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(1) Background: In health care and in society at large, sarcopaenia is a disorder of major importance that can lead to disability and other negative health-related events. Our study aim is to determine the prevalence of sarcopaenia among older people attended in primary care and to analyse the factors associated with this age-related clinical condition; (2) Methods: A multicentre cross-sectional study was conducted of 333 community-dwelling Spanish adults aged 65 years or more. Sociodemographic, clinical, functional, anthropometric, and pharmacological data were collected. Sarcopaenia was defined following European Working Group on Sarcopaenia in Older People (EWGSOP) criteria; (3) Results: Sarcopaenia was present in 20.4% of the study sample, and to a severe degree in 6%. The intensity of the association between sarcopaenia and frailty was weak-moderate (Cramer V = 0.45). According to the multinomial logistic regression model performed, sarcopaenia was positively associated with age and with the presence of psychopathology (OR = 2.72; 95% CI = 1.30–5.70) and was inversely correlated with body mass index (OR = 0.73, 95% CI = 0.67–0.80; (4) Conclusions: Sarcopaenia commonly affects community-dwelling older persons and may be associated with age, body mass index, and psychopathology. The latter factor may be modifiable or treatable and is therefore a possible target for intervention.

Background: This article proposes a methodological innovation in health economics for the second stage analysis of technical efficiency in hospitals. It investigates the relationship between the installed capacity in regions and hospitals and their ownership structure. Methods: A multilevel zero-one inflated beta regression model is employed to model pure technical efficiency more adequately than other models frequently used in econometrics. Results: Compared to publicly managed hospitals, the mean efficiency index of hospitals with public-private partnership (PPP) formulas was 4.27-fold. This figure was 1.90-fold for private hospitals. Concerning the efficiency frontier, the odds ratio (OR) of PPP models vs. public hospitals was 42.06. The OR of private hospitals vs. public hospitals was 8.17. A one standard deviation increase in the percentage of beds in intensive care units increases the odds of being situated on the efficiency frontier by 50%. Conclusions: The proportion of hospital beds in intensive care units relates to a higher chance of being on the efficiency frontier. Hospital ownership structure is related to the mean efficiency index of Spanish National Health Service hospitals, as well as the odds of being situated on the efficiency frontier., EUROPEAN REGIONAL DEVELOPMENT FUND (Operative Program: Andalusia 2014–2020. Ministry of Economy. Knowledge. Business and University. Junta de Andalucía. Spain. Grant number: B-SEJ-266-UGR18.

Frailty is an age-related clinical condition that typically involves a deterioration in the physiological capacity of various organ systems and heightens the patient’s susceptibility to stressors. For this reason, one of the main research goals currently being addressed is that of characterising the impact of frailty in different settings. The main aim of this study is to determine the prevalence of Fried’s frailty phenotype among community-dwelling older people and to analyse the factors associated with frailty. In this research study, 582 persons aged 65 years or more participated in this cross-sectional study that was conducted at primary healthcare centres in Málaga, Spain. Sociodemographic, clinical, functional and comprehensive drug therapy data were compiled. The relationship between the independent variables and the different states of frailty was analysed by using a multinomial logistic regression model. Frailty was present in 24.1% of the study sample (95% CI = 20.7–27.6) of whom 54.3% were found to be pre-frail and 21.6% were non-frail. The study variable most strongly associated with frailty was the female gender (OR = 20.54, 95% CI = 9.10–46.3). Other factors found to be associated with the state of frailty included age, dependence for the instrumental activities of daily living (IADL), polymedication, osteoarticular pathology and psychopathology. This study confirms the high prevalence of frailty among community-dwelling older people. Frailty may be associated with many factors. Some of these associated factors may be preventable or modifiable and, thus, provide clinically relevant targets for intervention. This is particularly the case for depressive symptoms, the clinical control of osteoarthritis and the use of polypharmacy.

To comparatively assess the prevalence rates of potentially inappropriate medications (PIMs) obtained by the former and latest versions of American Geriatrics Society Beers Criteria (AGS BC) and screening tool of older person’s potentially inappropriate prescriptions (STOPP), and analyze the factors of influence on PIM. Cross-sectional study including 582 community-dwelling older adults over the age of 65. Sociodemographic, clinical, functional, and comprehensive drug therapy data were collected. The primary endpoint was the percentage of patients receiving at least one PIM. A total of 3626 prescriptions were analyzed. PIMs were detected in 35.4% and 47.9% of patients according to the STOPP v1 and the 2012 AGS BC, respectively. This percentage rose to 54% when 2015 AGS BC were used and reached 66.8% with STOPP v2. The kappa coefficient between STOPP v2 and its former version was lower than the one between the updated Beers Criteria and their former version (0.41 vs 0.85). The agreement was good (0.65) between both latest criteria. The number of medications, psychological disorders, and insomnia were predictors of PIM. A novel finding was that bone and joint disorders increased the odds for PIM by 78%. The 2015 AGS BC showed high sensitivity and good applicability to the European older patients. Both updated tools identified some pharmacological groups (benzodiazepines, PPIs, and opioids, among others) and certain health problems (insomnia, psychological disorders, and osteoarticular diseases) as factors of influence on PIM. Based on these findings, interventions aimed at promoting appropriate use of medications should be developed.

Objective: To evaluate the relationship between the ownership structure of hospitals and the possibility of their being positioned on the frontier of technical efficiency in the economic crisis period 2010&ndash, 2012, adjusting for hospital variables and regional characteristics in the areas where the Spanish National Health System (SNHS) hospitals are located. Methods: 230 National Health System hospitals were studied over the two-year period 2010&ndash, 2012 according to their ownership structure&mdash, public hospitals, private hospitals and public&ndash, private partnership (PPP)&mdash, data envelopment analysis orientated to inputs was used to measure the overall technical efficiency, pure efficiency and efficiency of scale. A generalised linear mixed model (GLMM) with binomial distribution and logit link function was used to analyse the hospital and regional variables associated with positioning on the frontier. Results: There are substantial differences between the average pure technical efficiency of public, private and PPP hospitals, as well as a greater number of PPP models being positioned on the efficiency frontier (91.67% in 2012). The odds of being positioned on the frontier are 41.7 times higher in PPP models than in public hospitals. The average annual household income per region is related to the greater odds of hospitals being positioned on the frontier of efficiency. Conclusions: During the most acute period of recession in the Spanish economy, PPP formulas favoured hospital efficiency, by increasing the odds of being positioned on the frontier of efficiency when compared to private and public hospitals. The position on the frontier of efficiency of a hospital is related to the wealth of its region.

Resumen: Objetivo: Comparar las diferencias en la producción científica mundial sobre paternidad y maternidad (cantidad, momento de inicio y evolución temporal), conocer la distribución geográfica internacional de artículos sobre paternidad, y examinar la relación del índice de desarrollo humano (IDH) y del índice global de brecha de género (IGBG) con el número de artículos sobre paternidad. Método: Análisis descriptivo de artículos sobre paternidad y maternidad de la base Scopus desde 1788 hasta 2016, y análisis longitudinal de 2006 a 2015 de la relación entre la producción científica sobre paternidad, el IDH y el IGBG, mediante un modelo multinivel con distribución de Poisson y parámetro extra-Poisson. Resultados: Hay cuatro veces menos artículos sobre paternidad que sobre maternidad. Los artículos sobre paternidad se desarrollaron de forma más tardía, y la mayoría (85%) se publicaron en las dos últimas décadas, cuando se incrementaron en mayor proporción que los de maternidad. Se constatan desigualdades geográficas, con América del Norte, Europa y Oceanía a la cabeza. Hay una relación estadísticamente significativa entre el incremento del IDH y el IGBG de los países del mundo y el aumento de los artículos sobre paternidad. Conclusiones: El conocimiento en torno a la paternidad y la maternidad es desigual. Resulta imprescindible desarrollar un conocimiento no parcelado, no dividido y no reduccionista en el ámbito reproductivo. Es necesario visibilizar a los hombres como padres en la esfera científica, romper estereotipos de género e incorporar la corresponsabilidad en la crianza en las políticas y en las prácticas sociales como una cuestión de derecho fundamental. Abstract: Objective: To compare worldwide differences in scientific production on fatherhood and motherhood (quantity, start time and evolution over time), to determine the international geographic distribution of articles on fatherhood, and, to examine the relationship between the human development index (HDI), the global gender gap index (GGGI), and the number of articles on fatherhood. Method: Descriptive analysis of articles on fatherhood and motherhood from the Scopus database 1788-2016, and longitudinal analysis 2006-2015 of the relationship between scientific production on fatherhood, the HDI and the GGGI, by means of a multilevel model with Poisson distribution and extra-Poisson parameter. Results: We observed four times fewer articles on fatherhood than on motherhood. Articles on fatherhood were developed later than those on motherhood, and most (85%) were published in the last two decades, when they increased more than articles on motherhood. We identified geographical inequalities, with North America, Europe and Oceania leading the way. There is a statistically significant relationship between the increase in the HDI and the GGGI in world countries, and the increase in the articles on fatherhood. Conclusions: Socially built knowledge around fatherhood and motherhood is unequal. It is essential to develop non-parcelled, undivided and non- reductionist knowledge in the reproductive field. It is necessary to make men visible as fathers in the scientific sphere, to break gender stereotypes, and to incorporate childrearing co-responsibility in social policies and practices as a matter of right.

Analyze the relative risks of critical cardiovascular outcomes and mortality associated with adherence to statin treatment in a clinical setting in people with no history of prior cardiovascular disease (CVD).A systematic review of the literature was conducted up to December 2016. The outcomes of interest were cardiovascular fatal or nonfatal events and all-cause mortality.A total of 17 articles were included in a qualitative synthesis. Four were case-control nested in a retrospective cohort design and the other 11 were a cohort design. Seven studies compared the best adherer patients with the worst adherers. In the 3 studies (317 603 participants) that considered ischemic heart disease in this group, the pooled reduction in risk was 18% (95% confidence interval [CI]: 14%-22%, IAdherence to statins treatment is shown as a key element for primary prevention, although these are observational data and the risk of bias from confounding cannot be ruled out. Standardization of measures of adherence to treatment would improve comparability between studies. Further research is warranted to design effective interventions to improve patients' adherence.

The objectives of the study were to describe the extent and profile of off-label prescriptions, to evaluate the level of evidence supporting these indications, to assess the research activity in these conditions, and to determine to what extent these were authorized as new indications five years after the application.A cross-sectional study including all applications conducted in the Hospital Universitario Reina Sofía in Córdoba during 2010. level of evidence according to the criteria by SIGN-NICE (Scottish Intercollegiate Guidelines Network, National Institute for Health and Care Excellence) and CEBM (Centre for Evidence-based Medicine), registered clinical trials (source: ClinicalTrials.gov), and review of product specifications and monthly newsletters from the Spanish Agency of Medicines and Medical Devices.There were 190 applications for off-label prescription for 82 different indications. The most requested medications were: tacrolimus, mycophenolate, colistimethate and everolimus; the immunosuppressant group had the highest number of uses for non-approved indications. Out of the applications, 52.4% were based on some clinical trial, while the rest had a low level of evidence (observational studies and case reports). We have found on-going clinical trials for 67% of the indications, but new indications in their product specifications have only been authorized for nine drugs (bevacizumab, deferasirox, everolimus, lenalidomide, methotreate, sildenafil, sorafenib, raltegravir and tenofovir).We have detected a major volume of off-label prescription without good supporting evidence, which identifies these indications and medications as interesting research lines, but that require follow-up in terms of effectiveness and costs.Objetivo: Los objetivos del estudio fueron describir la magnitud y el perfil de las prescripciones fuera de ficha técnica (off-label), evaluar el nivel de evidencia en el que se sustentan estas indicaciones, valorar la actividad investigadora en estas enfermedades y determinar en qué grado se autorizan como nuevas indicaciones transcurridos cinco años desde la solicitud.Métodos: Estudio transversal que incluyó todas las solicitudes realizadas en el Hospital Universitario Reina Sofía de Córdoba durante 2010. Análisis: nivel de evidencia según criterios de SIGN-NICE (Scottish Intercollegiate Guidelines Network, National Institute for Health and Care Excellence) y del CEBM (Centre for Evidence-based Medicine), ensayos clínicos registrados (fuente: ClinicalTrials.gov) y la revisión de fichas técnicas e informes mensuales de la Agencia Española del Medicamento.Resultados: Hubo 190 solicitudes off-label para 82 indicaciones distintas. Los medicamentos más solicitados fueron tacrolimus, micofenolato, colistimetato y everolimus, constituyéndose el grupo de inmunosupresores como el de mayor número de usos en indicaciones no aprobadas. El 52,4% de las solicitudes estaban basadas en algún ensayo clínico, mientras que el resto tuvo un bajo nivel de evidencia (estudios observacionales y casos). Hemos encontrado ensayos clínicos en activo para el 67% de las indicaciones, pero solo nueve fármacos han visto autorizadas nuevas indicaciones en su ficha técnica (bevacizumab, deferasirox, everolimus, lenalidomida, metotrexato, sildenafilo, sorafenib, raltegravir y tenofovir).Conclusiones: Se ha detectado un importante volumen de usos offlabel en ausencia de buena evidencia, lo que identifica a estas indicaciones y medicamentos como líneas de investigación interesantes pero con necesidad de seguimiento de efectividad y costes.

The main aim of this study was to determine the association of various clinical, functional and pharmacological factors with the physical (PCS) and mental (MCS) summary components of the health-related quality of life (HRQoL) of community-dwelling older adults. Design: Cross-sectional study. Patients and setting: Sample of 573 persons aged over 65 years, recruited at 12 primary healthcare centres in M&aacute, laga, Spain. Sociodemographic, clinical, functional, and comprehensive drug therapy data were collected. The main outcome was HRQoL assessed on the basis of the SF-12 questionnaire. A multinomial logistic regression model was constructed to study the relationship between independent variables and the HRQoL variable, divided into intervals. The average self-perceived HRQoL score was 43.2 (&plusmn, 11.02) for the PCS and 48.5 (&plusmn, 11.04) for the MCS. The factors associated with a poorer PCS were dependence for the instrumental activities of daily living (IADL), higher body mass index (BMI), number of medications, and presence of osteoarticular pathology. Female gender and the presence of a psychopathological disorder were associated with worse scores for the MCS. The condition that was most strongly associated with a poorer HRQoL (in both components, PCS and MCS) was that of frailty (odds ratio (OR) = 37.42, 95% confidence interval (CI) = 8.96&ndash, 156.22, and OR = 20.95, 95% CI = 7.55&ndash, 58.17, respectively). It is important to identify the determinant factors of a diminished HRQoL, especially if they are preventable or modifiable.

To compare worldwide differences in scientific production on fatherhood and motherhood (quantity, start time and evolution over time), to determine the international geographic distribution of articles on fatherhood, and, to examine the relationship between the human development index (HDI), the global gender gap index (GGGI), and the number of articles on fatherhood.Descriptive analysis of articles on fatherhood and motherhood from the Scopus database 1788-2016, and longitudinal analysis 2006-2015 of the relationship between scientific production on fatherhood, the HDI and the GGGI, by means of a multilevel model with Poisson distribution and extra-Poisson parameter.We observed four times fewer articles on fatherhood than on motherhood. Articles on fatherhood were developed later than those on motherhood, and most (85%) were published in the last two decades, when they increased more than articles on motherhood. We identified geographical inequalities, with North America, Europe and Oceania leading the way. There is a statistically significant relationship between the increase in the HDI and the GGGI in world countries, and the increase in the articles on fatherhood.Socially built knowledge around fatherhood and motherhood is unequal. It is essential to develop non-parcelled, undivided and non- reductionist knowledge in the reproductive field. It is necessary to make men visible as fathers in the scientific sphere, to break gender stereotypes, and to incorporate childrearing co-responsibility in social policies and practices as a matter of right.

Resumen: Objetivo: Analizar la eficiencia técnica por tipo de propiedad y gestión de los hospitales generales del Sistema Nacional de Salud español (2010-2012) y sus variables explicativas hospitalarias y regionales. Método: Se estudian 230 hospitales combinando el análisis envolvente de datos y modelos transversales de regresión lineal multinivel de efectos fijos. Con el análisis envolvente de datos se miden la eficiencia técnica global, pura y de escala, y con los modelos multinivel, las variables explicativas de eficiencia. Resultados: El índice medio de eficiencia técnica global de los hospitales sin personalidad jurídica es inferior al de los hospitales con personalidad jurídica (0,691 y 0,876 en 2012). Existe una importante variabilidad en eficiencia técnica pura (ETP) por formas de gestión directa, indirecta y mixta. Un 29% de la variabilidad en la ETP es atribuible a diferencias entre comunidades autónomas. La dotación de personalidad jurídica del hospital aumenta en 11,14 puntos la ETP. Por otra parte, la mayoría de las formas de gestión alternativas al modelo tradicional aumentan en porcentajes variables la ETP. En el ámbito regional, según el escenario considerado, la insularidad y la renta media por hogar son variables explicativas de la ETP. Discusión: Tener personalidad jurídica favorece la eficiencia técnica. El marco de regulación y gestión de los hospitales, más que la propiedad pública o privada, parecen explicar la eficiencia técnica. Las características regionales explican de forma relevante la variabilidad en la ETP. Abstract: Objective: To analyze technical efficiency by type of property and management of general hospitals in the Spanish National Health System (2010-2012) and identify hospital and regional explanatory variables. Method: 230 hospitals were analyzed combining data envelopment analysis and fixed effects multilevel linear models. Data envelopment analysis measured overall, technical and scale efficiency, and the analysis of explanatory factors was performed using multilevel models. Results: The average rate of overall technical efficiency of hospitals without legal personality is lower than hospitals with legal personality (0.691 and 0.876 in 2012). There is a significant variability in efficiency under variable returns (TE) by direct, indirect and mixed forms of management. The 29% of the variability in TE es attributable to the Region. Legal personality increased the TE of the hospitals by 11.14 points. On the other hand, most of the forms of management (different to those of the traditional hospitals) increased TE in varying percentages. At regional level, according to the model considered, insularity and average annual income per household are explanatory variables of TE. Discussion: Having legal personality favours technical efficiency. The regulatory and management framework of hospitals, more than public or private ownership, seem to explain technical efficiency. Regional characteristics explain the variability in TE. Palabras clave: Eficiencia, Análisis envolvente de datos, Análisis multinivel, Sistema Nacional de Salud, Hospitales, Colaboración público-privada, Empresas públicas hospitalarias, Keywords: Efficiency, Data envelopment analysis, Multilevel analysis, National health service, Hospitals, Public-private partnership, Public hospital enterprises

Statistics plays a crucial role in research, planning and decision-making in the health sciences. Progress in technologies and continued research in computational statistics has enabled us to implement sophisticated mathematical models within software that are handled by non-statistician researchers. As a result, over the last decades, medical journals have published a host of papers that use some novel statistical method. The aim of this paper is to present a review on how the statistical methods are being applied in the construction of scientific knowledge in health sciences, as well as, to propose some improvement actions. From the early twentieth century, there has been a remarkable surge in scientific evidence alerting on the errors that many non-statistician researchers were making in applying statistical methods. Today, several studies continue showing that a large percentage of articles published in high-impact factor journals contain errors in data analysis or interpretation of results, with the ensuing repercussions on the validity and efficiency of the research conducted. Scientific community should reflect on the causes that have led to this situation, the consequences to the advancement of scientific knowledge and the solutions to this problem.

Resumen Objetivo Evaluar los usos off-label (fuera de ficha tecnica [FT]) y unlicensed (medicamentos no autorizados especificamente para ninos) en cuidados intensivos neonatales y pediatricos. Metodologia Se realizo un estudio transversal en la UCINP (Unidad de Cuidados Intensivos Neonatales y Pediatricos) de un hospital publico de tercer nivel de Granada, incluyendose a todos los ninos en los que se indicara al menos un tratamiento farmacologico, mediante reclutamiento consecutivo, y durante un periodo de 5 meses (N=81). Las variables recogidas fueron sociodemograficas, clinicas, y medicacion. Todas las prescripciones fueron clasificadas a partir de la informacion contenida en FT sobre uso en ninos. Resultados Hubo un total de 601 prescripciones, con una media de 7,4 ± 6 medicamentos por nino. Los farmacos mas empleados pertenecian a los grupos J (antiinfecciosos), N (sistema nervioso) y C (cardiovascular). Algo mas de la mitad de las prescripciones fueron off-label (52%), fundamentalmente por emplear una dosificacion distinta de la recomendada en FT (79%), seguida de diferente indicacion (13,5%), edad (5%) y via de administracion (2,5%). El uso de medicamentos no especificamente autorizados en ninos solo supuso el 5% de las prescripciones. Conclusiones El presente estudio aporta datos sobre este tipo de prescripciones en una UCINP espanola. Pone de manifiesto que el 89% de los ninos tiene al menos una prescripcion fuera de FT y un 22,3% al menos un uso de farmaco no autorizado para ninos. Cifras elevadas, pero justificables dentro del ambito de unos cuidados intensivos que, ademas, incluyen neonatos. Pero aunque muchos de los tratamientos esten protocolizados, seria deseable mejorar la evidencia disponible, asi como actualizar las FT.

The current treatment approach for patients in palliative care (PC) requires a health model based on shared and individualised care, according to the degree of complexity encountered. The aims of this study were to describe the levels of complexity that may be present, to determine their most prevalent elements and to identify factors that may be related to palliative complexity in advanced-stage cancer patients. An observational retrospective study was performed of patients attended to at the Cudeca Hospice. Socio-demographic and clinical data were compiled, together with information on the patients&rsquo, functional and performance status (according to the Palliative Performance Scale (PPS)). The level of complexity was determined by the Diagnostic Instrument of Complexity in Palliative Care (IDC-Pal&copy, ) and classified as highly complex, complex or non-complex. The impact of the independent variables on PC complexity was assessed by multinomial logistic regression analysis. Of the 501 patients studied, 44.8% presented a situation classed as highly complex and another 44% were considered complex. The highly complex items most frequently observed were the absence or insufficiency of family support and/or caregivers (24.3%) and the presence of difficult-to-control symptoms (17.3%). The complex item most frequently observed was an abrupt change in the level of functional autonomy (47.6%). The main factor related to the presence of high vs. non-complexity was that of performance status (odds ratio (OR) = 10.68, 95% confidence interval (CI) = 2.81&ndash, 40.52, for PPS values &lt, 40%). However, age was inversely related to high complexity. This study confirms the high level of complexity present in patients referred to a PC centre. Determining the factors related to this complexity could help physicians identify situations calling for timely referral for specialised PC, such as a low PPS score.

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

ResumenObjetivoEvaluar el perfil de prescripción y los usos off-label (fuera de ficha técnica [FT]) y unlicensed (medicamentos no autorizados específicamente para niños) de medicamentos a nivel ambulatorio.DiseñoEstudio transversal.EmplazamientoConsultas de pediatría de 2 centros de salud urbanos y sala de urgencia general del Hospital Materno-Infantil de Málaga.ParticipantesNiños de 0-14años que acudiesen a consulta y se les prescribiese al menos un medicamento.Mediciones principalesVariables sociodemográficas, motivo de consulta y medicación. Clasificación de las prescripciones según información contenida en FT.ResultadosSe incluyeron un total de 388 niños, una submuestra de 105 (27%) atendidos en urgencias, y se valoraron 462 prescripciones, que involucraron 74 principios activos diferentes. Cada niño recibió un promedio de 1,7 fármacos (IC95%: 1,6-1,9), siendo los más prescritos ibuprofeno, paracetamol, amoxicilina-clavulánico y budesonida. El grupo terapéutico más empleado y con mayor variedad de fármacos fue el respiratorio. El 27,4% de las prescripciones (IC95%: 23,5-31) fueron off-label, constituyéndose como causa más frecuente el uso del fármaco para una edad distinta de la autorizada (60%; IC95%: 54,1-63), seguida de distinta dosis (21,5%; IC95%: 18-25), diferente indicación (12%; IC95%: 9,2-15) y el 7% por distinta vía de administración (IC95%: 5,4-10).ConclusionesLa tasa de usos off-label presenta cifras intermedias, pudiendo recibir este tipo de prescripciones una tercera parte de los niños. Esto no significa que sean prescripciones incorrectas, pero es recomendable respaldarlas con la mejor evidencia, así como seguir las directrices de la normativa sobre medicamentos en situaciones especiales.AbstractObjectiveto evaluate the prescription profile and to assess the off-label and unlicensed uses of medicines among non-hospitalised pediatric patients.Designcross-sectional study.Settingpediatric units in two urban health centers and general emergency room (Hospital Materno-Infantil, Málaga).Main measurementssociodemographics variables, reasons for consultation and information about therapeutic medications. The classification of prescriptions was established according to information requirements contained in the Summary of Products Characteristics (SPC).ResultsA total of 388 children were included (a subsample of 105 treated in the emergency room). Four hundred sixty-two prescriptions (involving 74 different active ingredients) were evaluated. Each infant received and average of 1,7 drugs (95% CI: 1,6-1,9). The most prescribed medicines were ibuprofen, paracetamol, amoxicillin-clavulanate and budesonide. The therapeutic group with the greatest variety of drugs was the respiratory group. 27,4% (95% CI: 23,5-31) of prescriptions were off-label and the main cause was different age (60%; 95% CI: 54,1-63), followed by different dose (21,5%; 95% CI: 18-25), different indication (12%; 95% CI: 9,2-15) and different route of administration (7%; 95% CI: 5,4-10).ConclusionsThe rate of off-label uses presents intermediate figures. Around one third of the paediatric outpatients in our sample are exposed to at least one off-label or unlicensed prescription. We should, however, point out that such usage is based on scant official, quality information, although it is not necessarily incorrect. Evidence-based medicine should be encouraged to improve drug therapy in children, as well as following the rules on drugs in special situations.

Resumen Introduccion y objetivos La cardiopatia isquemica es la primera causa de muerte y una de las cuatro principales causas de carga de enfermedad en el mundo. El objetivo de este trabajo es evaluar los efectos edad-periodo-cohorte la mortalidad por cardiopatia isquemica en Andalucia (sur de Espana) y en cada una de sus provincias durante el periodo 1981-2008. Metodos Se realizo un estudio ecologico poblacional. Se analizaron las 145.539 defunciones por cardiopatia isquemica ocurridas en Andalucia durante el periodo de estudio a edades comprendidas entre 30 y 84 anos. Se estimo un modelo de regresion no lineal con funciones spline para cada sexo y area geografica. Resultados En la tasa de mortalidad masculina y femenina a partir de 30 anos de edad se observa tendencia a aumentar. El riesgo de muerte para varones y mujeres fue descendiente para las cohortes nacidas despues de 1920 y con una pendiente mas pronunciada despues de 1960 entre los varones. El analisis del efecto periodo mostro que el riesgo de mortalidad masculina y femenina se mantuvo estable desde 1981 hasta 1990, aumento entre 1990 y 2000 y volvio a disminuir desde 2000 hasta 2008. Conclusiones Los efectos edad-periodo-cohorte en la mortalidad fueron similares en todas las provincias de Andalucia y el conjunto de la comunidad autonoma. Si los efectos cohorte y periodo persisten, la mortalidad masculina y femenina por enfermedad isquemica cardiaca continuara disminuyendo.

The aim of this research was to study the association of the accumulated human exposure to persistent organic pollutants with serum lipid levels and obesity, in a cohort of 298 adults. In the multivariable analyses, HCB concentrations evidenced a significant quadratic association with levels of total cholesterol, HDL, LDL, and total serum lipids. Likewise, PCBs 138 and 180 were associated with triglycerides and total serum lipids, and PCB 153 with LDL. HCB, p,p′-DDE, and β-HCH showed quadratic associations with BMI. All quadratic models showed a positive trend at low exposure levels, while the slope decreased or even became negative at higher exposure levels. Additionally, PCB 138 was positively associated with BMI but in a linear manner. Our results suggest a potential relationship between historical POP exposure and serum lipids/obesity, which followed a non-linear pattern in most cases.

To analyze technical efficiency by type of property and management of general hospitals in the Spanish National Health System (2010-2012) and identify hospital and regional explanatory variables.230 hospitals were analyzed combining data envelopment analysis and fixed effects multilevel linear models. Data envelopment analysis measured overall, technical and scale efficiency, and the analysis of explanatory factors was performed using multilevel models.The average rate of overall technical efficiency of hospitals without legal personality is lower than hospitals with legal personality (0.691 and 0.876 in 2012). There is a significant variability in efficiency under variable returns (TE) by direct, indirect and mixed forms of management. The 29% of the variability in TE es attributable to the Region. Legal personality increased the TE of the hospitals by 11.14 points. On the other hand, most of the forms of management (different to those of the traditional hospitals) increased TE in varying percentages. At regional level, according to the model considered, insularity and average annual income per household are explanatory variables of TE.Having legal personality favours technical efficiency. The regulatory and management framework of hospitals, more than public or private ownership, seem to explain technical efficiency. Regional characteristics explain the variability in TE.

Resumen Objetivo: Analizar la eficiencia tecnica y la productividad de los hospitales generales del Sistema Nacional de Salud (SNS) espanol (2010-2012) e identificar variables hospitalarias y regionales explicativas. Metodos: Se estudian 230 hospitales del SNS mediante analisis envolvente de datos midiendo la eficiencia tecnica global, pura, de escala, y el indice de Malmquist. La robustez del analisis se evalua con modelos input-output alternativos. Se emplean modelos multinivel lineales transversales de efectos fijos para analizar las variables explicativas de eficiencia. Resultados: El indice medio de eficiencia tecnica global (ETG) es de 0,736 en 2012, con una importante variabilidad por comunidades autonomas. El indice de Malmquist (2010-2012) es de 1,013. Un 23% de la variabilidad en ETG es atribuible a la comunidad autonoma. Las variables exogenas estadisticamente significativas (residentes por cada 100 facultativos, indice de envejecimiento, renta media anual por hogar, gasto en servicios publicos fundamentales y gasto publico sanitario per capita) explican el 42% de la variabilidad de ETG entre hospitales y el 64% entre comunidades autonomas. El numero de residentes es estadisticamente significativo. En todas las comunidades autonomas existe una relacion lineal directa significativa entre la ETG y la renta anual per capita y el gasto en servicios publicos fundamentales, e indirecta con el indice de envejecimiento y el gasto publico sanitario per capita. Discusion: El importante margen de mejora en eficiencia de los hospitales esta condicionado por caracteristicas especificas de cada comunidad autonoma, particularmente el envejecimiento, la riqueza y las politicas de gasto publico de cada una.

Background The aim of this article is to evaluate the age-period-cohort effects on mortality from cerebrovascular disease in Andalusia (southern Spain) as a whole and in each of its 8 provinces during the period 1981-2008. Methods A population-based ecologic study was conducted. In all, 145,867 deaths were analyzed for individuals between the ages of 15 and 84 years who died in Andalusia in the period of study. A nonlinear regression model was estimated for each gender group and geographic area. The effects of age, year of death, and birth cohort were parameterized using spline smoothing functions. Results There is an upward trend in mortality from the age of 25 years. The risk of death was downward for cohorts born after 1896, decreasing after 1970 with steep slope. The analysis of the period effect showed that death rate first declined from 1981 to 1995 and then increased between 1995 and 2000, only to decrease again until 2008. Conclusions There is a similar age-period-cohort effect on male and female mortality from cerebrovascular disease in all the provinces of Andalusia and for Andalusia as a whole. A significant reduction of male and female mortality has been observed during the last decade.

Objectives: To determine the prevalence of potentially inappropriate medications (PIMs) and related factors through a comparative analysis of the Screening Tool of Older Person's Potentially Inappropriate Prescriptions (STOPP), the 2003 Beers criteria, and the 2012 AGS update of the Beers criteria. Design: Cross-sectional. Setting: Primary care. Participants: Community-dwelling persons aged 65 and older who live on the island of Lanzarote, Spain (N = 407). Measurements: Sociodemographic characteristics; independence in activities of daily living; cognitive function; Geriatric Depression Scale; clinical diagnoses; and complete data on indication, dosage, and length of drug treatments. One thousand eight hundred seventh-two prescriptions were examined, and the rate of PIMs was assessed with the three criteria. The primary endpoint was the percentage of participants receiving at least one PIM. Multivariate logistic regression was used to examine the factors related to PIMs. Results: Potentially inappropriate medications were present in 24.3%, 35.4%, and 44% of participants, according to the 2003 Beers criteria, STOPP, and 2012 Beers criteria, respectively. The profile of PIMs was also different (the most frequent being benzodiazepines in both Beers criteria lists and aspirin in the STOPP). The number of drugs was associated with risk of prescribing PIMs in all three models, as was the presence of a psychological disorder in the 2003 Beers criteria (odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.26–3.40) and the 2012 Beers criteria (OR = 2.91, 95% CI = 1.83–4.66). The kappa for degree of agreement between STOPP and the 2012 Beers criteria was 0.35 (95% CI = 0.25–0.44). Conclusion: The 2012 Beers criteria detected the highest number of PIMs, and given the scant overlapping with the STOPP criteria, the use of both tools may be seen as complementary.

Emerging and changing evidence made it necessary to update STOPP-START criteria, and version 2 was published recently. In this study the objectives were to determine the prevalence of potentially inappropriate medication prescribing (PIM) in primary care using STOPP versions 1 (v1) and 2 (v2), as well as 2012 AGS Beers criteria, and analyze the factors associated with inappropriate prescribing according to STOPP/START v2. A cross-sectional study was carried out including community-dwelling older adults over the age of 65. Socio-demographic, clinical, functional and comprehensive drug therapy data were collected. The primary endpoint was the percentage of patients receiving at least one PIM. This variable was measured using three tools: STOPP v1, 2012 AGS Beers criteria and STOPP v2. Similarly, the percentage of patients receiving at least one potential prescribing omission (PPO) was calculated using START versions 1 and 2. A total of 1,615 prescriptions were reviewed. The median number of medications per patient was 7.1 drugs (+/- 3.8). The prevalence of elderly people exposed to polypharmacy (>= 5 medications) was 72.9%, whereas 28.4% of the participants took >= 10 drugs regularly. PIM were present in 18.7%, 37.3% and 40.4% of participants, according to the STOPP v1, 2012 Beers criteria and STOPP v2, respectively. According to STOPP v2, the number of medications taken (OR: 1.14, 1.06-1.25), the presence of a psychological disorder (OR: 2.22, 1.13-4.37) and insomnia (OR: 3.35, 1.80-6.32) were risk factors for taking a PIM. The prevalence of PPOs was 34.7% and 21.8% according to version 1 and 2, respectively. In conclusion, STOPP-START criteria have been remarkably modified, which is evidenced by the different prevalence rates detected using version 2, as compared to version 1. In fact, the level of agreement between version 1 and the updated version is only moderate. Special attention should be paid on benzodiazepines, which keep being the most frequent PIM.

espanolEl desempleo, la privacion economica y la pobreza son indicadores de bienestar social. Todos forman un ciclo de factores encadenados que comienza con la perdida del empleo. Los objetivos de este estudio fueron describir la evolucion del desempleo, la privacion economica, la pobreza y el autoempleo en hombres y mujeres en Andalucia durante el periodo 2000-2013, asi como evaluar cambios en la tendencia tras el inicio de la Gran Recesion. Los resultados muestran un empeoramiento significativo de los indicadores de desempleo, privacion economica y riesgo de pobreza en Andalucia desde 2008 y una mejora del autoempleo en ambos sexos. EnglishUnemployment, economic deprivation and poverty are social welfare indicators. All form a cycle of chained factors which begins with the loss of employ. The objectives of this study were to describe the trend of unemployment, economic deprivation, poverty and self-employment in men and women in Andalusia during the period 2000-2013, as well as evaluating possible significant changes in trend after the beginning of the Great Recession. The results showed a significant worsening of the indicators of unemployment, economic deprivation and risk of poverty in Andalusia since 2008. On the other hand, an improvement of self-employment was observed in both sexes

Aims and objectives To know the male involvement during pregnancy and childbirth, with special attention to their participation in public services of perinatal health and the impact that this participation has on their subsequent involvement in child-rearing, to compare the male and female involvement in child-rearing and to identify the factors associated with a greater male involvement. Background Most of the research on male involvement in birth and child-rearing comes from Anglo-Saxon and Scandinavian countries. These studies show a lower involvement of men in relation to women, even in countries with instruments to promote gender shared responsibility. The Spanish Ministry of Health has developed strategies to improve the male involvement in the public services of perinatal health to advance in gender equality. This is a suitable context to contribute to the lack of information about fatherhood and the gender inequalities in the Spanish context. Design Transversal design. Methods A questionnaire was administered to 150 fathers and 157 mothers residing in Granada, with at least one biological child aged 2 months to 3 years. Results A minority of the men attended the childbirth education whereas most of them attended pregnancy check-ups and were present at birth. Women spent more time with their children and took charge of tasks of child-rearing to a larger extent. The profile of an involved father is a man with a higher level of education, not married, his partner has a full-time employment, born in Spain and attended to the childbirth education classes. Conclusion This study shows gender inequalities in the reproductive field beyond the biological conditions. Relevance to clinical practice The challenge of the health services is to promote social change and identify areas for improvement to include the father figure in public services of perinatal health.

The last published figures have shown geographical variations in mortality with respect to female breast cancer in European countries. However, national health policies need a dynamic image of the geographical variations within the country. The aim of this paper was to describe the spatial distribution of age-specific mortality rates from female breast cancer in the municipalities of Andalusia (southern Spain) and to analyze its evolution over time from 1981 to 2012. An ecological study was devised. Two spatio-temporal hierarchical Bayesian models were estimated. One of these was used to estimate the age-specific mortality rate for each municipality, together with its time trends, and the other was used to estimate the age-specific rate ratio compared with Spain as a whole. The results showed that 98% of the municipalities exhibited a decreasing or a flat mortality trend for all the age groups. In 2012, the geographical variability of the age-specific mortality rates was small, especially for population groups below 65. In addition, more than 96.6% of the municipalities showed an age-specific mortality rate similar to the corresponding rate for Spain, and there were no identified significant clusters. This information will contribute towards a reflection on the past, present and future of breast cancer outcomes in Andalusia Yes

Background Organochlorine pesticides are still used for vector control, and there is evidence of their recent illegal use in agriculture in several tropical and subtropical areas of South America, including Bolivia. Objectives To determine concentrations of three selected organochlorine pesticides (p,p’-DDT, p,p’-DDE, HCB) in adipose tissue and serum samples in several Bolivian population sub-groups. Results We found relatively high exposure levels in several Bolivian population groups, influenced by different factors from those observed in Europe and North America due to their specific occupational, lifestyle and dietary patterns. Especially elevated p,p’-DDE (main DDT metabolite) exposure levels were found in agricultural farmers from three rural communities in eastern Bolivia (subtropical area), with median serum concentrations of 19.7 ng/mL, which were 20-fold higher than those found in Bolivian urban dwellers. This is an alarming finding considering that this pesticide has been prohibited in the country since 1996. Additionally, multivariate models revealed a positive correlation between residence in the study area and exposure levels. Conclusion Our results point to the existence of heavily-polluted and previously unidentified hotspots in the region, underlining the need for the continuous monitoring of these populations given the potential associated health risks.

To analyse the technical efficiency and productivity of general hospitals in the Spanish National Health Service (NHS) (2010-2012) and identify explanatory hospital and regional variables.230 NHS hospitals were analysed by data envelopment analysis for overall, technical and scale efficiency, and Malmquist index. The robustness of the analysis is contrasted with alternative input-output models. A fixed effects multilevel cross-sectional linear model was used to analyse the explanatory efficiency variables.The average rate of overall technical efficiency (OTE) was 0.736 in 2012; there was considerable variability by region. Malmquist index (2010-2012) is 1.013. A 23% variability in OTE is attributable to the region in question. Statistically significant exogenous variables (residents per 100 physicians, aging index, average annual income per household, essential public service expenditure and public health expenditure per capita) explain 42% of the OTE variability between hospitals and 64% between regions. The number of residents showed a statistically significant relationship. As regards regions, there is a statistically significant direct linear association between OTE and annual income per capita and essential public service expenditure, and an indirect association with the aging index and annual public health expenditure per capita.The significant room for improvement in the efficiency of hospitals is conditioned by region-specific characteristics, specifically aging, wealth and the public expenditure policies of each one.

The organochlorine pesticide p,p′-Dichlorodiphenyltrichloroethane (DDT) was widely used in the early 1960s–70s for vector control in tropical and subtropical areas of South America. Due to its persistence, DDT has a high potential to bioaccumulate in the food chain and living organisms and is a major public health concern, especially in South America.The main purpose of the present study was to investigate predictors of serum and adipose tissue concentrations of p,p′-DDT and its main metabolite, p,p′-dichlorodiphenyldichloroethylene (p,p′-DDE), in an adult cohort (n=112) from Santa Cruz de la Sierra, Bolivia, using multiple linear regression models. These models explained 29.3–47.8% of the variability in adipose tissue concentrations of p,p′-DDT and p,p′-DDE, respectively, and 32.9–47.0% of that in serum. Main exposure predictors included age, occupational class, residence, diet, smoking habit, and accumulated breastfeeding time.This is one of the few studies to explore predictors of human exposure to these chemicals using a multivariate approach in a South American population. Results show that predictors of human exposure to p,p′-DDT and p,p′-DDE in Santa Cruz de la Sierra may diverge from those found in other populations of the world, due to particular sociodemographic and lifestyle characteristics of this region. Keywords: DDT, DDE, Serum, Adipose tissue, Exposure predictors, Multiple linear regression

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

The benefits of breastfeeding for the children's health have been highlighted in many studies. The innovative aspect of the present study lies in its use of a multilevel model, a technique that has rarely been applied to studies on breastfeeding. The data reported were collected from a larger study, the Family Budget Survey-Pesquisa de Orcamentos Familiares, carried out between 2002 and 2003 in Brazil that involved a sample of 48 470 households. A representative national sample of 1477 infants aged 0-6 months was used. The statistical analysis was performed using a multilevel model, with two levels grouped by region. In Brazil, breastfeeding prevalence was 58%. The factors that bore a negative influence on breastfeeding were over four residents living in the same household [odds ratio (OR) = 0.68, 90% confidence interval (CI) = 0.51-0.89] and mothers aged 30 years or more (OR = 0.68, 90% CI = 0.53-0.89). The factors that positively influenced breastfeeding were the following: higher socio-economic levels (OR = 1.37, 90% CI = 1.01-1.88), families with over two infants under 5 years (OR = 1.25, 90% CI = 1.00-1.58) and being a resident in rural areas (OR = 1.25, 90% CI = 1.00-1.58). Although majority of the mothers was aware of the value of maternal milk and breastfed their babies, the prevalence of breastfeeding remains lower than the rate advised by the World Health Organization, and the number of residents living in the same household along with mothers aged 30 years or older were both factors associated with early cessation of infant breastfeeding before 6 months.

Mortality is one of the most widely used indicators in small-area ecologic studies. Both accessibility to mortality data and advances in the development of new disease mapping techniques have contributed to an abundance of mortality maps and atlases over the last decade. Results may be biased in this kind of study if there has been unmeasured geographic mobility of the population. Most published papers tend to neglect this possibility. We use the theory of dynamics systems to demonstrate that migratory flows unmonitored by official population registers may lead to major errors in mortality rates and relative risks. Simulations in 4 scenarios showed more than 8% underestimation of the mortality rate and more than 11% underestimation of relative risk in areas with high uncontrolled emigration, and above 19% overestimation of mortality rate and above 15% overestimation of relative risk in areas with high uncontrolled immigration. Researchers conducting small-area epidemiologic studies should explore the reliability of population information in geographic areas before drawing hypothesis or conclusions on other possible causes of mortality differences.

Nowadays, there is a wide debate about what rural means. An operational definition of rural concept is essential in order to measure health problems, optimize resource allocation and facilitate decision making aimed at closing the gap on inequity between areas. In 2005, the rurality index for Small Areas in Spain (IRAP) was developed using the 1991 Census of Population data. Nevertheless, the concept and definition of rurality may evolve through time. In order to capture these changes, the variables used to make up the rurality index should be reviewed and updated periodically. Along these lines, and within the context of the rural-urban continuum, the aim of this paper is to replicate and update the IRAP using the data provided by the 2001 Census of Population, as well as to describe the changes in rurality observed in each municipality between 1991 and 2001. The index was updated on a Principal Components Factor Analysis, giving rise to a single factor that is correlated to the aging of the population, economic dependency, farming, livestock or fishing-related employment, self-employment, second dwelling ratio, popu- lation density, immigration and perception of noises and atmospheric pollution in the surroundings of the residential area. Most variables that made up the 1991 IRAP remain as important components of the 2001 index, indicating the robust nature of the measure. Only 10% of the Spanish municipalities have changed their rurality status between the two Censuses. The 2001 rurality index can be considered a good updated approach to the concept of rurality in Spain as well as an important criterion to social policies.

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

Los atlas de mortalidad publicados hasta la fecha son estáticos. La mayoría describen la distribución geográfica de la mortalidad agrupando datos de varios años y usando razones de mortalidad estandarizadas que resumen la mortalidad de todos los grupos de edad. Sin embargo, esta metodología presenta limitaciones para estudiar cambios temporales en la distribución geográfica de la mortalidad o diferencias entre grupos etarios. Aplicando una metodología alternativa surge el Atlas Interactivo de Mortalidad en Andalucía (AIMA), un Sistema de Información Geográfica dinámico que permite visualizar en web-site más de 12.000 mapas y 338.000 gráficos de tendencias correspondientes a la distribución espacio-temporal de las principales causas de muerte en Andalucía por grupos de edad y sexo desde 1981. El objetivo de este trabajo es describir la metodología utilizada para el desarrollo de AIMA, dar a conocer sus características y especificaciones técnicas y mostrar las posibilidades interactivas que ofrece. El sistema está disponible en el hipervínculo productos de www.demap.es. AIMA es el primer SIG interactivo de estas características implementado en España. Para el análisis de datos se han utilizado modelos jerárquicos bayesianos espacio-temporales, integrando posteriormente los resultados en web-site utilizando entorno PHP y cartografía dinámica en formato Flash. La selección de mapas temáticos muestra el carácter dinámico de la distribución geográfica de la mortalidad, con un patrón diferente para cada año, grupo de edad y sexo. La información contenida actualmente en este sistema y las futuras actualizaciones contribuirán a la reflexión sobre el pasado, presente y futuro de la salud en Andalucía.

The term deprivation is often used to refer to economic or social shortages in a given geographical area. This concept of deprivation has been identified for years using simple indicators such as income level, education and social class. One of the advantages of using simple indicators is the availability of data, since they come directly from sources of information like censuses and population registers. However, the main disadvantage of these indicators is their limited usefulness when measuring a concept as complex as deprivation with a single variable. One possible solution to this problem is using compound indices, made up of a combination of simple indicators. For years, the concept of material deprivation in Spain has been measured using indices or indicators imported from other countries. However, there are no studies that investigate if all of these variables are really related to material deprivation in Spain. In this context, the objective of this study is to create a synthetic index for material deprivation for the municipalities in Spain, bearing in mind the variables available from the Population and Housing Census. The index was built on a principal components factor analysis. The analysis showed two factors. The first factor showed a high positive correlation to the variables relating to illiteracy rate, unemployment rate and percentage of manual labourers, while the second factor was seen as highly positively correlated to the variables relating to the percentage of homes without access to a vehicle and the dependency index and also correlated, though negatively, to the percentage of foreigners between 16 and 49 who lived abroad in 1991. The variables that make up the first factor can be considered to be an approximation of the concept of deprivation in Spain. This study proposes a deprivation index made up of three simple indicators available from national information sources: percentage of illiteracy, percentage of unemployment and percentage of manual labourers. With this index, the criteria for measuring deprivation in Spanish municipalities can be unified and a comparison of the results of the different studies in our context facilitated.

The purpose of this paper is to study the linkage between type of habitat and mortality from all causes in small areas of Southern Spain. An ecological study was conducted on 99,870 people who died between 1985 and 1999. The municipality was taken as the unit of analysis. Data analysis was carried out through hierarchical spatio-temporal bayesian models. Results show a 13.3% reduction in mortality rates among men and 14.1% among women in the most rural areas compared to more urban environments. The study demonstrates the usefulness of socio-demographic indices in small-area geographical analyses.

An operational definition for “rural area” is pivotal if proposals, policies and decisions aimed at optimising the distribution of resources, closing the gap on inequity between areas and raising standards of living for the least advantaged populations are to be put in place. The concept of rurality, however, is often based on alternative and conflicting definitions, requiring clarification of the underlying theoretical model. Traditionally a geographical area has been classified as rural by taking into account either the number of inhabitants or population density. Two kinds of problem are raised with this approach, however, namely: it is inherently difficult to describe such a complex concept as rurality with a single variable; and reducing the concept down to a rural/urban dichotomy by setting a non-universal cut-off point does not usually provide an accurate account of reality. Within the context of the rural–urban continuum, this paper has devised a rurality index for Spanish municipalities based on the 1991 Population, Housing and Household Survey. The index was built on a principal components factor analysis, giving rise to a single factor that is correlated to the aging of the population, economic dependency, farming, livestock or fishing-related employment, habitability of housing and population density. A score to each municipality was allocated. This index can be regularly updated thus enabling the progress of the concept of rurality to be monitored in our setting over time and then compared with other countries using the same methods.

Objetivo. Describir la evolucion de la mortalidad por accidentes de trafico en Andalucia desde 1975 hasta 2001 y predecir las tasas de mortalidad para 2004. Diseno. Estudio ecologico de base poblacional. Emplazamiento. Residentes en Andalucia entre 1975 y 2001. Participantes. Defunciones por accidentes de trafico en Andalucia desde 1975 hasta 2001. Mediciones y resultados principales. Se calcularon las tasas de mortalidad ajustadas por edad en varones y mujeres y en los grupos de menores de 35 anos, de 35 a 64 anos y mayores de 64 anos. La evolucion de las tasas a traves del tiempo fue estudiada mediante analisis de tendencias. Se realizaron predicciones de las tasas de mortalidad a corto plazo. Las tasas ajustadas en los varones han pasado de 21,20 en 1975 a 20,21 por 100.000 habitantes en 2001. En las mujeres, la tasa cambio de 4,87 a 4,60 por 100.000 habitantes en los mismos anos. La evolucion de la mortalidad fue similar en ambos sexos. Conclusiones. La mortalidad por accidentes de trafico presento una evolucion oscilante, con un importante descenso a partir de 1989. Las tasas de mortalidad aumentan con la edad. Segun las predicciones realizadas, en los proximos anos continuara la tendencia estable iniciada a partir de 1995.

ObjetivoDescribir la evolución de la mortalidad por accidentes de tráfico en Andalucía desde 1975 hasta 2001 y predecir las tasas de mortalidad para 2004. Diseño. Estudio ecológico de base poblacionalEmplazamientoResidentes en Andalucía entre 1975 y 2001. Participantes. Defunciones por accidentes de tráfico en Andalucía desde 1975 hasta 2001Mediciones y resultados principalesSe calcularon las tasas de mortalidad ajustadaspor edad en varones y mujeres y en los grupos de menores de 35 años, de 35 a 64 años y mayores de 64 años. La evolución de las tasas a través del tiempo fue estudiada mediante análisis de tendencias. Se realizaron predicciones de las tasas de mortalidad a corto plazoLas tasas ajustadas en los varones han pasado de 21,20 en 1975 a 20,21 por 100.000 habitantes en 2001. En las mujeres, la tasa cambió de 4,87 a 4,60 por 100.000 habitantes en los mismos años. La evolución de la mortalidad fue similar en ambos sexosConclusionesLa mortalidad por accidentes de tráfico presentó una evolución oscilante, con un importante descenso a partir de 1989. Las tasas de mortalidad aumentan con la edad. Según las predicciones realizadas, en los próximos años continuará la tendencia estable iniciada a partir de 1995ObjectiveTo describe the evolution of mortality due to traffic accidents in Andalusia between 1975 and 2001 and to predict the mortality rates for 2004. Design. Ecological study with a population baseSettingResidents in Andalusia between 1975 and 2001ParticipantsDeaths due to traffic accidents in Andalusia between 1975 and 2001Main measurements and resultsMortality rates adjusted for age in men and women and in three groups: under-35s, from 35 to 64, and over 64. The evolution of rates over time was studied through trend analysis. Short-term predictions of the mortality rates were made. The adjusted rates for men fell from 21.20 per 100 000 inhabitants in 2001 to 20.21 in 2001. The rate for women fell from 4.87 to 4.60 during the same period. The evolution of mortality was similar for both sexesConclusionsTraffic accident mortality evolved in an oscillating way, with an important fall in numbers starting in 1989. Mortality rates increased with age. The predictions formulated indicate that the stable trend starting in 1995 will remain the same in the coming years