to use drugs unable to reduce blood pressure (BP) to target values. We published ATOM study, in which we found significant differences in the ability to reduce BP between the different drugs. The objective of the study was to determine the expected decrease in blood pressure with the use of commercialized doses of the drugs commonly used in the treatment of HT in clinical practice, to avoid the use of drugs or combinations that even with the best response, are unable to obtain the necessary BP decrease to reach the goal. Methods: The analysis was based on the results of the ATOM study. To convert the mean doses of the different drugs and combinations in commercialized doses, the conclusions of the study by Law et al have been applied. Results: Based on the results, two tables were drawn, one for systolic BP and the other for diastolic BP, where the doses of the different drugs and combinations are classified according to the BP decrease that can be expected from them. In order to favor the use of the tables in clinical practice, the different drugs have been grouped in intervals of 10millimeters of mercury (mmHg) for the decrease of the systolic BP and of 5 mmHg for the diastolic BP. Conclusions: Recommendations for the use of antihypertensive treatments should not be limited to pharmacological families. They should also consider differences between drugs or specific combinations. From the data of the ATOM study we have implemented tables that express the effect of the drugs commonly used in clinical practice and that should allow the clinicians to choose with care the treatment to use. Abbreviations: ARB = angiotensin receptor blocker, BMI = body mass index, BP = blood pressure, HCTZ = hydrochlorothiazide, HT = hypertension, mm Hg= millimeters of mercury

In this study we examined the shape of the association between temperature and mortality in 13 Spanish cities representing a wide range of climatic and socio-demographic conditions. The temperature value linked with minimum mortality (MMT) and the slopes before and after the turning point (MMT) were calculated. Most cities showed a V-shaped temperature-mortality relationship. MMTs were generally higher in cities with warmer climates. Cold and heat effects also depended on climate: effects were greater in hotter cities but lesser in cities with higher variability. The effect of heat was greater than the effect of cold. The effect of cold and MMT was, in general, greater for cardio-respiratory mortality than for total mortality, while the effect of heat was, in general, greater among the elderly.

Aim: To analyze the geographical pattern of diabetes mellitus (DM) mortality and its association with socioeconomic factors in 26 Spanish cities. Methods: We conducted an ecological study of DM mortality trends with two cross-sectional cuts (1996–2001; 2002–2007) using census tract (CT) as the unit of analysis. Smoothed standardized mortality rates (sSMR) were calculated using Bayesian models, and a socioeconomic deprivation score was calculated for each CT. Results: In total, 27,757 deaths by DM were recorded, with higher mortality rates observed in men and in the period 1996–2001. For men, a significant association between CT deprivation score and DM mortality was observed in 6 cities in the first study period and in 7 cities in the second period. The highest relative risk was observed in Pamplona (RR, 5.13; 95% credible interval (95%CI), 1.32–15.16). For women, a significant association between CT deprivation score and DM mortality was observed in 13 cities in the first period and 8 in the second. The strongest association was observed in San Sebastián (RR, 3.44; 95%CI, 1.25–7.36). DM mortality remained stable in the majority of cities, although a marked decrease was observed in some cities, including Madrid (RR, 0.67 and 0.64 for men and women, respectively). Conclusions: Our findings demonstrate clear inequalities in DM mortality in Spain. These inequalities remained constant over time are were more marked in women. Detection of high-risk areas is crucial for the implementation of specific interventions. This work was partially supported by FIS (PI0426, PI081488, PI080330, PI081017, PI081713), the DGA (PI126/08), FUNCIS (PI84/07), Fundación Caja Murcia (FFIS/CM10/27), and by CIBER Epidemiología y Salud Pública (CIBERESP).

[Objetivo] Proporcionar indicadores para evaluar, en Espana˜ y en sus comunidades autónomas, el impacto sobre la salud, sus determinantes sociales y las desigualdades en salud del contexto social y de la crisis económica más reciente. [Métodos] Basándonos en el marco conceptual de los determinantes de las desigualdades sociales en salud en Espana, ˜ identificamos indicadores secuencialmente a partir de documentos clave, Web of Science y organismos con estadísticas oficiales. La información recopilada dio lugar a un directorio amplio de indicadores que fue revisado por un panel de expertos. Posteriormente seleccionamos un conjunto de esos indicadores segúnuncriterio geográfico y otro temporal: disponibilidad de datos segúncomunidades autónomas y al menos desde 2006 hasta 2012. [Resultados] Identificamos 203 indicadores contextuales sobre determinantes sociales de la salud y seleccionamos 96 (47%) según los criterios anteriores. De los indicadores identificados, el 16% no cumplieron el criterio geográfico y el 35% no cumplieron el criterio temporal. Se excluyó al menos un 80% de los indicadores relacionados con la dependencia y los servicios de salud. Los indicadores finalmente seleccionados cubrieron todas las áreas de los determinantes sociales de la salud. El 62% de estos no estuvieron disponibles en Internet. Alrededor del 40% de los indicadores se extrajeron de fuentes relacionadas con el Instituto Nacional de Estadística. [Conclusiones] Proporcionamos un amplio directorio de indicadores contextuales sobre determinantes sociales de la salud y una base de datos que facilitarán la evaluación, en Espana˜ y sus comunidades autónomas, del impacto de la crisis económica sobre la salud y las desigualdades en salud., Este artículo ha contado con la financiación del Subprograma de Investigación en Crisis y Salud del CIBER de Epidemiología y Salud Pública (CIBERESP), así como de los proyectos FIS con números de expediente PI13/00897, PI13/02292 y PI13/00183.

ResumenObjetivoLa necesidad de conocer la percepción de la calidad asistencial recibida por los ciudadanos es clave para abordar con éxito mejoras en la prestación de los servicios de salud. El principal objetivo de este trabajo es presentar la aplicación de una metodología que permita identificar aspectos que facilitan la identificación de áreas de mejora.MétodoAplicación de un cuestionario a tres líneas de servicio en Cataluña (atención primaria [n=332], atención especializada ambulatoria [n=410] y urgencias hospitalarias [n=413]) para medir la satisfacción de los usuarios y evaluar la importancia otorgada a los aspectos analizados.ResultadosEl análisis de valoración-importancia permite señalar que los principales aspectos a mejorar en atención primaria son los que se refieren al tiempo que el profesional dedica a sus pacientes, así como su predisposición para escuchar sus opiniones. En urgencias hospitalarias, el principal aspecto de mejora se refiere a las condiciones físicas del establecimiento.ConclusionesLas herramientas diseñadas e implementadas por el Servicio Catalán de la Salud han demostrado ser instrumentos válidos para detectar los temas de actuación prioritarios para la mejora de la prestación de servicios y para fomentar la equidad territorial.AbstractObjectiveIdentifying users’ perceptions of the quality of care is essential to improve health services delivery. The main objective of this article was to describe the application of a methodology to identify factors that facilitate the identification of areas for improvement.MethodA questionnaire was applied in three health areas in Catalonia (Spain) (primary care [n=332], outpatient specialty care [n=410] and hospital emergency care [n=413]) to measure user satisfaction and assess the importance given to the aspects analyzed.ResultsThe main areas for improvement in primary care identified by an importance-performance analysis involved the time devoted to patients as well as health professionals’ willingness to listen to their views. In hospital emergency care, the main area of improvement was related to the hospital's physical conditions.ConclusionsThe tools designed and implemented by the Catalan Health Service (Spain) have proved to be valid for the detection of priority areas to improve service delivery and promote regional equity.

Summary Relative survival is a measure of survival corrected for the effect of independent causes of death other than the cancer of interest. It is provided by population-based cancer registries and constitutes an indicator of the quality of cancer patient management. Geographical variations in relative survival from cancer could reflect differences in the effectiveness of healthcare. Studies comparing geographical variations use estimates of relative survival obtained independently in each of the corresponding geographical units. When the units havesmall populations, the statistical stability of survival estimates could be seriously compromised.Our main objective is to assess the geographical variation in relative survival ratios from femalebreast cancer in the Girona Health Region (corresponding, virtually, to the province of Girona inCatalonia, in north-eastern Spain). Firstly, we propose smoothing relative survival estimates bymeans of a (full) Bayesian hierarchical model. Secondly, we investigate which geographicalunit will give more stable estimates and could therefore be used for the analysis of cancersurvival as a healthcare performance indicator. We find that the model with more success in controlling for extra variability in the estimation of relative survival from female breast cancer in theGirona Health Region is a (full) Bayesian hierarchical model that incorporates both heterogeneity and spatial random effects. The greatest stability of these relative survival estimates wasachieved when basic health areas were taken as geographical units.

Increased population flowing from abroad has generated an intense debate regarding the economic consequences of migration in public services such as health, where new and specific demands are being created. This new demand for health care gives rise to the need to identify those factors which influence the user’s decision to contact the health services and those which determine the quantity of services consumed. The aim of this study is to identify which variables affect these two stages of the use of such services in the Girona Health Region (RSG), where immigrant population represents 21.96% of the total population. Specification of a Hurdle model with a count response variable related to primary health care service visits in the RSG for 2006. The study data is based on a sample of users (immigrants and natives) taken from the population assigned to primary health care services in eight Basic Health Areas (ABS) of the RSG. Contacting primary health care services is associated with variables that ought to affect use of health care such as chronic illness and taking prescribed medication as well as being aged between 46 and 55. Using primary health care services once makes users more likely to make further visits. The number of visits is related not only with variables that ought affect use of health care but also with variables that ought not to affect use of health care such as working without a contract, living in rented accommodation, or being unemployed. Additionally, if we consider the birthplace of the user, we observe the same pattern, with different directions and intensities, depending on the origin of the patient. For example, a higher likelihood of first contact is shown in Eastern Europeans, South Americans, and North Africans that suffer from cholesterol. A higher attendance is observed in natives and Eastern Europeans that take prescribed medication as well as natives, Eastern Europeans, and North Africans living in rented accommodation. On the other hand, working without a contract supposes a higher attendance in natives but a lower attendance in Eastern Europeans and sub-Saharan Africans. We do not detect any socioeconomic barriers associated with making a first contact with primary health services for the users analyzed. However, we do note evidence of horizontal inequity in terms of attending health services, related to variables that ought to affect use of health care as well as socioeconomic factors (variables that ought not to affect use of health care). The user’s origin is an important key in detecting different intensities of access and regular visits to primary health care services.

Objective : To assess the association between the incidence of larynx cancer and socioeconomic conditions in the province of Girona from a spatial viewpoint. Materials and methods : Incidence cases of larynx cancer (CL) in 1994–2004 were provided by the Girona Cancer Registry. A census tract (CT) was assigned to all patients. Socioeconomic data were extracted from the 2001 Census. A deprivation index for each CT was obtained by principal component analysis, using four socioeconomic indicators. The standardised incidence ratio (SIR) was calculated using the CL incidence rates in the men of the province of Girona assuming a Poisson distribution. Relative risk was obtained applying the Besag, York and Mollie model. The deprivation index was introduced into the model and was categorised in quartiles. Results : Four hundred and seventy-six incident cases in men were registered. CTs in the lowest deprivation index had a lower risk of larynx cancer, with a risk increase in the higher quartiles. In the highest quartile it was 1.91 times greater than in the lowest. This association was significant when the whole province was considered. Discussion : The deprivation index explains only part of the geographical variability of CL incidence. Other risk factors without spatial structure may contribute to this explaination.

OBJECTIVES: To assess the impact of using data from the National Death Index (NDI) of Spain to estimate breast cancer survival rates among residents of Girona and Zaragoza diagnosed in 1995-1999. METHODS: This was an observational, longitudinal epidemiologic study, using two population- based cancer registries. Data collected were of female residents of Girona or Zaragoza who had been diagnosed with breast cancer in 1995-1999. Observed and relative 5-year survival rates were estimated, first using the information available from the Girona and Zaragoza cancer registries, and then with the inclusion of NDI data. The 5-year relative survival rate and corresponding 95% Confidence Intervals were estimated using the Hakulinen method. The Kaplan-Maier method and Log Rank test were used to compare survival curves. RESULTS: No statistically significant difference in survival curves was observed in Girona for the data obtained before and after cross-matching with the NDI. However, there was a significant difference in Zaragoza. A comparison of the relative survival rates of each of the two registries before NDI cross-matching showed differences of 3.9% (5-year) and 16.1% (10-year) between the two, whereas after the cross-match, the difference was only 0.5% (5-year) and 1.2% (10-year). CONCLUSIONS: In Spain it is imperative that there be systematic use of NDI data to supplement cancer registries, so that comparisons of relative survival rates between registries can be improved.OBJETIVO: Evaluar el efecto de utilizar los datos del Índice Nacional de Defunciones (IND) de España para estimar las tasas de supervivencia de cáncer de mama en las mujeres residentes en Girona y Zaragoza que recibieron el diagnóstico de cáncer de mama en 1995-1999. MÉTODOS: Se realizó un estudio epidemiológico observacional y longitudinal basado en el empleo de los registros de cáncer de mujeres residentes en Girona y Zaragoza que habían recibido el diagnóstico de cáncer de mama en 1995-1999. Se estimaron las tasas de supervivencias observada y relativa a 5 años, primero según la información disponible en los registros de cáncer de Girona y Zaragoza y luego con la inclusión de los datos del IND. Se calcularon las tasas de supervivencia relativa a 5 años y sus correspondientes intervalos de confianza de 95% por el método de Hakulinen. Las curvas de supervivencia se compararon por el método de Kaplan-Maier y la prueba de rangos logarítmicos. RESULTADOS: No se encontraron diferencias estadísticamente significativas entre las curvas de supervivencia de Girona antes y después de emparejar lo datos locales con los del IND; sin embargo, hubo diferencias significativas entre las curvas de Zaragoza. Al comparar las tasas de supervivencia relativa de cada uno de los registros antes de emparejarlos con los datos del IND se encontraron diferencias de 3,9% (a 5 años) y 16,1% (a 10 años), mientras que después del emparejamiento, la diferencia entre ellas fue solamente de 0,5% (a 5 años) y 1,2% (a 10 años). CONCLUSIONES: En España es imperativo el empleo sistemático de los datos del IND para complementar los registros de cáncer de manera de mejorar las comparaciones de las tasas de supervivencia relativa cuando se utilizan diferentes registros.

ResumenObjetivosa) Describir la metodología seguida en la construcción de un índice de privación por sección censal en ciudades, que permite identificar las secciones con situaciones socioeconómicas más desfavorables, y b) analizar la relación de este índice con la mortalidad general.MétodosSe elaboraron diversos indicadores socioeconómicos (Censo 2001) correspondientes a las secciones censales de las ciudades de Barcelona, Bilbao, Madrid, Sevilla y Valencia. Se estudiaron sus correlaciones con la razón estandarizada de mortalidad (1996-2003), así como sus dimensiones conceptuales. Finalmente, mediante el análisis de componentes principales, se agregaron en un índice los indicadores seleccionados, usando como valores de peso las saturaciones correspondientes al primer eje.ResultadosLos indicadores que presentaron mayores correlaciones con la mortalidad general fueron los referidos a trabajo, educación, vivienda-entorno y hogares monoparentales. En el análisis dimensional de los indicadores aparece una primera dimensión que contiene los indicadores relativos a trabajo (desempleo, trabajadores manuales y eventuales) y educación (instrucción insuficiente total y en jóvenes). El índice elaborado con estos 5 indicadores recoge, en todas las ciudades estudiadas, más del 75% de la variabilidad de los indicadores que lo componen. Las correlaciones de este índice con la mortalidad muestran, en general, mayores valores que las obtenidas individualmente con cada indicador.ConclusionesEl índice de privación que se propone puede ser un instrumento útil para la planificación sanitaria al detectar áreas pequeñas de grandes ciudades con una situación socioeconómica desfavorable, que se relaciona con la mortalidad, y puede contribuir al estudio de las desigualdades sociales en salud en España.AbstractObjectivesa) To describe the methodology used to construct a deprivation index by census tract in cities, to identify the tracts with the least favorable socioeconomic conditions, and b) to analyze the association between this index and overall mortality.MethodsSeveral socioeconomic indicators (Census 2001) were defined by the census tracts of the following cities: Barcelona, Bilbao, Madrid, Seville and Valencia. The correlations with the standardized mortality ratio (1996-2003), and the dimensionality of the socioeconomic indicators were studied. Finally, the selected indicators were aggregated in an index, in which the results of the factor loadings from extraction of a factor by principal components were used as weighting values.ResultsThe indicators with the strongest correlations with overall mortality were those related to work, education, housing conditions and single parent homes. In the analysis of dimensionality, a first dimension appeared that contained indicators related to work (unemployment, manual and eventual workers) and education (insufficient education overall and in young people). In all the cities studied, the index created with these 5 indicators explained more than 75% of their variability. The correlations between this index and mortality generally showed higher values than those obtained with each indicator separately.ConclusionsThe deprivation index proposed could be a useful instrument for health planning as it detects small areas of large cities with unfavorable socioeconomic characteristics and is associated with mortality. This index could contribute to the study of social inequalities in health in Spain.

Research report Objective: To study the linkage between material deprivation and mortality from all causes, for men and women separately, in the capital cities of the provinces in Andalusia and Catalonia (Spain). Methods: A small-area ecological study was devised using the census section as the unit for analysis. 188 983 Deaths occurring in the capital cities of the Andalusian provinces and 109 478 deaths recorded in the Catalan capital cities were examined. Principal components factorial analysis was used to devise a material deprivation index comprising the percentage of manual labourers, unemployment and illiteracy. A hierarchical Bayesian model was used to study the relationship between mortality and area deprivation. Main results: In most cities, results show an increased male mortality risk in the most deprived areas in relation to the least depressed. In Andalusia, the relative risks between the highest and lowest deprivation decile ranged from 1.24 (Malaga) to 1.40 (Granada), with 95% credibility intervals showing a significant excess risk. In Catalonia, relative risks ranged between 1.08 (Girona) and 1.50 (Tarragona). No evidence was found for an excess of female mortality in most deprived areas in either of the autonomous communities. Conclusions: Within cities, gender-related differences were revealed when deprivation was correlated geographically with mortality rates. These differences were found from an ecological perspective. Further research is needed in order to validate these results from an individual approach. The idea to be analysed is to identify those factors that explain these differences at an individual level. Yes

Our main hypothesis in this paper was that, once controlled for age and gender, the use of primary health care services of people in each of the groups defined by their degree of obesity (i.e. normal weight, overweight and obese) did not correspond to the need for care implied by the level of risk of the group he/she belonged to. This fact could reflect some inequity in the utilisation of such services. Using a survey of the general population from the Girona Health Region, Spain, carried out during the fourth quarter of 2002, we have found that: first, the probability of primary health care use decreased with income for GPs (until 1200 Euro) and increased for specialists (from 1500 Euro). Second, we could conclude by confirming our hypothesis, i.e. there was more probability of obese individuals using general practice care, public in particular, and less probability of them using specialists, private in particular, than the rest of individuals. Third, we conclude that the use of multilevel (also hierarchical or mixed) models could explain most of our original findings in this paper.

BACKGROUND AND OBJECTIVE Despite the number of plans leading to lose weight among individuals in the developed countries, the prevalence of obesity has increased since 1980. The knowledge of ponderal evolution in a given population is very important because the adverse effects of obesity vary greatly among individuals and populations. The objective of the present paper was to determine the modifications in the different degrees of body adiposity in a population in Catalunya. PATIENTS AND METHODS A measurement was made of weight and height of 24554 users aged over 14 years (10595 males and 13959 females) attended at four basic health areas (BHA): Girona 1, Girona 4, Salt and Camprodon, and a Primary Health Center (PHC) in the Girona province, for a five-year period, 1995-1999. The prevalence of the different degrees of obesity was compared with that obtained in a previous study with 6373 individuals during the 1986-1989 period (4,579 males and 1794 females). RESULTS The prevalence of women with overweight (defined as a body mass index [BMI] > 25 kg/m2) increased from 7.3% (1986-1989, study 0) to 17.6% (1995-1999, study 1) for women aged 15 to 24 years ( p 30 kg/m2) increased from 6.9% to 12.9%. Similar trends were observed among men, and the change in the 35-44 year age group (from 10.5 % of obese men to 16% [p < 0.001]), and 55 to 65 years (from 16.6% of obese men to 22.7% [p < 0.001] was particularly significant. And lastly, it is also noteworthy the proportion of individuals with low weight (BMI < 18.5 kg/m2) which increased from 7.3% to 11.6% for women aged 15 to 24 years, and from 0.3% to 2.2% for women aged 35 to 44 years. This trend was also observed for men aged 15 to 24 years (11% to 17.2%). CONCLUSIONS The relative increase in the prevalence of overweight and obesity runs in parallel to that found in other surrounding countries. Also, it is worth mentioning that among women aged 15 to 24 years the increase in the prevalence of low weight and obesity is almost identical, which invalidates the mean and median values as a means to assess the ponderal evolution in this population. The current compartmentalization between the extreme BMIs, particularly among the youngest portion of population should be addressed from a multidisciplinary perspective.

Background: Health and inequalities in health among inhabitants of European cities are of major importance for European public health and there is great interest in how different health care systems in Europe perform in the reduction of health inequalities. However, evidence on the spatial distribution of cause-specific mortality across neighbourhoods of European cities is scarce. This study presents maps of avoidable mortality in European cities and analyses differences in avoidable mortality between neighbourhoods with different levels of deprivation. Methods: We determined the level of mortality from 14 avoidable causes of death for each neighbourhood of 15 large cities in different European regions. To address the problems associated with Standardised Mortality Ratios for small areas we smooth them using the Bayesian model proposed by Besag, York and Mollie. Ecological regression analysis was used to assess the association between social deprivation and mortality. Results: Mortality from avoidable causes of death is higher in deprived neighbourhoods and mortality rate ratios between areas with different levels of deprivation differ between gender and cities. In most cases rate ratios are lower among women. While Eastern and Southern European cities show higher levels of avoidable mortality, the association of mortality with social deprivation tends to be higher in Northern and lower in Southern Europe. Conclusions: There are marked differences in the level of avoidable mortality between neighbourhoods of European cities and the level of avoidable mortality is associated with social deprivation. There is no systematic difference in the magnitude of this association between European cities or regions. Spatial patterns of avoidable mortality across small city areas can point to possible local problems and specific strategies to reduce health inequality which is important for the development of urban areas and the well-being of their inhabitants.

ResumenObjetivosEstimar y comparar la prevalencia de la obesidad y el sobrepeso en la población de Girona, entre 1995 y 1999, estratificando geográficamente por sexo y edad.MétodosMedidas directas de talla y peso correspondientes a 24.554 usuarios mayores de 14 años (10.595 varones y 13.959 mujeres) atendidos en cuatro áreas básicas de salud (ABS): Girona 1, Girona 4, Salt y Camprodon, así como en un centro de atención primaria (CAP) de la provincia de Girona. Se calculó el índice de masa corporal (IMC) como el cociente entre el peso y la talla al cuadrado. La obesidad se define como los grados II y III del índice de Garrow (IMC ≥ 30 kg/m2) y el sobrepeso como el grado I (25 kg/m2 ≤ IMC < 30 kg/m2). Al no utilizarse una muestra aleatoria de sujetos, el cálculo de prevalencias y de sus errores estándar se corrigió mediante el uso de ponderaciones adecuadas. La comparación de las prevalencias entre dos ABS distintas para cada sexo se realizó utilizando un contraste paramétrico de diferencia de proporciones. La comparación entre las prevalencias de un determinado grado del índice de Garrow, controlando por sexo y edad, se llevó a cabo utilizando una regresión logística jerárquica.ResultadosLa prevalencia de la obesidad se estimó en 15,6% entre los varones de 20 a 74 años (desde el 14,0% en Girona 1 hasta el 22,4% en Camprodon) y en un 17,5% entre las mujeres (un 15,6% en Girona 1 y un 22,7% en Camprodon), un 16,7% de promedio ponderado. La prevalencia del sobrepeso se sitúa en el 44% en varones y en un 33% en mujeres, un 37,8% de promedio ponderado. Existe una gradación en las prevalencias de la obesidad, con diferencias estadísticamente significativas: Girona 1, Salt, Girona 4, Camprodon y Sils.ConclusionesLas estimaciones de la prevalencia de la obesidad y sobrepeso obtenidas en este trabajo no están tan alejadas como se creía de las estimadas en poblaciones de nuestro entorno. De hecho, podrían ser muy similares a las estimadas en la Unión Europea y, para algunos grupos de edad, incluso a las de Estados Unidos.AbstractObjectivesTo estimate the prevalence of obesity and overweight in the population of Girona (Spain) between 1995 and 1999 and to divide the prevalences in geographical areas according to age and sex.MethodsHeight and weight were directly measures in 24,554 health care consumers older than 14 years (10,595 men and 13,959 women) treated in four primary health care areas: Girona 1, Girona 4, Salt and Camprodon and in one primary health care center in the province of Girona. Body mas index (BMI) was calcuted by dividing weight in kilograms bye height in meters squared. Obesity was defined as grades II and III of Garrow's index (BMI ≥ 30 kg/m2) and overweight as degree I (25 kg/m2 ≥ BMI < 30 kg/m2). Because the sample was not randomized, the prevalences were adequately weighted. The comparison between prevalences in two different primary health care areas for each sex (in the same Garrow's index and age group) was carried out using a parametric test of differences in proportions (Student's t-test). A hierarchical logistic regression was used to compare prevalences in the same grade Garrow's index, controlling for age and sex.ResultsThe prevalence of obesity was estimated as 15.6% in men aged from 20-74 years (from 14.0% in Girona 1 to 22.4% in Camprodon) and 17.5% for women (15.6% in Girona 1, 22.7% in Camprodon). The weighted mean was 16.7%. The prevalence of overweight was 44% in men and 33% in women and the weighted mean was 37.8%. The prevalence of obesity was graduated with statistically significant differences between Girona 1, Salt, Girona 4, Camprodon and Sils.ConclusionsThe estimates of the prevalences of obesity and overweight obtained in this study were closer to those of other studies in similar populations than previously believed. Inde-ed, the prevalences may be similar to those of the European Union and, in some age groups, to those of the United States.

This article draws a comparison and provides a discussion of the findings resulting from the local analyses of the 14 cities participating in the EMECAM Project. An analysis is made of the time series related to mortality, pollutants (particles in suspension, SO2, NO2, O3 and CO), temperature and other factors taken from records of public institutions. By using Poisson autoregressive regression, an estimate has been made of the short-term relationship between the number of deaths and the air pollution indicators in each one of the following cities: Barcelona, metropolitan area of Bilbao, Cartagena, Castellón, Gijón, Huelva, Madrid, Pamplona, Seville, Oviedo, Valencia, Vigo, Vitoria and Saragossa. The findings reveal the air pollution figures in our country to be similar to those of other European cities. The levels of the different pollutants point toward road traffic as being the main source of most of this pollution. A relationship has been found between the mortality and different pollutants in most cities, although the results are not homogeneous among the cities and show variability in the different causes under study. In some cities, especially in those having smaller populations, there have been no findings providing any evidence of a relationship, or the findings themselves are not highly consistent. The meta-analysis will provide estimates for all of the cities as a whole and will allow the possibility of making a more clear-cut assessment of the time lag impact of air pollution on the mortality. Worthy of special mention is the participation in this project of public health officers as actively involved researchers.

FUNDAMENTOS: La mayoría de los estudios que muestran la existencia de una asociación a corto plazo entre contaminación atmosférica y morbimortalidad, analizan los efectos de los contaminantes ‘clásicos’ cuya fuente es la combustión. Sin embargo, los cambios en las fuentes de emisión, fundamentalmente hacia el tráfico rodado, han modificado la contaminación atmosférica, haciendo más importante los componentes foto-químicos, como el ozono (O3) y el dióxido de nitrógeno (NO2). Barcelona es una ciudad situada en una zona templada y su contaminación atmosférica proviene principalmente de las emisiones de los vehículos. El principal objetivo de este artículo es el de analizar la relación entre los contaminantes foto-químicos, NO2 y O3, y la mortalidad por diferentes causas, en la ciudad de Barcelona desde 1991 hasta 1995, utilizando el protocolo de análisis elaborado dentro del proyecto EMECAM. MÉTODOS: Variaciones diarias del número de muertes por todas las causas, del número de muertes por todas las causas entre mayores de 70 años, del número de muertes por causas del aparato circulatorio y por causas respiratorias se relacionan con las variaciones diarias de los contaminantes foto-químicos, a través de modelos de Poisson autoregresivos, controlando confusores como la temperatura, la humedad relativa, la estructura temporal sistemática y la estructura autoregresiva. RESULTADOS: Excepto la relación entre O3 y mortalidad a causa de enfermedades respiratorias, las relaciones entre contaminantes foto-químicos y mortalidad por todas las causas consideradas resultaron estadísticamente significativas. Los riesgos relativos de morir ante incrementos de O3 fueron mayores que ante incrementos de NO2, casi el triple entre enfermedades del aparato circulatorio. Los riesgos relativos de morir por todas las causas son menores que por causas específicas y que para aquellos individuos mayores de 70 años. Los resultados del análisis por semestres son muy similares a los del global mostrando, en todo caso, riesgos relativos algo mayores en los meses cálidos (mayo a octubre). CONCLUSIONES: La contaminación fotoquímica, sobre todo la causada por O3, representa un riesgo para la salud. En el caso del NO2 podría ocurrir que no fuese más que un indicador de las partículas suspendidas o de otros contaminantes cuyo origen es el tráfico urbano. Podría existir cierta modificación entre semestres de los efectos del O3 sobre la mortalidad por causas del aparato circulatorio.

Background Although evidence of the effects of the economic crisis on suicides is quite low, a recent article shows that the increase in suicides in England between 2008 and 2010 could be associated with the rise in unemployment. Our study analysed whether this effect was the same for all regions of England, using a conditional model which explicitly allows estimation of regional time trends and the effects of unemployment on suicides at the regional level. Methods Hierarchical mixed models were used to assess both, suicides attributable to the financial crisis and the association between unemployment and suicides. The number and the (age-standardised) rate of suicides, for men and women separately, were the dependent variables. We considered the nine English regions based on the NUTS 2 level. Results There was an (not statistically significant) increase in the number of suicides between 2008 and 2010. The variation in rates was not statistically significant in England as a whole but there were statistically significant increases and decreases in some regions. Statistically significant associations between unemployment and suicides were only found at regional level. For men, statistically significant unemployment rates were positively associated with age-standardised suicide rates in the South West (0.384), North West (0.260) and North East (0.136), and negatively associated in the East of England (−0.444), East Midlands (−0.236) and London (−0.168). Conclusions The study provides evidence that, even with statistically significant associations, finding variability, but no clear pattern, between trends and associations and/or numbers and rates might in fact suggest relatively spurious relationships; this is a result of not controlling for confounders.

Identifying users' perceptions of the quality of care is essential to improve health services delivery. The main objective of this article was to describe the application of a methodology to identify factors that facilitate the identification of areas for improvement.A questionnaire was applied in three health areas in Catalonia (Spain) (primary care [n=332], outpatient specialty care [n=410] and hospital emergency care [n=413]) to measure user satisfaction and assess the importance given to the aspects analyzed.The main areas for improvement in primary care identified by an importance-performance analysis involved the time devoted to patients as well as health professionals' willingness to listen to their views. In hospital emergency care, the main area of improvement was related to the hospital's physical conditions.The tools designed and implemented by the Catalan Health Service (Spain) have proved to be valid for the detection of priority areas to improve service delivery and promote regional equity.

Introduction In recent decades, the foreign population in Spain has increased significantly, particularly for Catalonia, an autonomous region of Spain (2.90% in 2000 and 15.95% in 2010) and in particular Girona province (6.18% in 2000 and 21.55% in 2010). Several studies have shown a lower use of family planning methods by immigrants. This same trend is observed in Spain. The objective of this paper is to determine the existence of differences and possible sources of inequity in the use of family planning methods among health service users in Catalonia (Spain) by sex, health status, place of birth and socioeconomic conditions. Methods Data were taken from an ad-hoc questionnaire which was compiled following a qualitative stage of individual interviews. Said questionnaire was administered to 1094 Catalan public health service users during 2007. A complete descriptive analysis was carried out for variables related to public health service users’ sociodemographic characteristics and variables indicating knowledge and use of family planning methods, and bivariate relationships were analysed by means of chi-square contrasts. Considering the use (or non-use) of family planning methods as a dependent variable and a set of demographic, socioeconomic and health status variables as explanatory factors, the relationship was modelled using mixed models. Results The analysed sample is comprised of 54.3% women and 45.7% men, with 74.3% natives (or from the EU) and 25.7% economic immigrants. 54.8% use some method of family planning, the condom (46.7%) and the pill (28.0%) being the two most frequently used methods. Statistical modelling indicates that those factors which most influence the use of family planning methods are level of education (30.59% and 39.29% more likelihood) and having children over 14 (35.35% more likelihood). With regard to the origin of the user, we observe that patients from North Africa,sub. Saharan Africa and Asia are less likely to use family planning methods (36.68%, 38.59% and 70.51%, respectively). Conclusions The use of family planning methods is positively related to a higher level of education and having children over 14. Factors such as sex, age, income and self-perceived health do not appear to influence their use. Furthermore, being a native of this country, the European Union or Central/South America represents a greater likelihood of use than being African or Asian. Although no general differences in use were found between sexes, the difference found in the case of Asian women stands out, with a higher likelihood of use.

Background The research we present here forms part of a two-phase project - one quantitative and the other qualitative - assessing the use of primary health care services. This paper presents the qualitative phase of said research, which is aimed at ascertaining the needs, beliefs, barriers to access and health practices of the immigrant population in comparison with the native population, as well as the perceptions of healthcare professionals. Moroccan and sub-Saharan were the immigrants to who the qualitative phase was specifically addressed. The aims of this paper are as follows: to analyse any possible implications of family organisation in the health practices of the immigrant population; to ascertain social practices relating to illness; to understand the significances of sexual and reproductive health practices; and to ascertain the ideas and perceptions of immigrants, local people and professionals regarding health and the health system. Methods Qualitative research based on discursive analysis. Data gathering techniques consisted of discussion groups with health system users and semi-structured individual interviews with healthcare professionals. The sample was taken from the Basic Healthcare Areas of Salt and Banyoles (belonging to the Girona Healthcare Region), the discussion groups being comprised of (a) 6 immigrant Moroccan women, (b) 7 immigrant sub-Saharan African women and (c) 6 immigrant and native population men (2 native men, 2 Moroccan men and 2 sub-Saharan men); and the semi-structured interviews being conducted with the following healthcare professionals: (a) 3 gynaecologists, (b) 3 nurses and 1 administrative staff. Results Use of the healthcare system is linked to the perception of not being well, knowledge of the healthcare system, length of time resident in Spain and interiorization of traditional Western medicine as a cure mechanism. The divergences found among the groups of immigrants, local people and healthcare professionals with regard to healthcare education, use of the healthcare service, sexual and reproductive healthcare and reticence with regard to being attended by healthcare personnel of the opposite sex demonstrate a need to work with the immigrant population as a heterogeneous group. Conclusions The results we have obtained support the idea that feeling unwell is a psycho-social process, as it takes place within a specific socio-cultural situation and spans a range of beliefs, perceptions and ideas regarding symptomology and how to treat it.

At the end of 1998, foreign population in Spain supposed a 1.60% of the total population. Nowadays, this percentage rises at 13.01%. This change in the population socio-demographic structure means an alteration of the use of public services in our country. For this reason, this paper aims to analyze, for the Health Region Girona (RSG), the attended morbidity, the needs and the uses of primary health care services by immigrant population, compared with native users considering sex, age, ethnicity and sociodemographic conditions.The data on morbidity and on health care services utilization comes from medical records of the Catalan Health Institute (ICS); socio-economic information comes from a questionnaire administered to a sample of 645 users of primary health care services selected, using a non proportional stratified sampling method, from a previous population identification process. Data was analyzed with complex samples module of SPSSv15, through non-parametric and parametric contrasts.The results show an immigrant population healthier than the native (50.1% of visits compared to 61.2%, 50% of drug consumption versus 66.7% and 29.6% of chronic disorders versus 51.4%) although they persist in worst socio-economic conditions (9.4% unemployed compared to 5.6%, 38% are illiterate compared to 17.4%, or 53.5% of homes in rent versus 15%). Adjusting by these variables, frequentation rates do not differ by patients origin.Realized contrasts allow affirming that are, mainly, these socio-demographic conditions, and not uniquely the origin of the patient, those that determine the population needs and the population uses of health care services.

Background There is evidence that geographic variability of social health inequalities continues to exist even after individual risk factors have been taken into account. However, relatively few studies have examined the contribution of exposure to air pollutants to those inequalities. Objectives To study the geographic variability of inequalities in mortality and their associations with socioeconomic and environmental inequalities in small areas of the metropolitan of Barcelona during the period 1994 to 2003. Methods As in the MEDEA Project, the small area unit was the census tract. Study population consisted of the residents of the metropolitan area of Barcelona. Response variables were all-cause and specific-cause standardized mortality ratio (SMR). Explanatory variables were deprivation index, summarizing socioeconomic variables of the census tracts, and estimates of air pollutant exposures. Bayesian hierarchical models were used in order to reduce the extra variability when using SMR and to assess associations between mortality and deprivation and air pollution. Results Statistically significant associations with deprivation were found for the causes of death related to consumption of tobacco and alcohol for men and, besides lung cancer, diet-related causes for women. Statistically significant pollution coefficients were only found in the metropolitan area of Barcelona and in men. A positive interaction between pollutants and the deprivation index was statistically significant for respiratory mortality and PM 10 , and ischemic disease mortality and NO 2 , both for men. Conclusions We found deprivation to be associated in a statistically significant way with the geographical variation in mortality in the census tracts of the metropolitan area of Barcelona, in the period 1994 to 2003. Those air pollutants more directly related with traffic modify some of these associations.

Although there is some experience in the study of mortality inequalities in Spanish cities, there are large urban centers that have not yet been investigated using the census tract as the unit of territorial analysis. The coordinated projectSocioeconomic and environmental inequalities in mortality in Spanish cities. The MEDEA projectwas designed to fill this gap, with the participation of 10 groups of researchers in Andalusia, Aragon, Catalonia, Galicia, Madrid, Valencia, and the Basque Country. The MEDEA project has four distinguishing features: a) the census tract is used as the basic geographical area; b) statistical methods that include the geographical structure of the region under study are employed for risk estimation; c) data are drawn from three complementary data sources (information on air pollution, information on industrial pollution, and the records of mortality registrars), and d) a coordinated, large-scale analysis, favored by the implantation of coordinated research networks, is carried out. The main objective of the present study was to explain the methods for smoothing mortality indicators in the context of the MEDEA project. This study focusses on the methodology and the results of the Besag, York and Mollié model (BYM) in disease mapping. In the MEDEA project, standardized mortality ratios (SMR), corresponding to 17 large groups of causes of death and 28 specific causes, were smoothed by means of the BYM model; however, in the present study this methodology was applied to mortality due to cancer of the trachea, bronchi and lung in men and women in the city of Barcelona from 1996 to 2003. As a result of smoothing, a different geographical pattern for SMR in both genders was observed. In men, a SMR higher than unity was found in highly deprived areas. In contrast, in women, this pattern was observed in more affluent areas.