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In the context of a historical cohort study among workers in the pulp and paper industry, we examined the agreement between the underlying cause of death obtained from municipal mortality files and from the mortality register of Catalonia (n = 50 pairs). The percentage of simple agreement (P0) for major causes of death was 76%. The agreement and the Kappa index was higher for external causes (P0 = 98%; K = 0.87) and for cancer (P0 = 90%; K = 0.79). The agreement was moderate for mortality from circulatory diseases (K = 0.57). Agreement between 3 digit ICD codes was 48% but was higher for deaths from cancer (P0 = 67%). These results indicate that information on major causes of death and on specific causes of cancer retrieved from municipal mortality files may be used for the follow-up of historical cohort studies.

The creation of a national centre for public health, with adequate resources, will make it possible to face the public health challenges of the present and the future in our country. To this end, the proposed state agency, should hold functions based on advanced public health organizational schemes, while linking with the sustainable development goals. The coordination of a national public health strategy built on a collaborative network of networks would also be essential, as developing an innovative, benchmarked and prioritised public health communication strategy, among other tasks. The lack of resources, the current relative disconnection of essential public health functions at the state level, and the inequity in their development of these functions at the regional and municipal levels, favour the development of the agency project as a network of networks. In this paper we give ideas for a process that seems decisive for Spanish public health in the 21st century., (Copyright © 2021 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: The objective of this paper is to demonstrate that it is possible to monetize the social value generated by a hospital and use it to establish a different perspective to analyze the efficiency of public spending., Method: A public hospital in Spain was selected using the case method. It is suitable for two reasons; first, the hospital activity is small and therefore dialogue with stakeholders is easy; and second, as it is a hospital of a residential nature, it allows an easy, modifiable and testable approximation of social accounting in hospitals., Results: It establishes the monetary translation of the activity of a hospital, including the social part of the economic transactions (market), the variables that have not been created based on economic transaction, but have been perceived and valued by the stakeholders (not market), and the satisfaction of the stakeholders (emotional). This socio-emotional value amounts to approximately 60 million Euros per year from 2013 to 2017., Conclusions: The social value generated for the stakeholders, and its monetization, allows more efficient management of decisions towards the social purpose of public hospitals. In particular, the social value added index can be a tool for the social-efficiency of hospitals, as it establishes how much social value it generates from the public funding allocated to it. Thus, the decline in this value in recent years denotes a problem that, without this analysis with a social perspective and from the stakeholders, could not have been detected., (Copyright © 2019 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

During the economic crisis, developed countries have experienced financial fraud, with effects on the physical and mental health of the people affected, and on social domains. Based on the theoretical framework in literature reviews and in quantitative studies, this paper aims to obtain evidence on the effects of financial fraud on health and on the family and social environments of those affected. An intentional sample of 32 people affected by abusive and multi-currency mortgages, preferred and swap stock in Madrid was approached. In-depth interviews were conducted, and the resulting data was analysed using content analysis. Fraud-affected individuals had conditions of age, sex, educational level and occupations that possibly allowed them to accumulate economic resources throughout the course of their lives and, predictably in many cases, to take out fraudulent financial products, based on trust in the financial institutions. Financial fraud has led to the emergence of various processes of anomia and adverse health effects. The consequences on health were physical ailments (symptoms and diseases in various systems and parts of the body) and mental disorders (anxiety, depression, suicidal ideation), all affecting lifestyles, behaviour and personal and social relationships, both in affected individuals and their families. The increase in the use of medical drugs and health services serves as a final corollary to the imbalances on the affected people's health. Individuals and the Spanish society demand public health policy measures to mitigate the effects on health and the recovery of their confidence in the banking and political system., (Copyright © 2019 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

The biopsychosocial consequences in Spanish population affected by an eviction process were described in this paper. A scoping review was conducted, consulting the following databases: PubMed, Scopus, PsycINFO, CINAHL, LILACS, CSIC, MEDES, Scielo, Dialnet, Cuiden Plus and Cochrane. The search strategy was (Eviction OR "Home eviction" OR "Housing eviction" OR "Households at risk of eviction" OR Foreclosure) AND ("Health" OR "Mental Health" OR "Psychosocial impact" OR "Impacts on health" OR "Social impact indicators" OR "Social Determinants of Health" OR "Social Indicators").Eleven articles published between 2008 and September 2018 were selected. They followed a quantitative or qualitative methodology. The research quality was measured, and the results were organized according to the biopsychosocial model. From the physical perspective, results described a poor self-perception of health, as well as an increase of chronic diseases, pain, drug consumptions. From the psychological perspective, it was found negative thoughts, recurrent emotions and increased anxiety, depression, mental disorder and post-traumatic stress. From the social perspective, it was found that family, the offspring and the guarantor were affected, as well as the health system with greater medical visits and emergencies. This review showed worse health indicators among women, such as a headache, smoking habits, worse self-perception of health and more mental health disorders (depression, anxiety and other types of psychological distress). Daughters revealed worse self-perception of health than sons. It is necessary an approach from public health, epidemiological surveillance, action protocols and health programs, to advise, diagnose, prevent, protect and promote the health of the Spanish population affected., (Copyright © 2019 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

The objective of this article is to identify the effects of the Great Recession on the mental health of people residing in Spain. After presenting a conceptual framework on the mechanisms through which economic crises affect mental health, we describe the main results of 45 papers identified in our search. Studies indicate a worsening of mental health in Spain in the years of economic crisis, especially in men. Working conditions (unemployment, low wages, instability, precariousness) emerge as one of the main channels through which mental health is put at risk or deteriorates. This deterioration occurs with intensity in particularly vulnerable groups, such as immigrant population and families with economic burdens. In the case of suicides, the results were inconclusive. Regarding the use of health care services, an increase in the consumption of certain drugs seems to be identified, although the conclusions of all the studies are not coincidental. Social inequalities in mental health do not seem to have remitted. We conclude that Spain needs to improve information systems to a better understanding of the health effects of economic crises. In terms of public policies, together with the reinforcement of health services aimed at addressing mental health problems, an income guarantee network for people in vulnerable situations should be promoted, as well as the development of policies aimed at the labour market., (Copyright © 2020 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: In this paper we address whether the System for Personal Autonomy and Care of Dependent Persons contributes to increasing the volume of resources of the public social services system (displacement effect) or, on the contrary, whether this development has taken place at the expense of other social services (substitution effect)., Method: Panel data analysis is used to explain how per capita expenditure on social services evolves in the Spanish Regions under the common regime in the period 2002-2016., Results: The implementation of the Dependency Act is associated with a 14% increase in the level of per capita expenditure on social services. This effect raises 25% when the variable explained is expenditure on current transfers of a social nature. On the other hand, law changes introduced in 2012 and 2013 were associated with a reduction in per capita expenditure on current transfers of around 10%., Conclusions: This evidence would refute the hypothesis that the System for Personal Autonomy and Care of Dependent Persons had merely a "substitution" effect on autonomous spending on social services., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: Explore the strengths, weaknesses, opportunities and threats (SWOT) for development of public involvement in research by Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol) according to primary health care researchers in Catalonia (Spain)., Methods: Cross-sectional study carried out in 2017 with 36 primary health care research teams accredited by IDIAPJGol and its management staff. An open questionnaire (paper and online) was designed and piloted to develop a SWOT technique, and 65 answers were obtained (14 in paper and 51 online). A thematic content analysis was carried out., Results: Most informants consider public involvement in research a useful, innovative, viable and essential strategy, but it requires a change of mentality and a move away from the hierarchical paradigm. It can be difficult to execute and can complicate studies. They are concerned about which citizens should be involve, how to select them, possible conflicts of interest and training needs. The main proposals for its implementation are to disseminate previous strategies, encourage motivation and synergies among citizens, researchers and institutions, and to clarify the roles of the actors involved. IDIAPJGol should develop recommendations for the public involvement in research, encourage their inclusion, have a mentor and advise the research teams., Conclusions: Despite the challenges, developing public involvement in research in primary health care is essential and feasible, what it is more should be based on a participatory strategy with all actors. The citizens can participate in any kind of design and phase of the research, adapting each project, being the primary health care a privileged area to develop the public involvement in research., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

This paper describes the beginning of the implementation process of the health impact assessment in the Valencian Community (Spain), as an instrument to incorporate the framework of social determinants and health inequalities in the policies issued by the different departments of the Valencian government. The proposal involves: 1) political commitment, with legislative and strategic planning actions; 2) the creation of structures to allow intersectoral collaboration, with the establishment of the health impact assessment commission and the intersectoral technical committee; and 3) the design and validation of a tool for the simplified health impact assessment of non-health policies adapted to the Valencian Community. We highlight the importance of the participatory methodology used in the whole process and the potential of the health impact assessment for the development of public policies oriented to improve health and equity., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: This study examines individuals' choice of private health insurance in Spain. Private health insurance choices reveal the attributes of health care most highly valued by the population, and the perceived responsiveness of the public system in delivering those preferences., Method: The paper exploits the 2004, 2009 and 2014 waves of the national Health Barometer survey, examining the health insurance choice separately for the general population and a small but influential sector of elite public-sector employees who can opt out from the public health system (civil servants)., Results: Public healthcare is a highly regarded provider in terms of technology and doctor training, even by those who chose private health insurance, but falls short in terms of amenities such as comfort and speed of attendance. These findings confirm well-known strengths and criticisms of the public system. However, the study also finds that citizens are concerned about the performance of the public sector in key domains of health system responsiveness, such as personal contact and information and these concerns also influence their decision to opt for private provision. Finally, civil servants, even the minority who opted for public provision, tend to have a lower opinion of the public health service than non-civil servants, especially in terms of personal contact, information, primary care and specialist care., Conclusions: These perceptions and concerns of the public about the performance of the public health service will be of interest for policy makers and should be investigated further., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: This paper presents a methodology to optimize, using Altman's Z-Score for private companies, the prediction of private companies of the Spanish health sector entering a situation of bankruptcy., Method: The proposed method consists of the application of genetic algorithms (GA) to find the coefficients of the formula of the chain of ratios proposed by Altman in the version of the score for private companies which optimize the prediction for Spanish private health companies, maximizing sensitivity and specificity, and thereby reducing type I and type II errors. For this purpose, a sample of 5,903 companies from the Spanish private health sector obtained from the database of the Iberian Balance Analysis System (SABI) between 2007 and 2015 was used., Results: The results show that the predictive model obtained with the AG presents greater accuracy, sensitivity and specificity than that proposed by Altman for private companies with both test data and all sample data., Conclusions: The most important finding of this study was to establish a methodology that can identify the optimized coefficients for the Altman Z-Score, which allows a more accurate prediction of bankruptcy in Spanish private healthcare companies., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

This paper describes the use of focus groups as part of the evaluation of programmes to control food allergy and intolerance (FAI) in school settings in the city of Barcelona (Spain). After fostering their adoption and as a qualitative component of their evaluation, the public health services ran two focus groups, one with people from schools that manage their own kitchen, and another from companies that outsource this service. There were 28 participants from 46% of the centres invited. All the schools seem to have implemented a self-control programme on FAI. Although outsourcing companies already had a programme, the schools that managed their own service mostly adopted the programme promoted by the public health services. The number of schoolchildren with reported FAI reduced after the programme, as it required more rigorous documentation from families., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

It is essential to develop a comprehensive approach to institutionally promoted interventions to assess their impact on health from the perspective of the social determinants of health and equity. Simple, adapted tools must be developed to carry out these assessments. The aim of this paper is to present two tools to assess the impact of programmes and community-based interventions on the social determinants of health. The first tool is intended to assess health programmes through interviews and analysis of information provided by the assessment team. The second tool, by means of online assessments of community-based interventions, also enables a report on inequality issues that includes recommendations for improvement. In addition to reducing health-related social inequities, the implementation of these tools can also help to improve the efficiency of public health interventions., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Health promotion can contribute towards reducing inequality and ensuring equal opportunities, providing the means to enable the entire population to develop its maximum health possibilities. Women living in areas with social transformation needs (ASTN) are an especially vulnerable group due to the situation of material deprivation and social exclusion in which they live. Health promotion programmes for this group can bring about an improvement in their health. This paper describes the health promotion programme Socio-educational Groups of Primary Care for Women (SEGPC-W), and evaluates its implementation in ASTN in the city of Seville (Spain), as well as the benefits and difficulties of its development through a documentary analysis and interviews with participating professionals., (Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

In recent years, successful local health interventions have emerged in the field of community engagement in health. This paper presents a dialogue between different local actors about the key aspects which can enhance the success of these community experiences. The format chosen for our work is a semi-structured conversation where authors discuss different aspects related to the current context of community engagement in health, the identified barriers to participating, and the effective tools which might facilitate the development of successful experiences. Most of the community experiences, which are the basis of this analysis, are found in intersectoral workspaces; mainly in local committees and health councils, in which the authors of this paper are involved. Developing an inclusive model of community engagement is challenging, but we rely on different tools that allow us to promote the participation of citizens in the decisions taken concerning their health and that of their community. To facilitate the development of successful experiences, it is necessary to combine different normative, technical and methodological tools. Furthermore, we also need to guide our intervention to promote participation in all phases of the intervention cycle, including a health perspective in all the policies, and acting on determinants from an equity perspective., (Copyright © 2018 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

The thirteenth SESPAS (Spanish society of public health and health management) report is structured in three blocks Who, How and What about community health and local governance. In the who block the main agents working in community health are described: communities, health care system, and local government; and how their relations and implication in community health have evolved; which concepts are used; what is the current situation and which challenges they have. The How block contains methodological views, oriented towards implementation of community interventions, based upon participatory tools, development of networks and review of evidence and evaluations to build a National Strategy of Health Promotion of the Spanish Ministry of Health, welfare and consumers affairs including suitable deontologic principles. Finally, the what block refers to a wide range of experiences of community health at the local level as well as training in community health, urbanism, gender, neighborhoods, healthy universities. Additionally, besides regular papers, we show dialogs including debates to further develop community health. It contains 18 papers, without taking into account this introduction, authored by 40 men and 49 women., (Copyright © 2018. Publicado por Elsevier España, S.L.U.)

The way a person will develop over the lifespan is largely determined by the first few years of life. A substantial share of the inequalities in health and socioeconomic status observed in adult life originate during childhood (and even while in utero). In this paper, we first review the literature on the impact of childhood conditions throughout the life cycle. We next discuss some of the social and biological mechanisms behind the transmission of the effects of poverty during the prenatal period, childhood, and adulthood. We then analyze several international experiences aimed at reducing intergenerational transmission of poverty. The article ends with some critical thoughts and policy recommendations to avoid the possible long-term effects of the current crisis on the health and socioeconomic status of the "children of the crisis" in Spain., (Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.)

Objectives: Epidemiologic research on collective violence (violence exerted by and within groups in pursuit of political, social or economic goals) is very scarce despite its growing recognition as a major public health issue. This paper describes the conceptual model and design of one of the first research studies conducted in Spain aiming to assess the impact of collective violence in the health status of its victims (study known as ISAVIC, based on its Spanish title Impacto en la SAlud de la VIolencia Colectiva)., Methods: Starting with a comprehensive but non-systematic review of the literature, the authors describe the sequelae likely produced by collective violence and propose a conceptual model to explain the nature of the relationships between collective violence and health status. The conceptual model informed the ISAVIC study design and its measurement instruments., Results: The possible sequelae of collective violence, in the physical, emotional and social dimensions of health, are described. Also, the review distinguishes the likely impact in primary and secondary victims, as well as the interplay with the social environment. The mixed methodological design of the ISAVIC study supports the coherence of the conceptual model described., Conclusions: The ISAVIC study suggests that collective violence may affect the main dimensions of the health status of its victims, in intimate relation to the societal factors where it operates. It is necessary to validate these results with new studies., (Copyright © 2010 SESPAS. Published by Elsevier Espana. All rights reserved.)

Objective: To analyse Spanish scientific research output related to obesity during a 20-year period from 1988 to 2007 into context with the European Union productivity, Methods: The bibliometric study was based on research of the MEDLINE database in PubMed. Search terms were "obesity" appearing in MeSH. Linear regression was used to estimate trends in number of publications., Results: We retrieved 50,120 documents on obesity in the study period, and 1,407 were by Spanish authors (2.7% of the world production). Spain, accounting for 8.1% of scientific output in this area, was the fifth most productive country in the European Union; 932 (69.1%) of papers were published in English. The average yearly increase in publications was 15%, from 91 documents in the first five-year period to 702 in the last five-period. The most frequent specialty of first author was endocrinology (279 documents, or 22.8%), followed by physiology-nutrition-bromatology (203, or 16.6%), and biochemistry (161, or 13.2%). Journals publishing the largest numbers of papers on obesity were Medicina Clínica (83 or 6.1%), Obesity Surgery (79 or 5.8%), International Journal of Obesity (73) and Nutricion Hospitalaria (59). The most productive regions in Spain were Cataluña (338 or 24.9%), Madrid (286 or 20,6%), and Navarra (159 or 11,7%). The most productive institutions were hospitals, with 708 titles (52.1%), followed by universities, with 521 (38.5%)., Conclusions: Obesity research in Spain has increased over the last 20 years and accounted for a substantial proportion of European Union research in this field. Half of the papers by Spanish authors were published in international non-Spanish journals. Most of papers were carried out from hospital settings and universities., (Copyright 2009 SESPAS. Published by Elsevier Espana. All rights reserved.)

Interventions implemented by governments are very frequently related to the determinants of health. Health impact assessment (HIA) is used as a predictive tool to include health in nonhealth policymaking. This paper defines HIA, describes its methods, procedures and applications, and discusses opportunities and challenges associated with HIA. Doing a HIA implies studying the intervention, profiling the target population, and estimating its impacts on health by means of combining quantitative and qualitative evidence. HIA has been used in different kinds of policies (transports, urban regeneration, culture, energy development etc.), at different levels (local, national, European) and in many countries. Despite its scarce use in Spain, HIA allows to consider health in sectorial policymaking, taking into account social inequalities in health, so that healthier public policies can be designed. On the other hand, HIA is a tool under methodological development which use is hindered due to the existing narrow biomedical perspective on the determinants of health, and to the difficulties in working in public policy-making with multisectorial and participative perspectives.

The Spanish National Health System (SNHS) is currently in a complex equilibrium which, even if acceptable in the short term, faces major sustainability and governance challenges; the so far inconclusive outcome of the SNHS decentralization process clearly underlines the importance of seeking new alternatives to effectively bring about the real benefits of decentralization, while taking advantage of the system's economies of scale and achieving its equity objectives. To this end, four lines of action are proposed in this paper: first, redefine the SNHS based on universal public coverage, as a civic right and equal for all; second, reframe the financing system and the role of the Cohesion Fund; third, review the role of central government and its Ministry of Health, and fourth, create of a SNHS Agency headed by a Commissioner, for providing an organizational framework and identity for the SNHS, and serving as the cooperative body of the seventeen Autonomous Communities' Health Services.

The tendency for public welfare spending to be increasingly aimed at the elderly has been identified in several developed countries. While population aging is a common trend, it is not obvious why the shift in spending exceeds the trend in aging, or why per capita spending on the elderly is increasing. In the first part of the present article, we show that this trend is occurring in Spain, identify the losers from this development, discuss the policies that underlie it, and propose adjustments based on Musgrave's fixed proportions rule for fair intergenerational distribution. These policies aim to manage population aging, labor market participation of youth and women, as well as public policies that combine 'work-fare' strategies with the more traditional 'welfare' strategies. In the second part of this paper, we explore the contribution of public health expenditure to overall public social expenditure, and analyze the effect of increasing health on distributional fairness. This analysis is guided by our perception that social policy, including health policy, should be more horizontal, i.e. it should take into account the sum total of a mixed basket of resources aimed at any recipient group, to avoid the skewed allocation of resources that arises from compounding various independent distributions of resources. Coordination of the various channels of social expenditure should ensure precisely targeted recipients and cross-departmental sources. The normative fairness criterion to be used should be precisely specified. In Spain (1980-2000) the oldest segment of the population has gained the most, appropriating an increased share of resources. This increase goes beyond the amount that could be explained by population aging throughout the period. The 'losers' are individuals with different fragility conditions. On average the youngest working group has suffered the highest relative loss.

The paper comments on present and future scenarios for the pharmaceutical sector in Spain, framed a highly regulated system. So far the drug industry has evolved under the short term public financial constraints for additional health care spending and the long term efforts to innovate. This has not proved to offer a stable setting for the relationship between the industry and Health Authorities. The author offers from the economic analysis and a subjective appraisal from his experience some recommendations for regulatory changes in order to better align the incentives of the parts for improving the health system as a whole. The basic point is that 'consumption levels' (quantities) and not <> (unit costs) are the main challenge to tackle today in our Public Health Care system, and for this the decentralisation of financial responsibility is not in itself 'the' problem but it may well be a part of the solution.

Introduction: The object of this short paper is to present the results of Spanish public health care expenditures projections until 2013 according to the expected impact of the main demographic and technological health cost drivers., Material and Methods: Future annual health expenditures are estimated using a simple method based on the decomposition of the past main growth factors in two scenarios. The main cost drivers considered were the following: demography, which includes the increasing number of people and the impact of population ageing; the increase in the price of health care inputs above the general price level; and the impact of changes in medical practice related with expanding medical technology., Results and Discussion: In 2013, public health care expenditure may be around 5.7% and 6% of gross domestic product (GDP); that is, at least, between 0.24 and 0.53 additional GDP points will be spent on public health care. The main factor responsible for the future expenditure increase will continue to be the increase in the average health service intensity, followed by demographic factors. In the base-case scenario, public expenditure increase until 2013 will be compatible with a real 2.5% annual increase in consumption of non-health goods and services. In order to finance the future costs, the Spanish population will have to devote to public health expenditure less than 7% of income increase until 2013., Conclusion and Perspectives: Despite being important, the expected Spanish GDP growth until 2013 may be enough to finance the increase in public health expenditure as a result of the impact of demographic changes. Expanding medical technology is expected to continue being the main driver of future costs.

This article summarizes the impact of health care financing instruments on inequalities of supply, access and use of health care services. Firstly, the new scheme of regional and health care financing, apart from the initial gains in terms of equity and sufficiency, introduces uncertainty about the volume of resources that will be devoted to health care facilities by the regions. This fact may cause some inter-territorial inequalities in the health care supply and the access to public services. The Health Care Cohesion Fund, which was designed to guarantee equality of access to the National Health Service, is not the optimal instrument to achieve such an ambitious goal. Secondly, the change in composition of health care financing sources, by increasing the burden of indirect taxes, may imply some losses of vertical equity or progressiveness. Finally, this paper analyses the possible impact that the present allocation of public health funds, excessively biased to specialised health care, may have on inequalities in the use of health care facilities.

Both gender bias studies and evidence-based medicine share the hypothesis of the existence of empirical uncertainty in medical practice. Nevertheless there is a lack of information regarding variations and sex, possibly due to androcentric reasons. Many biomedical studies--including randomised controlled trials--, have used men as the population's prototype and applied its conclusions to women. This approach is based in an erroneous assumption of equality between men and women. Gender bias research on therapeutic efforts are focused on hospital accessibility for the two sexes for equivalent health needs, comparison in delays and waiting times from the early symptoms to care, differential therapeutic strategies and differential consumption of, and expenditure on, medication. Also, research on over prescription of therapies are included in the health problems affecting only or mainly women. Gender bias in therapeutic efforts depends on the gender bias in the diagnostic efforts. Insofar as the probability of being treated once suffering a problem vanishes if for any cause the individual in question is excluded from the diagnostic process, or diminishes if the appropriate tests are not performed in the diagnostic process. The aim of this paper is to present an approach to the evidence of gender bias in therapeutic strategies in Spain.

The objective of this study is to compile, describe and assess interventions to reduce health inequalities developed in Spain by administrations, NGO or other entities. The search was organized in three settings: governmental strategies, interventions, and among the latter, those particularly addressing excluded social groups. Administration actions and policies were investigated through formal surveys addressed to regional governments (17 regions and 2 cities). Production of information by gender and socio-economic level (SEL), plans and programs, as well as interventions was explored. Key informants were consulted and scientific literature was reviewed in order to identify interventions. Médicos del Mundo and Cáritas, two of the main national NGO were consulted. Fourteen administrations responded. In general, health information includes sex analysis, few administrations analyse by gender or SEL and six study inequalities in the general population. Most administrations produce specific information by pathologies (HIV/AIDS.) or social groups (women.). They mention intervention experiences applied to territories or vulnerable groups, evaluated through process indicators. In the period 1995-2002, 722 papers on inequalities in Spain have been published. Among them, 28 are interventions and 9 have been evaluated, mainly with quasi-experimental designs. Large NGO, sometimes with public funding, work with excluded populations through outreach programs. Most Spanish health information does not include yet inequalities analysis, although it is growing steadily. Publication of inequalities studies has increased sharply, but intervention publications are rare and evaluated interventions are extremely scarce. Administrations and NGO work in interventions mainly addressed to excluded populations.

The worst environmental disaster of the history of Spain favoured a renewed social awareness of the intimate relationships that exist between the state of the environment and the health of human beings. However, the health of the populations most involved in the Prestige oil spill was initially not the chief concern of political authorities. The main aims of the present paper are: first, to comment succinctly on some of the most significant activities conducted by a variety of social actors during the Prestige crisis; and second, to suggest the main potential objectives and characteristics of the epidemiological studies necessary to assess with a sound rational basis the possible impact of the accident on the health of workers, volunteers and residents in the spill areas. The authors hope that in the near future it will be possible to scientifically assess the results and implications of several studies (epidemiological and of other sorts) well designed and conducted.

Introduction: Gypsies form an ethnic minority settled in Spain in the 15th century. At present, this collective presents certain social, economic, and health inequalities in comparison with the remaining population. The need for health interventions among the gypsy population is well known., Objective: To determine which health-related matters among the Spanish gypsy community had received attention in the literature, and whether their ethnic differences and social inequalities in health had been studied., Methods: We reviewed the literature published in the last 20 years. An international Medline search was performed. We also searched national and local papers through the IME-CSIC (Spanish Medical Index) database and the Internet., Results: There were 96 valid articles on health among Spanish gypsies, of which 62 were published in Spanish journals and 47 had been published within the previous 6 years. Fifty-seven studies were performed in hospitals, 20 in public health centers and 13 in primary care centers. Eighty-eight percent were observational studies. The most frequent topics were genetics or congenital anomalies (30%), transmissible diseases (21%), child health (11%) and health sociology (11%). Fifty-seven percent of the studies reported some social inequalities in health., Discussion: The Spanish gypsy community constitutes a health risk group due to ethnic and genetic factors. Moreover, they also have strong social inequalities in health related to mortality and morbidity in transmissible, chronic and environmental diseases due to socioeconomic and cultural factors, as well as to insufficient access to and use of health services.

Objective: To analyse the contributions that the participants in a formative activity elaborated respect the viability of the coaching in the health environment., Method: Qualitative study of the contributions of the 18 participants in the workshop upon applications of the coaching in the health environment carried out the month of March 2002 at the Institute of Health Studies (IHS)., Results: The contributions deal with: a) the opportunities: help to healthcare professionals that become to exercise directive responsibilities and strategies to help for the cultural change, and b) the objections: resistance to change, utilization as punishment, results difficult to measure., Conclusions: The methodology of the coaching is susceptible of being applied in persons that they should exercise a key paper in a health organization, above all in process of change.

This paper analyzes the extent to which an increase in tobacco taxes affects the demand for tobacco products, especially for cigarettes. Comparison of the studies reviewed revealed that higher tobacco taxes result in higher tobacco prices. The price-elasticity of cigarette demand in low- and middle-income countries is about double that in high-income countries, about 0.4. Furthermore, because of the addictive nature of tobacco use, demand for tobacco products is more elastic in the long run than in the short run. The effect of higher tobacco taxes is greater on the young, among whom demand is more sensitive to price than among adults. The empirical evidence for Spain estimates the price elasticity of cigarette demand in the short run to be in the range of 0.5 to 0.3, a result which is similar to other studies. These results do not suggest that tax policy is an effective tool for tobacco control, although taxes are useful for their revenue generating potential and for compensating the external costs generated by tobacco consumption. Furthermore, when the possibilities of substitutions among brands and the strategies of the tobacco industry to compensate for the effects of taxes (lowering prices and encouraging cigarette smuggling) are considered, the panorama is even more pessimistic

Objective: The aim of this paper was to analyze how public health functions are covered in large or medium-sized cities in Catalonia (Spain) by assessing the role, activities and structure of local services., Methods: Data were collected through a questionnaire with items on public health functions and activities and on the structure of municipal services. The study population comprised the 43 cities of Catalonia with a population above 25,000 (3% of towns and 70% of the population). Answers were obtained from 28 cities (65%), covering 60% of the population of Catalonia and all towns with a population above 50,000 inhabitants., Results: The public health function in which local governments were least active was need assessment while they were more active in policy development and service delivery assurance. For public health activities, the role of local governments was relatively greater in health protection while few municipal services were active in epidemiological surveillance and substance abuse. Municipal public health expenditure per resident/year was estimated at 1,063 pesetas (approximately 6 Euros). Among the public health personnel, 72% worked full-time while the remaining (mainly members of the corps of health officers serving local administration) worked part-time. Local governments often mixed within the same structure public health services and services, mainly consumer affairs, environmental or social services., Conclusions: Local governments showed significant activity in public health. The volume of resources involved and management capacity were considerable. In some cities, some public health activities were perceived as not covered.

Objectives: The objectives of this paper were to analyse the effect of social, personal and medical risk factors on preterm birth (moderate versus very preterm) or on two preterm birth groups (spontaneous versus indicated)., Methods: Results from the Spanish collaborating centre of the European multicentre case-control study EUROPOP (European Program of Occupational Risks and Pregnancy Outcome) are presented. All preterm births (529) between 22 and 36 completed weeks of amenorrhea and 788 births of 37 or more completed weeks of amenorrhea (control group) are included. Explicative variables are divided in social, personal and medical factors. A univariate and multivariate analysis by means of a logistic regression were carried out., Results: Very preterm birth risk was higher for women over 34 years, adjusted OR: 2.53 (1.42-4.52), with lower educational level, adjusted OR: 1.79 (1.07-2.98), for primigravid women or multigravid women with only first trimestre abortion, adjusted OR: 1.86 (1.13-3.04), and for multigravid women with previous preterm birth or second trimestre abortion, adjusted OR: 5.53 (2.97-10.35). A similar trend was observed for moderate preterm birth. Probability of spontaneous preterm birth was higher for mother over 34 years, adjusted OR: 1.51 (1.01-2.26), with lower income, adjusted OR: 1.75 (1.07-2.88) and for multigravid women with previous preterm birth or second trimestre abortion, adjusted OR: 2.96 (1.86-4.71). Results were similar for indicated preterm birth., Conclusion: Social differences were found to be related to moderate and very preterm birth. No differences were observed between risk factors and kind of preterm birth: spontaneous or indicated.

Objective: To measure the mediatic effect of different communication strategies used in public health advocacy. More specifically, to compare the effectiveness of the World Wide Web as a tool to attract the attention of journalists, with other more traditional formulas., Methods: For the Spanish Public Health Association (SESPAS) Report 2000, two types of media strategies to communicate the report contents were programmed: a) traditional and passive strategies, centred in approaching journalists through press releases and press conferences around the SESPAS meeting (November 15-20 1999); b) interactive strategies, since August 15 to December 30, focused towards attracting health journalists to the non-embargoed, full text SESPAS report launched in a web site. To facilitate the web page use, we wrote a letter, in the first week of August, to all the members of the Spanish Health Communicators Association giving them the URL and the website map. In parallel, a monitoring system of the media impact was established from August to December 99, covering 250 magazines and 70 newspapers, in order to locate and recover all the stories about the SESPAS report for further analysis., Results: Sixty-six stories were recovered; they were published in 32 press media from 24 provinces with an advertising value of 18,243,873 Ptas. As a whole, smaller circulation rate papers published more stories than larger ones. During five months, the SESPAS report was present in the press agenda, even though stories were not distributed homogeneously over time. Information concentrated around three moments: the first one, a week after our summer mailing; the second one, in the occasion of the publication of a story about the increase in traffic accidents in El País, and the third one during the SESPAS meeting. There were significant differences among those stories published from the traditional strategies of communication and those published from the interactive ones, the latter being more diverse, with more contributions of the journalists and tackling a wider range of issues., Conclusions: The combination of traditional and alternative communication strategies was a effective option. Unlike previous experiences in this occasion, with the network aid, the presence of SESPAS in media was not punctual around the Congress, but maintained during five months. The results and the obtained experience of this research can be useful for future public health advocacy interventions in Spain.

Background: This paper is based on a qualitative study undertaken between July and August 1998 among the residents of the area close the mining waste spill that occurred the 25th of April 1998 in Aznalcóllar, Seville, Spain., Objectives: To contribute to the identification of some clues about risk perceptions among the population living at the vicinity of the toxic spill, focusing especially on the perceived health risks, the sources of information, their credibility, and the expectations for the future., Methodology: Combined qualitative research methodologies were used, including interviews and focal groups., Results: The findings show the existence of a perception of the economic consequences of the spill. In a second level possible the consequences for the health status were relevant. Perceived health risks referred to long term effects, such as malformations and cancer. No changes in habits and behaviour are expressed. The information comes from the media, even if mistrust and perplexity are associated with the information received. There is low of credibility towards the administration, ecologist groups and the media. The role of the health system appears poorly defined. The perceived absence of an adequate information to the audience is noted, and there is a demand from the affected population for an informed participation in the process of management of environmental risks., Conclusions: The findings of this work stress the importance of an adequate communication process in the management of health risks associated with environmental hazards. Moreover, it also highlights the need to improve the knowledge about environmental risk perceptions in our country through both quantitative and qualitative research, in the context of the modern risk management and the growing relevance of environmental topics in the social agenda.

Background and Objectives: The knowledge of time-related changes occurring in cancer incidence and mortality is an essential element for cancer control. This paper aims to describe the time trends of the more important cancer sites in Navarra and Zaragoza., Methods: The influence of age, diagnosis period and birth cohort on the observed time trend cancer incidence in Navarre and Zaragoza was assessed using a log-linear model. Results are showed graphically, for the different tumour sites by sex and each registry., Results: Among males, a considerable rise in the incidence of lung cancer (5% per year), prostate cancer (> 2% per year) and non-Hodgkin's lymphomas was found. Among females, the highest increases corresponded to non-Hodgkin's lymphomas, with a yearly rise greater than 7%, and ovarian cancer (4% per year). Breast cancer in women increased in both registries (3.5% per year in Navarre and 0.9% per year in Zaragoza), part of the increment in Navarra being explained by a higher case detection rate. Finally, the incidence of colorectal, bladder and kidney cancer rose more than a 3% per year in both registries and sexes. For most types of tumours, cancer risk increased with subsequent generations., Conclusion: The substantial cancer increment observed points out the inefficacy of primary prevention policies, the importance of studying cancer incidence for long time periods and the need to increase the population coverage of Spanish cancer registries.

The identification and measurement of the population health needs should be the first step in health planning. In order to guarantee equity criteria, to know the situation of the whole population, and therefore also that of women, is a key issue. Health interview surveys are a good tool for pinpointing the needs of the population, but mainly they are usually focused on health risk factors that explain men's health status such as health behaviours and paid job. These factors often fail to capture aspects that are relevant for women's health, such as household work. The main objective of this paper is to emphasise the importance of a gender perspective in the design and analysis of health interview surveys, and to propose variables that should be included in health surveys in order to better know gender health inequalities. Likewise, this article deals with the gender concept and its importance as a health inequality factor. Gender is an analytical construct based on the social organisation of the sexes that can be used to better understand the conditions and factors influencing women's and men's health beginning by the social roles that each culture and society assigns to people based on their sex. Health is a complex process determined by a wide range of factors: biological, social, environmental and health services related factors. Gender, because of its close relation to all of them, plays a key role. The gender approach is characterised by the analysis of the social relation between men and women, taking into account that sex is a determinant of social inequalities. This paper presents the variables that health interview surveys should include from a gender approach point of view: reproductive work, productive work, social class, social support, self-perceived health status, quality of life, mental health and chronic conditions. In addition, issues related to the wording of questions, data collection and analysis are discussed.

Objective: To characterise the factors that, from a primary care physician's point of view, are related to inappropriate referral from primary to specialised health care., Methods: We conducted two focus groups and two semi-structured interviews with primary care physicians. Each of the participant's profiles was defined according to variables related to inappropriate referral found in previous studies. Discussions were recorded on audio tape and later transcribed verbatim onto paper. We analysed the factors related to inappropriate referral according to frequency and capacity for generating discussion., Results: Primary care physicians have different concepts regarding inappropriate referral, besides health problems that can be solved in primary care. Inappropriate referral is usually justified. Factors related to inappropriate referral can be divided into four groups: 1) related to the patient and patient/doctor relationship: pressure exerted on the primary care physician, caused by a belief in specialists' greater competence, the right of the patient to specialist referral and mass media pressure; 2) related to the health system: lack of coordination between care levels, consultancy time pressure, lack of equipment and distance to the specialist; 3) related to primary care physicians: lack of training and defensive medical practise; 4) related to specialists: professional competence and behaviour with patients., Conclusions: A notable gap can clearly be seen between primary and specialised care, and this generates problems in the health system. It is difficult to implement prevention and control measures with the factors related to inappropriate referral. Primary care physicians form opinions that are not based on available evidence. Further research is needed in both qualitative and quantitative fields.

Introduction: The epidemic of heroin use began in Barcelona, as in the rest of Spain, in the late 70's, to reach its peak by the end of the 80's. In a first period, responsible officers experimented difficulties to define the specific objectives of opiate control policies. This paper reviews the effects of the adoption of an explicit policy on drug dependence grounded on a wide consensus in the City of Barcelona (Catalonia, Spain)., Subjects and Methods: Over a period of twelve years, from 1986 to 1997, both demand and offer of care and harm reduction services were analyzed, as well as the evolution of the adverse effects of drug use, such as mortality from acute adverse drug reaction, human immunodeficiency virus (HIV) infection, aids incidence, and incidence of tuberculosis. Data for city residents was compared through four different stages in this period., Results: Despite the lack of data in initial years, relevant changes are apparent. Treatment offer changes clearly, with significant increases in initial treatment, coverage of methadone maintenance programmes, and sterile syringes distribution. Therapeutic compliance of tuberculous intravenous drug users IVDU and risk of HIV infection improve. Emergency service use linked to heroin, overdose, or withdrawal syndrome decreases. Mortality rates decline, although this decline does not reach statistical significance., Discussion: Service offer shows a clear increase, reflected in treatment initiation, while harm reduction services expand. With the development of this process, outcome indicators change, both reflecting changes in the toll of the heroin epidemic (cases of tuberculosis and aids among IVDUs, HIV infection). and changes in a more comprehensive care (better treatment compliance of IVDUs with tuberculosis). There is a lower distortion of emergency services. These changes occur although the predominance of white heroin in Barcelona favors parenteral use.

In this brief paper, discussion focuses on options currently under consideration for the reform of the Spanish health care system. After a brief review, readers are advised, in view of the consequences of each option, to consider all the arguments in order to make fully informed decisions. Finally, it is proposed that, in view of what is known and unknown about the effects of different health care policy options, a research agenda be found that avoids both complacency and categorical affirmations regarding this complex topic. Arguments are roughly presented as an algorithm. Simplifications are made for the sake of clarity and the analysis is qualitative. Each nexus of the algorithm covers the most relevant aspects of the economic and health care issues that each alternative involves. In the author's opinion, these points should be kept in mind when making decisions.

Introduction: Despite of the fact that it was reported for years that emergency rooms are the first health services where drug users attend, there are very few direct studies of this population. In most emergency room studies, the information was obtained from data available in the clinical records, and in very few drug users were interviewed. With the aim of having a deeper knowledge of opiate users who attend the emergency room it was planned to carry out a cross-sectional study interviewing them. The aims of this paper are to describe demographic characteristics, patterns of drug use and to know whether they contact first to an emergency room or to a treatment centre., Methods: The sample included all patients detected and referred by the doctor as being current opiate users, defined as any use in the 30 days prior the interview. A descriptive bivariate analysis with simple stratification was carried out., Results: Of the subjects referred by the doctor 383 opiate users were interviewed and 76 were not interviewed. The male/female ratio for the 383 interviewed opiates users was 2. Women were younger than men (25.8 vs 28.3, p (3/4) 0.001). Heroin or cocaine ever injected was reported by 93% and 76% reported injecting in the last 30 days. The mean age at the first use of heroin was higher for those who started use during 1989 or after (21.6) than those who started before 1989 (17.9) (p (3/4) 0.0001). Patients attending the emergency room for organic pathology were older (28.5) than those who attended for withdrawal (26.2) and those who attended for overdose (27.3) (p (3/4) 0.05). Thirty eight percent reported to attend first an emergency room for a drug related problem since they started drug use, and 47% to contact first with a treatment centre for drug dependence., Conclusion: Drug users interviewed seem to be more heavy users than those who started drug treatment in the public centres of Barcelona in 1992. Also, the hypothesis that emergency rooms are for this population the first contact point with health services is not supported by this study.

Background: Because adolescence is the stage during which most people begin their drug use, we wanted to investigate adolescent's use of and attitudes towards drugs. This paper aims to describe prevalence of students (14-18 years old) drug use in the city of Terrassa (Spain) for the school year 1994-1995., Methods: A school survey was carried out for a representative sample of 1,269 students. A questionnaire was developed following W.H.O. guidelines. It includes information on demographic characteristics, legal and illegal drug use, information and attitudes towards drugs, and other related factors., Results: Thirty seven percent smoked within the last 30 days, and 60% drunk alcohol. Thirty-two percent had been drunk at least once. Cannabis was the most widely used drug (25.9%) followed by hallucinogens (7.2%), tranquillizers (4.4%), inhalants (4.3%), amphetamines (4%), cocaine (1.7%) and heroin (0.2%). The prevalence for the use of cannabis within the last 30 days was 11%, and around 1% for the use of all other drugs within the same period of time. Increased drug use was observed with age. No differences among sexes were observed for prevalence of tobacco and alcohol use, although boys showed a more intensive pattern. For the other drugs, higher prevalence was observed in the male population except for tranquillizers whose use was more prevalent among women., Conclusions: The high prevalence of drug use observed, suggest the need to introduce more extensively programs for the prevention of drug use, beginning in primary school.

This paper describes the process to design and plan a vaccination campaign against group C N. Meningitidis developed in the Autonomous Community of Galicia between December 9, 1996 and January 31, 1997. We also analyse the results of this process in terms of management results, vaccine coverage and preliminary estimates of effectiveness. A Work group was established, made up of professionals in charge of different intervention areas. A person was designated in charge of the whole campaign and a follow-up and information system was created. The work plan consisted of daily meetings for follow-up, co-ordination and task distribution; and periodical meetings with primary health care and peripheral public health coordinators. Strategies of implantation--in order to make sure the campaign accessibility and acceptability; of budget and of communication with health workers, inhabitants and mass media were developed. Up to 100 tasks were identified to develop the technical information and logistic activities: mailings, meetings, leaflets, ...; purchasing of 584.980 doses of vaccine, supplying to 715 vaccination points (1040 deliveries); problem solving and intervention recording. A vaccination coverage of 85% was achieved, with notification of 8 adverse reactions and 6 errors in the administration of the vaccine (34 children affected). The strategy chosen for the design and planning of the campaign has proven to be effective and valid and sufficient to achieve the final goals, in due time and without problems of misinformation, shortage of vaccine or lack of participation of professionals or people. Mistakes due to incorrect administration of the vaccine, management problems, rupture of the cold chain or recording failures were minimal and accidental.

Objective: Measuring social class is important for evaluating its influence on health status and on the access to health services. This paper is aimed to assess the construct validity of the classification of social class based on the individual's occupation., Methods: Data come from the Barcelona Health Interview Survey of 1986. In the survey, 2,205 households and 6,894 individuals participated (82% of the eligible households and 84% of the eligible individuals). Information was gathered on, among other issues, the following socioeconomic variables: annual family income, lack of some household services, property of the household, education level and occupation of the individuals, as well as their occupational situation and labor relationship. Data about the value of the household was collected from the City Council census (catastro). Social class was assigned using the individual's occupation or, if none, the head of the household's occupation in the following groups: I, II, III, IVa, IVb, V, and "Not Classified". The association between social class and socioeconomic variables was analyzed using: ANOVA for the comparisons of continuous variables, Chi-squared test for categorical variables, Spearman correlation coefficients and discriminant analysis., Results: A total of 3,357 individuals reported an occupation. "Employed in administrative services" was the most common (14.3%). Social class was "Not classified" in 6.4% of the individuals. All socio-economic variables showed statistically significant differences, following a predicted pattern: better indicators for more favoured social classes. Social class showed a moderate to high correlation with education level (r = 0.57) and somewhat lower with the other variables. Variance in socioeconomic variables explained by social class was higher than the 95% (p < 0.001)., Conclusions: The pattern of relationships between socio-economics variables was intense, monotone and consistent, suggesting that the occupation is a valid and feasible of social class. Routinely including occupation in health information systems should allow to monitor inequalities in health in Spain.

Objectives: The ambulatory care groups (ACGs) were developed at the Johns Hopkins University in 1987 and they differ from other systems because their longitudinal approach and its capability to describe the case-mix of a population of reference. This paper describes the ACGs and assess its potential application to spanish primary care (PC)., Methods: Observational study with the voluntary participation of 13 physicians (general practitioner and paediatrician) and nursing staff. During six months all diagnoses and interventions to a sample of attended patients were gathered., Results: The first stage in grouping involves ascribing one of the 34 ambulatory diagnostic groups (ADGs) to each of the health problems attended. The second stage involves, after several intermediates steps, assigning one of the 51 ACGs to each patient. The total number of episodes was 7,559 (input), the number of patients (output) 2,467, the ICD codes with error 292, and the number of patients with ICD codes with error 278. With 5 ACGs we classify 44% of all the patients and with 10 ACGs, 64% of all them. Only two ACGs were empty. The article explores the potential applications of the system in spanish PC: for provider financing when a capitation payment component were introduced, utilization review and quality assurance when we compare several providers or populations, and research interested to link the process and its outcomes., Conclusions: Among the various patients classification system for grouping ambulatory care, the ambulatory care groups (ACGs) appear as the method with more potentialities to PC in Spain. The ACGs should be validated before been applied and its adaption to a more suitable PC classification of diagnoses would assists its extension.

The analysis of small area variation (SAV) is useful to correlate hospital utilization rates with supply. In this paper the SAV techniques are applied to 26 areas of Catalonia, whose population is covered by the same hospital or group of hospitals in more than 75% of occasions, and hospitalization rates for several surgical procedures (appendectomy, herniorraphy, cholecystectomy, prostatectomy, hysterectomy, tonsillectomy and lens extraction) are analyzed. For these purposes, 26482 discharges recorded in the Minimum Basic Data Set of Hospital Discharges in 1993 were studied. The obtained results show a great variability between areas, which sometimes is larger than the reported in the literature. For amigdalectomy, the ratio between highest and lowest hospitalization rates is 8.8. For prostatectomy and lens extraction the ratios are 4.8 and 4.5, respectively.

In the context of Public Health in Spain, Environmental Health does not possess the consideration it should have, according to the General Health Law and to the attention given to it frequently by our politicians in their speeches. The objectives of this paper are, on the one hand, to make a working proposal in the Environmental Health arena for the different Autonomous Communities in our country that takes into consideration, both the historical context from which we depart, and the philosophical standpoint we believe must underlie in the proposals; and on the other hand, that this working proposal be able to connect with the concerns and the social sectors that can give it the sufficient energy it requires to be reactivated on behalf of the prevention of environmental hazards. Besides, another underlying purpose of this group is that starting from this opinion paper, we can open a debate about the role of Environmental Health. We consider that this debate has been delayed for much time. We propose a serious debate; scientific, reflexive, critical, deep and vehement, so that Environmental Health will come out to the light with its own tools; those of the fields of Environmental Epidemiology, Toxicology and the Evaluation of the Environmental Impacts on Health.

This paper explores the relation between ideology and efficiency of the health care systems. In order to achieve this goal, this study: analyzes the relation between ideology and health care system organization, defines the concept of health care system efficiency, and reviews the relation between health care organization and efficiency. The last part of the paper is devoted to discuss the relevance of the conclusions of the above mentioned analyses to the debate on the reform of the Spanish National Health Care System.

Establishing causal relationships has been and is today a matter of debate in epidemiology. The observational nature of epidemiological research rends difficult the proving of these relationships. Related to this, different models and causal criteria have been proposed in order to explain health and disease determinants, from pure determinism in Koch postulates, accepting unicausal explanation for diseases, to more realistic multicausal models. In occupational health it is necessary to formulate causal models and criteria to assess causality, and frequently causal assessment in this field has important social, economic and juridical relevance. This paper deal with evaluation of causal relationships in epidemiology and this evaluation is illustrated with a recent example of an occupational health problem in our milieu: the Ardystil case.