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Resumo Introdução Os medicamentos são a intervenção terapêutica mais utilizada e a mais custo efetiva para o tratamento de diversas patologias. A falta de acesso a medicamentos entre grupos com menores condições socioeconômicas representa uma iniquidade nos cuidados com a saúde. Nesse sentido, o fornecimento gratuito de medicamentos pelo setor público é essencial para a promoção da equidade. Objetivo Avaliar a mudança, no tempo, da prevalência de acesso gratuito, pela população adulta brasileira, a medicamentos prescritos no Sistema Único de Saúde (SUS) ao longo de 10 anos. Método Análise dos dados, por regressão logística, das Pesquisas Nacionais por Amostra de Domicílios (PNAD) realizadas no Brasil em 1998, 2003 e 2008. A variável de interesse foi o acesso gratuito a medicamentos prescritos. Resultados O acesso gratuito a medicamentos pelo Sistema Único de Saúde aumentou ao longo do tempo. Indivíduos com renda socioeconômica mais baixa tiveram maior chance de acesso a medicamentos e esse cenário se manteve constante ao longo dos anos avaliados. Conclusão Os achados revelam a importância do SUS como ferramenta efetiva para a promoção do acesso a medicamentos, especialmente para os indivíduos mais pobres. Entretanto, a redução da desigualdade no acesso a medicamentos permanece como desafio. Abstract Background The medicines are the most used and most effective therapeutic intervention for the treatment of various pathologies. The lack of access to medicines among groups with lower socioeconomic conditions represents an inequity in health care. In this sense, the public supply of medicines is free of charge by the public sector to promote equity. Objective To evaluate the change, in time and prevalence of free access, by the Brazilian adult population, to medicines prescribed in the Unified Health System (SUS) over 10 years. Method Data came from the National Household Sample Surveys (PNAD) conducted in Brazil in 1998, 2003 and 2008. The dependent variable was free access to prescribed medicines. Results Free access to medicines in the SUS increased over time. Individuals with lower socioeconomic income had higher chance to access the medicines and this scenario remained constant over the years evaluated. Conclusion The findings reveal the importance of SUS as an effective tool for promoting access to medicines, especially for the poorest individuals. However, reducing inequality in access to medicines remains a challenge.

Background The positive effects of cardiac rehabilitation are well established. However, it has an inherent challenge, namely the low attendance rate among older vulnerable patients, which illustrates the need for effective interventions. Peer mentoring is a low-cost intervention that has the potential to improve cardiac rehabilitation attendance and improve physical and psychological outcomes among older patients. The aim of this study was to test the feasibility and acceptability of a peer-mentor intervention among older vulnerable myocardial infarction patients referred to cardiac rehabilitation. Methods The study was conducted as a single-arm feasibility study and designed as a mixed methods intervention study. Patients admitted to a university hospital in Denmark between September 2020 and December 2020 received a 24-week peer-mentor intervention. The feasibility of the intervention was evaluated based on five criteria by Orsmond and Cohn: (a) recruitment capability, (b) data-collection procedures, (c) intervention acceptability, (d) available resources, and (e) participant responses to the intervention. Data were collected through self-administrated questionnaires, closed-ended telephone interviews, semi-structured interviews, and document sheets. Results Twenty patients were offered the peer-mentor intervention. The intervention proved feasible, with a low dropout rate and high acceptability. However, the original inclusion criteria only involved vulnerable women, and this proved not to be feasible, and were therefore revised to also include vulnerable male patients. Peer mentors (n = 17) were monitored during the intervention period, and the findings indicate that their mentoring role did not cause any harm. The peer-mentor intervention showed signs of effectiveness, as a high rate of cardiac rehabilitation attendance was achieved among patients. Quality of life also increased among patients. This was the case for emotional, physical, and global quality of life measures at 24-week follow-up. Conclusion The peer-mentor intervention is a feasible and acceptable intervention that holds the potential to increase both cardiac rehabilitation attendance and quality of life in older vulnerable patients. This finding paves the way for peer-mentor interventions to be tested in randomized controlled trials, with a view toward reducing inequality in cardiac rehabilitation attendance. However, some of the original study procedures were not feasible, and as such was revised. Trial registration The feasibility study was registered at ClinicalTrials.gov (ClinicalTrials.gov identification number: NCT04507529), August 11, 2020.

Aims To explore how maternal and child health nurses (MCHNs) working in a specific regionally located service perceive and experience delivering health care to a diverse population. Design Qualitative exploratory study. Methods Qualitative interviews were conducted with MCHNs (N = 6) working in a particular regionally located service. Data were selectively coded, categorized and interpreted through a process of argument writing influenced by poststructuralist thought and Foucauldian conceptualizations of power. Results The data analysed were interpreted into the following categories: (a) system‐level expectations of the maternal and child health role; (b) what these system‐level expectations mean for the role and practice of MCHNs; and (c) what MCHNs themselves report prioritizing in their work. The analysis suggests that a substantial hindrance to the development and support of culturally safe, inclusive and quality maternal and child health care lies in the very ways contemporary health institutions seek to discipline the routine practices of MCHNs.

Background: Homeless people are a socially excluded group whose health reflects exposures to intersecting social determinants of health. The aim of this study was to describe and compare the demographic composition, certain social determinants of health, and self-reported health among homeless people in Stockholm, Sweden, in 2006 and 2018.Methods: Analysis of data from face-to-face interviews with homeless people in Stockholm 2006 (n = 155) and 2018 (n = 148), based on a public health survey questionnaire adapted to the group, including the EQ-5D-3L instrument. The chi-squared test was employed to test for statistical significance between groups and the independent t-test for comparison of mean scores and values. Ordinary Least Squares (OLS) regression, with Robust Standard Errors (RSE) was performed on merged 2006 and 2018 data with mean observed EQ VAS score as outcome variable.Results: In 2018 more homeless people originated from countries outside Europe, had temporary social assistance than long-term social insurance, compared to in 2006. In 2018 more respondents reported lack of social support, exposure to violence, and refrained from seeking health care because of economic reasons. Daily smoking, binge drinking, and use of narcotic drugs was lower 2018 than 2006. In 2018 a higher proportion reported problems in the EQ-5D-3L dimensions, the mean TTO index value and the VAS index value was significantly lower than in 2006. In the regression analysis of merged data there was no significant difference between the years.Conclusions: Homeless people are an extremely disadvantaged group, have high rates of illness and disease and report poor health in all EQ-5D-3L dimensions. The EQ VAS score among the homeless people in 2018 is comparable to the score among persons aged 95–104 years in the general Swedish population 2017. The EQ-5D-3L instrument was easily administered to this group, its use allows comparison with larger population groups. Efforts are needed regarding housing, but also intensified collaboration by public authorities with responsibilities for homeless people's health and social welfare. Further studies should evaluate the impact of such efforts by health and social care services on the health and well-being of homeless people.

Resumo O objetivo do estudo é analisar a associação entre as desigualdades sociais e o risco gestacional em regiões administrativas do estado do Espírito Santo. Estudo transversal, com base em duas regiões administrativas do estado do Espírito Santo. A amostra foi composta por 1.777 mulheres que realizaram o pré-natal nos municípios da Região Metropolitana da Grande Vitória (RMGV-ES) e Microrregião de São Mateus internadas nos estabelecimentos da rede pública de saúde, por ocasião do parto, entre 2010 e 2012/2013. Realizou-se Regressão Logística Multivariada para testar a associação entre variáveis sociais e risco gestacional. As variáveis que apresentaram nível de significância menor que 20% no teste Qui-quadrado foram utilizadas para o modelo final, permanecendo aquelas com significância menor que 5%. Encontrou-se associação entre alto risco gestacional e o local de moradia da mulher na RMGV-ES (OR = 1,74; IC 95% 1,32-2,28), a chefia da mulher na família (OR = 3,03; IC 95% 1,64-5,61), a escolaridade da chefia familiar menor que cinco anos (OR = 1,58; IC 95% 1,14-2,20) e o recebimento do benefício social “Bolsa Família” (OR = 1,46; IC 95% 1,04-2,03). Apesar de algumas variáveis sociais comporem a classificação do risco gestacional, outros fatores sociais revelaram-se como produtores do risco gestacional. Abstract This study aims to analyze the association between social inequalities and gestational risk in administrative regions of the state of Espírito Santo. This is a cross-sectional study based on two administrative regions of the state of Espírito Santo. The sample consisted of 1,777 women who underwent prenatal care in the municipalities of the Greater Vitória Metropolitan Region (RMGV-ES) and São Mateus Microregion (MRSM) and were admitted to the public health facilities at the time of delivery between 2010 and 2012/2013. The multivariate logistic regression was performed to test the association between social and gestational risk variables. Variables with a significance level < 0.20 in the Chi-square test were adopted for the final model, and only those variables with a p-value < 0.05 remained. An association was found between high gestational risk and women’s dwelling place in the RMGV-ES (OR = 1.74; CI95% 1.32-2.28), women as head of households (OR = 3.03; CI95% 1.64-5.61), head of household with less than five years of schooling (OR = 1.58; CI95% 1.14-2.20) and receipt of social benefit “Bolsa Família” (Family Grant) (OR = 1.46; CI95% 1.04-2.03). While some social variables underpin the classification of gestational risk, other social factors have been shown to produce this risk.

Background: To evaluate the changes of mortality among children aged 1–14 yr due to road traffic injury and related demographic and economic factors in an ecological study undertaken in 33 European countries. Methods: Information about mortality due to road traffic injury among children aged 1–14 yr in European countries was obtained from the WHO database. Changes in the mortality for the years 2000–2009 were estimated as linear regression. These deaths were correlated with demographic and economic factors. Results: The greatest burden of child mortality due to road traffic accidents was observed in Baltic States, three times lower mortality levels than that in Northern States. Between 2000 and 2009, there was a significant reduction (P

Introduction and objective One of the main factors determining the burden of breast cancer is the effectiveness of measures taken to combat this cancer including urban-rural differences. The aim of the study was to analyse the differences in breast cancer incidence and disease stage distribution among urban and rural women in the Świętokrzyskie Province as a part of a strategy for breast cancer control. Material and methods The study of disease stage distribution included 483 female residents of Świętokrzyskie Province who were diagnosed in 2013 with invasive breast cancer, and reported to Świętokrzyskie Office for Cancer Registration. Urban-rural differences in breast cancer incidence in 2002–2013 were presented using Range Ratio (RR). Changes in incidence trends in urban and rural areas were analysed using joinpoint models. Annual Percentage Change (APC) of the rates was calculated for each time trend. Results Breast cancer incidence rate in the urban female population was higher than in rural women with RR, amounting to 1.43. However, the analysis of trends showed that the pace and direction of change were developing negatively among inhabitants of rural areas. In 2002–2013, in rural women, the age-standardized rate (ASR) values increased by 2.8% per year (p

Entre 2000 i 2005 Barcelona va experimentar un augment de les taxes de fecunditat, fecunditat adolescent i avortament, associat a la nova immigració econòmica. El 2006 l’Agència de Salut Pública de Barcelona va desenvolupar un projecte d’investigació per: a) promoure l’anticoncepció amb una intervenció en residents de barris desfavorits amb alta proporció d’immigració, i b) avaluar la seva eficàcia amb un assaig controlat aleatoritzat (ECA). El projecte SIRIAN, basat en models de conducta i en la diversitat cultural, es va pilotar i, entre 2011 i 2013, es va implementar en cinc barris desfavorits. En la salut reproductiva operen els determinants socials, que condueixen a un ús no equitatiu d’anticoncepció. Tot i que el consell anticonceptiu s'ha recomanat per promoure l’ús de mètodes efectius, no existeix evidència suficient sobre els seus efectes en poblacions immigrades i desfavorides. Aquesta tesi s’organitza en tres subestudis. Els seus objectius son: a) avaluar l'efectivitat de la intervenció SIRIAN en adolescents amb un estudi pre-post, b) avaluar els efectes en l'ús d'anticonceptius en les persones participants amb un ECA, i c) examinar l’impacte de la intervenció en les taxes de fecunditat adolescent dels barris intervinguts respecte a barris de comparació de similar nivell socioeconòmic. En l’estudi pre-post van participar adolescents de tres barris. Es va comparar l'ús d'anticoncepció en l'última relació sexual, i diversos coneixements, creences i autoeficàcies, estratificant per sexe i origen (autòcton o immigrant), amb proves de McNemar i Chi2. 138 adolescents (76%) van completar el seguiment (55% noies, 85% de 16-19 anys i 71% immigrants). Als tres mesos van millorar els coneixements i diverses autoeficàcies, l’ús de preservatiu va augmentar un 5,4% i l'absència de mètode es va reduir un 7,7%. En l’ECA van participar 746 dones (14-49 anys) i homes (14-39 anys) residents a dos barris desfavorits assignats aleatòriament a un grup d’intervenció o control. El resultats van ser l’ús continuat de mètodes anticonceptius efectius (ús òptim), l’ús incorrecte de mètodes efectius i l’ús de mètodes menys efectius, estratificats per sexe i estat migratori als tres mesos. Amb anàlisis per intenció de tractar i per protocol, i regressions robustes de Poisson ajustades, l'ús òptim va augmentar en homes, dones, immigrants, nadius i grup total en el grup d'intervenció (ORa:1,138 (IC95%:1,010–1,284) respecte al de control. En el grup d'intervenció, l'ús incorrecte de mètodes efectius va disminuir un 54,9% i el de mètodes menys efectius un 47,2%. En el tercer estudi es van analitzar les Diferències en Diferències entre un grup d’intervenció (cinc barris en el tercil més baix de la renda familiar disponible), i un grup de comparació (tres barris amb les taxes de fecunditat adolescent més altes, entre els del mateix districte municipal i tercil de renda). Amb models lineals generalitzats es van comparar les taxes de fecunditat adolescent (TFA) brutes i ajustades entre els períodes pre (2005-10) i post (2011-16). El 2005-10, la TFA del grup d’intervenció va ser de 27,90 (per 1000 dones 15-19) i de 21,84 en el grup de comparació. El 2011-16 la TFA del grup d’intervenció va experimentar un descens de -12,30 (IC95%:-12,45 a -12,21);p

Intersectoral action between public agencies across policy sectors, and between levels of government, is seen as essential for effective action by governments to address social determinants of health (SDH) and to reduce health inequities. The health sector has been identified as having a crucial stewardship role, to engage other policy sectors in action to address the impacts of their policies on health. This article reports on research to investigate intersectoral action on SDH and health inequities in Australian health policy. We gathered and individually analysed 266 policy documents, being all of the published, strategic health policies of the national Australian government and eight State/Territory governments, current at the time of sampling in late 2012-early 2013. Our analysis showed that strategies for intersectoral action were common in Australian health policy, but predominantly concerned with extending access to individualized medical or behavioural interventions to client groups in other policy sectors. Where intersectoral strategies did propose action on SDH (other than access to health-care), they were mostly limited to addressing proximal factors, rather than policy settings affecting the distribution of socioeconomic resources. There was little evidence of engagement between the health sector and those policy sectors most able to influence systemic socioeconomic inequalities in Australia. Refereed/Peer-reviewed

Esta tesis tiene como objetivo principal comprender la relación entre el empleo informal y las desigualdades en salud en Chile desde una perspectiva integral. Considerando un abordaje abductivo que incorpora el enfoque de una metodología mixta, se han realizado cuatro artículos que combinan distintas perspectivas metodológicas: revisión bibliográfica, metodología cualitativa y metodología cuantitativa epidemiológica. A partir de un desarrollo conceptual y empírico se obtuvo una definición original de empleo informal pertinente para Chile, en el marco del estudio de las desigualdades en salud. Así, se categorizó a la población trabajadora en función de su formalidad o informalidad en el empleo, pudiendo constatarse que, en general, los empleos informales están relacionados con un peor estado de salud de las personas. Los grupos más desfavorecidos pertenecen a la población trabajadora dependiente informal. Los mecanismos que inciden en esa relación se desprenden de las condiciones de vida (según dos dimensiones: incertidumbre y recursos materiales) y de las condiciones de trabajo (según tres dimensiones: riesgos psicosociales, seguridad en el trabajo, disponibilidad de tiempos e intensificación del trabajo). También se identificaron factores moderadores que disminuyen los efectos de la informalidad sobre las desigualdades en salud. El impacto del empleo informal también puede variar de acuerdo a los ejes de desigualdad, como el género. This thesis aims to understand the relationship between informal employment and health inequalities in Chile from a comprehensive perspective. By considering an abductive approach that includes mixed methodology, four papers have been developed combining: literature review, qualitative methodology and epidemiological quantitative methodology. Within the framework of social determinants of inequalities in health and based on a conceptual and empirical work, a new typology of informal employment, especially relevant to the Chilean context, was obtained. For this, the working population was categorized according to its formality or informality in employment, finding that, in general, informality is associated with poorer health status. The most disadvantaged groups of workers are informal dependent employees. The mechanisms that appear to be affecting this relationship are derived from their living conditions (according to two dimensions: uncertainty and material resources) and working conditions (according to three dimensions: psychosocial risks, safety at work, and intensification of working times). Some moderating factors that may reduce the negative effects of employment informality in health and health inequalities were also identified. The impact of informal employment may also vary according to the axes of inequality, such as gender, and the intersectionality among them.

How to determine if a population group has better overall (multidimensional) health status than another is a central question in the health and social sciences. We apply a multidimensional first order dominance concept that does not rely on assumptions about the relative importance of each dimension. In particular, we show how one can explore the “depth” of dominance relations by gradually refining the health dimensions to see which dominance relations persist. We analyze a Danish health survey with many health indicators. These are initially collapsed into a single composite health dimension and then refined to four, seven, and ten health dimensions, each representing an (increasingly refined) area of health. Overall we find that younger age groups dominate older age groups in up to four dimensions, but no dominance relations are present with a more refined view of health. Comparing education groups, we often see dominance relations in four and seven dimensions, but the depth of the dominance vary considerably. We also compare groups based on gender, marital status, region, and ethnicity, where we generally find less dominance relations. Our empirical illustration shows that it is possible to operationalize and meaningfully apply the multidimensional first order dominance concept with gradual refinements of health status in up to ten health dimensions.

DDEUIT

The SOPHIE Project (acronym for Structural Policies for Health Inequalities Evaluation) has focused on evaluating the impact of structural policies on health equity, considering as such all those policies that exert a powerful influence on the structural determinants of health (e.g., patterns of social stratification, living and working conditions) and thus on health-related exposures through intermediary determinants. In these sections of the International Journal of Health Services, we present some of the main findings of the SOPHIE Project. We include both articles that summarize all the evidence already published in the project on a thematic area (such as labor market, gender, or housing) and articles that present new, unpublished evidence on a specific health inequality or policy.

Habits of personal hygiene are mostly acquired during childhood, and are, therefore, influenced by one&rsquo, s family. Poor hygiene habits are a risk factor for preventable disease and social rejection. Social Determinants of Health (SDH) consist of contextual factors, structural mechanisms, and the individual&rsquo, s socioeconomic position, which, via intermediary determinants, result in inequities of health and well&ndash, being. Dysfunctional family situations may, therefore, be generated by an unequal distribution of factors determining SDH. Little attention has been paid to the influence of the family on personal hygiene and the perception of social rejection in children. We designed a study to examine differences in personal hygiene and in the perception of social rejection between children in reception centers and children living in a family setting. A validated questionnaire on children&rsquo, s personal hygiene habits was completed by 51 children in reception centers and 454 children in normal families. Hygiene habits were more deficient among the children in reception centers than among the other children in all dimensions studied. Deficient hygiene habits were observed in the offspring of families affected by the main features of social inequality, who were more likely to perceive social rejection for this reason and less likely to consider their family as the greatest influence on their personal hygiene practices.

Objectives The aim of this study was to estimate indirect costs associated with losses in productivity due to sickness absence among registered workers in Poland. Material and methods Data on sick leave durations in 2013 was obtained from the Social Insurance Institution (SII) (Zaklad Ubezpieczen Spolecznych - ZUS). Based on the number of assumptions, this data was used for calculating absence durations. The costs of lost productivity were estimated on the basis of the measure of gross value added. Results Estimated losses in productivity due to absenteeism in 2013 together accounted for 4.33% of gross domestic product (GDP) (17.09 billion euro). In the female population, the total value of losses amounted to 9.66 billion euro, but excluding the costs of pregnancy, childbirth, and puerperium (2.96 billion euro), it was 6.7 billion euro. In the male population, the loss amounted to 7.43 billion euro. The highest overall costs of sickness absence based on age were found in the age group of 30-39 years (5.14 billion euro, including pregnancy, childbirth, and puerperium - 1.474 billion euro; respiratory diseases - 0.632 billion euro, injuries and poisonings - 0.62 billion euro). In the group of people aged > 40 years, the highest cost was generated by bone-muscular diseases (1.553 billion euro) and injuries and poisoning (1.251 billion euro). Higher losses in the productivity of women in addition to pregnancy, childbirth, and puerperium were due to mental and behavioral disorders (0.71 billion euro), diseases of the genitourinary system (0.38 billion euro), and neoplasms (0.35 billion euro). At the same time, in men, compared to women, we observed higher losses due to injuries and poisoning (1.65 billion euro), and diseases of musculoskeletal (1.26 billion euro), nervous (0.79 billion euro), circulatory (0.65 billion euro), and digestive (0.41 billion euro) systems. Conclusions Improvement and further development of effective strategies for prevention of complications of pregnancy and chronic diseases in the workplace are necessary. Policies aimed at reduction of sickness absence could potentially increase prosperity and the socioeconomic situation in Poland. Int J Occup Med Environ Health 2017;30(6):917-932.

Udgivelsesdato: 2009-Feb-12 BACKGROUND: The aim of this study is to investigate the association between socio-occupational status and the frequency of major congenital anomalies in offspring. METHODS: The study population comprised 81 435 live singletons born to mothers enrolled in the Danish National Birth Cohort between 1996 and 2002. A total of 3352 cases of major congenital anomalies (EUROCAT criteria) were identified by linkage to the National Hospital Discharge Register. Malformations were recorded at birth or in the first year of life. Information about maternal and paternal socio-occupational status was collected prospectively using telephone interviews in the second trimester of pregnancy and was categorized as high, middle or low. Associations were measured as relative prevalence ratios using the highest socio-occupational status within the couple as the reference group. RESULTS: The prevalence of all recorded major congenital anomalies was similar, about 4%, in all the socio-occupational categories. Low social status of the couple did, however, correlate with a higher prevalence of congenital anomalies of the 'respiratory system'. No association was substantially attenuated when we adjusted for maternal and paternal age, smoking status, maternal alcohol habits, folic acid intake and body mass index. When malformations of the heart and the cardiovascular system were grouped together, they were more frequent in families where both parents presented a low socio-occupational status. CONCLUSION: We detected an association between low socio-occupational status and congenital anomalies of the respiratory system, the heart and the circulatory system. These malformations are good candidates for a large study on occupational, environmental and social determinants.

Background The experience of childhood poverty has a long-lasting, adverse impact on physical health outcomes in adulthood. We examined the mediating effects of adult socioeconomic status (SES) and social support on the association between childhood poverty and adult health-risk behaviors. Methods Cross-sectional data collected from Japanese community residents (N = 3836) were used. A binary indicator of the experience of childhood poverty was constructed by utilizing retrospectively assessed standard of living at age 15 and a set of parental SES variables. The associations of childhood poverty with smoking, lack of exercise, poor dietary habits, and excessive drinking at the time of survey were examined by logistic regression analysis. A mediation analysis was conducted to estimate the magnitudes of the mediating effects of adult SES and social support on these associations. Results Adult SES and social support together mediated 64.0, 29.4 and 30.6 % of the impacts of the experience of childhood poverty on smoking, lack of exercise, and poor dietary habits, respectively. Educational attainment had the largest mediating effect (58.2 %) on the impact of the experience of childhood poverty on smoking. Conclusions The results suggest that interventions and policies for supporting children living in poverty should aim to enhance their future SES and provide better social support, as this might improve their overall health.

The aim of this study was to analyze inequalities in the prevalence of poor mental health and their association with socioeconomic variables and with the care network in the Autonomous Communities in Spain. A cross-sectional multilevel study was performed, which analyzed individual data from the National Health Survey in Spain (ENS), in 2006 (n = 29,476 people over the age of 16). The prevalence of poor mental health was the dependent variable, measured by the General Health Questionnaire (GHQ-12 > = 3). Individual and contextual socioeconomic variables, along with mental health services in the Autonomous Communities, were included as independent variables. Models of multilevel logistic regression were used, and odds ratios (OR) were obtained, with confidence intervals (CI) of 95%. The results showed that there are inequalities in the prevalence of poor mental health in Spain, associated to contextual variables, such as unemployment rate (men OR 1.04 CI 1.01–1.07; women OR 1.02 CI 1.00–1.05). On the other hand, it was observed that inequalities in the mental health care resources in the Autonomous Communities also have an impact on poor mental health.

Background Preventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996–2001 and 2002–2007. Methods We analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used. Results Preventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996–2001 and 10.9 in 2002–2007), though not so clearly among women (3.3% in 1996–2001 and 2.9% in 2002–2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities. Conclusions Preventable mortality decreased between the 1996–2001 and 2002–2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process This work was partly supported by the FIS-FEDER projects PI080330, PI081713, PI081978, PI0463/2010, PI081017, PI081785, PI081058, PI080142, and the FUNDACIÓN CAJAMURCIA project FFIS/CM10/27

Background: Preventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996-2001 and 2002-2007. Methods: We analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used. Results: Preventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996-2001 and 10.9 in 2002-2007), though not so clearly among women (3.3% in 1996-2001 and 2.9% in 2002-2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities. Conclusions: Preventable mortality decreased between the 1996-2001 and 2002-2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process. © 2015 Nolasco et al.; licensee BioMed Central.

Background We aimed to determine the extent to which three core variables (school environment, peer group and family affluence) were associated with unhealthy behaviours and health outcomes among Tuscan adolescents. The unhealthy behaviours considered were smoking, alcohol consumption, sedentary lifestyle and irregular breakfast consumption; health outcomes were classified as self-reported health, multiple health complaints and life satisfaction. School environment was measured in terms of liking school, school pressure, academic achievement and classmate support; peer groups were evaluated in terms of the number of peers and frequency of peer contact. Family affluence was measured on a socioeconomic scale. Methods Data were taken from the Tuscan 2009/10 survey of “Health Behaviour in School-aged Children”, a WHO cross-national survey. A binary logistic multiple regression (95% confidence intervals) was implemented. Results The total sample comprised 3291 school students: 1135 11-year-olds, 1255 13-year-olds and 901 15-year-olds. Peer group and school environment were associated with unhealthy behaviours such as smoking, alcohol consumption and sedentary lifestyle. Family affluence proved to have less impact on unhealthy behaviours, except in the case of adolescents living in low-income families. Poor health outcomes were directly related to a negative school environment. Regarding the influence of family affluence, the results showed higher odds of life dissatisfaction and poor self-reported health status in medium-income families, while low-income families had higher odds only with regard to life dissatisfaction. A consistent pattern of gender differences was found in terms of both unhealthy behaviours and health outcomes. Conclusions Unhealthy behaviours are strongly related to the school environment and peer group. A negative school environment proved to have the strongest relation with poor health outcomes.

Background Nurses have long been identified as key contributors to strategies to reduce health inequalities. However, health inequalities are increasing in the UK despite policy measures put in place to reduce them. This raises questions about: convergence between policy makers’ and nurses’ understanding of how inequalities in health are created and sustained and educational preparation for the role as contributors in reducing health inequalities. Aim The aim of this qualitative research project is to determine public health nurse educators’ understanding of public health as a strategy to reduce health inequalities. Method 26 semi-structured interviews were conducted with higher education institution-based public health nurse educators. Findings Public health nurse educators described health inequalities as the foundation on which a public health framework should be built. Two distinct views emerged of how health inequalities should be tackled: some proposed a population approach focusing on upstream preventive strategies, whilst others proposed behavioural approaches focusing on empowering vulnerable individuals to improve their own health. Conclusion Despite upstream interventions to reduce inequalities in health being proved to have more leverage than individual behavioural interventions in tackling the fundamental causes of health inequalities, some nurses have a better understanding of individual interventions than take population approaches.

Background: Although mortality and health inequalities at birth have increased both geographically and in socioeconomic terms, little is known about inequalities at age 85, the fastest growing sector of the population in Great Britain (GB).Aim: To determine whether trends and drivers of inequalities in life expectancy (LE) and disability-free life expectancy (DFLE) at age 85 between 1991 and 2001 are the same as those at birth.Methods: DFLE at birth and age 85 for 1991 and 2001 by gender were calculated for each local authority in GB using the Sullivan method. Regression modelling was used to identify area characteristics (rurality, deprivation, social class composition, ethnicity, unemployment, retirement migration) that could explain inequalities in LE and DFLE.Results: Similar to values at birth, LE and DFLE at age 85 both increased between 1991 and 2001 (though DFLE increased less than LE) and gaps across local areas widened (and more for DFLE than LE). The significantly greater increases in LE and DFLE at birth for less-deprived compared with more-deprived areas were still partly present at age 85. Considering all factors, inequalities in DFLE at birth were largely driven by social class composition and unemployment rate, but these associations appear to be less influential at age 85.Conclusions: Inequalities between areas in LE and DFLE at birth and age 85 have increased over time though factors explaining inequalities at birth (mainly social class and unemployment rates) appear less important for inequalities at age 85.

Background: While research continues into indicators such as preventable and amenable mortality in order to evaluate quality, access, and equity in the healthcare, it is also necessary to continue identifying the areas of greatest risk owing to these causes of death in urban areas of large cities, where a large part of the population is concentrated, in order to carry out specific actions and reduce inequalities in mortality. This study describes inequalities in amenable mortality in relation to socioeconomic status in small urban areas, and analyses their evolution over the course of the periods 1996–99, 2000–2003 and 2004–2007 in three major cities in the Spanish Mediterranean coast (Alicante, Castellón, and Valencia). Methods: All deaths attributed to amenable causes were analysed among non-institutionalised residents in the three cities studied over the course of the study periods. Census tracts for the cities were grouped into 3 socioeconomic status levels, from higher to lower levels of deprivation, using 5 indicators obtained from the 2001 Spanish Population Census. For each city, the relative risks of death were estimated between socioeconomic status levels using Poisson’s Regression models, adjusted for age and study period, and distinguishing between genders. Results: Amenable mortality contributes significantly to general mortality (around 10%, higher among men), having decreased over time in the three cities studied for men and women. In the three cities studied, with a high degree of consistency, it has been seen that the risks of mortality are greater in areas of higher deprivation, and that these excesses have not significantly modified over time. Conclusions: Although amenable mortality decreases over the time period studied, the socioeconomic inequalities observed are maintained in the three cities. Areas have been identified that display excesses in amenable mortality, potentially attributable to differences in the healthcare system, associated with areas of greater deprivation. Action must be taken in these areas of greater inequality in order to reduce the health inequalities detected. The causes behind socioeconomic inequalities in amenable mortality must be studied in depth. This work was partly supported by the FIS-FEDER projects PI040170 and PI080330.

ResumenObjetivoPresentar las diferencias en el estado de salud de varones y mujeres en Cataluña a través de las principales fuentes de información disponibles.MétodosSe presentan las principales fuentes de información sanitaria institucionales referidas al ámbito catalán. Se hace una aproximación a la morbimortalidad según género.ResultadosLos varones mueren antes que las mujeres y presentan con mayor frecuencia patologías que requieren ingreso hospitalario. Las conductas poco saludables son más frecuentes en los varones que en las mujeres. Éstas, en general, cualquiera que sea la clase social a la que pertenecen, presentan más enfermedades crónicas y discapacidades y declaran peor percepción del estado de salud que los varones de la misma clase social.ConclusionesLas fuentes de información institucionales en Cataluña permiten caracterizar el estado de salud según género, si bien deberían incorporar variables que facilitaran el análisis de la información desde la perspectiva de género.SummaryObjectiveTo present health status differences between men and women in Catalonia across the main available data sources.MethodsThe main institutional health data sources of the Catalan population are presented. Mortality and morbidity differences by gender are studied.ResultsMen die before than women and present more frequently pathologies that require hospitalary care. Unhealthy behaviours are more frequent in men than in women. Women in general, in all social classes, present more frequently chronic disorders and disabilities and declare worse perception of health status than men of the same social class.ConclusionsInstitutional sources of data available in Catalonia allow the description of gender differences in health, nevertheless new variables should be included to improve gender perspective analyse.

SUMMARY This study sought to engage Traveller men in a discussion about their lives, their health and key determinants of their health, with a view to engaging Traveller men in health promotion initiatives. Irish Travellers are an indigenous ethnic minority, constituting 0.8% of the population. As a marginalized group, they experience significantly poorer health status than their counterparts in the settled community. Traveller men have 3.7 times the mortality of the males in the general population. Travellers are identified as a hard-to-reach group and Traveller men particularly so. Traveller men have rarely participated in the research studies on health and health service utilization, and the results of this study, in which Traveller men participated in three focus groups, are therefore of particular interest. The Traveller men, in discussing health, related it to the absence of specific illnesses and conditions, expressing a negative and a physical concept of health. The results of the study provide evidence for the role of social constructions of masculinity in determining the health and help-seeking behaviour of Traveller men, but also the influence of wider social determinants such as ethnicity and social status. The futility of approaches to health promotion that comprise simplistic health information/education interventions is outlined in this context. The study presents a challenge to both address hegemonic versions of masculinity and discrimination based on ethnic status, and rather than challenge the behaviour of men or of health services that they come into contact with, to changing the conditions of Traveller men’s lives.

Introduction. Inequalities in health are evident in the whole world and present an important and consistent public health issue. The highest contribution to the inequality in heath is attributable to the demographic and socioeconomic determinants of health. Objective. The aim of this study was to analyze the association between the demographic (gender, age, marital status and type of settlement) and socioeconomic determinants of health (education and Wealth Index), and self-perceived health. Methods. In the study the data from 2006 National Health Survey of the population of Serbia were used. The interview involved 14,522 adults aged ?20 years. The association between the demographic and socioeconomic determinants of health as independent variables, and self-perceived health as dependent variable were examined using bivariate and multivariate logistic regression analyses. The minimum level of significance was p

This article aims to review conceptual frameworks and some principles to be considered in research on social determinants of health and health inequalities. Some indicators of research on these issues in Spain are described. General expenditure on research and development in Spain is far from the Organisation for Economic Co-operation and Development mean. In addition, both globally and within Spain, the scientific production on health inequalities is very low, especially compared with other research areas. The budget for research on health inequalities is also reduced. A striking example is provided by analysis of the projects funded by the Marato de TV3, which seems to have little interest in funding research on health inequalities. However, both the scientific production and project financing on health inequalities have increased in the last decade. Finally, to advance research on health inequalities and its contribution to the incorporation of health in all policies, recommendations are made, which include redefining priorities, ensuring resources and promoting knowledge translation. (C) 2010 SESPAS. Published by Elsevier Espana, S.L. All rights reserved.

International Journal of Public Health, 54 (1), ISSN:1661-8556, ISSN:1661-8564

SummaryThis paper outlines the National Institute for Health and Clinical Excellence's (NICE) emerging conceptual framework for public health. This is based on the experience of the first 3 years of producing public health guidance at NICE (2005–2008). The framework has been used to shape the revisions to NICE's public health process and methods manuals for use post 2009, and will inform the public health guidance which NICE will produce from April 2009. The framework is based on the precept that both individual and population patterns of disease have causal mechanisms. These are analytically separate. Explanations of individual diseases involve the interaction between biological, social and related phenomena. Explanations of population patterns involve the same interactions, but also additional interactions between a range of other phenomena working in tandem. These are described. The causal pathways therefore involve the social, economic and political determinants of health, as well as psychological and biological factors. Four vectors of causation are identified: population, environmental, organizational and social. The interaction between the vectors and human behaviour are outlined. The bridge between the wider determinants and individual health outcomes is integration of the life course and the lifeworld.

ResumenEl estudio de los determinantes sociales de los estilos de vida asociados a enfermedad puede ser relevante para una mejor apreciación de la utilidad potencial de las políticas de salud. En el presente trabajo, se presentan los resultados del análisis de la Encuesta de Ciudades Sanas de Elche en relación a nivel económico (medido como renta familiar mensual) y a los estilos de vida asociados a enfermedad, como la realización de ejercicio físico y el consumo de cigarrillos y alcohol. Se encuestó mediante entrevista domiciliaría a 573 personas extraídas aleatoriamente del padrón municipal.Mientras que no se ha encontrado asociaciones con el consumo de alcohol y cigarrillos en la actualidad, la rentas más altas tienden a intentar dejar de fumar con más frecuencia y a hacer más ejercicio físico. Se ha encontrado una relación dosis-respuesta significativa (χ2 tendencia: 17,4 p < 0,01) y un gradiente diferencial del 177 % entre la frecuencia de ejercicio fisico entre los grupos de menor y mayor renta.Los resultados pueden ser importantes a la hora de llevar a cabo políticas de salud dirigidas a eliminar las desigualdades en salud: «intervenciones desiguales» pueden resultar más adecuadas.SummaryThe study of the determinants of disease-related lifestyles may be relevant for better understanding the potential of health polices. In the present work, results of the analysis of the Elche Healthy Cities Interview Survey prevalence of some disease related lifestyles (physical activity level, cigarrette consumption, and alcohol intake) are presented according to economic level as measured by monthly family income. 573 people randomly selected from de town rols were interviewed at home.No associations were found between economic level and alcohol intake or present smoking status. But, trying to stop smoking and regular exercise were more frequent behaviors in higher economic groups. The ratio of prevalence of regular excercise was 1.73 in favor of the highest economic levels. The gradient found was statistically significant (χ2 for trend=17.4, p < 0.01).The results may be of relevance when implementing health policies to overcome inequalities in health: «inequal interventions» may be more adequate.

One of the most controversial explanations of class inequalities in health is the health selection hypothesis or drift hypothesis which suggests there is a casual link between the health status of individuals and their chances of social mobility, both inter- and intra-generational. This study tests this hypothesis, and tries to answer three related questions: (a) to what extent does health status influence the chances of intra-generational mobility of individuals? (b) what is the impact on health inequalities of the various kinds of social mobility (both mobility in the labour market and exit from employment)-do they increase or reduce inequalities? (c) to what extent does health-related intra-generational social mobility contribute to the production of health inequalities? The data analysed in this paper were drawn from the records of the Turin Longitudinal Study, which was set up to monitor health inequality of the Turin population by combining census data, population registry records and medical records. Occupational mobility was observed during the decade 1981-1991. To evaluate the impact of the various processes of social mobility on health inequalities, mortality was observed over the period 1991-1999. The study population consists of men and women aged 25-49 at the beginning of mortality follow-up (1991), and registered as resident in Turin at both the 1981 and the 1991 censuses (N = 127,384). Health status was determined by observing hospital admission. For the purpose of the study healthy individuals were those with no hospital admissions during the period 1984-1986, while those admitted were classed as unhealthy. Social mobility in the labour market was measured via an interval data index of upward and downward movements on a scale of social desirability of occupations, designed for the Italian labour force via an empirical study carried out by de Lillo and Schizzerotto (La valutazione sociale delle occupazioni. Una scala di stratificazione occupazionale per l'Italia contemporanea, Il Mulino, Bologna, 1985). Movement out of the labour market was described by a discrete variable with four conditions: employed, unemployed, early retired and women returning from work to the housewife status. The relationship between health status and occupational mobility was analysed via analysis of variance and multinomial logistic regression. Health inequalities were measured by the ratio of standardised mortality rates in the unskilled working class and the upper middle class. The study found a weak relationship between health status and occupational mobility chances. Decidedly stronger was the impact on occupational mobility of gender, education and "ethnicity" (being born in the South of Italy). The relationship between occupational mobility and health takes two different forms. Occupational mobility in the labour market decreases health inequalities; occupational mobility out of the labour market (early retirement, unemployment, housewife return) widens them. The maximum contribution health-related intra-generational social mobility can make towards health inequalities was estimated at about 13% for men.

As a way of forecasting future evolution of inequalities in disease burden and mortality, trends in preventive health behaviours by social class were examined. Using the Spanish National Health Survey from 1987 to 1997 the evolution of the Health Practices Index (smoking, alcohol consumption, physical exercise, sleep hours and the Quetelet index) is described for the Spanish non-institutionalised adult population. In the last 10 years the disadvantaged population of Spain (social class groups IV and V) has not opted for healthier behavioural choices. On the contrary the Health Practices Index figures have worsened during the study period. Conversely, the more affluent groups (social class groups I, II and III) have exhibited a net gain in the index. Due to this, an increase in the existing gap in health inequalities in Spain in terms of morbidity and mortality can be forecast for the near future. As time trends of a summary indicator of preventive health behaviours by social class have not been described in other countries, a replication of this study in different cultural, social and economic milieus could produce valuable information.

Background. The objective of this study was to describe the evolution of social class inequalities in Barcelona (Spain) residents in perceived health status, health-related behaviors, and utilization of health services between 1983 and 1994. Methods. The information was obtained from the Health Interview Surveys conducted in 1983, 1986, 1992, and 1994 in Barcelona. In this study we included noninstitutionalized people ages >14 years. Social class was obtained from the Spanish adaptation of the British Registrar General classification. We studied health status, health-related behaviors, and health services utilization variables. Age-adjusted percentages and the relative index of inequality were obtained. Results. Of the health status variables, having been confined to bed and acute restriction of activity in the 2 weeks prior to the interview showed an increase in inequalities by social class in 1994. The pattern of chronic conditions by social class in men did not change between 1983 and 1994. Women had a higher prevalence of chronic conditions and the inequalities among social classes had increased. In men there were no social class inequalities in smoking in 1983. In 1992 and 1994 smoking was more prevalent in men of social classes IV and V. In women, smoking was more prevalent in social classes I and II in 1983 than in social classes IV and V, something that had changed by 1994. Lack of usual physical activity in men was always more prevalent in social classes I and II, and this difference increased since more people of advantaged classes moved into inactivity. Health services utilization showed no inequalities in the years studied. Conclusion. The changing pattern according to social class of smoking and physical activity practice needs to be taken into account by policy-makers and public health workers.

Para la compresión de la situación de salud y condiciones de vida de determinado territorio, es necesario indagar desde una perspectiva geo-histórica los procesos de división u organización político-administrativa, sus características geo-ecológicas, así como su proceso de transición demográfica. Diversos autores señalan que la sociedad modela su propia geo-ecología y esta a su vez revierte su efecto sobre las condiciones de salud de la población. La conformación del espacio venezolano ha sido el resultado de una dinámica histórica la cual ha estado determinada por el colonialismo español y el capitalismo mundial. Con el objetivo de analizar aspectos territoriales, geo-ecológicos y demográficos, como bases para la comprensión de las desigualdades en salud del estado Carabobo, se realizó una investigación documental con enfoque geohistórico y desde la perspectiva teórica de la epidemiologia crítica; se analizaron las tasas brutas de natalidad y de mortalidad del estado Carabobo y sus municipios durante los años 1999-2005, utilizando como fuentes de información, el Instituto Nacional de Estadística y la Dirección de Epidemiología del Instituto Carabobeño para la Salud. Desde su surgimiento como Provincia en 1824, el estado Carabobo ha tenido varias divisiones políticoadministrativas. Actualmente cuenta con 14 municipios y 38 parroquias, es un territorio de heterogeneidades demográficas, sociales, ambientales y económicas. In order to comprehend the health situation and living conditions of a territory, it's necessary to investigate, from a geohistorical perspective, the division processes and the politicaladministrative organization, geo-ecological characteristics and its demographic transition. Several authors point out that society shapes its own geo-ecology and this in turn has a reversed effect on the health status of the population. The constitution of the Venezuelan space has been the result of a historical dynamic that has been determined by Spanish colonialism and global capitalism. In order to analyze the regional, geo-ecological and demographic aspects as the basis for understanding health inequalities in Carabobo State, a documentary research was conducted with a geo-historical approach. From the theoretical perspective of critical epidemiology; birth and death rates of Carabobo state and its municipalities were analyzed during the years 1999-2005, using as sources of information, National Statistics Institute. and the Department of Epidemiology of Institute for Health of Carabobo. Since its inception as a province in 1824, Carabobo state has had several political and administrative divisions. Currently, it has 14 municipalities and 38 parishes. It's a land of diversities demographic, social, environmental and economic.