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Health Research Fund of the Ministry of Economy and Competitiveness, Grant/Award Numbers: PI13/01175, PI10/01468; Funding for open access charge: Universidad de Granada/CBUA, Rationale aims and objectives: The available evidence on the use of heuristics and their relationship with diagnostic error in primary care is very limited. The aim of the study is to identify the use of unknown thought and specifically the possible use of Representativeness, Availability and overconfidence heuristics in the clinical practice of primary care physicians in cases of dyspnoea and to analyse their possible relationship with diagnostic error. Methods: A total of 371 patients consulting with new episodes of dyspnoea in Primary Care centres in Spain were registered. Based on specific operational definitions, the use of unconscious thinking and the use of heuristics during the diagnostic process were assessed. Subsequently, the association between their use and diagnostic error was analysed. Results: In 49.6% of cases, the confirmatory diagnosis coincided with the first diagnostic impression, suggesting the use of the representativeness heuristic in the diagnostic decision process. In 82.3% of the cases, the confirmatory diagnosis was among the three diagnostic hypotheses that were first identified by the general physicians, suggesting a possible use of the availability heuristic. In more than 50% of the cases, the physicians were overconfident in the certainty of their own diagnosis. Finally, a diagnostic error was identified in 9.9% of the recorded cases and no statistically significant correlation was found between the use of some unconscious thinking tools (such as the use of heuristics) and the diagnostic error. Conclusion: Unconscious thinking manifested through the acceptance of the first diagnostic impression and the use of heuristics is commonly used by primary care physicians in the clinical decision process in the face of new episodes of dyspnoea; however, its influence on diagnostic error is not significant. The proposed explicit and reproducible methodology may inspire further studies to confirm these results., Health Research Fund of the Ministry of Economy and Competitiveness PI13/01175 PI10/01468

Rationale, aims and objectives: The available evidence on the existence and consequences of the use of heuristics in the clinical decision process is very scarce. The purpose of this study is to measure the use of the Representativeness, Availability and Overconfidence heuristics in real conditions with Primary Care physicians in cases of dyspnea and to study the possible correlation with diagnostic error. Methods: A prospective cohort study was carried out in 4 Primary Care centers in which 371 new cases or dyspnea were registered. The use of the three heuristics in the diagnostic process is measured through an operational definition of the same. Subsequently, the statistical correlation with the identified clinical errors is analyzed. Results: In 9.97% of the registered cases a diagnostic error was identified. In 49.59% of the cases, the physicians used the representativeness heuristic in the diagnostic decision process. The availability heuristic was used by 82.38% of the doctors and finally, in more than 50% of the cases the doctors showed excess confidence. None of the heuristics showed a statistically significant correlation with diagnostic error. Conclusion: The three heuristics have been used as mental shortcuts by Primary Care physicians in the clinical decision process in cases of dyspnea, but their influence on the diagnostic error is not significant. New studies based on the proposed methodology will allow confirming both its importance and its association with diagnostic error.

Rationale, aims and objectives: The available evidence on the existence and consequences of the use of heuristics in the clinical decision process is very scarce. The purpose of this study is to measure the use of the Representativeness, Availability and Overconfidence heuristics in real conditions with Primary Care physicians in cases of dyspnea and to study the possible correlation with diagnostic error. Methods: A prospective cohort study was carried out in 4 Primary Care centers in which 371 new cases or dyspnea were registered. The use of the three heuristics in the diagnostic process is measured through an operational definition of the same. Subsequently, the statistical correlation with the identified clinical errors is analyzed. Results: In 9.97% of the registered cases a diagnostic error was identified. In 49.59% of the cases, the physicians used the representativeness heuristic in the diagnostic decision process. The availability heuristic was used by 82.38% of the doctors and finally, in more than 50% of the cases the doctors showed excess confidence. None of the heuristics showed a statistically significant correlation with diagnostic error. Conclusion: The three heuristics have been used as mental shortcuts by Primary Care physicians in the clinical decision process in cases of dyspnea, but their influence on the diagnostic error is not significant. New studies based on the proposed methodology will allow confirming both its importance and its association with diagnostic error.

Evaluar la evidencia sobre el uso de heurísticos de representatividad, disponibilidad, anclaje y ajuste y exceso de confianza en la práctica clínica real, específicamente en el ámbito de la Atención Primaria. Se seleccionaron 48 estudios que analizaban heurísticos de disponibilidad (26), anclaje y ajuste (9), exceso de confianza (9) y representatividad (8). Resultados: La población de estudio incluía médicos (35,4%), pacientes (27%), residentes (20,8%), enfermeros (14,5%) y estudiantes (14,5%). Los estudios realizados en condiciones reales fueron 17 (35,4%). En 33 de los 48 estudios se observó el empleo del heurístico analizado en la población estudiada (68,7%). El uso de heurísticos durante el proceso diagnóstico fue analizado en 27 estudios (54,1%); en 5 de ellos, el estudio se realizó en escenarios reales (18%). De los 48 estudios, 6 se realizaron en Atención Primaria (12,5%), 3 de los cuales analizaban el proceso diagnóstico: solo en uno de los 3 se analizó el uso de heurístico en condiciones reales, sin demostrar la existencia de sesgo. La evidencia empírica disponible sobre la utilización de heurísticos y su papel en el error diagnóstico en condiciones reales es limitada. En particular, en el caso del proceso de decisión diagnóstica en Atención Primaria la evidencia es prácticamente inexistente., To assess the use of representativeness, availability, overconfidence, anchoring andadjustment heuristics in clinical practice, specifically in Primary Care setting. A total of 48 studies were selected that analyzed availability heuristics(26), anchoring and adjustment (9), overconfidence (9) and representativeness (8).Results: From the 48 studies selected, 26 analyzed availability heuristics, 9 anchoring andadjustment, 9 overconfidence; and 8 representativeness. The study population included physi-cians (35.4%), patients (27%), trainees (20.8%), nurses (14.5%) and students (14.5%). The studiesconducted in clinical practice setting were 17 (35.4%). In 33 of the 48 studies (68,7%) it wasobserved heuristic use in the population studied. Heuristics use on diagnostic process was foundin 27 studies (54.1%); 5 of them (18%) were carried out in clinical practice setting. Of the 48studies, 6 (12,5%) were performed in Primary Care, 3 of which studied diagnostic process: onlyone of them analyzed the use of heuristics in clinical practice setting, without demonstratingbias as consequence of the use of heuristic. The evidence about heuristic use in diagnostic process on clinical practice settingis limited, especially in Primary Care.

Evaluar la evidencia sobre el uso de heurísticos de representatividad, disponibilidad, anclaje y ajuste y exceso de confianza en la práctica clínica real, específicamente en el ámbito de la Atención Primaria. Se seleccionaron 48 estudios que analizaban heurísticos de disponibilidad (26), anclaje y ajuste (9), exceso de confianza (9) y representatividad (8). Resultados: La población de estudio incluía médicos (35,4%), pacientes (27%), residentes (20,8%), enfermeros (14,5%) y estudiantes (14,5%). Los estudios realizados en condiciones reales fueron 17 (35,4%). En 33 de los 48 estudios se observó el empleo del heurístico analizado en la población estudiada (68,7%). El uso de heurísticos durante el proceso diagnóstico fue analizado en 27 estudios (54,1%); en 5 de ellos, el estudio se realizó en escenarios reales (18%). De los 48 estudios, 6 se realizaron en Atención Primaria (12,5%), 3 de los cuales analizaban el proceso diagnóstico: solo en uno de los 3 se analizó el uso de heurístico en condiciones reales, sin demostrar la existencia de sesgo. La evidencia empírica disponible sobre la utilización de heurísticos y su papel en el error diagnóstico en condiciones reales es limitada. En particular, en el caso del proceso de decisión diagnóstica en Atención Primaria la evidencia es prácticamente inexistente. To assess the use of representativeness, availability, overconfidence, anchoring andadjustment heuristics in clinical practice, specifically in Primary Care setting. A total of 48 studies were selected that analyzed availability heuristics(26), anchoring and adjustment (9), overconfidence (9) and representativeness (8).Results: From the 48 studies selected, 26 analyzed availability heuristics, 9 anchoring andadjustment, 9 overconfidence; and 8 representativeness. The study population included physi-cians (35.4%), patients (27%), trainees (20.8%), nurses (14.5%) and students (14.5%). The studiesconducted in clinical practice setting were 17 (35.4%). In 33 of the 48 studies (68,7%) it wasobserved heuristic use in the population studied. Heuristics use on diagnostic process was foundin 27 studies (54.1%); 5 of them (18%) were carried out in clinical practice setting. Of the 48studies, 6 (12,5%) were performed in Primary Care, 3 of which studied diagnostic process: onlyone of them analyzed the use of heuristics in clinical practice setting, without demonstratingbias as consequence of the use of heuristic. The evidence about heuristic use in diagnostic process on clinical practice settingis limited, especially in Primary Care.

Objectives Diagnostic error (DE) is defined as a diagnosis unintentionally delayed (sufficient information was available earlier), wrong (another diagnosis was made before the correct one), or missed (no diagnosis was ever made) (Graber, 2012). More recently, it has been proposed to include overdiagnosis in DE definition (Zwaan, 2015). Usually, the standard to analyze diagnostic process is the appropriateness of code assigned to a problem using the International Classification of Diseases (ICD). However at least one third of common symptoms do not have a disease-based explanation (Kroenke, 2014). This approach mean all expressions of illness must be associated to a disease label, against the context of general practice (Heath, 2011). Objectives To assess diagnostic codes allocated to new cases of dyspnea in General Practice To study diagnostic error in patient attended by dyspnea in Primary Care To determine the relationship between the occurrence of diagnostic error and patient harm. Method Cohort study of new episodes of dyspnea in patients receiving care from general practitioners (GPs) and GPs trainees at Primary Care Practices in Granada (Spain). In addition to filling out the electronic medical record of the patients attended, each physician fills out two specially designed questionnaires about the diagnostic process performed in each case of dyspnea: the first questionnaire includes questions on the physician’s initial diagnostic impression, the three most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians’ perceived overwork and fatigue during patient care. The second questionnaire records the final diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. Our methods is based on the Zwaan methodology on Diagnostic errors in dyspnea patients treated in Dutch hospitals (Zwaan, 2009). Results Nine general practitioners and five GP trainees participated in this study. Initially, 373 records were collected for a year. 217 new cases of dyspnea were finally registered. Each of them received a diagnostic code by their general practitioner. The average number of cases recorded by each physician was 21.Mean time at until diagnosis was 32.89 days Final diagnosis included acute asthma exacerbation(37), acute bronchitis (34), asthma (30), COPD (27), other disease of respiratory system (26), anxiety (24) and congestive heart failure (20). In peer review process, Diagnostic testing requested were considered appropriate in 81.56% of the cases, Diagnostic process performed was considered not appropriate in 12.44%, and Diagnosis was wrong in 13.2% (32 of 217). Diagnostic error-related harm was not found. However, 4,15% of the cases in which a diagnostic tests were requested, adverse effects were found. Conclusions Although 1/3 of common symptoms don’t have a disease-based explanation, all new cases of dyspnea were categorized with a diagnostic code.It could can produce overdiagnosis, unnecessary tests and adverse effect. In our study, DE (13,2%) was similar to the only akin study (Zwaan, 2012), performed in five Dutch hospitals(13,8%). While in our study, carry out in PC, harm was not found as result of DE, patient was harmed in 11,3% cases in the Dutch study. The use of disease classifications as standard to define DE in PC may not reflect the general practice complexity: broad spectrum of symptoms, highest frequency of illness over disease, time as strategy to diagnosis (Irving, 2013). According to this, diagnosis-related harm (produced by missing, delayed or wrong diagnosis as well as early diagnostic and unnecessary procedures) could be an appropriate way to study DE in PC.

Resumen Objetivo Evaluar la evidencia sobre el uso de heurísticos de representatividad, disponibilidad, anclaje y ajuste y exceso de confianza en la práctica clínica real, específicamente en el ámbito de la Atención Primaria. Diseño Revisión panorámica (scoping review). Fuentes de datos Bases de datos de OvidMedline, Scopus, PsycoINFO, Cochrane Library y PubMed. Con el fin de facilitar la comprensión y replicabilidad de los estudios seleccionados se revisaron aplicando los criterios TIDieR (Template for Intervention Description and Replication). Selección de estudios Se seleccionaron 48 estudios que analizaban heurísticos de disponibilidad (26), anclaje y ajuste (9), exceso de confianza (9) y representatividad (8). Resultados La población de estudio incluía médicos (35,4%), pacientes (27%), residentes (20,8%), enfermeros (14,5%) y estudiantes (14,5%). Los estudios realizados en condiciones reales fueron 17 (35,4%). En 33 de los 48 estudios se observó el empleo del heurístico analizado en la población estudiada (68,7%). El uso de heurísticos durante el proceso diagnóstico fue analizado en 27 estudios (54,1%); en 5 de ellos, el estudio se realizó en escenarios reales (18%). De los 48 estudios, 6 se realizaron en Atención Primaria (12,5%), 3 de los cuales analizaban el proceso diagnóstico: solo en uno de los 3 se analizó el uso de heurístico en condiciones reales, sin demostrar la existencia de sesgo. Conclusiones La evidencia empírica disponible sobre la utilización de heurísticos y su papel en el error diagnóstico en condiciones reales es limitada. En particular, en el caso del proceso de decisión diagnóstica en Atención Primaria la evidencia es prácticamente inexistente.

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

Objectives To analyse the impact that the economic crisis and the evolution of socioeconomic inequality before (2007) and during (2011) the current crisis have had on unmet dental care needs in Spain. Methods The Living Conditions Surveys from the years 2007 and 2011 were used, including 44 138 adults aged under 65 years. A descriptive and stratified analysis was carried out along with the calculation of the concentration index and a multivariate logistic regression jointly and separately by gender. The dependent variable was unmet dental care needs and the independent variables were income, employment status, gender, age, education and chronic disease. A dummy variable was created for the year of survey completion as a proxy measure for the economic crisis. The SPSS V.20 software was used. Results During the period under analysis, the unmet needs for dental services increased (from 6.2% to 7.2%) along with the concentration index (from −0.1412 to −0.189). The main correlations with unmet needs were: unemployment (OR=1.46), lower income (OR=2.44 for the income quintile) and the year 2011 with respect to 2007 (OR 1.13). For women, the OR is greater according to income level (2.44 compared with 1.77 in men) and the year 2011 (1.21 compared with 1.06), while for men unemployment had a greater effect (OR=1.52 compared with 1.46). Conclusions There has been an increase in unmet dental care needs as well as in the social gradient for service access. The most vulnerable groups are those with less purchasing power and the unemployed. The economic crisis has also increased this unmet need.

Several studies show the association between economic crises, unemployment and health income. However, it is necessary to differentiate their impact according to gender. The objective of this study was to analyze the effect that the economic crisis, unemployment and income may have had on the perceived health of men and women in Spain.A cross-sectional study was conducted combining data from the 2007 and 2011 Living Conditions Surveys, which collect data from 43,900 adult individuals up to 65 years of age. A multivariate logistic regression analysis was performed, for the whole population as for each sex. The dependent variable was perceived health and the independent variables were income level, employment status, education level, chronic illness, and the year in which the survey was performed.Perceived health improved over the period under consideration, from 75.1% in 2007 to 83%,0 in 2011. Unemployment significantly increased the chances of reporting perceived bad health in men [OR=1.45; CI95%:1.26-1.67] but not in women [OR=1.20; CI95%:0.99-1.47]. ORs of perceived bad health were higher for women than for men in the lower-income [1.81; IC95%1,56-2,11 against 1.70; IC95%:1,46-1,97. 2011] was related to a lower probability of poor perceived health in both men [OR=0.41, CI95%: 0.37-0.46] and women [OR=0.39 ; CI95%:0.35-0.44].The association of the economic crisis with perceived health was similar in men and women. Unemployment was a risk factor for perceived bad health in the case of men. Available income, education level, and the presence of chronic illness had a larger influence as determinants of perceived bad health for women than they did for men.Diversos estudios muestran la asociación entre las crisis económicas, el desempleo y la renta con la salud. Sin embargo, se precisa diferenciar su impacto en función del sexo. El objetivo de este estudio fue analizar el efecto que la crisis económica, el desempleo y la renta pueden haber tenido en la salud percibida de hombres y mujeres en España.Se realizó un estudio transversal que combinó las Encuestas de Condiciones de Vida de 2007 y 2011, incluyendo a 43.900 personas adultas de hasta 65 años. Se realizó análisis estratificado y regresión logística multivariante. La variable dependiente fue la salud percibida y las variables independientes la renta, la situación laboral, la educación, la enfermedad crónica y el año de la encuesta.La buena salud percibida se incrementó del 75,1 % en 2007 al 83% en 2011. El desempleo se relacionó con mayor probabilidad de mala salud percibida en hombres: OR de 1,45; IC95%:1,26-1,67, mientras que en mujeres las diferencias fueron OR=1,20; IC95%:0,99-1,47. La probabilidad de mala salud percibida fueron mayores para mujeres (OR=1,81; IC95%:1,56-2,11) que para hombres (OR=1,7; IC95%:1,46-1,97). El año 2011 se relacionó con tener menor probabilidad de mala salud percibida tanto en hombres (OR=0,41; IC95%: 0,37-0,46) como en mujeres (OR=0,39; CI95%:0,35-0,44).La asociación de la crisis económica con la salud percibida fue similar en hombres y mujeres. El desempleo fue un factor de riesgo para la mala salud percibida en hombres mientras que la influencia del nivel de renta, del educativo y la enfermedad crónica fue mayor en mujeres que hombres.

RESUMEN Fundamentos: Las personas sin hogar presentan una mayor morbi-mortalidad que las que sí lo tienen. Este hecho no ha sido investigado suficientemente en España desde la perspectiva de la atención hospitalaria. El objetivo fue conocer las características de las hospitalizaciones de las personas sin hogar en dos hospitales de Sevilla. Métodos: Estudio observacional de 103.802 hospitalizaciones correspondientes a 71.756 personas ingresadas en los Hospitales Virgen del Rocío y Macarena (2013 y 2014) analizadas en función de si las personas ingresadas tenían o no hogar. Se realizó análisis bivariante mediante χ2 y t-Student y análisis multivariante con modelos de regresión logística binomial. Resultados: 163 (0,16%) de las hospitalizaciones correspondieron a personas sin hogar y 103.639 (99,84%) a personas con hogar. La edad media de ingreso de las personas sin hogar fue de 48 años, siendo el 76,5% hombres. La mortalidad intrahospitalaria se produjo a una edad media de 23 años menor que la de las personas con hogar (p=0,009). El 92% de sus ingresos fueron urgentes (p

The aim was to determine the characteristics of hospital admissions of homeless persons in Seville, Spain.Observational study of 103,802 hospital admissions of 71,756 patients admitted in the Hospitals "Virgen del Rocío" and "Virgen Macarena" (Seville), in 2013 and 2014. Bivariate analysis were performed using χ2 and t-Student tests and multivariate analysis using binomial logistic regression model.0.16% (n=163) of admissions were homeless persons and 99.84% (n=103,639) were not. The mean age at admission in homeless patients was 48 years and 76.5% of them were men. Hospital deaths of homeless patients occurred being 23 years younger. 92% of hospital admissions came from emergency departments and 10.0% of their discharges were against medical advice. The average length of stay was 4.8 days longer in homeless persons and the most frequent diagnoses on admission were mental (27.0%), infectious (19.6%) and respiratory diseases (18.4%). Mental disorders were present on 83.7% of homeless patients as secondary diagnose and 77.6% referred drugs consumption.Hospital admissions characteristics of homeless persons were particularly different. Homeless patients were hospitalized and died at a younger age than non-homeless patients. The morbidity and mortality of homeless persons reflect their vulnerable health condition.El objetivo fue conocer las características de las hospitalizaciones de las personas sin hogar en dos hospitales de Sevilla.Estudio observacional de 103.802 hospitalizaciones correspondientes a 71.756 personas ingresadas en los Hospitales Virgen del Rocío y Macarena (2013 y 2014) analizadas en función de si las personas ingresadas tenían o no hogar. Se realizó análisis bivariante y los test χ2 y t-Student análisis multivariante mediante modelos de regresión logística binomial.163 (0,16%) de las hospitalizaciones correspondieron a personas sin hogar y 103.639 (99,84%) a personas con hogar. La edad media de ingreso de las personas sin hogar fue de 48 años, siendo el 76,5% hombres. La mortalidad intrahospitalaria se produjo a una edad media de 23 años menor que la de las personas con hogar (p=0,009). El 92% de sus ingresos fueron urgentes y el 10,0% tuvieron altas voluntarias/fugas. La estancia media en las personas sin hogar fue 4,8 días mayor y sus principales motivos de ingreso fueron enfermedades mentales (27,0%), infecciosas (19,6%) y respiratorias (18,4%). El 83,7% de estas personas presentaron enfermedad mental como comorbilidad y el 77,6% consumía alguna droga, alcohol o tabaco.Las características de las hospitalizaciones de las personas sin hogar que ingresan en los dos hospitales con mayor actividad asistencial de Sevilla son distintas a las de las personas con hogar. Las personas sin hogar ingresan y fallecen a menor edad. Tanto su patrón de morbilidad como las características de sus hospitalizaciones reflejan su estado vulnerable de salud.

Resumen Objetivos Los factores asociados al abandono del tratamiento de la tuberculosis (TBC) pueden ser muy especificos de la poblacion y de la organizacion sanitaria locales. Hemos examinado los factores asociados al abandono del tratamiento de la TBC en la provincia de Granada. Sujetos y metodos Cohorte retrospectiva de los casos registrados en Granada y notificados en el Sistema de Vigilancia Epidemiologica de Andalucia durante los anos 2003-2010. Se calculo la incidencia en la poblacion nacional y extranjera. Se realizo un analisis univariante para describir las caracteristicas en ambos colectivos y se creo un modelo de regresion logistica para identificar los factores asociados al abandono terapeutico. Resultados Observamos una tendencia decreciente en la incidencia de TBC (20,47 casos en el ano 2007 y 11,00 en el 2010 por 100.000 habitantes; tasa de descenso de 9,47 casos por 100.000 habitantes). La edad media de los pacientes extranjeros fue menor que la de los enfermos nacionales (30,8 anos vs 46,0 anos; p Conclusiones La incidencia de TBC en la provincia de Granada se ha reducido alrededor de 10 casos por 100.000 habitantes y ano. El porcentaje de enfermos que abandonan el tratamiento TBC es considerable, siendo superior en los pacientes extranjeros que en los nacionales. El abandono del tratamiento TBC se asocio a ser varon, residir en el distrito Nordeste de Granada y padecer TBC extrapulmonar.

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

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

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

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

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

Introduction and objectives Ischemic heart disease is the leading cause of death and one of the top 4 causes of burden of disease worldwide. The aim of this study was to evaluate age-period-cohort effects on mortality from ischemic heart disease in Andalusia (southern Spain) and in each of its 8 provinces during the period 1981-2008. Methods A population-based ecological study was conducted. In all, 145 539 deaths from ischemic heart disease were analyzed for individuals aged between 30 and 84 years who died in Andalusia in the study period. A nonlinear regression model was estimated for each sex and geographical area using spline functions. Results There was an upward trend in male and female mortality rate by age from the age of 30 years. The risk of death for men and women showed a downward trend for cohorts born after 1920, decreasing after 1960 with a steep slope among men. Analysis of the period effect showed that male and female death risk first remained steady from 1981 to 1990 and then increased between 1990 and 2000, only to decrease again until 2008. Conclusions There were similar age-period-cohort effects on mortality in all the provinces of Andalusia and for Andalusia as a whole. If the observed cohort and period effects persist, male and female mortality from ischemic heart disease will continue to decline.

Colaboración especial Until now, mortality atlases have been static. Most of them describe the geographical distribution of mortality using count data aggregated over time and standardized mortality rates. However, this methodology has several limitations. Count data aggregated over time produce a bias in the estimation of death rates. Moreover, this practice difficult the study of temporal changes in geographical distribution of mortality. On the other hand, using standardized mortality hamper to check differences in mortality among groups. The Interactive Mortality Atlas in Andalusia (AIMA) is an alternative to conventional static atlases. It is a dynamic Geographical Information System that allows visualizing in web-site more than 12.000 maps and 338.00 graphics related to the spatio-temporal distribution of the main death causes in Andalusia by age and sex groups from 1981. The objective of this paper is to describe the methods used for AIMA development, to show technical specifications and to present their interactivity. The system is available from the link products in www.demap.es. AIMA is the first interactive GIS that have been developed in Spain with these characteristics. Spatio-temporal Hierarchical Bayesian Models were used for statistical data analysis. The results were integrated into web-site using a PHP environment and a dynamic cartography in Flash. Thematic maps in AIMA demonstrate that the geographical distribution of mortality is dynamic, with differences among year, age and sex groups. The information nowadays provided by AIMA and the future updating will contribute to reflect on the past, the present and the future of population health in Andalusia. Yes Los atlas de mortalidad publicados hasta la fecha son estáticos. La mayoría describen la distribución geográfica de la mortalidad agrupando datos de varios años y usando razones de mortalidad estandarizadas que resumen la mortalidad de todos los grupos de edad. Sin embargo, esta metodología presenta limitaciones para estudiar cambios temporales en la distribución geográfica de la mortalidad o diferencias entre grupos etarios. Aplicando una metodología alternativa surge el Atlas Interactivo de Mortalidad en Andalucía (AIMA), un Sistema de Información Geográfica dinámico que permite visualizar en web-site más de 12.000 mapas y 338.000 gráficos de tendencias correspondientes a la distribución espacio-temporal de las principales causas de muerte en Andalucía por grupos de edad y sexo desde 1981. El objetivo de este trabajo es describir la metodología utilizada para el desarrollo de AIMA, dar a conocer sus características y especificaciones técnicas y mostrar las posibilidades interactivas que ofrece. El sistema está disponible en el hipervínculo productos de www.demap.es. AIMA es el primer SIG interactivo de estas características implementado en España. Para el análisis de datos se han utilizado modelos jerárquicos bayesianos espacio-temporales, integrando posteriormente los resultados en web-site utilizando entorno PHP y cartografía dinámica en formato Flash. La selección de mapas temáticos muestra el carácter dinámico de la distribución geográfica de la mortalidad, con un patrón diferente para cada año, grupo de edad y sexo. La información contenida actualmente en este sistema y las futuras actualizaciones contribuirán a la reflexión sobre el pasado, presente y futuro de la salud en Andalucía.

This study describes the design and implementation of a health impact assessment (HIA) conducted in 2010 of the regeneration project of San Fernando Street, the main avenue crossing the San Miguel-El Castillo neighborhood in Alcala de Guadaíra (Seville, Spain). This project is part of the wider URBAN Plan aimed at the social, urban and economic regeneration of the city's historic center.This experience followed the standard HIA stages and procedures. The review of published evidence was complemented with new qualitative information gathered by means of a participative workshop with the local population and interviews with social and health workers involved in the neighborhood.During the building stage of the project, the adverse impacts were related to a worsening of the air quality, increased noise pollution, mobility restrictions and a higher risk of accidents, particularly among older or disabled people. Once the building stage was finished, the health benefits were associated with significant improvements in physical accessibility and the population's access to health services and other goods and services. Other positive effects were the enhanced safety and attractiveness of the neighborhood and the new opportunities for socializing, social cohesion and increasing the community's self-esteem.This is the first HIA experience in Andalusia whose results have been integrated into a formal cycle of decision making in the local community. This experience has provided new evidence of the potential of HIA and its applicability and acceptance at the municipal level and has has also facilitated a learning process and the piloting of new methods and tools associated with the HIA process.

The factors associated to tuberculosis (TB) treatment drop-out can be very specific to the population and the local health care organization. We have studied the factors associated to TB treatment drop out in the province of Granada.A retrospective cohort study of TB cases registered in the province of Granada by the Epidemiological Surveillance System of Andalusia (SVEA) between 2003 and 2010 was carried out. Incidence was calculated in the native and foreign population. An univariate analysis was performed to describe the characteristics in both groups and a logistic regression model was used to identify factors associated to therapeutic abandonment.A decreasing trend in the incidence of TB was observed, (20.47 in 2007 to 11 cases per 100,000 inhabitants in 2010, respectively. Mean age of foreign patients was lower than that of the natives (30.8 years vs. 46.0 years, P.001). The former predominately lived in the Granada district, while the natives lived in the Metropolitan district. The percentage of patients who abandoned antituberculous treatment was 12.2%, this being somewhat higher in the foreign patients than the national ones (14% vs 10%; P=.062). Being male (OR: 1.65; 95% CI: 1.04-2.60; P=.033), foreigner (OR: 1.72; 95% CI: 1.04-2.83; P=.032), resident in the North-east district (OR: 3.64; 95% CI: 1.76-7.52; P=.005) and/or having extrapulmonary TB (OR: 1.78; 95% CI: 1.06-3.00; P=.029) were associated significantly to therapeutic abandonment.The incidence of TB in the province of Granada has decreased to about 10 cases per 100,000 inhabitants/year. The percentage of patients who abandon TB treatment is significant, it being higher in foreign patients than in the natives. TB treatment abandonment was associated to being a man, living in the North-east district of Granada and having extrapulmonary TB.

The Ria of Huelva (south-west Spain) is a highly polluted estuary as a consequence of long-term mining and industrial activities. Between 2003 and 2004, we conducted a biomonitoring study of exposure to arsenic and some heavy metals (cadmium, chromium, copper and nickel) in urine samples of a representative sample (n=227) of children and adolescents residing in this area, and of a reference group of 196 children and adolescents living in other less industrialised areas of Andalusia (south Spain). We also assessed the determinants of the variability in urinary metals within the population of the Ria of Huelva. There were no significant differences in the concentration of metal compounds between the two groups with the exception of Cd levels, which were significantly higher in the reference group. Levels of the five metal ions in both groups were generally within the range of values reported by other biomonitoring studies for general children population, although mean Cd levels tended to be higher as compared to other European studies. Among the population of the Ria of Huelva, the main determinants of the interindividual variation in urinary metals were age, sex, area of residence, and frequency of intake of certain food items (mainly fish and shellfish). Overall, results suggest that living in the Ria of Huelva is not increasing current levels of exposure to certain metals among children and adolescents above those found in other urban areas of Andalusia. Keywords: Arsenic, Heavy metals, Biomonitoring, Urine, Children, Environmental exposure

Until now, mortality atlases have been static. Most of them describe the geographical distribution of mortality using count data aggregated over time and standardized mortality rates. However, this methodology has several limitations. Count data aggregated over time produce a bias in the estimation of death rates. Moreover, this practice difficult the study of temporal changes in geographical distribution of mortality. On the other hand, using standardized mortality hamper to check differences in mortality among groups. The Interactive Mortality Atlas in Andalusia (AIMA) is an alternative to conventional static atlases. It is a dynamic Geographical Information System that allows visualizing in web-site more than 12.000 maps and 338.00 graphics related to the spatio-temporal distribution of the main death causes in Andalusia by age and sex groups from 1981. The objective of this paper is to describe the methods used for AIMA development, to show technical specifications and to present their interactivity. The system is available from the link products in www.demap.es. AIMA is the first interactive GIS that have been developed in Spain with these characteristics. Spatio-temporal Hierarchical Bayesian Models were used for statistical data analysis. The results were integrated into web-site using a PHP environment and a dynamic cartography in Flash. Thematic maps in AIMA demonstrate that the geographical distribution of mortality is dynamic, with differences among year, age and sex groups. The information nowadays provided by AIMA and the future updating will contribute to reflect on the past, the present and the future of population health in Andalusia.

Los atlas de mortalidad publicados hasta la fecha son estáticos. La mayoría describen la distribución geográfica de la mortalidad agrupando datos de varios años y usando razones de mortalidad estandarizadas que resumen la mortalidad de todos los grupos de edad. Sin embargo, esta metodología presenta limitaciones para estudiar cambios temporales en la distribución geográfica de la mortalidad o diferencias entre grupos etarios. Aplicando una metodología alternativa surge el Atlas Interactivo de Mortalidad en Andalucía (AIMA), un Sistema de Información Geográfica dinámico que permite visualizar en web-site más de 12.000 mapas y 338.000 gráficos de tendencias correspondientes a la distribución espacio-temporal de las principales causas de muerte en Andalucía por grupos de edad y sexo desde 1981. El objetivo de este trabajo es describir la metodología utilizada para el desarrollo de AIMA, dar a conocer sus características y especificaciones técnicas y mostrar las posibilidades interactivas que ofrece. El sistema está disponible en el hipervínculo productos de www.demap.es. AIMA es el primer SIG interactivo de estas características implementado en España. Para el análisis de datos se han utilizado modelos jerárquicos bayesianos espacio-temporales, integrando posteriormente los resultados en web-site utilizando entorno PHP y cartografía dinámica en formato Flash. La selección de mapas temáticos muestra el carácter dinámico de la distribución geográfica de la mortalidad, con un patrón diferente para cada año, grupo de edad y sexo. La información contenida actualmente en este sistema y las futuras actualizaciones contribuirán a la reflexión sobre el pasado, presente y futuro de la salud en Andalucía. Until now, mortality atlases have been static. Most of them describe the geographical distribution of mortality using count data aggregated over time and standardized mortality rates. However, this methodology has several limitations. Count data aggregated over time produce a bias in the estimation of death rates. Moreover, this practice difficult the study of temporal changes in geographical distribution of mortality. On the other hand, using standardized mortality hamper to check differences in mortality among groups. The Interactive Mortality Atlas in Andalusia (AIMA) is an alternative to conventional static atlases. It is a dynamic Geographical Information System that allows visualizing in web-site more than 12.000 maps and 338.00 graphics related to the spatio-temporal distribution of the main death causes in Andalusia by age and sex groups from 1981. The objective of this paper is to describe the methods used for AIMA development, to show technical specifications and to present their interactivity. The system is available from the link products in www.demap.es. AIMA is the first interactive GIS that have been developed in Spain with these characteristics. Spatio-temporal Hierarchical Bayesian Models were used for statistical data analysis. The results were integrated into web-site using a PHP environment and a dynamic cartography in Flash. Thematic maps in AIMA demonstrate that the geographical distribution of mortality is dynamic, with differences among year, age and sex groups. The information nowadays provided by AIMA and the future updating will contribute to reflect on the past, the present and the future of population health in Andalusia.

The objective of this study is to review the health promotion interventions on spanish youths published in Spanish in the 1995-2000 period and to describe them in accordance with the scope within which they have been carried out, the topics addressed, the methodology, the evaluation design used and the results obtained. Two hundred and fourteen intervention were identified. Illegal drugs were the topic on which the largest number of interventions were focused (29.8%), followed by alcohol (15.9%), the risk-related sexual behaviours (14.6%) and leisure time (12.6%). The activities carried out most often were: participation-based educational methods (30.7%), explanatory education methods (11.5%) and the preparation of educational materials (11%). In 80.8% of the cases, some evaluation of the health promotion activities was found. The type of evaluation employed most often was the process evaluation (73.7%), and the medium-long term results evaluation being those employed the least (2.2%). The evaluation methodologies used most often were questionnaires (28.2%). A combination of qualitative and quantitative methods was employed in 13.2% of the cases. The four interventions in which the medium-long term impact was gauged had the purpose of preventing and reducing cigarette smoking and/or drinking and or marijuana smoking, all of these initiatives achieving a reduction in cigarette smoking. In conclusion, it seems necessary to improve the design of the evaluations of the health promotion initiatives addressed to young people in Spain and to increase the dissemination of the same by way of their publication.

Comparative Study; English Abstract; Journal Article; Review; The objective of this study is to review the health promotion interventions on spanish youths published in Spanish in the 1995-2000 period and to describe them in accordance with the scope within which they have been carried out, the topics addressed, the methodology, the evaluation design used and the results obtained. Two hundred and fourteen intervention were identified. Illegal drugs were the topic on which the largest number of interventions were focused (29.8%), followed by alcohol (15.9%), the risk-related sexual behaviours (14.6%) and leisure time (12.6%). The activities carried out most often were: participation-based educational methods (30.7%), explanatory education methods (11.5%) and the preparation of educational materials (11%). In 80.8% of the cases, some evaluation of the health promotion activities was found. The type of evaluation employed most often was the process evaluation (73.7%), and the medium-long term results evaluation being those employed the least (2.2%). The evaluation methodologies used most often were questionnaires (28.2%). A combination of qualitative and quantitative methods was employed in 13.2% of the cases. The four interventions in which the medium-long term impact was gauged had the purpose of preventing and reducing cigarette smoking and/or drinking and or marijuana smoking, all of these initiatives achieving a reduction in cigarette smoking. In conclusion, it seems necessary to improve the design of the evaluations of the health promotion initiatives addressed to young people in Spain and to increase the dissemination of the same by way of their publication. Yes El objetivo de este estudio ha sido revisar las intervenciones de promoción de la salud dirigidas a jóvenes españoles, publicadas entre los años 1995 y 2000 en español, y describirlas de acuerdo al ámbito en el que se han desarrollado, los temas a los que se han dirigido, la metodología y el diseño de evaluación utilizados y los resultados obtenidos. Se identificaron 214 intervenciones. Las drogas ilegales fueron el tema en el que se centraron el mayor número de intervenciones (29,8%), seguido por el alcohol (15,9%), las conductas sexuales de riesgo (14,6%) y el ocio (12,6%). Las actividades realizadas con mayor frecuencia fueron: técnicas educativas participativas (30,7%), técnicas educativas expositivas (11,5%) y elaboración de materiales educativos (11%). En el 80,8% de casos había constancia de que se había realizado una evaluación. De ellas, las más frecuente fueron las evaluaciones de proceso (73,7%), y las menos frecuente las evaluaciones de resultados a medio-largo plazo (2,2%). Las metodologías de evaluación más utilizadas fueron los cuestionarios (28,2%). La combinación de técnicas cualitativas y cuantitativas fue utilizada en el 13,2% de los casos. Las 4 intervenciones en las que se midió el impacto a medio-largo plazo tenían como objetivo la prevención o reducción del consumo de tabaco y/o alcohol y/o cánnabis, y todas ellas consiguieron reducir el consumo de tabaco. En conclusión, parece necesario mejorar el diseño evaluativo de las intervenciones de promoción de la salud dirigidas a jóvenes en nuestro país y aumentar la difusión de las mismas mediante su publicación

ObjetivoComparar los resultados de dos modalidades de enseñanza sobre uso racional de medicamentos en alumnos de centros de educación permanente de adultos (CEPA): la realizada a través del profesorado (formado previamente por los sanitarios) o mediante charla de educación impartida por el personal sanitario.DiseñoEstudio de intervención sin distribución aleatoria, con grupo control.EmplazamientoCinco CEPA de un núcleo urbano.ParticipantesTrescientos ochenta y cinco alumnos y 15 profesores de CEPA.IntervencionesTres grupos: a) grupo «profesores», constituido por alumnos que recibieron educación sobre medicamentos en el aula, mediante sus profesores, los cuales habían sido formados previamente por los sanitarios; b) grupo «charla»: alumnos que recibieron una charla de educación sanitaria sobre medicamentos impartida por los sanitarios, y c) grupo no intervención. En los 3 grupos se realizó encuesta previa y posterior a la intervención. Ambas encuestas fueron apareadas.Mediciones y resultados principalesDoscientos cuarenta y ocho sujetos completaron la primera encuesta y 149 la segunda. Sólo se encontraron ganancias significativas de conocimiento en el grupo de intervención con profesores (p < 0,01; 7,8% de ganancia de puntos relativa). Si dividíamos a los alumnos en terciles, estas ganancias eran superiores (11,7%) significativamente en los alumnos del grupo «profesores» con puntuaciones previas intermedias en la primera encuesta, en comparación con los alumnos de puntuación intermedia de los otros grupos.ConclusionesLa intervención mediante «profesores» parece mostrarse más efectiva que la realizada mediante «charla de educación sanitaria» o la «no intervención», y se diferencia de éstas en la mejoría de conocimientos en los alumnos con conocimientos previos intermedios.ObjectiveTo compare the results of two ways of teaching the rational use of medicines to students of centres of permanent education of adults (CPEA): one taught by the normal teachers (after training by health personnel) and one through a lecture given by the health staff.DesignIntervention study without randomised distribution and with a control group.SettingFive CPEA in an urban centre.Participants385 students and 15 CPEA teachers.InterventionsThree groups: a) «teachers» group: consisting of students who received education on medicines in the class-room through their teachers, who had been previously trained by health personnel; b) «lecture» group: students who had received a health education lecture on medicines given by health staff; c) non-intervention group. All three groups were administered a questionnaire before and after the intervention. Both questionnaires were paired.Measurements and main results248 people completed the first questionnaire and 149 the second. Significant gains in knowledge were only found in the teachers intervention group (p < 0.01; 7.8% increase in score). Dividing the students into terciles made these gains significantly greater (11.7%) in the students of the teachers group who in the first questionnaire had intermediate scores than in the students in the other groups who had intermediate scores.ConclusionsIntervention with teachers seems more effective than either a health education lecture or no intervention, especially in the improvement in knowledge of students who already had beforehand intermediate knowledge.

ResumenObjetivosSe presenta la experiencia de una evaluación del impacto en la salud realizada en 2010 sobre el proyecto de reurbanización de la calle San Fernando, vía principal de acceso al barrio de San Miguel-El Castillo, en Alcalá de Guadaíra (Sevilla). Constituye ésta una de las primeras actuaciones previstas en el Plan URBAN de regeneración social, urbana y económica del casco histórico del municipio.MétodosSe han seguido las cinco fases y los procedimientos clásicos de una evaluación del impacto en la salud. La revisión de la evidencia se ha complementado con una consulta a la población afectada en forma de taller participativo, así como con entrevistas a profesionales sociosanitarios con implicación en el barrio.ResultadosDurante las obras, los impactos negativos se relacionan con los efectos nocivos del proyecto sobre la calidad del aire, el nivel de ruidos, las restricciones a la movilidad y el riesgo de siniestralidad, en especial entre la población mayor o con movilidad reducida. Cuando finalicen, se prevén mejoras en determinantes del entorno físico tales como la accesibilidad y la conectividad del barrio con servicios sanitarios y otros bienes y servicios en otras zonas del municipio. También se prevén impactos positivos vinculados a la seguridad y el atractivo del barrio, así como nuevas oportunidades para la sociabilidad, la cohesión social y la autoestima comunitaria.ConclusionesSe trata de la primera experiencia en Andalucía cuyos resultados se han integrado en un ciclo formal de toma de decisiones de ámbito local. Ello ha permitido valorar el potencial, la aplicabilidad y la aceptación de la evaluación del impacto en la salud en el ámbito municipal, así como facilitar un proceso de aprendizaje y un pilotaje de métodos y herramientas adaptadas.AbstractObjectivesThis study describes the design and implementation of a health impact assessment (HIA) conducted in 2010 of the regeneration project of San Fernando Street, the main avenue crossing the San Miguel-El Castillo neighborhood in Alcala de Guadaíra (Seville, Spain). This project is part of the wider URBAN Plan aimed at the social, urban and economic regeneration of the city's historic center.MethodsThis experience followed the standard HIA stages and procedures. The review of published evidence was complemented with new qualitative information gathered by means of a participative workshop with the local population and interviews with social and health workers involved in the neighborhood.ResultsDuring the building stage of the project, the adverse impacts were related to a worsening of the air quality, increased noise pollution, mobility restrictions and a higher risk of accidents, particularly among older or disabled people. Once the building stage was finished, the health benefits were associated with significant improvements in physical accessibility and the population's access to health services and other goods and services. Other positive effects were the enhanced safety and attractiveness of the neighborhood and the new opportunities for socializing, social cohesion and increasing the community's self-esteem.ConclusionsThis is the first HIA experience in Andalusia whose results have been integrated into a formal cycle of decision making in the local community. This experience has provided new evidence of the potential of HIA and its applicability and acceptance at the municipal level and has has also facilitated a learning process and the piloting of new methods and tools associated with the HIA process.