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Background: Diet and physical activity (PA) in childhood are heavily influenced by the living environment. While diet quality follows a socioeconomic pattern, limited evidence is available in relation to PA in children. We assessed the effect of socioeconomic status at the individual (SES) and neighbourhood (NSES) levels on diet and PA among children from the general population of the Canary Islands, Spain., Methods: In this cross-sectional study, patients aged 6-14 years from the Canary Health Service in 2018 were included (n=89 953). Diet and PA surveys from the electronic health records of the well-child visit programme were used. A healthy habits (HH) score was defined to assess the level of adherence to the dietary and leisure time PA guidelines. We modelled the association between the HH score, SES and NSES using a stepwise multilevel linear regression analysis, differentiating between specific and general contextual observational effects., Results: A strong positive association between SES and the HH score was found, as children living in more affluent families were more likely to follow a healthy diet and being physically active. Differences in the HH score between geographical areas were of minor relevance (variance partition coefficient=1.8%) and the general contextual effects were not substantially mediated by NSES (proportional change in variance=3.5%). However, the HH score was significantly lower in children from areas with a higher percentage of annual incomes below the €18 000 threshold., Conclusion: HH followed a socioeconomic gradient at the individual and the neighbourhood level. In the study population, the geographical component of the inequalities found were low., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: We investigate the impact of a specific macroeconomic shock that occurred as a response to the SARS-COV-2 outbreak, namely the strict lockdown imposed in Spain on the March 14, 2020., Methods: We use fortnightly purchase data relating to over 50,000 households from a supermarket chain in Catalonia from March to June in 2019 and 2020. Using a panel data approach, we analyse the impact of the lockdown on the caloric content, sugar composition, and alcohol content in beverages and food purchases bought before and after lockdown. We corrected our results to take into account the likelihood of stockpiling., Results: The lockdown is related to an increase in unhealthy beverage and food purchases. We find heterogeneous effects across groups of the sample based on cardholder characteristics. Families with children or babies and those in the upper two income quintiles had the unhealthiest changes. As the lockdown went through phases of relaxation, households made better food decisions but maintained unhealthy beverage choices., Conclusions: The very restrictive lockdown negatively impacted the characteristics of food and beverage purchases made by Spaniards. However, we are unsure whether there was substitution to restaurant and bar visits. Additional work to find out whether there were permanent changes in purchasing behaviour after lockdown ended is needed in the future., Competing Interests: An unrestricted grant from the Ministry of Science supported this research. All authors have no financial or other conflicts of interest that are directly relevant to the content of this article., (© 2023 The Authors.)

Obesity has become a major epidemic in the 21st century. It increases the risk of dyslipidemia, hypertension, and type 2 diabetes, which are known cardiometabolic risk factors and components of the metabolic syndrome. Although overt cardiovascular (CV) diseases such as stroke or myocardial infarction are the domain of adulthood, it is evident that the CV continuum begins very early in life. Recognition of risk factors and early stages of CV damage, at a time when these processes are still reversible, and the development of prevention strategies are major pillars in reducing CV morbidity and mortality in the general population. In this review, we will discuss the role of well-known but also novel risk factors linking obesity and increased CV risk from prenatal age to adulthood, including the role of perinatal factors, diet, nutrigenomics, and nutri-epigenetics, hyperuricemia, dyslipidemia, hypertension, and cardiorespiratory fitness. The importance of 'tracking' of these risk factors on adult CV health is highlighted and the economic impact of childhood obesity as well as preventive strategies are discussed.

Objective: Some hormonal and targeted treatment options are available in the first line of metastatic HR+ & HER2- breast cancer. This study aimed to quantify the preferences of Iranian breast cancer patients regarding the levels of attributes of hypothetical treatment options., Methods: The discrete choice experiment included 16 orthogonally designed scenarios. A novel method (named "the World Cup") was used to offer the scenarios to the respondents. Each choice task had 2 hypothetical treatments. A conditional logit regression model was used to obtain preference estimates, based on an expected utility model without interactions between attributes., Results: A total of 78 patients with breast cancer participated in the survey. The effectiveness was the main concern of the patient, which was followed by monthly cost. Participant patients significantly preferred to avoid adverse events; preference dummy-coded estimates were reported., Conclusion: Followed by the effectiveness and cost, the risk of neutropenia, stomatitis, and arthralgia was least prioritized by the respondents. The estimation for the levels of the attribute "administration mode" is not significant (P = .690). Patients with breast cancer were willing to pay significant amounts to gain the benefit of the treatments and showed a significant willingness to accept to avoid the adverse events of the treatments., (Copyright © 2020. Published by Elsevier Inc.)

It is unclear what the effects of taxes on sugar sweetened beverages (SSBs) are on consumer behaviour and which consumers may be affected the most. We evaluate the effect of the SSB tax introduced in Catalonia (but not in the rest of Spain) in May 2017 using loyalty card data of monthly purchases by 884,843 households from May 2016 to April 2018. Using a Difference-in-Differences approach, we study the SSB tax effect on the purchased quantity of beverages and sugar. Our results suggest a reduction in purchases of taxed beverages and a small increase in purchases of untaxed beverages. Households have substituted taxed beverages with their lower sugar (untaxed) counterparts. This has led to a 2.2% overall reduction in sugar purchases from beverages. Our study implies that although sin taxes moderately change consumer behaviour, a combination of different policies would be required to tackle obesity., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

This article provides a critical review of international experiences regarding the professional organization of physicians and the registration of doctors in developed countries. The problems faced by professional medical organizations in the EU-15 countries, Japan, the United States and Canada, are examined. Medical professional groups differ in several dimensions, including obligatory registration versus voluntary membership or types of registration (centralized, indirect, or delegated). The centralization-decentralization axis is a key aspect for the analysis. While decentralized systems are better able to adapt to the idiosyncrasy of a particular region, decentralization is identified as a source of potential problems in the organization of medical doctors. Some of these problems (discrepancies in positions on health matters, problems with the reliability of statistical information on medical demography at national level, deficient mechanisms for the control of doctors who have lost their licenses) might have consequences for the quality of the health care system., Competing Interests: Conflict of interest: The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript., (© 2019 the Author(s), licensee AIMS Press.)

A randomised control trial was conducted to determine changes in the food and drink choices of adolescents following their participation in a 50-min nutrition workshop. The experiment was conducted at 104 schools in Barcelona (126 classes, 3,291 adolescents). Schools were randomly selected and stratified by district and by public or private status. The students were given three types of vouchers with different options regarding the type of food for which the vouchers could be exchanged (standard for healthy food and drink, two for one for unhealthy food, and two for one for unhealthy drink). Difference-in-differences linear models that control for individual, family, school or neighbourhood characteristics, and the influence of peers were applied. The probability of students' choosing unhealthy food and drink fell by 7.1% and 4.4%, respectively, following participation in the nutrition workshop. The promotion of unhealthy beverages counteracted the positive impact of the workshop on beverage choice., (Copyright © 2017 The Authors. Health Economics published by John Wiley & Sons Ltd.)

In Spain's 'MIR' system, medical school graduates are ranked by their performance on a national exam and then sequentially choose from the available residency training positions. We took advantage of a unique survey of participants in the 2012 annual MIR cycle to analyze preferences under two different choice scenarios: the residency program actually chosen by each participant when it came her turn (the 'real') and the program that she would have chosen if all residency training programs had been available (the 'counterfactual'). Utilizing conditional logit models with random coefficients, we found significant differences in medical graduates' preferences between the two scenarios, particularly with respect to three specialty attributes: work hours/lifestyle, prestige among colleagues, and annual remuneration. In the counterfactual world, these attributes were valued preferentially by those nearer to the top, while in the real world, they were valued preferentially by graduates nearer to the bottom of the national ranking. Medical graduates' specialty preferences, which we conclude, are not intrinsically stable but depend critically on the 'rules of the game'. The MIR assignment system, by restricting choice, effectively creates an externality in which those at the bottom, who have fewer choices, want what those at the top already have. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

This paper reviews economic and medical research publications to determine the extent to which the measures applied in Spain to control public health spending following the economic and financial crisis that began in 2008 have affected healthcare utilization, health and fairness within the public healthcare system. The majority of the studies examined focus on the most controversial cutbacks that came into force in mid-2012. The conclusions drawn, in general, are inconclusive. The consequences of this new policy of healthcare austerity are apparent in terms of access to the system, but no systematic effects on the health of the general population are reported. Studies based on indicators of premature mortality, avoidable mortality or self-perceived health have not found clear negative effects of the crisis on public health. The increased demands for co-payment provoked a short-term cutback in the consumption of medicines, but this effect faded after 12-18 months. No deterioration in the health of immigrants after the onset of the crisis was unambiguously detected. The impact of the recession on the general population in terms of diseases associated with mental health is well documented; however, the high levels of unemployment are identified as direct causes. Therefore, social policies rather than measures affecting the healthcare system would be primarily responsible. In addition, some health problems have a clear social dimension, which seems to have become more acute during the crisis, affecting in particular the most vulnerable population groups and the most disadvantaged social classes, thus widening the inequality gap.

Background: Social health inequalities in adult population are partly due to socioeconomic circumstances in childhood. A better understanding of how those circumstances affect health during adulthood may improve the opportunities for reducing health disparities. The objective of this study is to investigate the effect of parental socioeconomic status, which is proxied by occupation, on adult Spaniards' health by birth cohort. The analysis will allow checking not only the direct impact of parental occupation on their offspring's health, but also whether inherited inequality has been reduced over time., Methods: We use data from the Bank of Spain's Survey of Household Finances on Spanish households from 2002 to 2008. Sequential models were used to estimate the influence of the father's and mother's occupation on their offspring's health, trying to disentangle direct from indirect effects. With a sample of 26,832 persons we consider effects for four different cohorts by birth periods ranging from 1916 to 1981., Results: The results show that parental occupation has a significant direct impact on individuals' health (p < 0.01). The effect of father's occupation exceeds that of mother's. For those born before 1936, the probability of reporting a good health status ranges from 0.31 (95% confidence interval (CI) 0.14-0.48), when fathers were classified as unskilled elementary workers, to 0.98 (95% CI 0.98-0.99) when they were managers or mid-level professionals. For those born during the period 1959-1975, those probabilities are 0.49 (95% CI 0.39-0.59) and 0.97 (95% CI 0.96-0.98), respectively. Therefore, health inequalities linked to parental socioeconomic status have been noticeably reduced, although discrimination against unskilled workers persists over time., Conclusions: Great progress has been made in the health area during the twentieth century, so that the impact of parental socioeconomic status on individuals' health has been significantly tempered for those at the bottom of the social scale. However, more efforts focused on the improvement of living conditions for most socioeconomically disadvantaged are needed in order to further reduce social inequalities in health.

Objectives: To estimate the impact of (particularly long-term) unemployment on the overall and mental health of the Spanish working-age population and to check whether the effects of unemployment on health have increased or been tempered as a consequence of the economic crisis., Methods: We apply a matching technique to cross-sectional microdata from the Spanish Health Survey for the years 2006 and 2011-2012 to estimate the average treatment effect of unemployment on self-assessed health (SAH) in the last year, mental problems in the last year and on the mental health risk in the short term. We also use a differences-in-differences estimation method between the two periods to check if the impact of unemployment on health depends on the economic context., Results: Unemployment has a significant negative impact on both SAH and mental health. This impact is particularly high for the long-term unemployed. With respect to the impact on mental health, negative effects significantly worsen with the economic crisis. For the full model, the changes in effects of long-term unemployment on mental problems and mental health risk are, respectively, 0.35 (CI 0.19-0.50) and 0.20 (CI 0.07-0.34)., Conclusions: Anxiety and stress about the future associated with unemployment could have a large impact on individuals' health. It may be necessary to prevent health deterioration in vulnerable groups such as the unemployed, and also to monitor specific health risks that arise in recessions, such as psychological problems.

Background: After more than three decades of free medicines for the elderly in Spain, in the context of heavy austerity reforms of public financing, a set of cost-sharing reforms on pharmaceutical prescriptions with regional variants have been established in Spain since July 2012., Objective: The purpose of this analysis is to present the first attempt to provide accurate estimates of the overall impact at the regional level of these cost-sharing reforms., Methods: We estimated the impact of the reforms on the quantity of dispensed medicines during the first 14 months. We estimated 17 autoregressive integrated moving average (ARIMA) time series models of the monthly number of prescriptions dispensed in pharmacies for the period January 2003-May 2012 in each one of the 17 regions (Autonomous Communities) of Spain. We calculated dynamic forecasts for the horizon June 2012-July 2013 in order to estimate the counterfactual (number of prescriptions that would had been observed without the intervention), and we estimated the impact of cost-sharing changes as the difference between the observed number of accumulated prescriptions at 3, 6, 12, and 14 months and the number predicted by our time-series models (in percentages)., Results: During the last decade the number of dispensed prescriptions has experienced rapid and continuous increases. In the first 14 months after the co-payment reform, the total number of prescriptions decreased dramatically, by more than 20% in Catalunya, Valencia, and Galicia, by more than 15% in nine other regions, and by more than 10% in 15 of the 17 Spanish regions. The results of our model suggest that the new co-payment caused an abrupt shift in the mean level of the time series. No shift in trend has been detected; the previous positive trend remains unchanged in most of the Autonomous Communities., Conclusion: After decades of unsuccessfully trying to reduce drug spending in the Spanish National Health System through actions on prices and on prescribers, the co-payment established in mid-2012 led to a dramatic reduction in the use of drugs. The health effects of this reduction are not known.

Background: Medical school graduates in Spain must take a uniform national exam (called "examen MIR") in order to enter postgraduate training in a specialty. Its results offer a unique opportunity to rank medical schools according to this exam., Objectives: We measured differences in the MIR exam results among Spanish medical schools and assessed the stability of the MIR-based rankings for the period 2003-2011., Results: In the year 2011 a total of 6873 residency positions nationwide were offered by the Spanish Ministry of Health, Social Services and Equality. These positions covered 47 specialties distributed over 231 training centers. A total of 11,550 medical graduates (including 1997 foreign graduates) took the MIR examination. Marked differences among medical schools were evident. The median graduate from medical school #1 and #29 occupied the positions 1477 and 5383, respectively. These figures correspond to a standardized ranking of 21 out of 100 for medical school #1 (that is, 1477/6873; half of medical school #1 obtained better [below position 21%] and half worse [over position 21%] results) and a standardized ranking of 70 out of 100 for medical school #29. While 81% of the medical school #1 graduates were amongst the best 3000 MIR exams and only 5% above the 5000 position the corresponding figures for medical school #29 graduates were 21% and 44%, respectively. The ranking position of the 29 medical schools was very stable between the years 2003 and 2011., Conclusion: There are marked differences in medical schools in Spain and these differences are very consistent over the years 2003-2011., (Copyright © 2013 Elsevier España, S.L. All rights reserved.)

The present financial crisis will affect primary cancer prevention through several avenues: personal lifestyle choices, exposure to environmental risk factors, decisions made in the private sector and public policy on cancer prevention. Whilst it is clearly problematic to reach solid conclusions on a direct connection between economic crises and cancer mortality, we can identify trends that provide guidance for further action. For some lifestyle choices such as smoking or diet, we argue that public policy may channel existing tendencies during times of crisis for clear added value. In other areas, including research and health system investments, we will make the case that the resources not used now for cancer prevention efforts will lead to increased costs (both financial and human) down the road. Policy makers face a clear choice: they can follow a cost contention strategy, which may reduce expenditure in the short-term only to increase it in the long-term, or they can use the financial crisis as an opportunity to make difficult choices in terms of health service rationalisation, whilst at the same time strengthening evidence-based prevention policies. In short, we argue that despite the scarcity of funds and the governmental priorities on economic recovery, cancer prevention is more relevant now than ever., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: To review the recommendations on Human Papillomavirus (HPV) vaccination issued by different medical societies, as well as disclosures of any conflict of interests regarding such recommendations., Methods: The search for recommendations was mainly conducted through the Internet, together with a bibliography search on Pubmed (November 2008). The countries were selected to encompass a broad range of healthcare systems and income levels., Results: In all, 18 documents were identified: 4 from the U.S., 5 from Canada, and 1 from France (all 10 in favor of recommending vaccination), 5 from Spain (3 in favor of vaccination and 2 recommending no vaccination until further evidence of the vaccine effectiveness to prevent cervical cancer becomes available), 2 from Argentina (one in favor of vaccination and another pointing to the missing information on the vaccine's cost-effectiveness), and 1 from Chile (recommending no vaccination until more information becomes available). Only two documents disclose specific conflicts of interests for authors (American Cancer Society and Chilean Working Group on HPV). One of the Canadian documents did not include any conflict of interest statement, although Merck and GSK are listed among the sponsors., Conclusions: Disclosure of conflicts of interest in documents where medical societies issue recommendations on HPV vaccination is very unusual. However, lack of disclosure is more frequent (near twice) when recommendations are in favor of the vaccination.

Objective: We describe the heterogeneity of the estimates of the incremental cost per quality-adjusted year of life (QALY) within and between cost-utility studies of the human papillomavirus (HPV) vaccine., Method: We searched for articles in English published in peer-reviewed journals that perform cost-utility analyses to evaluate the addition of HPV vaccine to 12-year-old girls to existing cervical cancer screening practices. Fifteen studies were selected according to our inclusion and exclusion criteria., Results: There are large within-study variations in estimates of the cost per QALY gained. The most influential source of uncertainty is the duration of the vaccine protection. Between-study variations are mainly due to three causes: methodological differences, assumptions, and local conditions in the application area. We find large variations between studies for a given country., Discussion: Economic evaluation models are increasingly sophisticated, but scientific treatment of epidemiological and market uncertainty does not compensate for the lack of basic information., Conclusions: The large disparities in cost per QALY estimates of massive vaccination programs around the world may be attributed to several critical sources (unavoidable and avoidable) of uncertainty. An asset of economic evaluation is the ability to highlight the areas of research that could be undertaken to reduce uncertainty.