[Show abstract][Hide abstract] ABSTRACT: Introduction: Urban populations are growing and to accommodate these numbers, cities are becoming more involved in urban renewal programs to improve the physical, social and economic conditions in different areas. This paper explores some of the complexities surrounding the link between urban renewal, health and health inequalities using a theory-driven approach. Methods: We focus on an urban renewal initiative implemented in Barcelona, the Neighbourhoods Law, targeting Barcelona's (Spain) most deprived neighbourhoods. We present evidence from two studies on the health evaluation of the Neighbourhoods Law, while drawing from recent urban renewal literature, to follow a four-step process to develop a program theory. We then use two specific urban renewal interventions, the construction of a large central plaza and the repair of streets and sidewalks, to further examine this link. Discussion: In order for urban renewal programs to affect health and health inequality, neighbours must use and adapt to the changes produced by the intervention. However, there exist barriers that can result in negative outcomes including factors such as accessibility, safety and security. Conclusion: This paper provides a different perspective to the field that is largely dominated by traditional quantitative studies that are not always able to address the complexities such interventions provide. Furthermore, the framework and discussions serve as a guide for future research, policy development and evaluation.
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to analyze the association between social class and psychosocial occupational risk factors and self-rated health and mental health in a Chilean population. A cross-sectional study analyzed data from the First National Survey on Employment, Work, Quality of Life, and Male and Female Workers in Chile (N = 9,503). The dependent variables were self-rated health status and mental health. The independent variables were social class (neo-Marxist), psychosocial occupational risk factors, and material deprivation. Descriptive and logistic regression analyses were performed. There were inequalities in the distribution of psychosocial occupational risk factors by social class and sex. Furthermore, social class and psychosocial occupational risk factors were associated with unequal distribution of self-rated health and mental health among the working population in Chile. Occupational health interventions should consider workers' exposure to socioeconomic and psychosocial risk factors.
Cadernos de saúde pública. 10/2014; 30(10):2219-34.
[Show abstract][Hide abstract] ABSTRACT: to Describe perceived health, mental health and certain health-related behaviors according to sexual attraction and behavior in the population residing in Barcelona in 2011.
[Show abstract][Hide abstract] ABSTRACT: Introduction: In Czechia, immigrants without permanent residence are not entitled to public health insurance and should purchase a commercial insurance.
Methods: Using data from a survey of Ukrainian immigrants and a country-wide Health Interview Survey for Czechs, we analyse inequalities in access to different healthcare services.
Results: Ukrainians with a permanent visa have lower access than Czechs to specialist and dental care. Ukrainians with a long-term visa have a lower access than Czechs to all types of care, and than compatriots with a permanent visa to primary care (adjusted Prevalence Ratio 0.45, 95%CI 0.34-0.61), hospitalization (0.29, 0.12-0.71) and emergency room (0.60, 0.37-1.00).
Conclusions: The exclusion of long-term immigrants from the public healthcare system should be revised on grounds of equity and public health protection.
[Show abstract][Hide abstract] ABSTRACT: a b s t r a c t Few studies have addressed the effect of gender policies on women's health and gender inequalities in health. This study aims to analyse the relationship between the orientation of public gender equality policies and gender inequalities in health in European countries, and whether this relationship is mediated by gender equality at country level or by other individual social determinants of health. A multilevel cross-sectional study was performed using individual-level data extracted from the Eu-ropean Social Survey 2010. The study sample consisted of 23,782 men and 28,655 women from 26 European countries. The dependent variable was self-perceived health. Individual independent variables were gender, age, immigrant status, educational level, partner status and employment status. The main contextual independent variable was a modification of Korpi's typology of family policy models (Dual-earner, Traditional-Central, Traditional-Southern, Market-oriented and Contradictory). Other contextual variables were the Gender Empowerment Measure (GEM), to measure country-level gender equality, and the Gross Domestic Product (GDP). For each country and country typology the prevalence of fair/poor health by gender was calculated and prevalence ratios (PR, women compared to men) and 95% confi-dence intervals (CI) were computed. Multilevel robust Poisson regression models were fitted. Women had poorer self-perceived health than men in countries with traditional family policies (PR ¼ 1.13, 95%CI: 1.07e1.21 in Traditional-Central and PR ¼ 1.27, 95%CI: 1.19e1.35 in Traditional-Southern) and in Contradictory countries (PR ¼ 1.08, 95%CI: 1.05e1.11). In multilevel models, only gender inequalities in Traditional-Southern countries were significantly higher than those in Dual-earner countries. Gender inequalities in self-perceived health were higher, women reporting worse self-perceived health than men, in countries with family policies that were less oriented to gender equality (espe-cially in the Traditional-Southern country-group). This was partially explained by gender inequalities in the individual social determinants of health but not by GEM or GDP.
Social Science [?] Medicine 07/2014; 117. · 2.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The economic crisis has adverse effects on determinants of health and health inequalities. The aim of this article was to present a set of indicators of health and its determinants to monitor the effects of the crisis in Spain. On the basis of the conceptual framework proposed by the Commission for the Reduction of Social Health Inequalities in Spain, we searched for indicators of social, economic, and political (structural and intermediate) determinants of health, as well as for health indicators, bearing in mind the axes of social inequality (gender, age, socioeconomic status, and country of origin). The indicators were mainly obtained from official data sources published on the internet. The selected indicators are periodically updated and are comparable over time and among territories (among autonomous communities and in some cases among European Union countries), and are available for age groups, gender, socio-economic status, and country of origin. However, many of these indicators are not sufficiently reactive to rapid change, which occurs in the economic crisis, and consequently require monitoring over time. Another limitation is the lack of availability of indicators for the various axes of social inequality. In conclusion, the proposed indicators allow for progress in monitoring the effects of the economic crisis on health and health inequalities in Spain.
[Show abstract][Hide abstract] ABSTRACT: In the last decade, the Neighbourhoods Law in Catalonia (Spain) funded municipalities that presented urban renewal projects within disadvantaged neighbourhoods focusing on physical, social and economic improvements. The objective of the study was to evaluate the effects of this law on the health and health inequalities of residents in the intervened neighbourhoods in the city of Barcelona.
A quasi-experimental predesign and postdesign was used to compare adult residents in five intervened neighbourhoods with eight non-intervened comparison neighbourhoods with similar socioeconomic characteristics. The Barcelona Health Survey was used for studying self-rated and mental health in pre (2001, 2006) and post (2011) years. Poisson regression models stratified by sex were used to compute prevalence ratios comparing 2011 with 2006, and later stratified by social class, to study health inequalities.
The intervened neighbourhoods had a significant decrease in poor self-rated health in both sexes while no significant changes occurred in the comparison group. When stratified by social class, a significant improvement was observed in poor self-rated health in the manual group of the intervened neighbourhoods in both sexes, resulting in a decrease in self-rated health inequalities. Similar results were observed in poor mental health of women, while in men, poor mental health worsens in both neighbourhood groups but mostly in the comparison group.
The Neighbourhoods Law had a positive effect on self-rated health and seems to prevent poor mental health increases in both sexes and especially among manual social classes.
Journal of epidemiology and community health 05/2014; · 3.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the knowledge and beliefs of public policymakers on social inequalities in health and policies to reduce them in cities from different parts of Europe during 2010 and 2011.
BMJ Open 05/2014; 4(5):e004454. · 2.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: European city councils are increasingly developing interventions against health inequalities. There is little knowledge about how they are perceived. This study describes and analyses good practices and challenges for local interventions on inequalities in health through the narratives of European city managers. Methods: A qualitative study was conducted. Each participating city (Amsterdam, Barcelona, Cluj-Napoca, Helsinki, Lisbon, London, Madrid, Rotterdam) selected interventions following these criteria: at least 6 months of implementation; an evaluation performed or foreseen; the reduction of health inequalities among their objectives, and only one of the interventions selected could be based on health care. Managers of these local interventions were interviewed following an outline. Eleven individual in-depth interviews describing nine local interventions were obtained. A thematic content analysis was performed. Results: One or more local interventions against health inequalities were identified in each city. Most relied on quantitative data and were linked to national strategies. Few interventions addressed socio-economic determinants. Health care, employment and education were the main determinants addressed. With variable depth, evidence-base, participation and intersectorality were regular components of the interventions. Half of them targeted the city and half some deprived neighbourhoods. Few interventions had been evaluated. Scarcity of funding and sustainability of the projects were the main perceived barriers by the managers. Conclusions: City intervention managers were familiar with health inequalities and concepts as intersectorality, participation and evidence-based action, but others such as socioeconomic aims, gradient approach, evaluation and sustainability were not so widely applied. Managers' capacities and political leadership in governance for health should be reinforced.
Scandinavian Journal of Public Health 04/2014; · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Publication of recent papers such as the one by Schoenbaum and colleagues entitled 'Mortality Amenable to Health Care in the United States: The Roles of Demographics and Health Systems Performance' has stimulated this commentary. We discuss strengths and limitations of amenable and avoidable mortality in health-care systems' performance and their contribution to health inequalities. To illustrate, we present a case study of avoidable and amenable mortality in Spain over 27 years. We conclude that amenable mortality is not a good indicator of health-care systems' performance, or for determining whether it could give rise to health inequalities. To understand health problems and to assess the impact of interventions affecting health requires good, basic, and routine monitoring of health indicators and of socioeconomic determinants of health.Journal of Public Health Policy advance online publication, 13 March 2014; doi:10.1057/jphp.2014.8.
Journal of Public Health Policy 03/2014; · 1.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Health and inequalities in health among inhabitants of European cities are of major importance for European public health and there is great interest in how different health care systems in Europe perform in the reduction of health inequalities. However, evidence on the spatial distribution of cause-specific mortality across neighbourhoods of European cities is scarce. This study presents maps of avoidable mortality in European cities and analyses differences in avoidable mortality between neighbourhoods with different levels of deprivation.
We determined the level of mortality from 14 avoidable causes of death for each neighbourhood of 15 large cities in different European regions. To address the problems associated with Standardised Mortality Ratios for small areas we smooth them using the Bayesian model proposed by Besag, York and Mollie. Ecological regression analysis was used to assess the association between social deprivation and mortality.
Mortality from avoidable causes of death is higher in deprived neighbourhoods and mortality rate ratios between areas with different levels of deprivation differ between gender and cities. In most cases rate ratios are lower among women. While Eastern and Southern European cities show higher levels of avoidable mortality, the association of mortality with social deprivation tends to be higher in Northern and lower in Southern Europe.
There are marked differences in the level of avoidable mortality between neighbourhoods of European cities and the level of avoidable mortality is associated with social deprivation. There is no systematic difference in the magnitude of this association between European cities or regions. Spatial patterns of avoidable mortality across small city areas can point to possible local problems and specific strategies to reduce health inequality which is important for the development of urban areas and the well-being of their inhabitants.
International Journal of Health Geographics 03/2014; 13(1):8. · 2.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To explore inequalities in total mortality between small areas of 16 European cities for men and women, as well as to analyse the relationship between these geographical inequalities and their socioeconomic indicators. Methods: A cross-sectional ecological design was used to analyse small areas in 16 European cities (26,229,104 inhabitants). Most cities had mortality data for a period between 2000 and 2008 and population size data for the same period. Socioeconomic indicators included an index of socioeconomic deprivation, unemployment, and educational level. We estimated standardised mortality ratios and controlled for their variability using Bayesian models. We estimated relative risk of mortality and excess number of deaths according to socioeconomic indicators. Results: We observed a consistent pattern of inequality in mortality in almost all cities, with mortality increasing in parallel with socioeconomic deprivation. Socioeconomic inequalities in mortality were more pronounced for men than women, and relative inequalities were greater in Eastern and Northern European cities, and lower in some Western (men) and Southern (women) European cities. The pattern of excess number of deaths was slightly different, with greater inequality in some Western and Northern European cities and also in Budapest, and lower among women in Madrid and Barcelona. Conclusions: In this study, we report a consistent pattern of socioeconomic inequalities in mortality in 16 European cities. Future studies should further explore specific causes of death, in order to determine whether the general pattern observed is consistent for each cause of death.
Scandinavian Journal of Public Health 02/2014; · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Health inequalities can be tackled with appropriate health and social policies, involving all community groups and governments, from local to global. The objective of this study was to carry out a scoping review on social and health policies or interventions to tackle health inequalities in European cities published in scientific journals.
Scoping review. The search was done in "PubMed" and the "Sociological Abstracts" database and was limited to articles published between 1995 and 2011. The inclusion criteria were: interventions had to take place in European cities and they had to state the reduction of health inequalities among their objectives.
A total of 54 papers were included, of which 35.2% used an experimental design, and 74.1% were carried out in the United Kingdom. The whole city was the setting in 27.8% of them and 44.4% were based on promoting healthy behaviours. Adults and children were the most frequent target population and half of the interventions had a universal approach and the other half a selective one. Half of the interventions were evaluated and showed positive results.
Although health behaviours are not the main determinants of health inequalities, the majority of the selected documents were based on evaluations of interventions focusing on them.
BMC Public Health 02/2014; 14(1):198. · 2.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background : Women experience poorer health than men despite their longer life expectancy, due to a higher prevalence of non-fatal chronic illnesses. This paper aims to explore whether the unequal gender distribution of roles and resources can account for inequalities in general self-rated health (SRH) by gender, across social classes, in a Southern European population. Methods : Cross-sectional study of residents in Catalonia aged 25-64, using data from the 2006 population living conditions survey (n=5,817). Poisson regression models were used to calculate the fair/poor SRH prevalence ratio (PR) by gender and to estimate the contribution of variables assessing several dimensions of living conditions as the reduction in the PR after their inclusion in the model. Analyses were stratified by social class (non-manual and manual). Results : SRH was poorer for women among both non-manual (PR 1.39, 95% CI 1.09-1.76) and manual social classes (PR 1.36, 95% CI 1.20-1.56). Adjustment for individual income alone eliminated the association between sex and SRH, especially among manual classes (PR 1.01, 95% CI 0.85-1.19; among non-manual 1.19, 0.92-1.54). The association was also reduced when adjusting by employment conditions among manual classes, and household material and economic situation, time in household chores and residential environment among non-manual classes. Discussion : Gender inequalities in individual income appear to contribute largely to women's poorer health. Individual income may indicate the availability of economic resources, but also the history of access to the labour market and potentially the degree of independence and power within the household. Policies to facilitate women's labour market participation, to close the gender pay gap, or to raise non-contributory pensions may be helpful to improve women's health.
Global Health Action 02/2014; 7:23189. · 2.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Health system reforms are undertaken with the aim of improving equity of access to health care. Their impact is generally analyzed based on health care utilization, without distinguishing between levels of care. This study aims to analyze inequities in access to the continuum of care in municipalities of Brazil and Colombia.
A cross-sectional study was conducted based on a survey of a multistage probability sample of people who had had at least one health problem in the prior three months (2,163 in Colombia and 2,167 in Brazil). The outcome variables were dichotomous variables on the utilization of curative and preventive services. The main independent variables were income, being the holder of a private health plan and, in Colombia, type of insurance scheme of the General System of Social Security in Health (SGSSS). For each country, the prevalence of the outcome variables was calculated overall and stratified by levels of per capita income, SGSSS insurance schemes and private health plan. Prevalence ratios were computed by means of Poisson regression models with robust variance, controlling for health care need.
There are inequities in favor of individuals of a higher socioeconomic status: in Colombia, in the three different care levels (primary, outpatient secondary and emergency care) and preventive activities; and in Brazil, in the use of outpatient secondary care services and preventive activities, whilst lower-income individuals make greater use of the primary care services. In both countries, inequity in the use of outpatient secondary care is more pronounced than in the other care levels. Income in both countries, insurance scheme enrollment in Colombia and holding a private health plan in Brazil all contribute to the presence of inequities in utilization.
Twenty years after the introduction of reforms implemented to improve equity in access to health care, inequities, defined in terms of unequal use for equal need, are still present in both countries. The design of the health systems appears to determine access to the health services: two insurance schemes in Colombia with different benefits packages and a segmented system in Brazil, with a significant private component.
International Journal for Equity in Health 01/2014; 13(1):10. · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Over the last decades of the 20th century, a widening of the gap in death rates between upper and lower socioeconomic groups has been reported for many European countries. For most countries, it is unknown whether this widening has continued into the first decade of the 21st century. METHODS: We collected and harmonised data on mortality by educational level among men and women aged 30-74 years in all countries with available data: Finland, Sweden, Norway, Denmark, England and Wales, Belgium, France, Switzerland, Spain, Italy, Hungary, Lithuania and Estonia. RESULTS: Relative inequalities in premature mortality increased in most populations in the North, West and East of Europe, but not in the South. This was mostly due to smaller proportional reductions in mortality among the lower than the higher educated, but in the case of Lithuania and Estonia, mortality rose among the lower and declined among the higher educated. Mortality among the lower educated rose in many countries for conditions linked to smoking (lung cancer, women only) and excessive alcohol consumption (liver cirrhosis and external causes). In absolute terms, however, reductions in premature mortality were larger among the lower educated in many countries, mainly due to larger absolute reductions in mortality from cardiovascular disease and cancer (men only). Despite rising levels of education, population-attributable fractions of lower education for mortality rose in many countries. CONCLUSIONS: Relative inequalities in premature mortality have continued to rise in most European countries, and since the 1990s, the contrast between the South (with smaller inequalities) and the East (with larger inequalities) has become stronger. While the population impact of these inequalities has further increased, there are also some encouraging signs of larger absolute reductions in mortality among the lower educated in many countries. Reducing inequalities in mortality critically depends upon speeding up mortality declines among the lower educated, and countering mortality increases from conditions linked to smoking and excessive alcohol consumption such as lung cancer, liver cirrhosis and external causes.
[Show abstract][Hide abstract] ABSTRACT: The Ineq-Cities project analyzed inequalities in mortality in small areas and described interventions to reduce inequalities in health in 16 European cities. This field note describes the dissemination of the project in Spain. In accordance with the recommendations of the project, the objective was to translate relevant results to key stakeholders – mainly technical staff, municipal officers and local social agents – and to provide an introduction to urban inequalities in health and strategies to address them. Twenty-four workshops were given, attended by more than 350 professionals from 92 municipalities. Knowledge dissemination consisted of the publication of a short book on inequalities in health and the approach to this problem in cities and three articles in nonspecialized media, a proposal for a municipal motion, and knowledge dissemination activities in social networks. Users rated these activities highly and stressed the need to systematize these products. This process may have contributed to the inclusion of health inequalities in the political agenda and to the training of officers to correct them.