A City Surveillance System for Social Health Inequalities: The Case of Barcelona.

INTRODUCTION: In the past, health inequalities were not prioritised in the political agenda of Barcelona. The change of city government (2015) was an opportunity to develop a Surveillance System for Social Health Inequalities in the city, which is described in this article. METHODS: The design of the Surveillance System formed part of the Joint Action for Health Equity in Europe (JAHEE), funded by the European Union. Various steps were considered by the experts to set up the System: define its objectives, target population, domains and indicators, and sources of information; perform data analysis; implement and disseminate the system; define the evaluation; and perform regular data updates. RESULTS: The System considers the following domains: social determinants of health, health-related with behaviours, use of healthcare, and health outcomes, and includes eight indicators. As axes of inequality, the experts chose sex, age, social class, country of origin, and geographical area. The Surveillance System for Social Health Inequalities is presented on a website including different types of figures. CONCLUSION: The methodology used to implement the Surveillance System can be used to implement similar systems in other urban areas around the world.

Tackling health inequalities in a public health organization: the case of the Barcelona Public Health Agency.

BACKGROUND: Municipalities are important actors in the implementation of policies to tackle health inequalities, which requires political will, the availability of financial support, and technical and human resources. With the aim of aligning with local government political priorities, in 2017 the Barcelona Public Health Agency (Agència de Salut Pública de Barcelona, henceforth ASPB), which is responsible for the public health functions of the city, launched a strategy to improve the approach to tackling health inequalities in all its services. The objectives of this study were to show how social health inequalities were addressed in the ASPB from 2017 to 19 and to describe which actions were proposed after a participatory process aiming to create a plan to systematically incorporate health inequalities in ASPB actions. METHODS: The ASPB has 304 workers, 8 directors and 20 services or departments. Participatory methodologies were carried out: 1) semi-structured interviews with department heads (N = 12, 60%); 2) world cafe workshops open to a group of workers (N = 63, 37%); 3) a Quick and Colorful voting session open to a group of workers (N = 108, 63%); and 4) Hanlon matrix with 19 actions to be prioritized (N = 12 services, 60%). RESULTS: Semi-structured interviews and world cafe workshops provided 40 potential actions. After a step by step process of participatory prioritization, seven lines of action emerged: 1) to make progress in collaborative networking; 2) to promote policy evaluation; 3) to increase the ability of the ASPB to evaluate policies to reduce health inequalities; 4) to incorporate the axes of inequalities in all ASPB products; 5) to improve information on vulnerable groups; 6) to incorporate the gender perspective; and 7) to participate in an internal training plan to address health inequalities. CONCLUSIONS: The participation of ASPB public health professionals and staff allowed the organization to design a shared plan of actions to address health inequalities. This experience could be useful for other municipalities whose political agendas include tackling inequalities in health.

Multi-level policy responses to tackle socioeconomic inequalities in the incidence of COVID-19 in a European urban area.

BACKGROUND: Spain has been hit hard by COVID-19 since March 2020, especially in its metropolitan areas. We share experiences from Barcelona in measuring socioeconomic inequalities in the incidence of COVID-19 in the different waves, and in implementing coordinated and equity-oriented public health policy responses. METHODS: We collected daily data on confirmed COVID-19 cases, geocoded the address of residence to assign each case to one of the 73 neighborhoods and 1068 census tracts, and calculated the cumulative incidence of COVID-19 by neighborhood and five income groups (quintiles of census tracts) by sex across four waves of the pandemic. We adjusted hierarchical Bayesian spatial models to obtain the relative risk (RR) of cumulative incidences in each quintile compared with the richest areas. A variety of public health policies implemented to tackle the pandemic and especially these inequalities in COVID-19 incidence and vaccination are selected and described. RESULTS: Area-level income inequalities in the incidence of COVID-19 were present at different degree in all four waves. In the second wave (10/1/2020 to 12/6/2020), RR for the poorest income quintile census tracts compared with the richest was 1.43 (95% credible interval-CI-: 1.22-1.67) for men and 1.58 (95% CI: 1.35-1.83) for women. Later, inequalities in vaccination coverage also arose. Equity-oriented policy responses included: "health hotels" or home delivery of basic products for individuals with COVID-19 and without adequate conditions for isolation; new emergency facilities for homeless people, including those with active drug use; mass screening in high incidence areas; contingency plans for nursing homes and schools; adapting community health programs for their early reactivation; digital self-appointment support points and community vaccination days. CONCLUSION: COVID-19 hit Barcelona neighborhoods unequally, with variations between waves. The rapid availability of geolocalized data and by socioeconomic level helped public authorities to implement targeted policies and collaborative interventions for the most vulnerable populations. Further studies would be needed to evaluate their impact.

Improving mental health and wellbeing in elderly people isolated at home due to architectural barriers: A community health intervention.

OBJECTIVES: To explore the health effects of a community health intervention on older people who are isolated at home due to mobility problems or architectural barriers, to identify associated characteristics and to assess participants' satisfaction. DESIGN: Quasi-experimental before-after study. SETTING: Five low-income neighbourhoods of Barcelona during 2010-15. PARTICIPANTS: 147 participants, aged ≥59, living in isolation due to mobility problems or architectural barriers were interviewed before the intervention and after 6 months. INTERVENTION: Primary Health Care teams, public health and social workers, and other community agents carried out a community health intervention, consisting of weekly outings, facilitated by volunteers. MEASUREMENTS: We assessed self-rated health, mental health using the General Health Questionnaire (GHQ-12), and quality of life through the EuroQol scale. Satisfaction with the programme was evaluated using a set of questions. We analysed pre and post data with McNemar tests and fitted lineal and Poisson regression models. RESULTS: At 6 months, participants showed improvements in self-rated health and mental health and a reduction of anxiety. Improvements were greater among women, those who had not left home for ≥4 months, those with lower educational level, and those who had made ≥9 outings. Self-rated health [aRR: 1.29(1.04-1.62)] and mental health improvements [ß: 2.92(1.64-4.2)] remained significant in the multivariate models. Mean satisfaction was 9.3 out of 10. CONCLUSION: This community health intervention appears to improve several health outcomes in isolated elderly people, especially among the most vulnerable groups. Replications of this type of intervention could work in similar contexts.

Socioeconomic Inequalities in COVID-19 in a European Urban Area: Two Waves, Two Patterns.

Background: The objective of this paper is to analyze social inequalities in COVID-19 incidence, stratified by age, sex, geographical area, and income in Barcelona during the first two waves of the pandemic. Methods: We collected data on COVID-19 cases confirmed by laboratory tests during the first two waves of the pandemic (1 March to 15 July and 16 July to 30 November, 2020) in Barcelona. For each wave and sex, we calculated smooth cumulative incidence by census tract using a hierarchical Bayesian model. We analyzed income inequalities in the incidence of COVID-19, categorizing the census tracts into quintiles based on the income indicator. Results: During the two waves, women showed higher COVID-19 cumulative incidence under 64 years, while the trend was reversed after that threshold. The incidence of the disease was higher in some poor neighborhoods. The risk ratio (RR) increased in the poorest groups compared to the richest ones, mainly in the second wave, with RR being 1.67 (95% Credible Interval-CI-: 1.41-1.96) in the fifth quintile income group for men and 1.71 (95% CI: 1.44-1.99) for women. Conclusion: Our results indicate the existence of inequalities in the incidence of COVID-19 in an urban area of Southern Europe.

[Modified version of the PCAT-A10 tool for the evaluation of primary care]. / Evaluación de la atención primaria, versión modificada del instrumento PCAT-A10.

OBJECTIVE: To evaluate the measurement characteristics of the Spanish and Catalan versions of the 10-Item Primary Care Assessment Tool for adults (PCAT-A10), shortened from the original Primary Care Assessment Tool (PCAT), with a new mental health item. DESIGN: Cross-sectional observational study. LOCATION: The city of Barcelona. PARTICIPANTS: Of the 3,496 people over 14 years of age from the representative random sample of the Barcelona population, from the 2016-17 Barcelona Health Survey, those who declared they had a family doctor, and had visited a specialist at some time in their lives, and had answered more than 50% of PCAT-A10 items were selected (n=3,107). MAIN MEASUREMENTS: Item descriptive analysis, analysis of internal consistency, corrected item - total correlation, of the PCAT-A10 index and the 10 items that make it up. Three scenarios for non-response to treatment were analysed: substitution by 0, by the intermediate value, and excluding people who did not answer any item. RESULTS: The PCAT-A10 index obtained Cronbach alphas of 0.73, 0.79, and 0.85 in the three mentioned scenarios, correlation item total corrected between 0.41 and 0.66, and 20.8% non-responses to the mental health item. CONCLUSIONS: The new version of PCAT-A10 has a high reliability with a higher response in the mental health item compared to the previous version.

Barcelona Salut als Barris: Twelve years' experience of tackling social health inequalities through community-based interventions.

Community health can reduce inequalities in health and improve the health of the most disadvantaged populations. In 2007, Barcelona Salut als Barris (Barcelona Health in the Neighbourhoods) was launched, a community health programme to reduce social inequalities in health. In 2018, this programme reached the 25 most disadvantaged neighbourhoods of the city. This article shares the lessons learned after 12 years of work. The programme was initially funded by a research grant and the funds were maintained during the economic crisis and were tripled when the programme became a political priority in the last municipal government. During the 12-year period, partnerships with stakeholders were generally stable and productive. Maximum community participation was obtained in the detection of health assets and needs and in action plans. During 2018, Barcelona Salut als Barris worked with more than 460 agents that co-produced 183 interventions involving more than 13,600 people. Most of the interventions assessed showed improvements in the health of participants, which could help to reduce health inequalities. The greatest difficulties were: a) citizen participation, b) the sustainability of working groups over the years, c) conflicts of interest, d) the sustainability of interventions, e) reaching certain minority groups and f) evaluation. The increase in resources in the last period contributed to the maturity and expansion of the programme. Key factors in its scope and results were political will, strong technical capacity and methodology, strong intersectoral partnerships and continued community work.

[Health inequalities as a political priority in Barcelona]. / Las desigualdades en salud como prioridad política en Barcelona.

There is a wealth of information and research on health inequalities in Barcelona, but this issue has not been clearly prioritised on the political agenda. The arrival in government of a new left-wing party (Barcelona en Comú) in 2015, gave an important boost to the political agenda to reduce inequalities and health inequalities. The aim of this review is to describe the progress made in relation to health inequalities in these four years and especially in the areas involving public health. With respect to evidence and communication on health inequalities, the progress made is presented in the Barcelona annual health report and the creation of the Observatory on Health, Inequalities and Impacts of Municipal Policies. The policies presented refer to different municipal strategies, the Health Plan, the promotion of the Barcelona Health in the Neighbourhoods programme and the Plan for Tackling Inequalities in the Barcelona Public Health Agency. The combination of political will, technical capacity and the drive of citizens have facilitated progress in the city of Barcelona in policies to reduce social inequalities in health.

Community action for health in socioeconomically deprived neighbourhoods in Barcelona: Evaluating its effects on health and social class health inequalities.

BACKGROUND: The aim of this study was to analyse trends in several health-related indicators in socioeconomically deprived neighbourhoods in Barcelona with strong community action for health (CA), and compare them to neighbourhoods without such community action. A secondary goal was to analyse trends in socioeconomic inequalities in health in both types of neighbourhood. METHODS: We performed a quasi-experimental pre-post study using data from the Barcelona Health Surveys of 2001 and 2011. Our dependent variables were self-perceived health, mental health, previous drug use, and smoking cessation. We used Poisson regression with robust variance to calculate prevalence ratios (PR) and 95% Confidence Intervals (95% CI). RESULTS: The percentage of men who had ever used drugs decreased over time in neighbourhoods with strong CA (PR = 0.48; 95% CI:0.25-0.92, from 2001 to 2011), but not in neighbourhoods without CA (PR = 1.02; 95% CI:0.74-1.40). However, the prevalence of poor mental health among men increased more in neighbourhoods with strong CA than in neighbourhoods without CA (p-value = 0.025). Among women, social class inequalities in poor mental health and smoking cessation decreased over time in neighbourhoods with strong CA but not in neighbourhoods without CA. CONCLUSIONS: Our study shows promising results regarding the effect of community action on health, particularly in terms of inequalities. Our results highlight the importance of allocating resources to implement and continuously evaluate CA initiatives.

Adaptación transcultural colaborativa de cuestionarios PCAT para Colombia / Collaborative transcultural adaptation of the PCAT questionnaires for Colombia / Adaptação transcultural colaborativa de questionários PCAT para Colômbia

Objetivo: obtener versiones de los cuestionarios Primary Care Assessment Tool (PCAT) para Colombia (CO-PCAT), dirigidos a profesionales (PCAT-PE), gestores y directivos de atención primaria (PCAT-FE) a través de un proceso colaborativo internacional. Metodos: proceso de adaptación transcultural modificado a partir de las versiones adaptadas y validadas en español, en consenso con la Colaboración Iberoamericana IA-PCAT. El método busca conseguir la equivalencia de la versión CO-PCAT de los cuestionarios con la versión original de Estados Unidos de América. Se desarrollaron tres fases de trabajo: I) valoración de la adecuación de versiones iberoamericanas en lengua española y adaptación al contexto colombiano, II) revisión internacional realizada por investigadores de la Colaboración Iberoamericana PCAT y III) pruebas preliminares de los cuestionarios. Consideraciones éticas: es una investigación sin riesgos para los seres humanos conforme a la Resolución 08430 de 1993 de Colombia y la Declaración de Helsinki. Resultados: del PCAT-PE se incluyeron en la versión colombiana 182 ítems. En cuanto al PCAT-FE se trabajó con 197 ítems en total. Conclusión: se obtuvieron versiones adaptadas al sistema de salud colombiano. La metodología empleada puede contribuir al logro de mayor equivalencia entre instrumentos de diferentes países.

Objective: Obtain versions of the Primary Care Assessment Tool (PCAT) questionnaires for Colombia (CO-PCAT), directed to professionals (PCAT-PE), managers and directives of primary care (PCAT-FE) through an international, collaborative process. Methods: a transcultural adaptation process modified from the adapted and validated Spanish versions, in consensus with the Ibero-American Collaboration IA-PCAT. The method intends to get an equivalence of the CO-PCAT questionnaires version with the original version of the United States. Three phases of the work were developed: I) assessment of the adaptation of ibero-american versions in Spanish and adaptation to the Colombian context. II) international review performed by researchers of the Ibero-American Collaboration PCAT, and III) preliminary trials of the questionnaires. Ethical considerations: it is a non-risk research for human beings according to the Resolution 08430 of 1993 of Colombia and the Declaration of Helsinki. Results: From the PCAT-PE, 182 items were included in the Colombian version. Regarding PCAT-PE, the research worked with a total of 197 items. Conclusion: Adapted versions to the Colombian health system were obtained. The methodology used can contribute to the accomplishment of a greater equivalence between instruments of different countries.

Objetivo: obter versões dos questionários Primary Care Assessment Tool (PCAT) para Colômbia (CO-PCAT), dirigidos a professionais (PCAT-PE), encargados e diretivos de atenção primária (PCAT-FE) através de um processo colaborativo internacional. Métodos: processo de adaptação transcultural modificado a partir das versões adaptadas e validadas em espanhol, em consenso com a Colaboração Ibero-americana IA-PCAT. O método procura alcançar a equivalência da versão CO-PCAT dos questionários com a versão original de Estados Unidos da América. Desenvolveram-se três fases de trabalho: I) valoração da adequação de versões Ibero-americanas em língua espanhola e adaptação ao contexto colombiano, II) revisão internacional realizada por pesquisadores da Colaboração Ibero-americana PCAT e III) testes preliminares dos questionários. Considerações éticas: é uma pesquisa sem riscos para os seres humanos conforme à Resolução 08430 de 1993 da Colômbia e a Declaração de Helsinki. Resultados: do PCAT-PE se incluíram na versão colombiana 182 itens. Em quanto ao PCAT-FE se trabalho com 197 itens em total. Conclusão: obtiveram-se versões adaptadas ao sistema de saúde colombiano. A metodologia utilizada pode contribuir para a obtenção de maior equivalência entre instrumentos de diferentes países.

[Evaluation a parenting skills pilot programme from a public health perspective]. / Evaluación de un programa piloto promotor de habilidades parentales desde una perspectiva de salud pública.

OBJECTIVE: To evaluate the process and the results of the pilot phase of the Parenting skills development programme for families (PSP), an evidence-based strategy to promote positive parenting skills in socio-educational and community settings. METHODS: Before-after quasi-experimental design without a control group for the evaluation of the pilot phase of the PSD carried out in Barcelona (Spain) between October 2011 and June 2013. Eleven groups were established with the participation of 128 parents and 28 professionals. The intervention consisted of 10 or 11 sessions. Information was collected through questionnaires for parents and in-depth individual or group interviews for professionals. Parenting skills were identified through a questionnaire with six dimensions. The situation before the intervention (T0) and immediately after (T1) was compared. RESULTS: In T1 the number of participants decreased to 83 (retention=64.8%). Participants showed a high level of satisfaction with different dimensions of the program. On a maximum score of 10, the satisfaction of professionals was 8.7. Several key aspects and areas for improvement were identified for the future of the intervention. The quantitative analysis revealed improvements in all parenting skills dimensions and these improvements were consistent with the results of the qualitative analysis. CONCLUSIONS: The results of the pilot phase of this program suggest that a universal intervention on parenting skills can improve wellbeing among parents.

[Childhood obesity prevention from a community view]. / La prevención de la obesidad infantil desde una perspectiva comunitaria.

The percentage of failure and relapse in the treatment of obesity is high. Where possible, the preferred strategy for preventing obesity is to modify eating habits and lifestyles. This article aims to provide a framework for evidence on the most effective interventions for addressing childhood obesity, both from a prevention point of view, as well as reducing it, when it is already established. After a review of the scientific literature, the issues that must be considered both in the universal and selective prevention of childhood obesity are presented. Also, in light of the controversy over the tools for measuring and controlling the problem, some clarification is provided on the criteria. Finally, the approach to the prevention of overweight and obesity with a community perspective is separated, with two short protocols being offered with diagrams of the basic procedure to follow.

Experiências com a atenção primária associadas à saúde, características sociodemográficas e uso de serviços em crianças e adolescentes / Experiences with primary care associated to health, socio-demographics and use of services in children and adolescents / Experiencias con la atención primaria asociadas a la salud, características sociodemográficas y uso de servicios en niños y adolescentes

Este estudo avaliou as experiências com a atenção primária à saúde para crianças e adolescentes, considerando níveis de saúde, características sociodemográficas e o uso de serviços de saúde. A Enquete de Saúde de Catalunha de 2006 incluiu uma amostra representativa da população de 0 a 14 anos (n = 2.200). Pessoas adultas informaram suas experiências com a atenção primária à saúde de seus filhos com uma seleção de 17 itens do Primary Care Assessment Tool. Estimaram-se razões de prevalência (RP) de baixa pontuação em seis funções da atenção primária à saúde mediante modelos multivariados. A declaração de doenças crônicas se associou à baixa pontuação no primeiro contato-acessibilidade. Os pais imigrantes declararam pior experiência com várias funções da atenção primária à saúde. As pontuações no primeiro contato-acessibilidade, continuidade da atenção e competência cultural foram mais altas quando as crianças tinham cobertura sanitária dupla e mais baixas quando tinham visitado os serviços de emergência. Melhorias em algumas funções da atenção primária à saúde poderiam reduzir o uso de serviços de urgência e iniquidade.

This study aimed to evaluate user experiences with primary care for children and adolescents according to health, socio-demographic characteristics, and use of healthcare services. The 2006 Catalan Health Interview Survey studied a representative sample of the population aged 0 to 14 (n = 2,200). Parents reported their experiences with primary care through 17 items from the Primary Care Assessment Tool. Multivariate models were fitted to estimate prevalence ratios (PR) of scoring low on experiences with primary care by health, use of services, and socio-demographic variables. A low first contact-accessibility score was associated with declared chronic conditions. Immigrant parents declared a poor experience with several primary care functions. A low score on first contact-accessibility, continuity of care, and cultural competence was less likely when children had double healthcare coverage and more likely when they had visited emergency services. Improvement of some aspects of primary care services may reduce both use of emergency services and inequity in this area.

Este estudio evaluó las experiencias en la atención primaria de salud para niños y adolescentes, considerando niveles de salud, características sociodemográficas y el uso de servicios de salud. La Encuesta de Salud de Cataluña de 2006 incluyó una muestra representativa de la población de 0 a 14 años (n = 2.200). Personas adultas informaron sobre sus experiencias con la atención primaria de salud de sus hijos con una selección de 17 ítems del Primary Care Assessment Tool. Se estimaron razones de prevalencia (RP) de baja puntuación en seis funciones de la atención primaria de salud, mediante modelos multivariados. La declaración de enfermedades crónicas se asoció a la baja puntuación en primer contacto-accesibilidad. Los padres inmigrantes declararon peor experiencia con varias funciones de la atención primaria de salud. Las puntuaciones en primer contacto-accesibilidad, continuidad de la atención y competencia cultural fueron más altas cuando los niños tenían cobertura sanitaria doble y más bajas cuando habían visitado los servicios de emergencia. Mejoras en algunas funciones de la atención primaria de salud podrían reducir el uso de servicios de urgencia y la inequidad.

Socioeconomic inequalities in mortality in 16 European cities.

AIMS: 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.

[Experiences with primary care associated to health, socio-demographics and use of services in children and adolescents]. / Experiências com a atenção primária associadas à saúde, características sociodemográficas e uso de serviços em crianças e adolescentes.

This study aimed to evaluate user experiences with primary care for children and adolescents according to health, socio-demographic characteristics, and use of healthcare services. The 2006 Catalan Health Interview Survey studied a representative sample of the population aged 0 to 14 (n = 2,200). Parents reported their experiences with primary care through 17 items from the Primary Care Assessment Tool. Multivariate models were fitted to estimate prevalence ratios (PR) of scoring low on experiences with primary care by health, use of services, and socio-demographic variables. A low first contact-accessibility score was associated with declared chronic conditions. Immigrant parents declared a poor experience with several primary care functions. A low score on first contact-accessibility, continuity of care, and cultural competence was less likely when children had double healthcare coverage and more likely when they had visited emergency services. Improvement of some aspects of primary care services may reduce both use of emergency services and inequity in this area.

Evaluation of the effectiveness of a school-based cannabis prevention program.

BACKGROUND: The effectiveness of a cannabis prevention program in high school students was assessed. METHODS: A quasi-experimental study was designed to evaluate the effectiveness of an intervention implemented in an intervention group (IG) with 39 schools compared with a control group (CG) of 47 schools not exposed to the intervention. Of 224 secondary schools in Barcelona, 86 were assessed in the 2005-2006 school year through a personal questionnaire administered at baseline and 15 months after the intervention. Participants consisted of 4848 ninth graders (14-15 year-olds), 2803 assigned to the IG and 2043 to the CG, according to the type and size of the school and the socioeconomic status of the school's neighborhood. The intervention consisted of a school-based cannabis prevention program (xkpts.com), with four sessions and 16 activities, implemented over 6-10h, with materials for parents and web-based student involvement. Last-month cannabis use was assessed at baseline and at 15 months' follow-up. Process evaluation indicators were assessed. RESULTS: At 15 months follow-up, 8.2% of boys and 8.3% of girls in the IG became last-month cannabis users versus 11.8% of boys and 11.6% of girls in the CG. These differences were statistically significant (p=0.003), representing a 29% reduction in last-month cannabis users in the IG compared with the CG. The incidence of last-month cannabis use was lowest in classrooms that adhered to the program protocol. CONCLUSIONS: The xkpts.com program was effective in preventing progression to last-month cannabis use. Effectiveness was higher in classrooms that adhered closely to the protocol.

Evaluation of primary care: The "Primary Care Assessment Tools - Facility version" for the Spanish health system.

OBJECTIVE: To obtain versions of the Primary Care Assessment Tools (PCAT)-Facility version to evaluate primary care (PC) in the Spanish context, and to analyze its feasibility, reliability and validity. METHODS: Cultural adaptation was performed through the use of forward and backward translations into Spanish and Catalan, observations and opinions of a panel of experts, and cognitive interviews with target users (PC team managers). A pilot phase was carried out in a sample of 130 managers of PC teams in Catalonia. A post-test questionnaire was sent 4-5 months later to all 194 managers of PC teams in the Barcelona health region. Analysis of metric properties included: 1) description of items and verification of Likert assumptions, since domain scores are obtained by summing item scores; 2) reliability analysis (Cronbach's alpha coefficient, Pearson's correlation coefficient, test-retest analysis); and 3) validity analysis (expert panel, cognitive interviews, and convergent and discriminant validity). RESULTS: Substantial adaptation was required for the accessory section of the questionnaire, but less was required in PC domain measurements. Items were added to the comprehensiveness domain to reflect services usually available in Spain. The lowest Cronbach's alpha scores were found for Access (0.62) and Coordination (0.59 and 0.65), while values were >0.70 for the remaining domains. CONCLUSION: The Spanish version of the PCAT-Facility questionnaire is now available and shows adequate reliability and validity. The Spanish PCAT version will facilitate national and international comparisons of PC and analysis of the determinants of quality of service provision.