Prevalence and gender disparities of type 2 diabetes mellitus and obesity in Esmeraldas, Ecuador: a population-based survey in a hard-to-reach setting.

BACKGROUND: Type 2 Diabetes (T2DM) prevalence is increasing in low- and middle-income countries along with high levels of obesity which vary according to socioeconomic and contextual characteristics. We aim to estimate the prevalence of T2DM and obesity in men and women in a hard-to-reach rural area in northern Ecuador considering socio-demographic characteristics. METHODS: Cross-sectional descriptive study based on a population-based survey in the Eloy Alfaro health district of Esmeraldas between October 2020 and January 2022. We collected sociodemographic information and risk factors for non-communicable diseases with an adapted version of the STEPS survey, performed oral glucose tolerance tests, biochemistry and took physical measurements. We estimated the prevalence of T2DM, obesity, and calculated Odds Ratios (OR) with confidence intervals by logistic regression in Stata v.15. RESULTS: The overall prevalence of T2DM was 6.8% (CI95%: 4.9-8.7), markedly higher among women compared to men (10.4%, CI95% 7.3-13.4%, compared 2.0%, CI95% 0.4-3.7% respectively). The risk of having T2DM in women was 5 times higher than in men adjusting for age, ethnicity, employment, household earnings and obesity (OR: 5.03; 95%CI: 1.68-15.01). Regarding age, the risk of T2DM increased by 6% per year (adjusted OR: 1.06; 95%CI: 1.03-1.08). Obesity prevalence was 30.8% (CI95%: 27.3-34.3), in women was nearly three times higher than in men (43.2% CI95%: 38.2-48.2, compared to 14.7% prevalence, CI95%: 10.6-18.8). Indigenous women had a lower prevalence of obesity compared with the Afro-Ecuadorian women (OR: 0.05; 95%CI: 0.02-0.18) after adjusting for age, employment status, household earnings and setting. CONCLUSION: We found alarming differences between the prevalence of T2DM and obesity in women and men that may be explained by gender roles, exacerbated in the rural context. Health promotion measures with a gender perspective should be adapted according to the characteristics of isolated rural contexts.

Differences in the clinical management of women and men after detection of a solitary pulmonary nodule in clinical practice.

OBJECTIVES: To explore differences in the clinical management of men and women in the 5 years after detecting a solitary pulmonary nodule (SPN) by chest radiograph or CT in routine clinical practice. METHODS: We followed up 545 men and 347 women with an SPN detected by chest radiograph or CT in a retrospective cohort of 25,422 individuals undergoing routine thoracic imaging in 2010-2011. We compared the frequency of each management strategy (no further test, immediate intervention or follow up) according to sex by means of chi-squared. We estimated the relative risk of women versus men of having been followed up instead of an immediate intervention using multivariate logistic regression. We compared by sex the time between detection of the nodule and lung cancer diagnosis, the time between diagnosis and death by means of Mann-Whitney U test and the cumulative effective dose of radiation in each management strategy by means of t test. RESULTS: Women were more likely than men to have follow-up rather than immediate intervention (aRR = 1.8, CI 1.3-2.7, p = 0.002), particularly in those who underwent CT (aRR = 4.2, CI 1.9-9.3, p < 0.001). The median time between SPN detection and lung cancer diagnosis was higher in women (4.2 months, interquartile range (IQR) 5.1) than in men (1.5 months, IQR 16.2). The mean cumulative effective dose was 21.3 mSv, 19.4 mSv in men and 23.9mv in women (p = 0.023). CONCLUSIONS: Our results could reflect decisions based on a greater suspicion of lung cancer in men. The incidental detection of SPNs is increasing, and it is necessary to establish clear strategies aimed to reduce variability in their management according to patient's sex. KEY POINTS: • After incidental finding of SPN, women were less likely to receive an immediate intervention. • Accumulative radiation was higher in women than in men. • Our results could reflect decisions based on a greater suspicion of lung cancer in men.

Diagnostic Biomarkers: Are We Moving from Discovery to Clinical Application?

BACKGROUND: Despite considerable research investment, moving from biomarker discovery to clinical application has presented unique challenges. We aimed to evaluate progress toward clinical application of a sample of molecular- and "omics"-based diagnostic tests over a 10-year period. METHODS: We used Scopus to locate studies, published before the December 31, 2016, citing 107 original-research articles published in 2006 that assessed the diagnostic value of a molecular- or "omics"-based test. We identified diagnostic studies of the same test and disease and determined whether the article represented progress in the validation of the molecular test. We classified the types of progress: (a) clinical validation (measuring diagnostic accuracy in a series of patients similar to the population in which the test will be used in practice), (b) technical improvement, (c) extended diagnostic application (modification of the diagnostic question attended initially by the test), (d) economic evaluation, or (e) clinical use or implementation. RESULTS: In the 10-year period analyzed, 4257 articles cited the 107 diagnostic studies; 118 (2.8%) were diagnostic studies of the same test, and of these papers, 25 (21.2%) did not constitute progress toward validation of the test for use in clinical practice (potential research waste). Of the 107 molecular- or "omics"-based tests described in 2006, only 28 (26.2%) appeared to have made progress toward clinical application. Only 4 (9.1%) of 44 proteomics-based tests had made progress toward clinical application. CONCLUSIONS: Articles evaluating molecular- or "omics"-based diagnostic tests are numerous in biomedical journals. Few tests have made progress toward clinical application in the 10 years following their discovery.

Does the scientific evidence support the advertising claims made for products containing Lactobacillus casei and Bifidobacterium lactis? A systematic review.

BACKGROUND: To analyse the scientific evidence that exists for the advertising claims made for two products containing Lactobacillus casei and Bifidobacterium lactis and to conduct a comparison between the published literature and what is presented in the corporate website. METHODS: Systematic review, using Medline through Pubmed and Embase. We included human clinical trials that exclusively measured the effect of Lactobacillus casei or Bifidobacterium lactis on a healthy population, and where the objective was related to the health claims made for certain products in advertising. We assessed the levels of evidence and the strength of the recommendation according to the classification criteria established by the Oxford Centre for Evidence Based Medicine (CEBM). We also assessed the outcomes of the studies published on the website that did not appear in the search. RESULTS: Of the 440 articles identified, 16 met the inclusion criteria. Only four (25%) of these presented a level of evidence of 1b and a recommendation grade of A, all corresponding to studies on product containing Bifidobacterium lactis, and only 12 of the 16 studies were published on the corporate website (47). CONCLUSIONS: There is insufficient scientific evidence to support the health claims made for these products, especially in the case of product containing Lactobacillus casei.

Knowledge and practices regarding prostate cancer screening in Spanish men: The importance of personal and clinical characteristics (PROSHADE study).

INTRODUCTION: Patients' decisions on prostate cancer (PCa) opportunistic screening may vary. This study aimed to assess how demographic and health-related characteristics may influence knowledge and decisions regarding PCa screening. METHODS: A cross-sectional survey was conducted among men aged over 40, randomly sampled from the Spanish population, 2022. The survey underwent development and content validation using a modified Delphi method and was administered via telephone. Binomial logistic regression was used to explore the relationship between respondents' characteristics and participants' knowledge and practices concerning PCa and the PSA test. RESULTS: Out of 1,334 men, 1,067 (80%) respondents were interviewed with a mean age of 58.6 years (sd 11.9). Most had secondary or university studies (787, 73.8%) and 61 (5.7%) self-reported their health status as bad or very bad. Most of the respondents (1,018, 95.4%) had knowledge regarding PCa with nearly 70% expressed significant concern about its potential development (720, 70.8%), particularly among those under 64 years (p = 0.001). Out of 847 respondents, 573 (67.7%) reported that they have knowledge regarding the PSA test: 374 (65.4%) reported receiving information from a clinicians, 324 (86.6%) information about the benefits of the test and 189 (49,5%) about its risks, with differences based on educational background. In a multivariable analysis (adjusted for age, educational level and previous prostate problems), respondents with higher levels of education were more likely to have higher knowledge regarding the PSA test (OR 1.75, 95%CI 1.24-2.50, p<0.001). CONCLUSIONS: Although most of the patients reported to have knowledge regarding PCa, half of the interviewed men reported knowledge about PSA test. Differences in knowledge prostate cancer screening and undesirable consequences highlight the need to develop and provide tailored information for patients.

[Evolution of the presence of women in decision-making bodies of the Spanish national health system]. / Evolución de la presencia de mujeres en los órganos de decisión del Sistema Nacional de Salud en España.

OBJECTIVE: To examine the presence of women in the organs of the Interterritorial Council of the Spanish National Health System (CISNS). METHOD: Annual reports of the CISNS from 2005 to 2022 were analyzed. Artificial intelligence was used to assign gender, and percentages of women's participation were calculated. Temporal evolution, vertical segregation, and horizontal segregation were analyzed. RESULTS: Between 2005 and 2022, there were 14,308 participations in 85 organs, with 52% women, rising from 42% in 2005 to 61% in 2022. There was a higher participation of women in propositional organs (54%), followed by executive ones (50%), and plenary sessions (40%). The General State Administration had 61% women compared to 48% in autonomous communities. Women's participation varied by topic, being higher (82%) in gender violence and lower (35%) in inspection. CONCLUSIONS: Although there is a slight reduction in the participation gap between women and men, inequalities persist. Women have less presence in higher hierarchical levels (plenary sessions), maintaining vertical segregation. Additionally, women's representation in certain topics remains low, maintaining horizontal segregation. Concrete actions must be taken to continue advancing equality and improving health outcomes in society as a whole.

Looking twice at the gender equity index for public health impact.

BACKGROUND: It has been shown that gender equity has a positive impact on the everyday activities of people (decision making, income allocation, application and observance of norms/rules) which affect their health. Gender equity is also a crucial determinant of health inequalities at national level; thus, monitoring is important for surveillance of women's and men's health as well as for future health policy initiatives. The Gender Equity Index (GEI) was designed to show inequity solely towards women. Given that the value under scrutiny is equity, in this paper a modified version of the GEI is proposed, the MGEI, which highlights the inequities affecting both sexes. METHODS: Rather than calculating gender gaps by means of a quotient of proportions, gaps in the MGEI are expressed in absolute terms (differences in proportions). The Spearman's rank coefficient, calculated from country rankings obtained according to both indexes, was used to evaluate the level of concordance between both classifications. To compare the degree of sensitivity and obtain the inequity by the two methods, the variation coefficient of the GEI and MGEI values was calculated. RESULTS: Country rankings according to GEI and MGEI values showed a high correlation (rank coef. = 0.95). The MGEI presented greater dispersion (43.8%) than the GEI (19.27%). Inequity towards men was identified in the education gap (rank coef. = 0.36) when using the MGEI. According to this method, many countries shared the same absolute value for education but with opposite signs, for example Azerbaijan (-0.022) and Belgium (0.022), reflecting inequity towards women and men, respectively. This also occurred in the empowerment gap with the technical and professional job component (Brunei:-0.120 vs. Australia, Canada Iceland and the U.S.A.: 0.120). CONCLUSION: The MGEI identifies and highlights the different areas of inequities between gender groups. It thus overcomes the shortcomings of the GEI related to the aim for which this latter was created, namely measuring gender equity, and is therefore of great use to policy makers who wish to understand and monitor the results of specific equity policies and to determine the length of time for which these policies should be maintained in order to correct long-standing structural discrimination against women.

Contextual Factors That May Impact on the Development and Implementation of the Sugary Drinks Policy Comment on "Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative Interview Study in the United Kingdom, 2019".

Forde et al proposed an interesting framework to understand marketing response to a tax in sugary drinks based on stakeholder interviews. Sugary drinks regulation can lead to various strategies in the industry's marketing activity. That is, it can either result in the industry introducing no changes or it can lead to changes, which can conflict or align with public health objectives. The importance of Forde and colleagues' analysis lies in the potential for governments to anticipate the industry's reaction to the legislation and the need of drivers to enable both big and small companies to follow the rules. Governments must not forget the importance of other contextual factors that will have an impact both on the development and implementation of this type of policies and on possible responses that could mitigate their impact such as public acceptance, the influence of mass media and corporate activities aimed at influencing policy.

Gender Differences in the Impact of Recommendations on Diagnostic Imaging Tests: A Retrospective Study 2007-2021.

(1) Background: The frequency of imaging tests grew exponentially in recent years. This increase may differ according to a patient's sex, age, or socioeconomic status. We aim to analyze the impact of the Council Directive 2013/59/Euratom to control exposure to radiation for men and women and explore the impact of patients' age and socioeconomic status; (2) Methods: The retrospective observational study that includes a catchment population of 234,424. We included data of CT, mammography, radiography (conventional radiography and fluoroscopy) and nuclear medicine between 2007-2021. We estimated the associated radiation effective dose per test according using previously published evidence. We calculated a deprivation index according to the postcode of their residence. We divided the study in 2007-2013, 2014-2019 and 2020-2021 (the pandemic period). (3) Results: There was an increase in the number of imaging tests received by men and women after 2013 (p < 0.001), and this increase was higher in women than in men. The frequency of imaging tests decreased during the pandemic period (2020-2021), but the frequency of CT and nuclear medicine tests increased even during these years (p < 0.001) and thus, the overall effective mean dose. Women and men living in the least deprived areas had a higher frequency of imaging test than those living in the most deprived areas. (4) Conclusions: The largest increase in the number of imaging tests is due to CTs, which account for the higher amount of effective dose. The difference in the increase of imaging tests carried out in men and women and according to the socioeconomic status could reflect different management strategies and barriers to access in clinical practice. Given the low impact of the available recommendations on the population exposure to radiation and the performance of high-dose procedures such as CT, deserve special attention when it comes to justification and optimization, especially in women.

Addressing Health Disparities through Community Participation: A Scoping Review of Co-Creation in Public Health.

BACKGROUND: There is general agreement regarding the relevance of community involvement in public health policy, practice, and research to reduce health inequities. OBJECTIVE: This review aims to analyse the experiences of community engagement in public health actions, with particular attention to methodologies used and how community participation is articulated. METHOD AND ANALYSIS: We searched the Web of Science, EBSCO, and ProQuest for scientific articles published in peer-reviewed journals. We recorded methodological aspects, the approach to equity, actors that participated in the actions, and participation of the community in different phases (agenda setting, design, implementation, and evaluation). RESULTS: Of 4331 records, we finally included 31 studies published between 1995 and 2021. Twelve studies referred to Community-Based Participatory Research as the framework used. The actions addressed equity, mainly by tackling economic vulnerability (n = 20, 64%) and racial discrimination (n = 18, 58%). Workshops were the most used method. Participation was frequently observed in the design and implementation phases of the action, but it was reduced to community feedback in the evaluation. CONCLUSIONS: Co-created public health actions offer the opportunity to reduce health inequity and promote social change; yet, further effort is needed to involve communities in the entire cycle of decision making.

Access to health services for chronic disease care during the COVID-19 pandemic in Ecuador: A qualitative analysis using a Social Determinants of Health approach.

This qualitative study aims to explore how the COVID-19 pandemic impacted healthcare access for patients with chronic conditions in Ecuador from the patient's perspective. We interviewed 19 patients diagnosed with arterial hypertension or type 2 diabetes in rural and urban areas of Ecuador during August and September 2020. We used the Framework Method to analyse the interview transcripts with ATLAS.Ti 8.4 and organised the ideas discussed using categories from the World Health Organization Commission on the Social Determinants of Health conceptual framework. Reorganization of health services during the pandemic meant that patients with arterial hypertension or diabetes could no longer attend face-to-face appointments for disease follow-up. System failures related to medication supply led to increased out-of-pocket payments, which, together with reduced or absent earnings, and in a context with limited social protection policies, meant that patients frequently went for prolonged periods without medication. Rural health initiatives, support from family and use of traditional medicine were reported as ways to manage their chronic condition during this time. Barriers to disease management disproportionately affected individuals with low socioeconomic positions. Stock shortages, lack of protective labour policies and limited reach of anticipatory policies for health emergencies likely worsened pre-existing health inequities in Ecuador.

Epidemiological study on gender bias and low-value practices in primary care: a study protocol.

INTRODUCTION: Evidence shows that gender has a substantial impact on health behaviours, access to and use of health systems and health system responses. This study aims to assess gender bias in patients subjected to low-value practices in the primary care setting and to develop recommendations for reducing adverse events that women experience for this reason. METHODS AND ANALYSIS: A Delphi study will be performed to reach a consensus on the 'Do Not Do' recommendations with a possible gender bias. A retrospective cohort study in a random selection of medical records will then be carried out to identify the frequency of adverse events that occur when the selected 'Do Not Do' recommendations are ignored. Qualitative research techniques (consensus conference and nominal group) will be carried out to develop recommendations to address any gender bias detected, considering barriers and facilitators in clinical practice. ETHICS AND DISSEMINATION: The study was approved by the ethics committee of San Juan de Alicante Hospital (San Juan de Alicante, Spain) Reference N. 21/061. We will disseminate the research findings via peer-reviewed articles, presentations at national and international scientific forums and webinars. TRIAL REGISTRATION NUMBER: The study was registered at ClinicalTrials.gov (NCT05233852) on 10 February 2022.

Solving gender gaps in health, what else is missing?

In recent years, a great deal of attention has been paid to gender inequities in health. However, while we have a good body of evidence on the impact of gender on the health and vulnerability of women and men, we have not yet been able to generate sufficient evidence on effective interventions that can transform this situation or can influence public health policy making. Only a limited number of educational interventions on gender-sensitivity, gender bias in clinical practice and policies to tackle gender inequalities in health have been formulated, implemented and evaluated. Even in the current pandemic situation caused by SARS-CoV2, we have seen the lack of gender mainstreaming reflected in the global response. This happens even when we have tools that facilitate the formulation and implementation of actions to reduce gender inequities in health. We consider that the current initiatives organized to carry out advocacy activities on gender inequity in health to be very positive. In the same line of these initiatives, we propose that while academic and institutional research on gender and health remains essential, we need to shift the focus towards action. In order to move forward, we need public health researchers questioning what public health practice need to do to address gender inequities and shake structural and social power inequities in order to increase the gender equity in health.

It Is Not Enough to Assess Conflicts of Interest When We Bring the Commercial Sector to the Policy Table Comment on "Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool".

Ralston et al offer us an interesting analysis of the consultation process of World Health Organization's (WHO's) "Draft approach on the prevention and management of conflicts of interests in the policy development and implementation of nutrition programs at country level," in which it shows us how the industry tries to frame the discussion in individual conflicts of interest, avoiding structural conflicts of interest. We must not forget other issues of importance in policy-making, such as the imbalance of power between different actors and the strategies of undue influence used by food and beverage corporations. It is essential to develop regulatory-based tools and procedures that embody ethics and good governance and that can be applied systematically and routinely to prevent corporate influence in health policy-making. A global observatory of corporate practices would also be needed to recommend to governments efficient actions to avoid corporate capture of their policies.

Evaluation of Diagnostic Strategies for Identifying SARS-CoV-2 Infection in Clinical Practice: a Systematic Review and Compliance with the Standards for Reporting Diagnostic Accuracy Studies Guideline (STARD).

We aimed to review strategies for identifying SARS-CoV-2 infection before the availability of molecular test results, and to assess the reporting quality of the studies identified through the application of the STARD guideline. We screened 3,821 articles published until 30 April 2021, of which 23 met the inclusion criteria: including at least two diagnostic variables, being designed for use in clinical practice or in a public health context and providing diagnostic accuracy rates. Data extraction and application of STARD criteria were performed independently by two researchers and discrepancies were discussed with a third author. Most of the studies (16, 69.6%) included symptomatic patients with suspected infection, six studies (26.1%) included patients already diagnosed and one study (4.3%) included individuals with close contact to a COVID-positive patient. The main variables considered in the studies, which included symptomatic patients, were imaging and demographic characteristics, symptoms, and lymphocyte count. The values for area under the receiver operating characteristic curve (AUC)ranged from 53-97.4. Seven studies (30.4%) validated the diagnostic model in an independent sample. The average number of STARD criteria fulfilled was 17.6 (maximum, 27 and minimum, 5). High diagnostic accuracy values are shown when more than one diagnostic variable is considered, mainly imaging and demographic characteristics, symptoms, and lymphocyte count. This could offer the potential to identify individuals with SARS-CoV-2 infection with high accuracy when molecular testing is not available. However, external validation for developed models and evaluations in populations as similar as possible to those in which they will be applied is urgently needed. IMPORTANCE According to this review, the inclusion of more than one diagnostic test in the diagnostic process for COVID-19 infection shows high diagnostic accuracy values. Imaging characteristics, patients' symptoms, demographic characteristics, and lymphocyte count were the variables most frequently included in the diagnostic models. However, developed models should be externally validated before reaching conclusions on their utility in practice. In addition, it is important to bear in mind that the test should be evaluated in populations as similar as possible to those in which it will be applied in practice.

[Framing of childhood obesity in Spanish lay press]. / Encuadre mediático de la obesidad infantil en las noticias de prensa generalista en España.

OBJECTIVE: To explore the frame, individual or collective, of childhood obesity in the main Spanish lay media. METHOD: Analysis of a convenience sample of 132 publications regarding childhood obesity (August 2016-September 2018). Descriptive analysis about approach, measures and causes of obesity and food industry influence in the development of the publication. RESULTS: 47% of the publications presented an individual approach. 54% included eating and physical activity as cause. 29% of the measures propose a healthy environment and 27% individual recommendations. Individual frame was present in 77% of the news influenced by the industry. CONCLUSION: Publications on childhood obesity of the main Spanish lay press reveal a predominance of the individual approach to the problem. This majority perception may condition the development and implementation of public health policies or interventions.

Have Policies Tackled Gender Inequalities in Health? A Scoping Review.

Gender is recognized as one of the most relevant determinants of health inequalities. This scoping review sought to identify and analyse policies, either implemented or formulated as proposals, which aimed to reduce gender inequalities in health. We searched Medline, Web of Science, and Scielo. Of 2895 records, 91 full text articles were analysed, and 33 papers were included. Of these papers, 22 described the process of formulation, implementation, or evaluation of policies whose aim was to reduce gender inequalities in health; six focused on recommendations, and the remaining five dealt with both issues. Our review showed that the policies aimed at reducing gender inequalities in health, either implemented or formulated as proposals, are scarce. Moreover, despite some success, overall progress has been slow. The studies show failures in design and particularly in the implementation process. We found a lack of awareness and capacity in the policy-making progress, under-financing, bureaucratization, shortage of relevant data, and absence of women's participation in decision-making. Therefore, an emphasis on the design and implementation of gender-sensitive policies seems essential to advance gender equality in health. This scoping review gathers evidence to support the design of such policies and recommendations that can facilitate their implementation.

Contextualizing Evidence for Action on Diabetes in Low-Resource Settings-Project CEAD Part-II, Strengthening the Health System: A Mixed-Methods Study Protocol.

Diabetes is a major public health problem, increasingly affecting low- and middle-income countries. The project CEAD (Contextualizing Evidence for Action in Diabetes in low-resource settings) aims to evaluate the implementation of comprehensive diabetes care in two low-resource settings in Ecuador and to stimulate context-led health systems innovations to improve diabetes care and reduce inequity. The mixed-methods approach includes a 24-month retrospective study to assess the current level of implementation of comprehensive diabetes care and participants will be followed up prospectively for two years to assess changes in healthcare and clinical outcomes from the outset of the research. We will include individuals diagnosed with type-2 diabetes aged over 18 years, who are accessing diabetes care in health facilities in the study districts. Varied stakeholders (patients and family members, community members, healthcare workers and decision-makers) will interpret the underlying causes of the observed weaknesses and propose solutions to strengthen diabetes-related healthcare in focus group discussions (FG). A second set of FG will analyze perceived improvements in healthcare based on prospective cohort findings and consider the success/failure of any context-led innovations occurring throughout the research. Our study will demonstrate how evidence can be contextualized to stimulate local innovations and overcome weaknesses of diabetes-related healthcare in low resource settings.

Hormone replacement therapy advertising: sense and nonsense on the web pages of the best-selling pharmaceuticals in Spain.

BACKGROUND: The balance of the benefits and risks of long term use of hormone replacement therapy (HRT) have been a matter of debate for decades. In Europe, HRT requires medical prescription and its advertising is only permitted when aimed at health professionals (direct to consumer advertising is allowed in some non European countries). The objective of this study is to analyse the appropriateness and quality of Internet advertising about HRT in Spain. METHODS: A search was carried out on the Internet (January 2009) using the eight best-selling HRT drugs in Spain. The brand name of each drug was entered into Google's search engine. The web sites appearing on the first page of results and the corresponding companies were analysed using the European Code of Good Practice as the reference point. RESULTS: Five corporate web pages: none of them included bibliographic references or measures to ensure that the advertising was only accessible by health professionals. Regarding non-corporate web pages (n = 27): 41% did not include the company name or address, 44% made no distinction between patient and health professional information, 7% contained bibliographic references, 26% provided unspecific information for the use of HRT for osteoporosis and 19% included menstrual cycle regulation or boosting feminity as an indication. Two online pharmacies sold HRT drugs which could be bought online in Spain, did not include the name or contact details of the registered company, nor did they stipulate the need for a medical prescription or differentiate between patient and health professional information. CONCLUSIONS: Even though pharmaceutical companies have committed themselves to compliance with codes of good practice, deficiencies were observed regarding the identification, information and promotion of HRT medications on their web pages. Unaffected by legislation, non-corporate web pages are an ideal place for indirect HRT advertising, but they often contain misleading information. HRT can be bought online from Spain, without a medical consultation or prescription constituting a serious issue for public health. In our information society, it is the right and obligation of public health bodies to ensure that such information is not misleading.