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Objective: Obtaining reliable health estimates at the small area level (such as neighbourhoods) using survey data usually poses the problem of small sample sizes. To overcome this limitation, we explored smoothing techniques in order to estimate poor mental health prevalence at the neighbourhood level and analyse its profile by income in Barcelona city (Spain). Method: A Bayesian smoothing model with a logit-normal transformation was applied to four repeated cross-sectional waves of the Barcelona health survey for 2001, 2006, 2011 and 2016. Mental health status was identified from the 12-item General Health Questionnaire. Income inequalities were analysed with neighbourhood income in quantiles for each year and trends in the pooled analysis. Results: The prevalence of poor mental health ranged from 14.6% in 2001 to 18.9% in 2016. The yearly difference between neighbourhoods was 12.4% in 2001, 16.7% in 2006, 14.2% in 2011, and 20.0% in 2016. The odds ratio and 95% credible interval (95%CI) of experiencing poor mental health was 1.40 times higher (95%CI: 1.02-1.91) in less advantaged neighbourhoods than in more advantaged neighbourhoods in 2001, 1.61 times higher (95%CI: 1.01-2.59) in 2006 and 2.31 times higher (95%CI: 1.57-3.40) in 2016. Conclusions: This study shows that the Bayesian smoothed techniques allows detection of inequalities in health in neighbourhoods and monitoring of interventions against them. In Barcelona, mental health problems are more prevalent in low-income neighbourhoods and raised in 2016. Resumen: Objetivo: Obtener estimadores de salud en áreas pequeñas (como los barrios) utilizando datos de encuestas supone hacer frente al problema de insuficiente tamaño muestral. Para superar esta limitación exploramos técnicas de alisado con el fin de estimar la prevalencia de mala salud mental a nivel de barrio y analizar su patrón por renta en la ciudad de Barcelona (España). Método: Se aplicó un modelo de alisado bayesiano con transformación logística-normal a cuatro muestras transversales repetidas de la Encuesta de Salud de Barcelona para los años 2001, 2006, 2011 y 2016. La salud mental fue identificada con el Cuestionario General de Salud de 12-items. Las desigualdades de ingreso se analizaron por cuantiles de la renta por barrio para cada año y las tendencias en el análisis conjunto. Resultados: La prevalencia de mala salud mental oscila entre el 14,6% en 2001 y el 18,9% en 2016. La diferencia entre barrios fue del 12,4% en 2001, del 16,7% en 2006, del 14,2% en 2011 y del 20,0% en 2016. La odds ratio y el intervalo creíble al 95% (IC95%) de experimentar mala salud mental fue 1,4 veces superior (IC95%: 1,02-1,91) en los barrios menos aventajados respecto de los más aventajados en 2001, de 1,61 (IC95%: 1,01-2,59) en 2006 y de 2,31 (IC95%: 1,57-3,40) en 2016. Conclusiones: Este estudio muestra que las técnicas de alisado bayesiano permiten la detección de desigualdades en salud a nivel de barrios para su monitorización e intervención con el fin de reducirlas. En Barcelona, los problemas de salud mental son más prevalentes en los barrios de menor renta y se incrementaron en 2016.

Energy poverty (EP) is becoming an increasingly important problem in the urban contexts of southern Europe. In Barcelona, EP indicators are higher than those of the European Union and are strongly associated with poor health status and high use of health services and medication, becoming a major public health problem. EP is unevenly distributed in the population of Barcelona, according to axes of social stratification. However, its geographic distribution at the small-area level remains unknown because it cannot be directly estimated with the available information sources and commonly used methods. Therefore, the aim of this study was to analyze geographical inequalities in EP in Barcelona by estimating reliable small-area EP indicators and a composite indicator (index). We used a novel method that allowed us to obtain 6 EP indicators for the 73 Barcelona neighborhoods and an EP index from a principal component analysis of these indicators. We found major geographical inequalities in the distribution of EP in Barcelona. Many neighborhoods had significantly higher EP than the city average, and these areas made up 3 well-defined spatial clusters. Therefore, the estimated small-area indicators and index allowed identification of the most affected neighborhoods. These results indicate the need to prioritize these areas for local interventions to alleviate EP, and could also be used for policy making.

Abstract Background Spain has been hit hard by COVID-19 since March 2020, especially in its metropolitan areas. We share experiences from Barcelona in measuring socioeconomic inequalities in the incidence of COVID-19 in the different waves, and in implementing coordinated and equity-oriented public health policy responses. Methods We collected daily data on confirmed COVID-19 cases, geocoded the address of residence to assign each case to one of the 73 neighborhoods and 1068 census tracts, and calculated the cumulative incidence of COVID-19 by neighborhood and five income groups (quintiles of census tracts) by sex across four waves of the pandemic. We adjusted hierarchical Bayesian spatial models to obtain the relative risk (RR) of cumulative incidences in each quintile compared with the richest areas. A variety of public health policies implemented to tackle the pandemic and especially these inequalities in COVID-19 incidence and vaccination are selected and described. Results Area-level income inequalities in the incidence of COVID-19 were present at different degree in all four waves. In the second wave (10/1/2020 to 12/6/2020), RR for the poorest income quintile census tracts compared with the richest was 1.43 (95% credible interval-CI-: 1.22–1.67) for men and 1.58 (95% CI: 1.35–1.83) for women. Later, inequalities in vaccination coverage also arose. Equity-oriented policy responses included: “health hotels” or home delivery of basic products for individuals with COVID-19 and without adequate conditions for isolation; new emergency facilities for homeless people, including those with active drug use; mass screening in high incidence areas; contingency plans for nursing homes and schools; adapting community health programs for their early reactivation; digital self-appointment support points and community vaccination days. Conclusion COVID-19 hit Barcelona neighborhoods unequally, with variations between waves. The rapid availability of geolocalized data and by socioeconomic level helped public authorities to implement targeted policies and collaborative interventions for the most vulnerable populations. Further studies would be needed to evaluate their impact.

Objective: To describe and compare the health status between vulnerable population participating in a program to tackle energy poverty (Energía, la justa) and the non-energy poor Barcelona (Spain) population and to analyse among participants the effect of energy poverty intensity on health. Method: Cross-sectional study based on data from program participants obtained before the intervention. Participants (1799 women and 671 men) were compared to non-energy poor population of Barcelona (1393 women and 1215 men) sampled from the Barcelona Public Health Survey (2016). Standardized prevalence and prevalence ratios of self-perceived poor health, asthma, chronic bronchitis, and depression and/or anxiety were estimated, and among participants the association between health status and energy poverty intensity was estimated with multivariate models. Results: The probability of poor self-perceived physical and mental health ranged from 2.2 to 5.3 times greater in the program participants than non-energy poor Barcelona population. Among program participants, those most affected were found to be the most likely to report poor health outcomes, regardless of other sociodemographic factors. Conclusions: The prevalence of poor physical and mental health was considerably higher among women and men participating in the programme compared to the non-energy poor population and was even worse among those who were more severely affected. Public policies that tackle energy poverty and its consequences are urgently needed in Spain. Resumen: Objetivo: Describir y comparar el estado de salud entre la población vulnerable que participa en un programa de lucha contra la pobreza energética (Energía, la justa) y la población sin pobreza energética de Barcelona (España), y analizar entre las personas participantes el efecto de la intensidad de la pobreza energética en la salud. Método: Estudio transversal basado en datos de los/las participantes en el programa obtenidos antes de la intervención. Se compararon los/las participantes (1799 mujeres y 671 hombres) con población sin pobreza energética de Barcelona (1393 mujeres y 1215 hombres) seleccionada de la Encuesta de Salud Pública de Barcelona (2016). Se estimaron la prevalencia estandarizada y las razones de prevalencia de mala salud, asma, bronquitis crónica y depresión o ansiedad autopercibida. Entre los/las participantes se estimó la asociación entre el estado de salud y la intensidad de la pobreza energética con modelos multivariantes. Resultados: Los/las participantes presentaron entre 2,2 y 5,3 veces peores resultados en salud que la población sin pobreza energética. Entre los/las participantes se encontró que las personas más afectadas eran las que tenían más probabilidades de reportar peores resultados de salud, independientemente de otros factores sociodemográficos. Conclusiones: La prevalencia de mala salud física y mental era considerablemente mayor en las mujeres y los hombres que participaron en el programa en comparación con la población sin pobreza energética, y era aún peor entre los/las más severamente afectados. En España se necesitan con urgencia políticas públicas que aborden la pobreza energética y sus consecuencias.

Resumen: Objetivo: Presentar la metodología seguida en el diseño y la implementación de un índice de privación por sección censal, y describir la situación socioeconómica en España en 2011. Método: La unidad de análisis fue la sección censal (N = 35.960). Los datos proceden del Censo de Población y Viviendas de 2011. Teniendo en cuenta el carácter muestral del censo y las limitaciones normativas de confidencialidad de datos, las variables se calcularon indirectamente usando los complementarios de las variables disponibles. Se efectuaron comprobaciones para asegurar su fiabilidad. En la selección de indicadores se consideró la comparabilidad con el índice MEDEA y se exploró la incorporación de nueva información. Se elaboró un índice de privación mediante análisis de componentes principales. Se realizó un análisis de sensibilidad del índice en ámbitos urbanos y en el resto de los territorios. Resultados: Con la información censal se elaboraron 22 indicadores para 35.917 secciones censales. El índice de privación se basó en seis indicadores: población trabajadora manual, población asalariada eventual, desempleo, personas de 16 y más años y de 16 a 29 años con instrucción insuficiente, y viviendas principales sin acceso a Internet. El mapa de España muestra un eje decreciente de privación de suroeste a nordeste. Conclusiones: Se ha aprovechado sistemáticamente la información socioeconómica del censo de 2011 por sección censal. El índice elaborado, similar al MEDEA, facilitará el estudio actualizado de las desigualdades en salud para toda España después de la crisis económica iniciada en 2008. Abstract: Objective: To present the methodology used in the design and implementation of a deprivation index by enumeration district, and to describe the socioeconomic situation of Spain in 2011. Method: The unit of analysis was the enumeration district (N = 35,960). Data came from the 2011 Population and Housing Census of Spain. Given both the sampling nature of the Census and the regulatory limitations of data confidentiality, variables were calculated indirectly by using the complement of the available variables. Checks were made to ensure reliability. The selection of the indicators took into account comparability with the MEDEA index. The inclusion of additional information was explored. A deprivation index was built using Principal Component Analysis. Sensitivity analysis of the index was performed for urban areas and the rest of the regions. Results: Using the census information, 22 indicators were calculated for 35,917 enumeration districts. The deprivation index was based on six indicators: manual and temporary workers, unemployment, insufficient education overall and in young people (aged 16 to 29 years), and dwellings without access to the internet. The map of Spain shows a gradient of decreasing deprivation from south-west to north-east. Conclusions: The socioeconomic information of the 2011 census by enumeration district was used systematically. The drafted index, similar to the MEDEA, will facilitate the updated study of health inequalities for Spain overall following the economic recession that began in 2008.

Objective: To analyse socioeconomic inequalities in all-cause mortality among men and women in nine European urban areas during the recent economic crisis, and to compare the results to those from two periods before the crisis. Method: This is an ecological study of trends based on three time periods (2000-2003, 2004-2008 and 2009-2014). The units of analysis were the small areas of nine European urban areas. We used a composite deprivation index as a socioeconomic indicator, along with other single indicators. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyse the evolution of socioeconomic inequalities, we fitted an ecological regression model that included the socioeconomic indicator, the period of time, and the interaction between these terms. Results: We observed significant inequalities in mortality among men for almost all the socioeconomic indicators, periods, and urban areas studied. However, no significant changes occurred during the period of the economic crisis. While inequalities among women were less common, there was a statistically significant increase in inequality during the crisis period in terms of unemployment and the deprivation index in Prague and Stockholm, respectively. Conclusions: Future analyses should also consider time-lag in the effect of crises on mortality and specific causes of death, and differential effects between genders. Resumen: Objetivo: Analizar las desigualdades socioeconómicas en la mortalidad por todas las causas en hombres y mujeres de nueve áreas urbanas europeas durante la reciente crisis económica, y comparar los resultados con dos periodos previos a la crisis. Método: Estudio ecológico de tendencias basado en tres periodos (2000-2003, 2004-2008 y 2009-2014). Las unidades de análisis fueron las áreas pequeñas de nueve zonas urbanas europeas. Se utilizaron un índice compuesto de privación socioeconómica como indicador socioeconómico y otros indicadores simples. Como indicador de mortalidad se usó la razón de mortalidad estandarizada suavizada, calculada utilizando el modelo jerárquico bayesiano propuesto por Besag, York y Mollié. Para analizar la evolución de las desigualdades socioeconómicas se utilizó un modelo de regresión ecológico que incluía el indicador socioeconómico, el periodo y la interacción de ambos. Resultados: Se observaron desigualdades significativas en la mortalidad en los hombres para casi todos los indicadores socioeconómicos, periodos y áreas urbanas. Sin embargo, no hubo cambios significativos en las desigualdades en el periodo de crisis. Aunque las desigualdades entre las mujeres fueron menos comunes, hubo un incremento significativo en las desigualdades en mortalidad en el periodo de crisis en términos de desempleo y del índice de privación en Praga y Estocolmo, respectivamente. Conclusiones: Futuros análisis deberán tener en cuenta el tiempo transcurrido entre la crisis y su efecto en la mortalidad, así como diferentes causas de mortalidad y el efecto diferencial entre géneros.

Abstract Background Population health measurements are recognised as appropriate tools to support public health monitoring. Yet, there is still a lack of tools that offer a basis for policy appraisal and for foreseeing impacts on health equity. In the context of persistent regional inequalities, it is critical to ascertain which regions are performing best, which factors might shape future health outcomes and where there is room for improvement. Methods Under the EURO-HEALTHY project, tools combining the technical elements of multi-criteria value models and the social elements of participatory processes were developed to measure health in multiple dimensions and to inform policies. The flagship tool is the Population Health Index (PHI), a multidimensional measure that evaluates health from the lens of equity in health determinants and health outcomes, further divided into sub-indices. Foresight tools for policy analysis were also developed, namely: (1) scenarios of future patterns of population health in Europe in 2030, combining group elicitation with the Extreme-World method and (2) a multi-criteria evaluation framework informing policy appraisal (case study of Lisbon). Finally, a WebGIS was built to map and communicate the results to wider audiences. Results The Population Health Index was applied to all European Union (EU) regions, indicating which regions are lagging behind and where investments are most needed to close the health gap. Three scenarios for 2030 were produced – (1) the ‘Failing Europe’ scenario (worst case/increasing inequalities), (2) the ‘Sustainable Prosperity’ scenario (best case/decreasing inequalities) and (3) the ‘Being Stuck’ scenario (the EU and Member States maintain the status quo). Finally, the policy appraisal exercise conducted in Lisbon illustrates which policies have higher potential to improve health and how their feasibility can change according to different scenarios. Conclusions The article makes a theoretical and practical contribution to the field of population health. Theoretically, it contributes to the conceptualisation of health in a broader sense by advancing a model able to integrate multiple aspects of health, including health outcomes and multisectoral determinants. Empirically, the model and tools are closely tied to what is measurable when using the EU context but offering opportunities to be upscaled to other settings.

Resumen: Las encuestas de salud son una herramienta clave para la toma de decisiones en políticas de salud y para la planificación de los servicios de salud. El uso de métodos estadísticos para áreas pequeñas que utilizan información de diferentes ámbitos geográficos puede resultar útil para estimar indicadores de salud a una escala geográfica menor que la originalmente considerada en el diseño de una encuesta. Abstract: Health surveys are a key tool for decision-making in health policies and health services planning. The use of small-area statistical methods that use information at different geographic levels may be useful for estimating health indicators at a lower geographical level than originally considered in the survey design. Palabras clave: Análisis de áreas pequeñas, Encuesta de salud, Estadística espacial, Keywords: Small area analysis, Health survey, Spatial statistics

Objective: To determine if the onset of the economic crisis in Spain affected cancer mortality and mortality trends. Method: We conducted a longitudinal ecological study based on all cancer-related deaths and on specific types of cancer (lung, colon, breast and prostate) in Spain between 2000 and 2013. We computed age-standardised mortality rates in men and women, and fit mixed Poisson models to analyse the effect of the crisis on cancer mortality and trends therein. Results: After the onset of the economic crisis, cancer mortality continued to decline, but with a significant slowing of the yearly rate of decline (men: RR = 0.987, 95%CI = 0.985-0.990, before the crisis, and RR = 0.993, 95%CI = 0.991-0.996, afterwards; women: RR = 0.990, 95%CI = 0.988-0.993, before, and RR = 1.002, 95%CI = 0.998-1.006, afterwards). In men, lung cancer mortality was reduced, continuing the trend observed in the pre-crisis period; the trend in colon cancer mortality did not change significantly and continued to increase; and the yearly decline in prostate cancer mortality slowed significantly. In women, lung cancer mortality continued to increase each year, as before the crisis; colon cancer continued to decease; and the previous yearly downward trend in breast cancer mortality slowed down following the onset of the crisis. Conclusions: Since the onset of the economic crisis in Spain the rate of decline in cancer mortality has slowed significantly, and this situation could be exacerbated by the current austerity measures in healthcare. Resumen: Objetivo: Determinar si el inicio de la crisis económica en España afectó a la mortalidad por cáncer y sus tendencias. Método: Estudio ecológico longitudinal que analiza todas las muertes por cáncer y por tipos específicos de cáncer (pulmón, colon, mama y próstata) en España entre 2000 y 2013. Se estimaron las tasas de mortalidad estandarizadas por edad en hombres y mujeres, y se ajustaron modelos mixtos de Poisson para analizar el efecto de la crisis sobre la mortalidad por cáncer y sus tendencias. Resultados: Después del inicio de la crisis económica, la mortalidad por cáncer continuó su tendencia a la baja, pero con una disminución significativa del decrecimiento anual (hombres: riesgo relativo [RR] = 0,987, intervalo de confianza del 95% [IC95%] = 0,985-0,990, antes de la crisis, y RR = 0,993, IC95% = 0,991-0,996 después; mujeres: RR = 0,990, IC95% = 0,988-0,993, antes, y RR = 1,002, IC95% = 0,998-1,006 después). En los hombres, la mortalidad por cáncer de pulmón se redujo, continuando la tendencia observada en el periodo anterior a la crisis; la tendencia en la mortalidad por cáncer de colon no cambió significativamente y siguió aumentando; y la disminución anual de la mortalidad por cáncer de próstata se desaceleró significativamente. En las mujeres, la mortalidad por cáncer de pulmón continuó aumentando cada año, como antes de la crisis; el cáncer de colon continuó disminuyendo; y la tendencia a la disminución de la mortalidad por cáncer de mama se desaceleró después del inicio de la crisis. Conclusiones: Desde el inicio de la crisis económica en España, la disminución de la tasa de mortalidad por cáncer se ha desacelerado significativamente y esta situación podría verse exacerbada por las actuales medidas de austeridad en el sistema sanitario. Keywords: Economic crisis, Austerity, Health care cuts, Cancer, Financial crisis, Mortality, Palabras clave: Crisis económica, Austeridad, Recortes en salud, Cáncer, Crisis financiera, Mortalidad

Abstract Background Mortality registries are an essential data source for public health surveillance and for planning and evaluating public policy. Nevertheless, there are still large inequalities in the completeness and quality of mortality registries between and within countries. In Ecuador, there have been few nationwide evaluations of the mortality registry and no evaluations of inequalities between provinces. This kind of analysis is fundamental for strengthening the vital statistics system. Methods Ecological study assessing the completeness, quality and internal consistency of mortality data in the provinces of Ecuador, using 13 years of mortality data (2001–2013). Completeness was assessed using three types of death distribution methods (DDMs), quality by estimating the percentages of garbage codes and deaths with unspecified age or sex in the registered deaths, and internal consistency by estimating the percentage of deaths with reported causes of deaths considered impossible in some age–sex combinations. Finally, we propose a classification of the mortality registry in the studied areas based on completeness and quality. Results Completeness estimates (mean of the three methods used) in the provinces ranged from 21 to 87% in women and from 35 to 89% in men. The percentage of garbage codes in the provinces ranged from 21 to 56% in women and from 25 to 52% in men. Garbage coding was higher in women and in older age groups. The percentage of deaths with unspecified age or sex, and the percentage of deaths with reported causes of deaths considered impossible in some age–sex combinations was low in all the studied areas. The mortality registry could only be classified as acceptable in one area for men and one area for women. Conclusions We found substantial inequalities by sex, geographical areas and age in the completeness and quality of the mortality registry of Ecuador. The findings of this study will be helpful to direct measures to improve Ecuador’s vital statistics system and to generate strategies to reduce bias when using mortality data to analyse health inequalities in the country.

Abstract Background Prior studies have identified a decrease in ischaemic heart disease mortality during the recent economic recession. The Spanish population was severely affected by the Great Recession, however, there is little evidence on its effects on socioeconomic inequalities in ischaemic heart disease mortality. This study examines trends in socioeconomic inequalities in mortality due to ischaemic heart disease (IHD). Methods We used linked census records with mortality registers available from the Basque Country and Barcelona city for population above 25 years, between 2001 and 04, the accelerated economic growth period of 2005–08, and 2009–12, with the last period coinciding with the Great Recession. Applying Poisson models, we calculated relative and absolute indexes of inequalities by education level for each period, age group, gender, and site. Results We found moderate age-adjusted inequalities in IHD with a gradient of increasing rates through less educational level, but no significant evidence of increasing trends in socioeconomic inequalities in IHD mortality, rather an inverted U-shape time trend in some groups below 75 years in relative inequalities. Absolute inequalities decrease in the last period except for women from 50 to 64 years. Conclusions This study shows that the economic crisis has not increased socioeconomic inequalities in IHD mortality in two geographical settings in Spain.

Energy poverty (EP) is defined as the inability of a household to secure a socially and materially required level of energy services in the home. The main objective of this study was to analyse the association between EP and distinct indicators of health status, health services utilisation and medication use in southern Europe, using the city of Barcelona as a case study.We conducted a cross-sectional study using the data of the Barcelona Health Survey for 2016 (n = 3519, 53.3% women). We calculated EP percentages according to age, country of birth and social class. We analysed the association between EP and 26 health-related indicators through prevalence ratios (PR), and quantified the impact of EP on health at the population level by calculating the percentage of population attributable risk (PAR%).In Barcelona, 13.3% of women and 11.3% of men experienced EP. The most frequently affected groups were people born in low- and middle-income countries, those from more disadvantaged social classes, and women aged 65 years and older. We found a strong association between EP and worse health status, as well as higher use of health services and medication. For example, compared with women without EP, those with EP reported poor mental health 1.9 (95% CI: 1.6–2.4) times more frequently. Compared with men without EP, those with EP reported poor mental health 2.1 (95% CI: 1.6–2.8) times more frequently. The combination of high EP prevalence and the strong association between EP and negative health outcomes resulted in high PAR%, indicating the striking impact of EP on health and health services at the population level.EP is an important public health problem in southern European urban contexts that should be included in policy priorities in order to address its structural causes and minimise its unfair and avoidable health effects.

Introduction: Low birth weight is one of the main health predictors for childhood and adulthood. It is highly prevalent in developing countries and in children from poorer social classes. Objective: To analyze the geographical distribution and the trends of full-term low birth weight in the 125 municipalities of the department of Antioquia and their association with the socioeconomic conditions of the municipalities between 2000 and 2014. Materials and methods: We conducted a longitudinal ecological study. The dependent variable was the prevalence of full-term low birth weight in 125 municipalities. The socioeconomic conditions of the municipalities were evaluated using the Human Development Index and the unsatisfied basic needs index. Results: Between 2000 and 2014, the prevalence of full-term low birth weight in Antioquia was 2.7 per 100 live births; this prevalence decreased steadily over time. This trend was also observed between regions, with the exception of the Occidente and Urabá regions, which showed increases of approximately 20.0%. The results also showed a reduction in geographical differences between the 125 municipalities, with the coefficient of variation decreasing from 20.6% to 13.72% over the 14-year period. Finally, we found a positive social gradient between the full-term low birth weight prevalence and the level of development in the municipalities. Conclusion: Full-term low birth weight prevalence decreased between 2000 and 2014, with some regions showing greater reductions than others. Paradoxically, less developed and poorer areas had a lower prevalence, which may be a result of underreporting of birth weight information in these municipalities.

ABSTRACT OBJECTIVES: To develop a deprivation index to study health inequalities in 221 areas of Ecuador, to describe the pattern of deprivation in Ecuador, and to explore the applications of the index to study health inequalities by analysing the association between deprivation and mortality in the study areas. METHODS: We performed principal component analyses of available indicators of the 221 cantons of Ecuador. A set of 41 sociodemographic, social capital, and subjective well-being variables were obtained from the 2010 National Population Census and the National Living Conditions Survey 2013–2014. To explore the application of the index in public health, the association between the index and standardised mortality ratios was estimated through a Poisson regression model. RESULTS: The final index was constructed with 17 indicators. The first component explained 51.8% of the total variance of the data. A geographic pattern and a positive association of the index with the standardised mortality ratios of the cantons were observed in both men and women. CONCLUSIONS: We constructed a deprivation index that can identify disadvantaged areas in Ecuador. This index could be a valuable tool for the detection of vulnerabilised populations and the development of interventions and policies adapted to local needs.

Following the publication of this article [1], the authors reported a typesetting error in Table 1 that caused the columns of the table to be ordered incorrectly, and a typographical error in a sentence in the Conclusions section.

Abstract Background An increase in suicide mortality is often observed in economic recessions. The objective of this study was to analyse trends in socioeconomic inequalities in suicide mortality before and during the economic recession in two geographical settings in Spain. Methods This study analyses inequalities in mortality according to educational level during 3 different time periods based on individual data from the Basque Country and Barcelona city. We analysed suicide mortality data for all residents over 25 years of age from 2001 to 2012. Two periods before the crisis (2001–2004 and 2005–2008) and another during the crisis (2009–2012) were studied. We performed independent analyses for sex, age group, and for the two geographical settings. We fit Poisson regression models to study the relationship between educational level and mortality, and calculated the relative index of inequality (RII) and the slope index of inequality (SII) as comparative measures. Results For men in the Basque Country, all RII values for the three time periods were similar and almost all were greater than 2; in Barcelona the RII values were generally lower. The SII values for Barcelona tended to decrease over time, whereas in the Basque Country they showed a U-shaped pattern. Among women aged 25–44 years we found an association between educational level and suicide mortality during the first time period; however, we found no clear association for other age groups or time periods. Conclusion This study within two geographical settings in Spain shows that trends in inequalities in suicide mortality according to educational level remained stable among men before and during the economic recession.

Resumen: Objetivo: Proporcionar indicadores para evaluar, en España 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 España, 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 según un criterio geográfico y otro temporal: disponibilidad de datos según comunidades 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 España y sus comunidades autónomas, del impacto de la crisis económica sobre la salud y las desigualdades en salud. Abstract: Objective: To provide indicators to assess the impact on health, its social determinants and health inequalities from a social context and the recent economic recession in Spain and its autonomous regions. Methods: Based on the Spanish conceptual framework for determinants of social inequalities in health, we identified indicators sequentially from key documents, Web of Science, and organisations with official statistics. The information collected resulted in a large directory of indicators which was reviewed by an expert panel. We then selected a set of these indicators according to geographical (availability of data according to autonomous regions) and temporal (from at least 2006 to 2012) criteria. Results: We identified 203 contextual indicators related to social determinants of health and selected 96 (47%) based on the above criteria; 16% of the identified indicators did not satisfy the geographical criteria and 35% did not satisfy the temporal criteria. At least 80% of the indicators related to dependence and healthcare services were excluded. The final selection of indicators covered all areas for social determinants of health, and 62% of these were not available on the Internet. Around 40% of the indicators were extracted from sources related to the Spanish Statistics Institute. Conclusions: We have provided an extensive directory of contextual indicators on social determinants of health and a database to facilitate assessment of the impact of the economic recession on health and health inequalities in Spain and its autonomous regions. Palabras clave: Determinantes sociales de la salud, Desigualdades en salud, Indicadores de salud, Identidad de género, Recesión económica, España, Vigilancia en salud pública, Keywords: Social determinants of health, Healthcare inequalities, Health indicators, Gender identity, Economic recession, Spain, Public health surveillance

Resumen: Se presenta el protocolo de los dos subestudios sobre el efecto de la crisis económica en la mortalidad, la salud reproductiva y las desigualdades en salud en España. Subestudio 1: describir la evolución de la mortalidad y la salud reproductiva entre 1990 y 2013 mediante un estudio longitudinal ecológico en las comunidades autónomas. Se analizarán los cambios producidos por la crisis económica en la tendencia de los indicadores de mortalidad y salud reproductiva utilizando datos panel (17 comunidades autónomas por años de estudio) y ajustando modelos de Poisson de efectos aleatorios. Subestudio 2: analizar las desigualdades según la privación socioeconómica en la mortalidad y en la salud reproductiva en varias zonas de España. Se realizará un estudio ecológico de tendencias en el cual se analizará la precrisis (1999-2003 y 2004-2008) y la crisis (2009-2013). Se ajustarán modelos de efectos aleatorios según Besag York y Mollié para estimar los indicadores de mortalidad y de salud reproductiva suavizados en secciones censales. Abstract: The aim is to present the protocol of the two sub-studies on the effect of the economic crisis on mortality and reproductive health and health inequalities in Spain. Substudy 1: describe the evolution of mortality and reproductive health between 1990 and 2013 through a longitudinal ecological study in the Autonomous Communities. This study will identify changes caused by the economic crisis in trends or reproductive health and mortality indicators using panel data (17 Autonomous Communities per study year) and adjusting Poisson models with random effects variance. Substudy 2: analyse inequalities by socioeconomic deprivation in mortality and reproductive health in several areas of Spain. An ecological study analysing trends in the pre-crisis (1999–2003 and 2004–2008) and crisis (2009–2013) periods will be performed. Random effects models Besag York and Mollié will be adjusted to estimate mortality indicators softened in reproductive health and census tracts. Palabras clave: Crisis económica, Desigualdades, Mortalidad, Salud reproductiva, Keywords: Economic recession, Inequalities, Mortality, Reproductive health

Objetivo: Analizar la evolución de las inequidades en la mortalidad por causas externas en los municipios de Antioquia, departamento de Colombia, entre los años 2000 y 2010, y la asociación con sus condiciones socioeconómicas. Las causas externas incluyen, entre otras, las muertes violentas como los homicidios, los suicidios y los accidentes de tránsito. Método: Diseño ecológico de tendencias de mortalidad con los 125 municipios del departamento de Antioquia como unidad de análisis. Para cada uno de los municipios se estimó la razón de mortalidad estandarizada y suavizada (RMEs) ajustada por la edad utilizando un modelo bayesiano empírico. Las diferencias en los riesgos de mortalidad entre los municipios más pobres y menos pobres se analizaron mediante un modelo jerárquico de dos niveles (nivel 1: año; nivel 2: municipio). Resultados: La mortalidad por causas externas presenta una tendencia decreciente en el departamento en el periodo analizado, pero la situación no es similar en todos los municipios. Los resultados muestran que municipios pobres y con bajo desarrollo incrementan significativamente el riesgo de morir por causas externas. Conclusiones: Es necesaria una intervención con políticas que tengan en cuenta las diferencias municipales en la mortalidad por causas externas.

Abstract Background In Spain, several ecological studies have analyzed trends in socioeconomic inequalities in mortality from all causes in urban areas over time. However, the results of these studies are quite heterogeneous finding, in general, that inequalities decreased, or remained stable. Therefore, the objectives of this study are: (1) to identify trends in geographical inequalities in all-cause mortality in the census tracts of 33 Spanish cities between the two periods 1996–1998 and 2005–2007; (2) to analyse trends in the relationship between these geographical inequalities and socioeconomic deprivation; and (3) to obtain an overall measure which summarises the relationship found in each one of the cities and to analyse its variation over time. Methods Ecological study of trends with 2 cross-sectional cuts, corresponding to two periods of analysis: 1996–1998 and 2005–2007. Units of analysis were census tracts of the 33 Spanish cities. A deprivation index calculated for each census tracts in all cities was included as a covariate. A Bayesian hierarchical model was used to estimate smoothed Standardized Mortality Ratios (sSMR) by each census tract and period. The geographical distribution of these sSMR was represented using maps of septiles. In addition, two different Bayesian hierarchical models were used to measure the association between all-cause mortality and the deprivation index in each city and period, and by sex: (1) including the association as a fixed effect for each city; (2) including the association as random effects. In both models the data spatial structure can be controlled within each city. The association in each city was measured using relative risks (RR) and their 95 % credible intervals (95 % CI). Results For most cities and in both sexes, mortality rates decline over time. For women, the mortality and deprivation patterns are similar in the first period, while in the second they are different for most cities. For men, RRs remain stable over time in 29 cities, in 3 diminish and in 1 increase. For women, in 30 cities, a non-significant change over time in RR is observed. However, in 4 cities RR diminishes. In overall terms, inequalities decrease (with a probability of 0.9) in both men (RR = 1.13, 95 % CI = 1.12–1.15 in the 1st period; RR = 1.11, 95 % CI = 1.09–1.13 in the 2nd period) and women (RR = 1.07, 95 % CI = 1.05–1.08 in the 1st period; RR = 1.04, 95 % CI = 1.02–1.06 in the 2nd period). Conclusions In the future, it is important to conduct further trend studies, allowing to monitoring trends in socioeconomic inequalities in mortality and to identify (among other things) temporal factors that may influence these inequalities.

Objective: To describe the magnitude and characteristics of crashes and drivers involved in head-on crashes on two-way interurban roads in Spain between 2007 and 2012, and to identify the factors associated with the likelihood of head-on crashes on these roads compared with other types of crash. Methods: A cross-sectional study was conducted using the National Crash Register. The dependent variables were head-on crashes with injury (yes/no) and drivers involved in head-on crashes (yes/no). Factors associated with head-on crashes and with being a driver involved in a head-on crash versus other types of crash were studied using a multivariate robust Poisson regression model to estimate proportion ratios (PR) and confidence intervals (95% CI). Results: There were 9,192 head-on crashes on two-way Spanish interurban roads. A total of 15,412 men and 3,862 women drivers were involved. Compared with other types of crash, head-on collisions were more likely on roads 7 m or more wide, on road sections with curves, narrowings or drop changes, on wet or snowy surfaces, and in twilight conditions. Transgressions committed by drivers involved in head-on crashes were driving in the opposite direction and incorrectly overtaking another vehicle. Factors associated with a lower probability of head-on crashes were the existence of medians (PR = 0.57; 95%CI: 0.48-0.68) and a paved shoulder of less than 1.5 meters (PR = 0.81; 95%CI: 0.77-0.86) or from 1.5 to 2.45 meters (PR = 0.90; 95%CI: 0.84-0.96). Conclusions: This study allowed the characterization of crashes and drivers involved in head-on crashes on two-way interurban roads. The lower probability observed on roads with median strips point to these measures as an effective way to reduce these collisions

Objective: To examine trends in the prevalence of problematic cocaine use in a large city and describe the problems encountered when estimating these trends using capture-recapture techniques based on secondary data Methods: We used clinical data on accident and emergency department episodes at four university hospitals in Barcelona (Spain) between 1999 and 2008 (3 capture periods per year). Users were categorized into two subgroups depending on concomitant heroin use (cocaine plus heroin, cocaine without heroin). Results: The mean age of users was 34 years and 25% were women (2008). The mean number of episodes per user differed between drug subgroups and over time. The estimated total number of cocaine users increased from 6,028 (95% confidence interval [95%CI]: 4,086-9,327) in 1999 to 22,640 (95%CI: 14,001-37,500) in 2006, but decreased thereafter. The prevalence of problematic use of cocaine plus heroin was stable throughout the study. Thus, trends in the prevalence of problematic cocaine use differed depending on concomitant heroin use. Conclusion: Our results are consistent with those provided by health surveys and treatment registries. They also highlight the pitfalls of applying the capture-recapture approach to secondary data, and the need for a better understanding of how information is collected and changes over time.

Objetivo: Conocer el uso de indicadores socioeconómicos de área en estudios epidemiológicos en España. Métodos: Se incluyeron estudios, publicados en revistas con revisión por pares, que analizaban la asociación de indicadores socioeconómicos de área con indicadores de salud en España. La búsqueda electrónica se realizó en PubMed-Medline, SCI-Expanded, SSCI, Embase e Índice Médico Español (hasta el 31 de diciembre de 2012), y se revisaron las referencias de los estudios seleccionados. Cada uno de los artículos inicialmente seleccionados por título y resumen fue revisado por dos investigadores. Se extrajo información relativa a la publicación y la metodología (diseño y áreas geográficas de estudio, fuentes de información, indicadores socioeconómicos y de salud, y análisis estadístico). Resultados: Se incluyeron 142 estudios, publicados desde 1988 (el 58,4% a partir de 2005) y el 59,9% en inglés. El nivel de análisis fue ecológico en un 73,2% y multinivel en un 19,0%. Las áreas analizadas con mayor frecuencia fueron las secciones censales (35 estudios), sobre todo en el ámbito de ciudades o de una comunidad autónoma, seguidas de las provincias (30 estudios) en su mayoría referentes a toda España. La mortalidad es la variable dependiente analizada con mayor frecuencia y el empleo es la dimensión socioeconómica más utilizada (71,1%). Conclusiones: En la última década se observa en España un incremento en el número de estudios que analizan la asociación de indicadores socioeconómicos de área con indicadores de salud, así como una mayor complejidad del diseño y en el análisis.

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Fundamento, Las defunciones por causas externas requieren exámenes complementarios para determinar la causa demuerte. Si no se incorporan estos resultados a los registros de mortalidad estas causas pueden quedar mal clasificadas. El objetivo del estudio es validar la causa básica de defunción del Registro de Mortalidad con la obtenida de las fuentes forenses,en Barcelona entre los años 2004 y 2006. Métodos, Diseño transversal. La población de estudio son los fallecidos residentes en Barcelona con intervención medicolegal entre 2004 y 2006. Las fuentes de información son el Registro de Mortalidad y el archivo de patología forense delInstituto de Medicina Legal de Catalunya (IMLC) (estándar de comparación). Las variables son la causa de defunción, el sexoy la edad. Se calcula la sensibilidad, el porcentaje de confirmación (PC) y sus intervalos de confianza al 95% (IC95%). Resultados, La sensibilidad de las causas externas es 59,7% (IC95%,56,5-62,9) y el PC 96,7% (IC95%,94,8-98,0). Las lesiones por tráfico, las intoxicaciones y los suicidios estánsubnotificados en el Registro de Mortalidad siendo la sensibilidad inferior al 45% y el PC superior al 80%. Las causas maldefinidas están sobrenotificadas siendo la sensibilidad de 89,2% (IC95%,83,4-93,4) y el PC de 28,0% (IC95%,24,232,1). No hay diferencias por sexo y edad. Conclusiones, La validez de las causas externas del Registro de Mortalidad es escasa por la subnotificación y el elevadoporcentaje de causas mal definidas. Según los resultados, incorporar la información de las fuentes forenses al Registro deMortalidad aumenta la calidad de las estadísticas de mortalidad.

Objetivo: Describir las desigualdades de género en las posiciones de liderazgo y de reconocimiento científico en la Sociedad Española de Salud Pública y Administración Sanitaria (SESPAS), la Sociedad Española de Epidemiología (SEE) y la Asociación de Economía de la Salud (AES), de 2000 a 2009. Métodos: Estudio descriptivo de la distribución por sexo de juntas directivas, comités científicos, comité organizador y moderadores de mesa de congresos de la SESPAS, la SEE y la AES, así como del comité editorial de Gaceta Sanitaria, de los editoriales de la revista, y de editores del Informe SESPAS. Resultados: En el periodo 2000-2009, en la SESPAS se produjo un ligero aumento de participación de las mujeres, la SEE cuenta con más paridad de género, y la AES tiene una baja representación de mujeres. Conclusiones: La persistencia de desigualdades de género en las sociedades profesionales de salud pública requiere seguir analizando sus causas, así como promover acciones que permitan cambiar la presente situación.Objective: To describe gender inequalities in positions of leadership and scientific recognition in activities carried out by the Spanish Public Health and Health Administration Society (SESPAS), the Spanish Epidemiology Society (SEE) and the Health Economics Association (AES) for 2000-2009. Methods: We performed a descriptive study of the gender distribution of the boards of directors, scientific and conference organization committees and chairpersons of the SESPAS, SEE and AES. The gender distribution of the editorial board of Gaceta Sanitaria, and of the authors of editorials published in the journal, as well as that of the editors of SESPAS Reports, was also analyzed. Results: Between 2000 and 2009, there was a slight increase in women's participation in the SESPAS and there was greater gender parity in the SEE. However, representation of women in the AES was low. Conclusions: The causes of gender inequalities in public health professional societies should continue to be analyzed and actions should be taken to change the present situation.

Objetivo: Analizar la evolución de las desigualdades socioeconómicas en la mortalidad por todas las causas en Barcelona durante los años 1983-2004. Métodos: Estudio ecológico de tendencias con 4 cortes transversales (1983-1988, 1989-1994, 1995-1999 y 2000-2004), con el área básica de salud (ABS) como unidad de análisis. La población de estudio fueron los varones y mujeres residentes en Barcelona, de 20 o más años de edad. Las fuentes de información fueron el registro de mortalidad, el padrón municipal y el censo de habitantes y viviendas. Como variable dependiente se utilizó la tasa de mortalidad específica (TME) por todas las causas. Como variable independiente se calculó un índice compuesto de privación socioeconómica de las ABS; las ABS se agruparon en cuartiles según los valores del índice. Se ajustaron modelos de Poisson para estimar el riesgo relativo (RR) de mortalidad por todas las causas en las 4 agrupaciones de ABS, estratificado por grupos de edad y sexo. Resultados: En todos los períodos de estudio se observan desigualdades en la mortalidad según el ABS de residencia, tanto en varones como en mujeres. Las TME de las ABS con mayor privación socioeconómica fueron mayores que las de aquellas con menor privación, y también fueron mayores en los varones que en las mujeres. Asimismo, los grupos de edad más jóvenes presentan mayor RR de mortalidad que los de edad avanzada. No obstante, las desigualdades disminuyeron tanto en términos absolutos como en términos relativos a partir del segundo período de estudio, especialmente en los varones. Conclusiones: Este estudio ha demostrado que, a pesar de haber desigualdades en mortalidad en las ABS de Barcelona, éstas han disminuido a lo largo de 2 décadas. Las políticas públicas deberían tener en cuenta esta información en el abordaje de las desigualdades entre ABS.Objective: To analyze the trend in socioeconomic inequalities in all-cause mortality in Barcelona from 1983 to 2004. Methods: We performed an ecological study of trends over 4 cross-sections (1983-1988, 1989-1994, 1995-1999 and 2000-2004), with the basic health area (BHA) as the unit of analysis. The study population consisted of men and women aged 20 years or more living in Barcelona. The information sources were the mortality registry, the municipal census and the census of inhabitants and dwellings. The age- and sex-specific mortality rate (ASMR) for all causes was used as the dependent variable. As the independent variable, a composite index of socioeconomic deprivation of the BHA was calculated; BHAs were grouped in quartiles according to the values on the index. Poisson models were adjusted to estimate the relative risk of mortality from all causes in the 4 groups of BHA, stratified by age groups and sex. Results: In all the study periods, inequalities in mortality were found, depending on the BHA of residence, both for men and for women: the ASMR of the most deprived BHAs were greater than those of less deprived BHA, and were greater among men than among women. Likewise, relative risks in the youngest age groups were higher than in the oldest age groups. However, from the second to fourth study periods, inequalities decreased in absolute and relative terms, especially among men. Conclusions: Inequalities in mortality persist in BHA in Barcelona but have decreased over the last 2 decades. Public policies should take this information into account when tackling inequalities among BHA.

OBJECTIVE: To assess differences between the risk of injury for motorcycle riders before and after the passing of a law allowing licenced car drivers to drive light motorcycles without having to take a special motorcycle driving test. METHODS: We carried out a quasi-experimental study involving comparison groups, and a time-series analysis from 1 January 2002 to 30 April 2008. The study group was composed of people injured while driving or riding a light motorcycle (engine capacity 51-125 cubic centimetres), while the comparison groups consisted of riders of heavy motorcycles (engine capacity > 125 cc), mopeds (engine capacity

In recent years, small-area-based ecological regression analyses have been published that study the association between a health outcome and a covariate in several cities. These analyses have usually been performed independently for each city and have therefore yielded unrelated estimates for the cities considered, even though the same process has been studied in all of them. In this study, we propose a joint ecological regression model for multiple cities that accounts for spatial structure both within and between cities and explore the advantages of this model. The proposed model merges both disease mapping and geostatistical ideas. Our proposal is compared with two alternatives, one that models the association for each city as fixed effects and another that treats them as independent and identically distributed random effects. The proposed model allows us to estimate the association (and assess its significance) at locations with no available data. Our proposal is illustrated by an example of the association between unemployment (as a deprivation surrogate) and lung cancer mortality among men in 31 Spanish cities. In this example, the associations found were far more accurate for the proposed model than those from the fixed effects model. Our main conclusion is that ecological regression analyses can be markedly improved by performing joint analyses at several locations that share information among them. This finding should be taken into consideration in the design of future epidemiological studies.

Abstract Objective: To compare the oral health profile of institutionalized elderly persons in Brazil and in Barcelona, Spain, by gender and country of residence. Methods: A cross-sectional study was performed of individuals aged 65 years and above (n=1,440), resident in the health region of Barcelona and in Brazil. Two surveys and exams relating to the oral health status of institutionalized elderly persons in Brazil (in 2008) and in Barcelona, Spain (in 2009) were carried out. Periodontal disease, tooth loss and dental caries were analyzed, considering age and cognitive ability. The sample was stratified by gender and country. Bivariate and multivariate Robust Poisson Regression models were used to obtain adjusted Prevalence Ratios (aPR), and a 95% confidence interval (95%CI) was employed. Results: In Barcelona, men and women had a higher prevalence of periodontal illness: Men - calculus (aPR:1.5; CI:1.08-2.19) and pocket (aPR:2.05; CI:1.43-2.93) results. Women - calculus (aPR:2.4; CI:1.77-3.24) and pocket (aPR:3.2; CI:2.29-4.53) results. In Barcelona there was a lower prevalence of edentulism (aPR:0.49; CI:0.37-0.65) and functional edentulism (aPR:0.49; CI:0.40-0.60) among men. The same results were found among women with a lower prevalence of edentulism (aPR:0.49; CI: 0.41-0.58) and functional edentulism (aPR:0.42; CI: 0.30-0.49). Conclusions: A poor state of oral health of men and women was observed in both countries, with the elderly from Barcelona having worse periodontal health and the elderly from Brazil having greater tooth loss.

ABSTRACT OBJECTIVE To evaluate the “ Energía, la justa ” program, aimed at reducing energy poverty in the city of Barcelona, from the point of view of the target population and the workers involved in the intervention. METHODS A qualitative, descriptive and exploratory pilot study was carried out, with a phenomenological approach. Twelve semi-structured interviews were conducted: to three users, three energy agents who performed interventions in the homes, and six professionals who participated in the program coordination. A thematic content analysis was carried out using Atlas-ti software . Interviews were conducted between October 2016 and March 2017. RESULTS Trust in a contact person (e.g. social workers) facilitated the participation, although there were difficulties reaching people who had illegal energy supplies, immigrant women or immigrants who subrent properties. Regarding implementation, home visits, energy efficiency advice and the relationship with energy agents were the best assessed aspects. However, not being able to carry out reforms in deteriorated dwellings was considered a limitation. The program also contributed to raise awareness on energy rights, to save on utility bills and to generate tranquility and social support. CONCLUSIONS Programs such as this one can promote energy empowerment and improve psychosocial status. However, strategies with a gender and equity perspective should be considered to reach other vulnerable groups.