Inequalities in Health Services Usage in a National Health System Scheme: The Case of a Southern Social European Region.

BACKGROUND: Health services can reduce inequalities caused by other determinants of health or increase them due to the effect of the inverse care law-the principle that the availability of good quality care tends to vary inversely with the need for it in the population served. OBJECTIVE: The purpose of the research was to describe inequalities in the use of nursing services, medical services in primary care, specialist care, and services not fully covered by the Basque public health system in Spain. METHODS: A cross-sectional study of adults aged at least 25 years who completed the 2013 Basque Health Survey (N = 10,454) was conducted. Age-standardized prevalence and prevalence ratios for use of services that are covered and noncovered in the health system were computed. The association of health services usage with socioeconomic variables was estimated using a Poisson regression model with robust variance. The relative index of inequality (RII) was used to measure the magnitude of socioeconomic status inequalities in health service use. All analyses were carried out separately for men and women. RESULTS: Individuals with lower socioeconomic status were more likely to use primary care (RII = 0.87, 95% CI [0.79, 0.97]) and less likely to use specialist services (RII = 0.82, 95% CI [0.75, 0.89]). Across noncovered health services, inequalities between the highest and lowest social groups were significant in all cases and especially marked in men's use of physiotherapists (RII = 0.46, 95% CI [0.35, 0.61]) and podiatrists (RII = 0.24, 95%CI [0.15, 0.38]). DISCUSSION: There are significant inequalities in primary and specialist health service use based on individual socioeconomic status, particularly for services that are not provided free of charge within the existing health system. This suggests that health service systems that are not explicitly designed to provide universal access may actually amplify preexisting social and health inequalities within their target populations.

Urban regeneration as population health intervention: a health impact assessment in the Bay of Pasaia (Spain).

BACKGROUND: An important health issue in urban areas is how changes arising from the regeneration of city-areas affect social determinants of health and equity. This paper examines the impacts attributable to a new fish market and to delays in the regeneration of a port area in a deteriorated region of the Bay of Pasaia (Spain). Potential differential impacts on local residents and socially vulnerable groups were evaluated to determine health inequalities. METHODS: An in-depth, prospective and concurrent Health-Impact-Assessment (HIA) focused on equity was conducted by the regional Public Health Department, following the Merseyside guidelines. Data from different sources was triangulated and impacts were identified using qualitative and quantitative methods. RESULTS: The intervention area is characterised by poor social, environmental, and health indicators. The distinctness of the two projects generates contrasting health and inequality impacts: generally positive for the new fish market and negative for the port area. The former creates recreational spaces and improves urban quality and social cohesion. By contrast, inaction and stagnation of the project in the port area perpetuates deterioration, a lack of safety, and poor health, as well as increased social frustration. CONCLUSIONS: In addition to assessing the health impacts of both projects this HIA promoted intersectoral partnerships, boosted a holistic and positive view of health and incorporated health and equity into the political discourse. Community-level participatory action enabled public health institutions to respond to new urban planning challenges and responsibilities in a more democratic manner.

[Towards good governance for health: incorporating the diversity of perceptions around urban health]. / Hacia el buen gobierno por la salud: incorporación de la diversidad de percepciones en salud urbana.

OBJECTIVE: To analyse the similarities and differences in the discourse surrounding the conceptualisation of health and the perceived health assets and needs in the neighborhoods and city of Bilbao in a participatory process. METHOD: Participatory workshops were held with professionals, neighbors and associated citizens. The differences in perceptions of the three content blocks were analysed on the basis of the health model referred, as well as the typologies -of a more individual or structural nature- of identified health needs and assets. RESULTS: The conceptualisation of health from a biopsychosocial perspective was clearer among professionals, although both profiles pointed to the importance of its social determinants. The formulation of needs and assets in health by the neighbors was made from the impact on their daily life and from a position of users with respect to a service provider administration. Among the associated citizens and professionals, intermediate and structural determinants were more frequently mentioned, as well as issues related to the administration's scope of action. CONCLUSIONS: The inclusion of the multiplicity and diversity of perceptions in planning is key to good local government for health. To address their contradictions, a commitment by governments to effectively incorporate citizen participation is needed.

Differences in sentinel influenza confirmed incidence rates and clinical presentation of influenza virus: 2008-09 seasonal vs 2009-10 pandemic influenza.

The Influenza sentinel surveillance network of Catalonia (PIDIRAC) allows for the study of circulating influenza virus (IV). The aim of this work was to assess differences between two influenza seasons, the 2008-2009 A(H3N2) season and the 2009-2010 season with predominance of pandemic influenza virus circulation. Incidence rate (IR) of confirmed influenza illness were calculated for both periods and age group. Clinical presentation features by age group (0-4,5-14,15-64 and > 64 y.o.) were studied and compared for both seasons. Statistical significance of proportion differences assessed by statistic z and Mantel Hanzel's Woolf test. The level of statistical significance was established at α=0.05. In both seasons studied, the 5-14 y.o. age group presented the highest confirmed influenza IR and highest presentation of cephalalgia as a symptom in the pandemic A(H1N1)2009 season. In conclusion, the significant burden of influenza, both seasonal and pandemic , on children should encourage upgrading vaccination coverage in these age groups and especially for those included in risk groups for whom yearly vaccination is recommended.

Health Impact Assessments in Spain: Have They Been Effective?

BACKGROUND: Health impact assessment (HIA) has scarcely been developed in Spain, in comparison with other European countries. Moreover, little is known about the effectiveness of HIA, taking into account direct impacts-changes on the decision-making process-as well as indirect impacts or those related to the process outcomes. From this broad perspective of HIA usefulness, the purpose was to assess the effectiveness of five HIAs carried out in Spain at the local level, and the role played by context and process factors on these impacts. METHODS: We carried out a qualitative study based on 14 interviews to HIAs participants from different sectors. A documentary review and nonparticipant observation techniques were implemented for an in depth understanding. RESULTS: The direct effectiveness of the HIAs was partial, but they had indirect effectiveness in all cases. The institutional and socio-political context, however, was not favorable to effectiveness. The elements of the process were largely determined by the context, although their influence, mediated by the role of proactive individuals, favored the effectiveness of the HIAs. CONCLUSIONS: When assessing HIA effectiveness, it is important to take into account a broad perspective on the nature of impacts and those factors influencing direct and indirect effectiveness. In Spain, the institutional and sociopolitical context was less favorable to HIA effectiveness than process-related factors. In order to implement the Health in All Policies strategy, will be necessary to improve context-related factors, such as institutional facilitators for HIA and democratic quality.

Hacia el buen gobierno por la salud: incorporación de la diversidad de percepciones en salud urbana / Towards good governance for health: incorporating the diversity of perceptions around urban health

Objetivo: Analizar las similitudes y diferencias discursivas en torno a la conceptualización de la salud y los activos y necesidades en salud percibidas en los barrios y la ciudad de Bilbao, en un proceso participativo. Método: Se realizaron talleres participativos con profesionales, vecinos/as y ciudadanía asociada. Se analizaron las diferencias de percepciones en torno a los tres bloques de contenido con base en el modelo de salud referido, así como los tipos -de carácter más individual o estructural- de necesidades y activos de salud identificados. Resultados: La conceptualización de la salud desde una mirada biopsicosocial fue más clara entre las/los profesionales, si bien ambos perfiles apuntaron a la importancia de sus determinantes sociales. La formulación de necesidades y activos en salud por parte de las/los vecinas/os se realizó desde el impacto en su vida cotidiana y desde una posición de usuarias/os con respecto a una Administración proveedora de servicios. Entre la ciudadanía asociada y las/los profesionales, se aludió en mayor medida a determinantes intermedios y estructurales, así como a cuestiones relacionadas con el ámbito de actuación de la Administración. Conclusiones: La inclusión de la multiplicidad y la diversidad de percepciones en la planificación son aspectos clave para el buen gobierno local por la salud. Para afrontar sus contradicciones es necesario un compromiso de los gobiernos por la incorporación efectiva de la participación ciudadana. (AU)

Objective: To analyse the similarities and differences in the discourse surrounding the conceptualisation of health and the perceived health assets and needs in the neighborhoods and city of Bilbao in a participatory process. Method: Participatory workshops were held with professionals, neighbors and associated citizens. The differences in perceptions of the three content blocks were analysed on the basis of the health model referred, as well as the typologies -of a more individual or structural nature- of identified health needs and assets. Results: The conceptualisation of health from a biopsychosocial perspective was clearer among professionals, although both profiles pointed to the importance of its social determinants. The formulation of needs and assets in health by the neighbors was made from the impact on their daily life and from a position of users with respect to a service provider administration. Among the associated citizens and professionals, intermediate and structural determinants were more frequently mentioned, as well as issues related to the administration's scope of action. Conclusions: The inclusion of the multiplicity and diversity of perceptions in planning is key to good local government for health. To address their contradictions, a commitment by governments to effectively incorporate citizen participation is needed. (AU)

[Influenza (H1N1) 2009 outbreaks in educational settings. Catalonia]. / Brotes escolares de gripe (H1N1) 2009 en Cataluña.

BACKGROUND: In spite of the advances in the knowledge of the influenza A (H1N1) 2009 virus the efficiency of its transmission among close contacts, and the efficiency of non pharmacological interventions to reduce the attack rates AR is not well known. The goal of this study is to characterize the occurrence of confirmed influenza A (H1N1) 2009 virus outbreaks in school settings in Catalonia during the pandemic period and to assess the effectiveness of interventions carried out for their control. METHODS: Incidence of A (H1N1) 2009 outbreaks reported from may to December 2009 and their attack rates were calculated whether preventive recommendations were issued and interventions implemented. Variable associations were calculated by χ² test, means were compared by t-Student and proportions by the statistic z , statistical significance was established at α=0,05. RESULTS: In total 238 outbreaks were notified. The global attack rate was 15.5%. The AR was only available for 173 (72.7%) outbreaks, of which, 142 (82.1%; p<0.001) had an AR below 25%. The main area of transmission was the school, where 209 outbreaks occurred (88%; p<0.001), of which 187 (78.6%; p<0.001) corresponded to elementary-high school educational centers. There was significantly shorter mean duration of outbreaks depending on the emission of recommendations (p=0.04). CONCLUSIONS: The assessment of influenza A(H1N1)2009 outbreaks presents supporting evidence of preventive measures and hygiene in the control of transmission in school settings.

[Factors associated with household transmission of influenza (H1N1) 2009]. / Factores asociados a la transmisión a los convivientes de gripe (H1N1) 2009.

BACKGROUND: A good part of the transmission of influenza occurs in the household context. The main objective of this study was to evaluate the factors associated with the index cases generating secondary cases in household. METHODS: We designed an observational, retrospective, multicenter through the implementation of a telephone survey in three regions of Spain. The study population were hospitalized and outpatient cases of confirmed H1N1 (2009) reported to the surveillance units from week 44 of 2009. We calculated the secondary attack rate within the household (TAI) and confidence interval of 95%. Factors associated with household transmission were analyzed by logistic regression, calculating odds ratios and confidence intervals at 95%. RESULTS: the secondary attack rate was 11.3% (95% CI 9.9 to 12.7) within the household. The number of household contacts was the main factor associated with the transmission (OR: 5,02 CI95% 1,78-14,13). CONCLUSION: The factor most associated with the generation of secondary cases is the family size, being greater the larger the group of cohabiting, which is consistent with the data provided by WHO.

Brotes escolares de gripe (H1N1) 2009 en Cataluña / Influenza (H1N1) 2009 outbreaks in educational settings. Catalonia

Fundamento: A pesar de los avances en el conocimiento del virus de la gripe (H1N1) 2009, la eficacia de su transmisión entre contactos, así como la eficacia de las intervenciones no farmacológicas es poco conocida. El objetivo de este trabajo es caracterizar la ocurrencia de brotes confirmados de virus (H1N1) 2009 en Cataluña en el ámbito escolar durante el período pandémico y evaluar las actuaciones llevadas a cabo para su control. Métodos: Se estudió la incidencia de brotes de VGA(H1N1)2009 de mayo a diciembre 2009. Se calcularon las tasas de ataque en función de emisión de recomendaciones preventivas y ejecución de intervenciones. La asociación entre variables se calculó mediante χ2, comparación de medias mediante t-Student y comparación de proporciones mediante estadístico z , estableciendo el grado de significación estadística en α=0,05. Resultados: En total se notificaron 238 brotes. La TA global fue del 15,5%. Del total de brotes sólo se conoce la tasa de ataque de 173 (72,7%), de los cuales 142 (82,1%; p<0,001) tuvieron una TA inferior al 25%. El principal ámbito de transmisión fue el escolar, donde se produjeron 209 (88%; p<0,001) brotes, de los cuales 187 (78,6%; p<0,001) correspondían a centros educativos. La duración media de los brotes fue significativamente menor en función de la emisión de recomendaciones (p=0,04). Conclusiones: El estudio de los brotes de gripe A/H1N1 2009 permite evidenciar que la adopción de medidas preventivas y de higiene es de vital importancia para el control de la transmisión en centros educativos(AU)

Background: In spite of the advances in the knowledge of the influenza A(H1N1)2009 virus the efficiency of its transmission among close contacts, and the efficiency of non pharmacological interventions to reduce the attack rates AR is not well known. The goal of this study is to characterize the occurrence of confirmed influenza A(H1N1)2009 virus outbreaks in school settings in Catalonia during the pandemic period and to assess the effectiveness of interventions carried out for their control. Methods: Incidence of A(H1N1)2009 outbreaks reported from may to December 2009 and their attack rates were calculated whether preventive recommendations were issued and interventions implemented. Variable associations were calculated by χ2 test, means were compared by t-Student and proportions by the statistic z , statistical significance was established at α=0,05. Results: In total 238 outbreaks were notified. The global attack rate was 15.5%. The AR was only available for 173 (72.7%) outbreaks, of which, 142 (82.1%; p<0.001) had anAR below 25%. Themain area of transmission was the school, where 209 outbreaks occurred (88%; p<0.001), of which 187 (78.6%; p<0.001) corresponded to elementary-high school educational centers. There was significantly shorter mean duration of outbreaks depending on the emission of recommendations (p=0.04). Conclusions: The assessment of influenza A(H1N1)2009 outbreaks presents supporting evidence of preventive measures and hygiene in the control of transmission in school settings(AU)

Factores asociados a la transmisión a los convivientes de gripe (H1N1) 2009 / Factors associated with household transmission of influenza (H1N1) 2009

Fundamentos: El entorno domiciliario ofrece importantes posibilidades de estudio de la transmisibilidad de la influenza (H1N1) 2009. El objetivo principal del estudio fue valorar los factores asociados a los casos índices que generaron casos secundarios en el ámbito domiciliario. Método: Se diseñó un estudio observacional, retrospectivo, , multicéntrico mediante la aplicación de una encuesta telefónica en tres Comunidades Autónomas de España. La población de estudio fueron los casos hospitalizados y ambulatorios confirmados de gripe H1N1 (2009) declarados a las unidades de vigilancia a partir de la semana 44 de 2009. Se calculó la tasa de ataque secundaria intradomiciliaria (TAI) y su intervalo de confianza del 95% (IC95%). Los factores asociados a la transmisión domiciliaria se analizaron mediante regresión logística, calculándose las odds ratios (OR) y sus intervalos de confianza al 95%. Resultados: la tasa de ataque intradomiciliaria fue de 11,3% (IC95% 9,9 – 12,7). El número de contactos convivientes fue el factor más asociado a la transmisión (OR: 5,02 IC95% 1,78-14,13). Conclusión: El factor más asociado a la generación de casos secundarios es el tamaño del grupo familiar, siendo mayor mientras más grande es el grupo de convivientes, lo que es congruente con los datos aportados por la OMS(AU)

Bakcground: A good part of the transmission of influenza occurs in the household context. The main objective of this study was to evaluate the factors associated with the index cases generating secondary cases in household. Methods: We designed an observational, retrospective, multicenter through the implementation of a telephone survey in three regions of Spain. The study population were hospitalized and outpatient cases of confirmed H1N1 (2009) reported to the surveillance units from week 44 of 2009.We calculated the secondary attack rate within the household (TAI) and confidence interval of 95%. Factors associated with household transmission were analyzed by logistic regression, calculating odds ratios and confidence intervals at 95%. Results: the secundary attack rate was 11.3% (95% CI 9.9 to 12.7) within the household. The number of household contacts was the main factor associated with the transmission (OR: 5,02 CI95% 1,78-14,13). Conclussion: The factor most associated with the generation of secondary cases is the family size, being greater the larger the group of cohabiting, which is consistent with the data provided by WHO(AU)