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Migrants and refugees try to reach Europe to seek protection and a better life. The responsiveness and stewardship of the European countries health system have an impact on the ability to access healthcare. This study aims to investigate the differential probability of healthcare unmet needs among migrants living in four European countries. We used a 2019 cross-sectional data from the European Union Income and Living Conditions survey. We performed a two-stage probit model with sample selection, first to identify the respondents with need for care, then those who need it but have not received it. We analysed reasons for unmet needs through accessibility, availability and acceptability. We then performed country studies assessing the national health systems, financing mechanisms and migration policies. Bringing together data on financial hardship and unmet needs reveals that migrants living in Europe have a higher risk of facing unmet healthcare needs compared to native citizens, and affordability of care remains a substantial barrier. Our results showed the country heterogeneity in the differential migrants’ unmet needs according to the place where they live, and this disparity seems attributed to the health system and policies applied. Given the diversity of socioeconomic conditions throughout the European countries, the health of migrants depends to a large degree on the integration and health policies in place. We believe that EU policies should apply further efforts to respect core health and protection ethics and to acknowledge, among others, principles of ‘do-no-harm’, equity and the right to health.

Objective: We address the hypothesis that the extraordinary sandstorm occurred on 22-24 February 2020 might have a role in the different cumulated incidence of COVID-19 cases between the islands of Tenerife and Gran Canaria, since it obliged to reduce significantly air traffic and forced to suspend all major carnival street events in all most locations. Method: We performed a retrospective analysis of COVID-19 cases as to 1 April 2020 according to symptoms onset, weather-related data and Carnival events in Tenerife and Gran Canaria. Results: The sandstorm occurred on February 22-24, 2020, forced air traffic to close, reducing the influx of tourists to the Canary Islands and suspending carnival events in most places, except in Santa Cruz de Tenerife. Cumulated incidence as to 1 April was 132.81/100,000 in Tenerife, and 56.04/100,000 in Gran Canaria. Conclusions: The suspension of Carnival events due to the sandstorm in the Canary Islands contributed to reduce differently the SARS-CoV-2 spread in Tenerife and Gran Canaria. Resumen: Objetivo: Investigar la hipótesis de que la extraordinaria tormenta de arena ocurrida el 22-24 de febrero de 2020 pudo tener un papel en la diferente incidencia acumulada de casos de COVID-19 entre las islas de Tenerife y Gran Canaria, en cuanto conllevó una reducción significativa del tráfico aéreo y la cancelación de las mayores celebraciones del carnaval en muchas poblaciones. Método: Se realiza un análisis retrospectivo de los casos de COVID-19 hasta el 1 abril de 2020 según fecha de inicio de los síntomas, de los datos climáticos y de las celebraciones de carnaval en Tenerife y Gran Canaria. Resultados: La tormenta de arena ocurrida el 22-24 de febrero de 2020 obligó a cerrar el tráfico aéreo, reduciendo la llegada de turistas a Canarias, y a suspender las celebraciones de los carnavales en muchas poblaciones, excepto en Santa Cruz de Tenerife. El 1 abril de 2020, la incidencia acumulada de casos era de 132,81/100.000 en Tenerife y de 56,04/100.000 en Gran Canaria. Conclusiones: La cancelación de las celebraciones de carnaval debido a la tempestad de arena en las Islas Canarias parece que contribuyó de manera diferente a la reducción de la incidencia del SARS-CoV-2 en Tenerife y Gran Canaria.

Research question We analyzed two questions. First, the effectiveness of public Assisted Reproductive Technologies (ART) in Spain compared with private ones, measured by the time since initiating ART treatment until achieving pregnancy, accounting for age and socioeconomic factors. Second, socioeconomic determinants of access to ART, referring primarily to financial means derived by employment, income, and wealth. Design We applied statistical models on data extracted from the national Spanish Fertility Survey from 2018. The first topic was analyzed by competing risk survival analysis conducted on a sample of 667 women who initiate ART treatment since 2000. The second, by a Bivariate Probit model conducted on a sample of 672 women older than 41 years who required ART services. Results The first analysis raised that throughout the treatment, patients treated exclusively in private clinics had on average a higher cumulative incidence of becoming pregnant compared with patients who approached public clinics. The second analysis raised that both higher household equivalent income and higher education increase the likelihood of accessing ART in a private clinic and decrease the tendency of accessing public clinics or failing to access any service. Moreover, being single decreases the likelihood of accessing public clinics or ART services in general. Conclusions Long waiting periods could be the main reason for the lower incidence of getting pregnant in public healthcare, explaining why patients choose private over public care. We develop a broader discussion over the extent of Spanish public funding of ART, the unequal medical outcome, and potential options for optimization.

This study estimated the impact of reducing a capped low coinsurance rate for outpatient medicines to nil for low-income pensioners and disabled individuals in the Valencian Community (Spain). This reduction was implemented in January 2016 as a regional reform which modified the national cost-sharing reform adopted in July 2012. The impact of this intervention on the number of monthly prescriptions dispensed between July 2012 and December 2018 was estimated using two different approaches of the synthetic control method, the classical method and the method based on Bayesian structural time series. The estimates from both methods were similar, showing significant overall increases of 6.34% and 6.70% [95% credible interval: 4.05, 9.47], respectively in the number of prescriptions dispensed in this region. These results are similar to those of the previous studies indicating that reducing price from a small amount to zero discontinuously boosts demand. This evidence indicates that the impact of this intervention on the budget of the regional health service is far greater than the amount of the subsidy in the public budget. These results are useful for making accurate budgetary projections for similar eliminations of charges for low-income pensioners in the Spanish National Health Service.

Objective: To measure and assess differences by educational level in the place of death for cancer patients, and to determine whether patterns of geographical disparities are associated with access to palliative care services in the municipality of residence. Method: We analysed the death certificates of adults (older than 24) who died of cancer (ICD-10 C00 to C97) in Spain during 2015, either at home, in hospital or in a long-term care centre. Of the 105,758 individuals included in the study population, 75.2% lived in one of the 746 identifiable municipalities (more than 10,000 inhabitants). This individual database was combined with three economic databases at municipal level and with a directory of palliative care resources published by the Sociedad Española de Cuidados Paliativos. Multilevel models were estimated to predict the place of death according to individual characteristics. Generalised least squares regression models were then applied to the municipal effects estimated in the first stage. Results: The probability of dying in long-term care centre decreases as levels of education increase; the probability of dying at home, rather than in hospital, is higher for patients with higher education. Dying in hospital is an urban phenomenon. There are large differences between Spanish regions. Access to palliative services is only of marginal significance in accounting for the systematic differences observed between municipalities. Conclusions: Developing specific plans for palliative care, with an active role being played by primary care teams, may help improve end-of-life care in Spain. Resumen: Objetivo: Medir y evaluar las diferencias por nivel educativo respecto al lugar de muerte de pacientes con cáncer en España, y determinar si los patrones de desigualdad geográfica están asociados con el acceso a servicios de cuidados paliativos en el municipio de residencia. Método: Analizamos los certificados de defunción de mayores de 24 años que murieron de cáncer (CIE-10 C00-C97) en España durante 2015, en el hogar, en el hospital o en una residencia sociosanitaria. Sobre una población total de 105.758 personas, el 75,2% vivía en uno de los 746 municipios identificables (más de 10.000 habitantes). La base de datos individual se combina con datos económicos de ámbito municipal y con el directorio de recursos de cuidados paliativos publicado por la Sociedad Española de Cuidados Paliativos. Se estiman modelos multinivel para predecir el lugar de la muerte de acuerdo con las características individuales. A continuación, se estiman modelos de regresión por mínimos cuadrados generalizados sobre los efectos municipales estimados en el modelo anterior. Resultados: La probabilidad de morir en casa, frente al hospital, es mayor en los pacientes con educación superior. Morir en el hospital resulta un fenómeno urbano. Hay grandes diferencias entre regiones. El acceso a los servicios paliativos solo tiene una importancia marginal en la explicación de las diferencias entre municipios. Conclusión: El desarrollo de planes específicos para cuidados paliativos, con un papel más activo de los equipos de atención primaria, puede ayudar a mejorar la atención sanitaria al final de la vida en España. Keywords: Palliative care, Death, Neoplasms, Socioeconomic factors, Spain, Palabras clave: Cuidados paliativos, Muerte, Cáncer, Factores socioeconómicos, España

Under national health services (NHS), non-urgent access to specialist doctors is not straightforward and sometimes leads to long waiting times. Consequently, some citizens may decide to pay for private specialist care to complement the services provided publicly, trying to shorten their NHS waiting times. This strategic behaviour may lead to inequities in access to public specialist services. A way to approach this phenomenon is to analyse those patients that use private and public specialist care simultaneously. The aim of this paper is to determine the proportion of patients who combine both types of services, their profile and to analyse whether the recent economic crisis has accentuated this phenomenon or not. With survey data from the Spanish Health Barometer between 2005 and 2015, probit models of the probability of combining public and private specialist visits are estimated, controlling for socio-economic, demographic and other individual characteristics. Models are estimated using the Heckman correction technique to solve the potential selection bias problem. Almost one in ten patients who visited a public specialist in the previous year also visited a private specialist. Insofar as these patients have used private specialist care strategically, as complementary services to those of the Spanish NHS, this phenomenon might contribute to generate horizontal inequity in access favouring such individuals, whose profiles respond to a high socio-economic level, young and resident in the regions of Canarias, C. Valenciana, Cataluna, Navarra or Cantabria. With the economic crisis and public budget cuts, the proportion of patients who combine private and public specialist care has declined probably due to the predominance of a “household income effect”.

En los últimos años el consumo de eventos futbolísticos a través de los medios audiovisuales está superando los mercados nacionales para globalizarse. La sostenibilidad económica de los clubes de fútbol depende cada vez más de la difusión masiva en medios audiovisuales y de su capa- cidad para mantenerse como un producto atractivo, competitivo y social- mente relevante. En la actualidad en muchas ligas europeas, entre ellas la española, el lugar que ocupa un equipo al final del campeonato repercute en los ingresos por televisión, en los cinco años siguientes, recibidos por la venta conjunta de los derechos de audiovisuales, es el conocido como pago por mérito. Sin embargo, la clasificación no tiene por qué estar relacionada con el espectáculo que ofrece un equipo en el campo, y por tanto con las posibilidades comerciales de sus partidos en países donde el fútbol está bus- cando su lugar como deporte espectáculo. Abstract: In recent years the consumption of football events through au- diovisual media has transcend national borders to globalize. The economic sustainability of the football clubs increasingly depends on media diffusion and their capacity to remain as an attractive, competitive and socially rele- vant product. Currently, in many European football leagues, including the Spanish “La Liga”, the club’s final position within the league table has a di- rect impact on the next five years’ revenues from TV broadcasting as a result of the joint selling of football broadcasting rights. This is commonly known as merit payment. However, the league table position does not have to be related to the quality of the match or the level of entertainment offered by the football team in the field, and therefore with the commercial possibi- lities of their matches in countries where football is not yet conceived as a sport of entertainment.

Background: The COVID-19 pandemic has hit both the Spanish economy and the population’s health hard. The result is an unprecedented economic and social crisis due to uncertainty about the remedy and the socioeconomic effects on people’s lives. Methods: We performed a retrospective analysis of the macroeconomic impact of the COVID-19 pandemic in 2020 using key indicators of the Spanish economy for the 17 Autonomous Communities (ACs) of the country. National statistics were examined in the search for impacts or anomalies occurring since the beginning of the pandemic. To estimate the strength of the impact on each of the indicators analyzed, we used Bayesian structural time series. We also calculated the correlation between the rate of GDP decline during 2020 and the cumulative incidence of COVID-19 cases per 100,000 inhabitants in the ACs. Results: In 2020, the cumulative impact on the gross domestic product was of −11.41% (95% credible interval: −13.46, −9.29). The indicator for business turnover changed by −9.37% (−12.71, −6.07). The Spanish employment market was strongly affected, our estimates showed a cumulative increase of 11.9% (4.27, 19.45) in the rate of unemployment during 2020. The worst indicators were recorded in the ACs most economically dependent on the services sector. There was no statistical association between the incidence of COVID-19 in 2020 and the fall in GDP in the ACs. Conclusions: Our estimates portray a dramatic situation in Spain, where the COVID-19 crisis has had more serious economic and health consequences than in other European countries. The productive system in Spain is too dependent on sectors vulnerable to the pandemic, and it is necessary to design and implement profound changes through the European Next Generation program.

In the Llanos Norte area, ESP systems represent 92% of the installed artificial lift systems. According to the current production strategy in this field, there is a need for intervention in low quality sand. The design of the artificial lift system is affected by the uncertainty of the productivity index and expected flow rates. 25% of the completions designed for low flows have had deviations greater than or equal to 50% between the design parameters and the actual parameters. This condition has led to the search for alternatives for intervention and completion of this type of wells, this because the conventional technology of the pumps used historically in the field does not allow producing efficiently in such a wide uncertainty production ranges. Service Provider, from the hand of the Operator implemented a pump called FLEX-ER (extended range pump). This solution allows extending the range of the efficiency cone of the pump from 50BFPD and up to 2900BFPD, this feature helps to mitigate the uncertainty in the available design parameters, keep the pump in the optimal ranges of operation, avoid the up and down wear of the stages, thus increasing the lifetime of the electrosubmersible system. The implementation of this technology has allowed having an ESP equipment available to cover the production needs of the wells in low quality sands of northern plains. The wide range of operation of this stage allows to be protected against uncertainty in productivity and facing the changes that the well may have during its production stage. Additionally, the implementation evaluation model for 8 wells resulted in a projected saving of USD 1.4 million, as a consequence of the reduction in intervention costs, energy consumption and NPT reduction. According to these results, it is expected for the next well drilling and reconditioning campaigns, including the standardization of the technology in order to optimize the production processes of Occidental. This paper aims to present the most important technology implementations, follow up and results as well as the impact in field performance KPI.

Sugar-sweetened beverage (SSB) taxes related to the quantity of sugar have appeared as a popular regulatory tool around the world during the last decade showing important variations in their implementation and impact. We evaluated the impact of a new SSB tax implemented in Catalonia since May 1, 2017 on the purchased quantities and penetration rates of taxed and untaxed cola beverages. We use aggregate time series of cola beverages purchases in all 17 Spanish Autonomous Communities before and after the implementation of the SBB tax in Catalonia, from January 2013 to June 2019. A comparison between two different types of causal inference methods was conducted: a two-way fixed effects difference in differences model and a modified synthetic control model. Regular cola purchases decreased 12.1% and their penetration rate decreased by 1.27 points during the two post-intervention years using the preferred model. Diet cola purchases increased 17.0% and their penetration rate also increased by 1.65 points. Only regular cola results were robust to all placebo test checks. The SSB tax implemented in Catalonia in 2017 significantly reduced the volume and penetration rates of regular colas with no robust evidence for the substitution effect on diet colas.

Background Horizontal equity in access to public general practitioner (GP) services by socioeconomic group has been addressed econometrically by testing the statement “equal probability of using public GP services for equal health care needs, regardless of socioeconomic status”. Based on survey data, the conventional approach has been to estimate binomial econometric models in which when the respondent reports having visited a public GP, it counts as 1, otherwise it counts as 0. This is what we call a compartmentalised approach. Those respondents who did not visit a public GP but visited instead another doctor (specialist or private GP) would count as 0 (despite having used instead other modes of health care), thus conclusions of the compartmentalised approach might be biased. In such cases, a multinomial econometric model -that we called comprehensive approach- would be more appropriate to analyse horizontal equity in access to public GP services. The objective of this paper is to test for this potential bias by comparing a compartmentalised and a comprehensive approach, when analysing horizontal equity in access to public GP. Methods Using data from the 2016/17 Spanish National Health Survey, we estimate the probability of visiting a public GP as determined by socioeconomic status, health care need and demographic characteristics. We use binomial and multinomial logit and probit models in order to highlight the potential differences in the conclusions regarding socioeconomic inequities in access to public GP services. Socioeconomic status is proxied by education level, social class and employment situation. Results Our results show that conclusions are sensitive to the approach selected. Particularly, the horizontal inequity favouring individuals with lower education that resulted from the compartmentalised approach disappears under a comprehensive approach and only a social class effect remains. Conclusion An analysis of horizontal equity in access to a particular health care service (like public GP services) undertaken following a compartmentalised approach should be compared with a comprehensive approach in order to test that there is no bias as a consequence of considering as zeros the utilisation of other types of health care.

In January 2006, the Spanish government enacted a tobacco control law that banned smoking in bars and restaurants, with exceptions depending on the floor space of the premises. In January 2011, further legislation in this area was adopted, removing these exceptions. We analyse the effect produced on cigarette sales by these two bans. We approach this problem using an interrupted time series analysis while accounting for the potential effects of autocorrelation and seasonality. The data source used was the official data on legal sales of tobacco in Spain, from January 2000 to December 2015 (excluding the Canary Islands and the autonomous cities of Ceuta and Melilla). As confounder variables, we use the log-transformed average prices for manufactured and hand-rolled cigarettes (or the average minimum excise tax as a proxy), and log-transformed real-household disposable income. The implementation of a total smoke-free ban in Spain was associated with an immediate reduction in cigarette sales between 9% to 11%. In contrast, in the period immediately following the partial ban, no such reduction was detected, beyond the trend already present. Our results indicate that, in Spain, partial bans on smoking in public places failed, and that only a total tobacco ban worked.

The Bayesian structural time series model, used in conjunction with a state–space model, is a novel means of exploring the causal impact of a policy intervention. It extends the widely used difference–in–differences approach to the time series setting and enables several control series to be used to construct the counterfactual. This paper highlights the benefits of using this methodology to estimate the effectiveness of an absolute ban on smoking in public places, compared with a partial ban. In January 2006, the Spanish government enacted a tobacco control law which banned smoking in bars and restaurants, with exceptions depending on the floor space of the premises. In January 2011, further legislation in this area was adopted, removing these exceptions. The data source used for our study was the monthly legal sales of cigarettes in Spain from January 2000 to December 2014. The potential control series were the monthly tourist arrivals from the United Kingdom, the total number of visitors from France, the unemployment rate and the average price of cigarettes. Analysis of the state–space model leads us to conclude that the partial ban was not effective in reducing the tobacco sold in Spain, but that the total ban contributed significantly to reducing cigarette consumption.

Mental health disorders are highly prevalent across countries. They increase over time and impose a severe burden on individuals and societies. This paper examines the evolution of mental health over a period of 15 years, paying special attention on the impact of the most recent economic downturn and subsequent recovery, in Spain. We use data coming from the National Health Surveys of 2006/2007, 2011/2012 and 2016/2017. Mental health is proxied by two measures, doctor-diagnosed mental disorder and psychological distress (based on the 12-item General Health Questionnaire). To account for the relationship between the two mental health indicators, we estimate a bivariate probit model. The potential endogeneity of unemployment status is considered. We observe different patterns of the two mental health indicators over time. Psychological distress in men increased during recession years, but slightly decreased among women. Diagnosed mental disorders declined during the peak years of the crisis. Unemployment is a major risk factor for mental distress. Irrespective of the economic conditions, belonging to a higher social class acts as a buffer against psychological distress for women, but not for men. The remaining determinants acted as expected. Women declared worse psychological health than men, and were also more often diagnosed with mental disorders. Having a partner had a protective impact, while providing intensive care to a dependent relative exerted the opposite effect. Education acted as buffer against the onset of psychological distress in women. Even though the need for mental healthcare increased during the recession, the fact that fewer people were diagnosed suggests that barriers to accessing mental healthcare may be aggravated during the crisis. Policies aiming to tackle the challenges posed by the high prevalence of mental disorders have to be particularly attentive to changes in individuals’ socioeconomic situation, including education, unemployment and social class.

To compare the differences in the use of healthcare services: visits to the doctor and hospitalisation, performance of routine tests, and preventive influenza vaccination, between users and non-users of homeopathic products. We used the microdata for adults over 15 years old from three waves of the Spanish National Health Survey, corresponding to the years 2011, 2014 and 2017. We proposed a comparative design of a quasi-experimental type, considering as the treatment group the respondents who said that they had used homeopathic products in the past two weeks; and another group, for control, comprising respondents who said that they had not used this type of products, but only conventional medicines, with observable characteristics similar to those of the treatment group. We used a model for rare events logistics regression (relogit) to estimate the probability of using homeopathy. From the propensity score and a vector of control variables, we used techniques of genetic matching to match individuals from the treatment group with similar individuals belonging to the control group. There are no statistically significant differences between users and non-users of homeopathy in visits to the general practitioner (P>|z| 0.387), to the specialist (P>|z| 0.52), in hospitalisations (P>|z| 0.592) or in the use of emergency services (P>|z| 0.109). Nor were there any statistically significant differences in the performance of routine tests, except for the faecal occult blood test, which is more prevalent in users of homeopathic products. 20.9% of users of homeopathy had done this test compared with 15.3% of non-users (P>|z| 0.022). There are also significant differences in vaccination against influenza with 12.6% of homeopathy users stating that they had been vaccinated in the last influenza campaign, against 21.0% of non-users (P>|z

Mental health is not only the lack of mental disorders but is considered a crucial resource for overall health and well-being (including employment and productivity). The current paper tries to shed some light on the evolution of mental well-being over a period of 15 years, including the years before, during and after the most recent economic downturn. We use data coming from the Spanish National Health Surveys of 2006/2007, 2011/2012 and 2016/2017. Mental health is proxied by two measures, doctor-diagnosed mental disorder and psychological distress (based on GHQ-12). To account for the causal relationship between the two mental health indicators, we estimate a bivariate probit model. We observe different patterns of the two mental health indicators over time. Psychological distress increased during recession years, due to major risk factors as unemployment and loss of socioeconomic status. Even though the need for mental healthcare increased during the recession, the fact that fewer people were diagnosed suggests that barriers to access to mental healthcare may be aggravated during the crisis.

Objective: To test the hypothesis that leadership and management skills protect dental practices against the effects of an economic recession. Methods: This was a cross-sectional exploratory study. Dentists (n = 232) were randomly selected to participate in an online survey in which they were asked about their practice activity. Results: A total of 162 questionnaires were returned (response rate 70%). Results indicated that improved leadership and management skills are positively related to the probability that a practice remained stable or increased its productivity during the economic recession: OR = 2.39 (95% CI; 1.08-5.3). Conclusions: Our findings suggest that dental practices applying leadership and management skills are related to attract and retain patients, as measured by increased numbers of both initial consultations and continued patronage (return visits); and keep the economic crisis’ impact on revenue manageable.

Introduction The potential of smoke-free bans to negatively impact the hospitality business has been an argument of the hospitality and tobacco industry against such legislation. A partial smoke-free legislation was introduced in Spain in 2006 allowing smoking in most bars and restaurants due to the pressure of the hospitality sector. However, this partial ban was later amended in 2011 to include all the hospitality premises without exceptions. The stepped Spanish process permits to evaluate whether the entry into force of the smoke-free legislation had any effect on the economic activity of the hospitality sector. Methods We employed a pooled time series cross-sectional design, with national data over 6 years (2006-2011). The dependent variable used was the total number of bars and restaurants per 100,000 inhabitants. The explanatory variables used were the average amount of spending per household in bars and restaurants, and the total unemployment rate in Spain by regions. Results For every 1% increase in the unemployment rate there was a 0.05% decrease in the number of bars and restaurants. In 2007, the number of bars and restaurants was significantly reduced by 13.06% (all others factors being held constant), 4.87% in 2008, and 10.42% in 2009. No statistically significant effect of the smoke-free legislation emerged from 2010 (6.76%) to 2011 (7.69%). Conclusion The new Spanish smoke-free legislation had no effect on the number of bars and restaurants.

ResumenObjetivoanalizar el impacto sobre el consumo en bares, cafeterías y restaurantes de la Ley 42/2010 de modificación de medidas sanitarias frente al tabaquismo.Métodosexplotación de los microdatos de la Encuesta de Presupuestos Familiares en 2010 y 2011. Los ficheros de enlace nos permiten hacer un seguimiento a un amplio número de hogares que permanecen en la muestra 2 años consecutivos. Tomando como referencia el año 2010 se cuantifica cómo han cambiado las pautas de consumo en los establecimientos hosteleros, diferenciando entre hogares fumadores y no fumadores.Resultadoslos efectos marginales en la primera etapa del modelo en dos partes muestran una probabilidad media de realizar algún gasto del 96% en las familias fumadoras,frente al 86% de las no fumadoras, sin variaciones significativas entre 2010 y 2011. En lo que respecta a la proporción sobre el gasto total del hogar, las familias fumadoras gastaron en establecimientos hosteleros un 7,961% en 2010 y un 7,796% en 2011, frente al 7,25% y el 7,272%, respectivamente, de las familias no fumadoras. El estimador de dobles diferencias, entre años y entre familias, no resulta estadísticamente significativo.Conclusionesla Ley 42/2010 no ha tenido influencia en los cambios de los hábitos de consumo de las familias españolas en los establecimientos de hostelería. Las decisiones de consumo están más relacionadas con las características sociodemográficas (como el número de hijos del hogar) y con el impacto de la crisis económica (desempleo y reducción de los ingresos).AbstractObjectiveto analyze the impact of Spanish smoke-free legislation (Law 42/2010) on the business activity of bars, cafés, and restaurants.Methodswe used the micro-data from the Household Budget Survey for 2010 and 2011. The linking files allowed close follow-up of the households that remained in the sample for 2 consecutive years. Taking the year 2010 as the base reference for our analyses, we quantified how levels of consumption expenses on hospitality venues have changed over the years, differentiating between smoking households and non-smoking households.Resultsthe marginal effects of the first stage of the two-part model showed that the mean probability of expenditure on hospitality venues was 96% in smoking households and was 86% in non-smoking households. There were no statistically significant variations in the probability of expenditure between 2010 and 2011. The proportion of expenditure on hospitality venues in total household consumption expenditure in smoking households was 7.961% and 7.796% in 2010 and 2011, respectively. These proportions were 7.25% in 2010 and 7.272% in 2011 for non-smoking households. The difference in differences estimator, which takes into account both differences between years and households, showed no statistically significant differences in levels of household consumption.Conclusionsthe introduction of the Law 42/2010 has had noimpact on the levels of household consumption expenses on hospitality venues. Changes in consumption expenses could be explained by sociodemographic characteristics (such as the number of children per household) and the impact of the economic crisis (unemployment and a decrease in household income).

El objetivo de esta investigacion consiste en analizar si existe equidad en el acceso a los servicios sanita-rios publicos por niveles socioeconomicos. se analiza conjuntamente la probabilidad de utilizar los servi-cios sanitarios y los tiempos de espera hasta ser atendidos, corrigiendose asi el sesgo de seleccion que sederivaria de su estudio separado, tal y como se evidencia en esta investigacion. se propone una aproxima-cion bayesiana y se hace uso de la informacion a nivel individual sobre la utilizacion sanitaria, tiempos deespera, nivel socioeconomico, necesidad sanitaria y otras variables sociodemograficas contenidas en la En-cuesta nacional de salud (2006). Los resultados muestran que hay inequidad en el acceso a los serviciosespecializados y hospitalarios (tanto en utilizacion como en tiempos de espera) que perjudica a los nivelessocioeconomicos inferiores. En los servicios de medicina general, si bien la utilizacion beneficia relativa-mente mas a los grupos de menor nivel socioeconomico, los tiempos de espera perjudican a los de menornivel educativo.

El objetivo de esta investigación consiste en analizar si existe equidad en el acceso a los servicios sanitarios públicos por niveles socioeconómicos. Se analiza conjuntamente la probabilidad de utilizar los servicios sanitarios y los tiempos de espera hasta ser atendidos, corrigiéndose así el sesgo de selección que se derivaría de su estudio separado, tal y como se evidencia en esta investigación. Se propone una aproximación bayesiana y se hace uso de la información a nivel individual sobre la utilización sanitaria, tiempos de espera, nivel socioeconómico, necesidad sanitaria y otras variables sociodemográficas contenidas en la En-cuesta nacional de salud (2006). Los resultados muestran que hay inequidad en el acceso a los servicios especializados y hospitalarios (tanto en utilización como en tiempos de espera) que perjudica a los niveles socioeconómicos inferiores. En los servicios de medicina general, si bien la utilización beneficia relativa-mente más a los grupos de menor nivel socioeconómico, los tiempos de espera perjudican a los de menor nivel educativo.

RESUMEN Este artículo aporta una revisión crítica acerca de los retos a los que se enfrentan los impuestos sobre las bebidas azucaradas como instrumento de políticas de salud, para revertir la tendencia epidémica de la obesidad. Se valoran las experiencias de los países más significados, en particular México, y se reflexiona sobre el contrapeso que ejerce la industria a las políticas antiobesidad y el poder de los lobbies. Esas políticas impositivas en pro de la salud pública han de sobreponerse a la enorme fuerza de la industria, que es ejercida en varios niveles -ciencia e investigación, reputación de marca, influencia en reguladores-. Se sugiere que un impuesto específico sobre bebidas azucaradas tiene bastante potencial para reducir enfermedades no transmisibles y riesgos -diabetes mellitus, hipertrigliceridemia, lipoproteínas de baja densidad, hipetensión diastólica-, a través de la reducción del consumo, al ser alta la elasticidad del precio de estas bebidas. Además, los efectos incluso se amplifican a medio plazo, una vez establecidos nuevos hábitos de consumo más saludable. Los impuestos podrían fomentar la innovación empresarial sin infligir costes de pérdida de empleos y contribuirían a reducir el gradiente social de la obesidad. ABSTRACT This article provides a critical review about the challenges that taxes on sugary drinks as an instrument of health policy must face to reverse the trend of the current epidemics of obesity. We analyzed the experiences of the leading countries, particularly Mexico, and reflect on the counterweight exerted by the industry against obesity policies, and on the power of lobbyists. Those tax policies for public health have to overcome the enormous strength of the industry, which is exerted in several-science and research, brand reputation, influence on regulators-levels. We suggest that a specific tax on sugary drinks has enough potential to reduce noncommunicable diseases and risk -diabetes mellitus, hypertriglyceridemia, lipoproteins, LDL, blood pressure- via reduced consumption thanks to the high price elasticity of those drinks. Furthermore, the effects are amplified even in the medium term, once established new habits to healthier eating. These taxes could encourage business innovation without inflicting costs of lost jobs and contribute to reducing the social gradient in obesity.

ResumenLa evaluación de políticas públicas no siempre resulta una tarea obligatoria para las administraciones. A priori, los instrumentos de intervención por parte del estado se eligen y calculan para maximizar la función de bienestar social, la cual debe estar implícita en las políticas llevadas a cabo o en el programa electoral del gobierno. Sin embargo, sorprende que en ocasiones el estado actúa sin cuestionarse si el funcionamiento de las instituciones y las políticas públicas correspondientes pueden lograr de manera efectiva y eficiente ese objetivo. La ausencia de evaluación lleva a que programas inefectivos e ineficientes provoquen el drenaje de los escasos recursos disponibles, que podrían utilizarse en otras iniciativas de mayor efecto sobre el bienestar de la población.AbstractPublic policy evaluation is not always a mandatory task for administrations. A priori, the instruments for government intervention are chosen and calculated to maximize the social welfare function that should be implicit in the policies undertaken, or in the government’s electoral program. However, it is surprising how the government sometimes acts without questioning whether institutional functioning and the corresponding public policies can effectively and efficiently achieve this objective. The absence of evaluation drains the scarce available resources towards ineffective and inefficient programs, which could be otherwise used in other initiatives with a greater impact on the population’s welfare.

The aim of this paper is to analyse if there is horizontal equity in the utilisation of public health care services by región (comunidad autónoma) of residence in Spain. Data from the 2006 National Health Survey were considered to undertake a multilevel analysis, using a binary logistic function for each of the public health care services analysed (general practitioner –GP- visits, specialist visits and hospitalisations). Health care need and other socioeconomic and demographic characteristics were controlled at individual level. It can be concluded that, although there is no evidence of territorial inequity in hospitalisations, there is territorial inequity in the case of GP and also of specialist visits, which can not be explained by regional differences in the availability of resources at both health care levels

We investigate the main sources of heterogeneity in regional efficiency. We estimate a translog stochastic-frontier production function in the analysis of Spanish regions in the period 1964–96, to attempt to measure and explain changes in technical efficiency. Our results confirm that regional inefficiency is significantly and positively correlated with the ratio of public capital to private capital. The proportion of service industries in private capital, the proportion of public capital devoted to transport infrastructures, the industrial specialization, and spatial spillovers from transport infrastructures in neighbouring regions significantly contributed to improving regional efficiency.

Introduction Adult oral health is predicted by oral health in childhood. Prevention improves oral health in childhood and, consequently in adulthood, so substantial cost savings can be derived from prevention. The burden of oral disease is particularly high for disadvantaged and poor population groups in both developing and developed countries. Therefore, an appropriate and egalitarian access to dental care becomes a desirable objective if children’s dental health is to be promoted irrespective of socioeconomic status. The aim of this research is to analyse inequalities in the lack of access to dental care services for children in the Spanish National Health System by socio-economic group over the period 1987–2011. Methods Pooled data from eight editions of the Spanish National Health Survey for the years 1987–2011, as well as contextual data on state dental programmes are used. Logistic regressions are used to examine the related factors to the probability of not having ever visited the dentist among children between 6 and 14 years old. Our lack of access variable pays particular attention to the socioeconomic level of children’s household. Results The mean probability of having never been to the dentist falls considerably from 49.5% in 1987 to 8.4% in 2011. Analysis by socioeconomic level indicates that, in 1987, the probability of not having ever gone to the dentist is more than two times higher for children in the unskilled manual social class than for those in the upper non-manual social class (odds ratio 2.35). And this difference is not reduced significantly throughout the period analysed, rather it increases as in 1993 (odds of 2.39) and 2006 (odds of 3.03) to end in 2011 slightly below than in 1987 (odds ratio 1.80). Conclusion There has been a reduction in children’s lack of access to dentists in Spain over the period 1987–2011. However, this reduction has not corrected the socioeconomic inequalities in children’s access to dentists in Spain.

This paper describes the causes that generate the relatively high – among comparable OECD countries – prevalence of tobacco consumption in Spain. It evaluates the current policy interventions geared towards reducing incidence and prevalence. It argues that, despite a recent major breakthrough in legislation on advertising and consumption in public places, one of the major shortcomings of current policies is the lack of an effective fiscal policy. This lack of effectiveness is explained by some idiosyncrasies of the Spanish cigarette market that call for specific measures.

ResumenObjetivoAnalizar los factores que determinan la adquisición y posterior consolidación del consumo de tabaco en los jóvenes adolescentes.Material y métodoEstudio longitudinal de 3 años de duración (2000-2002) sobre jóvenes estudiantes de enseñanza obligatoria, con una edad al inicio del estudio de 13-14 años. Los datos fueron recogidos mediante encuesta individual, cuyo ámbito de estudio era la isla de Gran Canaria, con una muestra final de 745 individuos. Se estimaron modelos de elección binaria condicional de efectos fijos para datos longitudinales, para determinar la probabilidad de probar por primera vez el tabaco («modelo de inicio»), así como sobre la probabilidad de ser fumador occasional o habitual («modelo de experimentación»).ResultadosEn el último año, el 57% de los adolescents encuestados ha tenido contacto con el tabaco alguna vez, un 25% más que en el primer año, algunos de ellos (el 9%) de forma diaria. En el «modelo de inicio» los determinantes del consumo de tabaco son el interés por el colegio (odds ratio [OR]=0,27; intervalo de confianza [IC] del 95%, 0,08-0,87, y OR=0,14; IC del 95%, 0,03-0,58 para los que manifestaron bastante y mucho interés por el colegio, respectivamente), el consumo de tabaco por parte del mejor amigo (OR=7,44; IC del 95%, 2,59-21,4), el consumo de alcohol (OR=11,82; IC del 95%, 4,96-28,2, y OR=15,42; IC del 95%, 4,68-50,7 para los que beben alcohol de manera ocasional o frecuente, respectivamente), y el dinero disponible (euros semanales) (OR=1,13; IC del 95%, 1,07-1,19). Para el «modelo de experimentación», el consumo de tabaco por parte del mejor amigo (OR=7,01; IC del 95%, 2,96-16,5), el consumo de alcohol (OR=5,71; IC del 95%, 1,98-16,4, y OR=5,22; IC del 95%, 1,56-17,5 para los que beben alcohol de manera ocasional o frecuente, respectivamente) y los años que lleva como fumador (OR=1,44; IC del 95%, 1,11-,86).ConclusionesEl estudio destaca, principalmente, los efectos del grupo de amigos, el consumo de bebidas alcohólicas y el poco interés por los estudios como factores asociados al consumo de tabaco.AbstractObjectiveTo analyse the determining of the acquisition and later consolidation of the tobacco consumption in young adolescents.Material and methodLongitudinal study of three years of duration (2000-2002). Subjects were students of secondary education between 13 and 14 years old at the beginning of the study. The research was performed in Gran Canaria Island with a final sample of 745 subjects. Models of conditional binary election were considered for longitudinal data where the dependent variable reflects decisions of the adolescents through time, with regard to the probability of beginning to smoke, «beginning model», and the probability of being occasional or habitual smoker, «experimentation model».ResultsIn the last year, 57% of the young teenagers surveyed use tobacco, a 25% more than in the first year, some of them, 9% on a daily basis. In the «beginning model» the determining of the tobacco consumption are interest in studies (odds ratio [OR]=0.27; 95% confidence interval (CI), 0.08-0.87 and OR=0.14; 95% CI, 0.03-0.58 for the students having enough and much interest in studies, respectively), to have a smoker as the best friend (OR=7.44; 95% CI, 2.59-21.4), the alcohol consumption (OR=11.82; 95% CI, 4.96-28.2 and OR=15.42; 95% CI, 4.68-50.7 for youngs who drink alcohol occasionally or frequently) and having more pocket money (euros per week) (OR=13; 95% CI, 1.07-1.19). For the «experimentation model», to have a smoker as the best friend (OR=7.01; 95% CI, 2.96-16.5), the alcohol consumption (OR=5.71; 95% CI, 1.98-16.4 and OR=5.22; 95% CI, the 1.56-17.5 for youngs who drink alcohol occasionally or frequently) and the number of years since the student started smoking (OR=1.44; 95% IC, 1.11-1.86).ConclusionsOur study emphasizes, peer group effect, drinking alcoholic beverages and lack of interest in studies as factors associated to the tobacco consumption.

This paper contributes to the empirical knowledge of determinants of smoking initiation in adolescents. The instrument we used was a structural equation model, which is a powerful tool to analyze causal relationships in nonexperimental studies. We used a school-based sample of 1198 teenagers from Spain. We measured the attitude of the adolescents towards tobacco. Attitudes and smoking status are related. Attitudes become more favorable to smoking, as experimentation with cigarettes progresses and pupils become older. Teenagers who have tried at least one cigarette are on average more favorable to smoking than those who had never smoked. The study's limitations were noted.

To understand the context for tobacco smoking in young adolescents, estimating the effects of individual, family, social, and school related factors.Cross sectional analysis performed by multilevel logistic regression with pupils at the first level and schools at the second level. The data came from a stratified sample of students surveyed on their own, their families' and their friends' smoking habits, their schools, and their awareness of cigarette prices and advertising.The study was performed in the Island of Gran Canaria, Spain.1877 students from 30 secondary schools in spring of 2000 (model's effective sample sizes 1697 and 1738).14.2% of the young teenagers surveyed use tobacco, almost half of them (6.3% of the total surveyed) on a daily basis. According to the ordered logistic regression model, to have a smoker as the best friend increases significantly the probability of smoking (odds ratio: 6.96, 95% confidence intervals (CI) (4.93 to 9.84), and the same stands for one smoker living at home compared with a smoking free home (odds ratio: 2.03, 95% CI 1.22 to 3.36). Girls smoke more (odds ratio: 1.85, 95% CI 1.33 to 2.59). Experience with alcohol, and lack of interest in studies are also significant factors affecting smoking. Multilevel models of logistic regression showed that factors related to the school affect the smoking behaviour of young teenagers. More specifically, whether a school complies with antismoking rules or not is the main factor to predict smoking prevalence in schools. The remainder of the differences can be attributed to individual and family characteristics, tobacco consumption by parents or other close relatives, and peer group.A great deal of the individual differences in smoking are explained by factors at the school level, therefore the context is very relevant in this case. The most relevant predictors for smoking in young adolescents include some factors related to the schools they attend. One variable stood out in accounting for the school to school differences: how well they enforced the no smoking rule. Therefore we can prevent or delay tobacco smoking in adolescents not only by publicising health risks, but also by better enforcing no smoking rules in schools.