Multiple health behaviour change primary care intervention for smoking cessation, physical activity and healthy diet in adults 45 to 75 years old (EIRA study): a hybrid effectiveness-implementation cluster randomised trial.

BACKGROUND: This study aimed to evaluate the effectiveness of a) a Multiple Health Behaviour Change (MHBC) intervention on reducing smoking, increasing physical activity and adherence to a Mediterranean dietary pattern in people aged 45-75 years compared to usual care; and b) an implementation strategy. METHODS: A cluster randomised effectiveness-implementation hybrid trial-type 2 with two parallel groups was conducted in 25 Spanish Primary Health Care (PHC) centres (3062 participants): 12 centres (1481 participants) were randomised to the intervention and 13 (1581 participants) to the control group (usual care). The intervention was based on the Transtheoretical Model and focused on all target behaviours using individual, group and community approaches. PHC professionals made it during routine care. The implementation strategy was based on the Consolidated Framework for Implementation Research (CFIR). Data were analysed using generalised linear mixed models, accounting for clustering. A mixed-methods data analysis was used to evaluate implementation outcomes (adoption, acceptability, appropriateness, feasibility and fidelity) and determinants of implementation success. RESULTS: 14.5% of participants in the intervention group and 8.9% in the usual care group showed a positive change in two or all the target behaviours. Intervention was more effective in promoting dietary behaviour change (31.9% vs 21.4%). The overall adoption rate by professionals was 48.7%. Early and final appropriateness were perceived by professionals as moderate. Early acceptability was high, whereas final acceptability was only moderate. Initial and final acceptability as perceived by the participants was high, and appropriateness moderate. Consent and recruitment rates were 82.0% and 65.5%, respectively, intervention uptake was 89.5% and completion rate 74.7%. The global value of the percentage of approaches with fidelity ≥50% was 16.7%. Eight CFIR constructs distinguished between high and low implementation, five corresponding to the Inner Setting domain. CONCLUSIONS: Compared to usual care, the EIRA intervention was more effective in promoting MHBC and dietary behaviour change. Implementation outcomes were satisfactory except for the fidelity to the planned intervention, which was low. The organisational and structural contexts of the centres proved to be significant determinants of implementation effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03136211 . Registered 2 May 2017, "retrospectively registered".

Medication-related problems in older people in Catalonia: A real-world data study.

PURPOSE: The aim of this study was to determine medication-related problems (MRPs) in primary care patients over 65 years of age. METHODS: Cross-sectional study based on the electronic health records of patients (65-99 years of age) visited in 284 primary health care centers during 2012 in Catalonia. VARIABLES: age, sex, sociodemographic variables, number of drugs, kidney and liver function and MRPs (duplicate therapy, drug-drug interactions, potentially inappropriate medications [PIMs] and drugs contraindicated in chronic kidney disease and in liver diseases). Unconditional logistic regression models were used to identify the factors associated with MRPs in patients with multimorbidity. RESULTS: 916 619 older people were included and 853 085 of them met the criteria for multimorbidity. Median age was 75 years and 57.7% of them were women. High percentages of MRPs were observed: PIMs (62.8%), contraindicated drugs in chronic kidney disease (12.1%), duplicate therapy (11.1%), contraindicated drugs in liver diseases (4.2%), and drug-drug interactions (1.0%). These numbers were higher in the subgroup of patients with ≥10 diseases. The most common PIMs were connected to drugs that increase the risk of fall (66.8%), antiulcer agents without criteria for gastroprotection (40.6%), and the combination of drugs with anticholinergic effects (39.7%). In the multivariate analysis, the variables associated with all MRPs among the patients with multimorbidity were the number of drugs and the number of visits. CONCLUSIONS: The coexistence of multimorbidity and polypharmacy is associated with an elevated risk of MRPs in older people. Medication safety for older patients constitutes a pressing concern for health services.

Multimorbidity patterns, polypharmacy and their association with liver and kidney abnormalities in people over 65 years of age: a longitudinal study.

BACKGROUND: The implementation of individual clinical practice guidelines in patients with multimorbidity often results in polypharmacy. Our aim was to analyse medication use according to longitudinal multimorbidity patterns (MP) and determine during a 5-year period (2012-16) which MP are associated with abnormal liver and kidney function in primary care patients over 65 years of age living in Catalonia. METHODS: Design: Longitudinal study (years 2012 to 2016) based on the electronic health records contained in Information System for Research in Primary Care database of the Catalan Institute of Health (SIDIAP). VARIABLES: age, sex, MP, medication and polypharmacy (drug exposure obtained from the Pharmacy Invoice Registry). Medicines were classified in accordance with the Anatomical Therapeutic Chemical Classification System (ATC). Glomerular filtration rate was used to determine abnormal kidney function, and serum levels of alkaline phosphatase, alanine transaminase and gamma-glutamyl transpeptidase were used to diagnose abnormal liver function. STATISTICS: For medication use in MP, we calculated annual mean packages of each drug in each MP, and observed/expected ratios were obtained by dividing mean packages in the cluster by mean packages of the same drug in the overall population. Logistic regression models were fitted to estimate the association between MP at baseline and abnormal kidney and liver function tests during follow up. RESULTS: Nine hundred sixteen thousand six hundred nineteen patients were included, and 743,827 completed the follow up. We identified one polypharmacy profile per MP, and concluded that the most prescribed drugs in each pattern corresponded to the diseases overrepresented in that specific MP. The median of drugs ranged from 3 (Cluster 1 - Non-Specific) to 8 (Cluster 10 - Multisystem Pattern). Abnormal kidney function was most commonly observed in the Cluster 4 - Cardio-Circulatory and Renal (Odds Ratio [OR] 2.19; Confidence interval [CI] 95% 2.15-2.23) and Cluster 3 - Minority Metabolic Autoimmune-Inflammatory (OR 2.16; CI 95% 2.12-2.20) MP. A higher risk of abnormal liver function was observed in the Cluster 8 - Digestive (OR 3.39; CI 95% 3.30-3.49), and Cluster 4 - Cardio-Circulatory and Renal (OR 1.96; CI 95% 1.91-2.02) MP. CONCLUSIONS: A higher risk of abnormal kidney and liver function was observed in specific MP. The long-term characterisation of MP and polypharmacy illustrates the burden of chronic multimorbidity and polypharmacy in the elderly population.

Medication patterns in older adults with multimorbidity: a cluster analysis of primary care patients.

BACKGROUND: Older adults suffer from various chronic conditions which make them particularly vulnerable. The proper management of multiple drug use is therefore crucial. The aim of our study was to describe drug prescription and medication patterns in this population. METHODS: A cross-sectional study in Barcelona (Spain) using electronic health records from 50 primary healthcare centres. Participants were aged 65 to 94 years, presenting multimorbidity (≥2 chronic diseases), and had been prescribed at least 1 drug for 6 months or longer during 2009. We calculated the prevalence of prescribed drugs and identified medication patterns using multiple correspondence analysis and k-means clustering. Analyses were stratified by sex and age (65-79, 80-94 years). RESULTS: We studied 164,513 patients (66.8% women) prescribed a median of 4 drugs (interquartile range [IQR] = 3-7) in the 65-79 age-group and 6 drugs (IQR = 4-8) in the 80-94 age-group. A minimum of 45.9% of patients aged 65-79 years, and 61.8% of those aged 80-94 years, were prescribed 5 or more drugs. We identified 6 medication patterns, a non-specific one and 5 encompassing 8 anatomical groups (alimentary tract and metabolism, blood, cardiovascular, dermatological, musculo-skeletal, neurological, respiratory, and sensory organ). CONCLUSIONS: Drug prescription is widespread among the elderly. Six medication patterns were identified, 5 of which were related to one or more anatomical group, with associations among drugs from different systems. Overall, guidelines do not accurately reflect the situation of the elderly multimorbid, new strategies for managing multiple drug uses are needed to optimize prescribing in these patients.

Effect of the comprehensive smoke-free law on time trends in smoking behaviour in primary healthcare patients in Spain: a longitudinal observational study.

OBJECTIVE: This study aimed to analyse the impact of comprehensive smoke-free legislation (SFL) on the prevalence and incidence of adult smoking in primary healthcare (PHC) patients from three Spanish regions, overall and stratified by sex. DESIGN: Longitudinal observational study conducted between 2008 and 2013. SETTING: 66 PHC teams in Catalonia, Navarre and the Balearic Islands (Spain). PARTICIPANTS: Population over 15 years of age assigned to PHC teams. PRIMARY AND SECONDARY OUTCOMES MEASURES: Quarterly age-standardised prevalence of non-smoker, smoker and ex-smoker and incidence of new smoker, new ex-smoker and ex-smoker relapse rates were estimated with data retrieved from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardised prevalence and incidence rates. Trends were expressed as annual percentage change and average annual percent change. RESULTS: The overall standardised smoker prevalence rate showed a significant downward trend (higher in men than women) and the overall standardised ex-smoker prevalence rate showed a significant increased trend (higher in women than men) in the three regions. Standardised smoker and ex-smoker prevalence rates were higher for men than women in all regions. With regard to overall trends of incidence rates, new smokers decreased significantly in Catalonia and Navarre and similarly in men and women, new ex-smokers decreased significantly and more in men in Catalonia and the Balearic Islands, and ex-smoker relapse increased in Catalonia (particularly in women) and decreased in Navarre. CONCLUSIONS: Trends in smoking behaviour in PHC patients remain unchanged after the implementation of comprehensive SFL. The impact of the comprehensive SFL might have been lessened by the effect of the preceding partial SFL.

Coping Strategies and Social Support in a Mobile Phone Chat App Designed to Support Smoking Cessation: Qualitative Analysis.

BACKGROUND: Smoking is one of the most significant factors contributing to low life expectancy, health inequalities, and illness at the worldwide scale. Smoking cessation attempts benefit from social support. Mobile phones have changed the way we communicate through the use of freely available message-oriented apps. Mobile app-based interventions for smoking cessation programs can provide interactive, supportive, and individually tailored interventions. OBJECTIVE: This study aimed to identify emotions, coping strategies, beliefs, values, and cognitive evaluations of smokers who are in the process of quitting, and to analyze online social support provided through the analysis of messages posted to a chat function integrated into a mobile app. METHODS: In this descriptive qualitative study, informants were smokers who participated in the chat of Tobbstop. The technique to generate information was documentary through messages collected from September 2014 through June 2016, specifically designed to support a smoking cessation intervention. A thematic content analysis of the messages applied 2 conceptual models: the Lazarus and Folkman model to assess participant's experiences and perceptions and the Cutrona model to evaluate online social support. RESULTS: During the study period, 11,788 text messages were posted to the chat by 101 users. The most frequent messages offered information and emotional support, and all the basic emotions were reported in the chat. The 3 most frequent coping strategies identified were physical activity, different types of treatment such as nicotine replacement, and humor. Beliefs about quitting smoking included the inevitability of weight gain and the notion that not using any type of medications is better for smoking cessation. Health and family were the values more frequently described, followed by freedom. A smoke-free environment was perceived as important to successful smoking cessation. The social support group that was developed with the app offered mainly emotional and informational support. CONCLUSIONS: Our analysis suggests that a chat integrated into a mobile app focused on supporting smoking cessation provides a useful tool for smokers who are in the process of quitting, by offering social support and a space to share concerns, information, or strategies.

Complex multiple risk intervention to promote healthy behaviours in people between 45 to 75 years attended in primary health care (EIRA study): study protocol for a hybrid trial.

BACKGROUND: Health promotion is a key process of current health systems. Primary Health Care (PHC) is the ideal setting for health promotion but multifaceted barriers make its integration difficult in the usual care. The majority of the adult population engages two or more risk behaviours, that is why a multiple intervention might be more effective and efficient. The primary objectives are to evaluate the effectiveness, the cost-effectiveness and an implementation strategy of a complex multiple risk intervention to promote healthy behaviours in people between 45 to 75 years attended in PHC. METHODS: This study is a cluster randomised controlled hybrid type 2 trial with two parallel groups comparing a complex multiple risk behaviour intervention with usual care. It will be carried out in 26 PHC centres in Spain. The study focuses on people between 45 and 75 years who carry out two or more of the following unhealthy behaviours: tobacco use, low adherence to the Mediterranean dietary pattern or insufficient physical activity level. The intervention is based on the Transtheoretical Model and it will be made by physicians and nurses in the routine care of PHC practices according to the conceptual framework of the "5A's". It will have a maximum duration of 12 months and it will be carried out to three different levels (individual, group and community). Incremental cost per quality-adjusted life year gained measured by the tariffs of the EuroQol-5D questionnaire will be estimated. The implementation strategy is based on the "Consolidated Framework for Implementation Research", a set of discrete implementation strategies and an evaluation framework. DISCUSSION: EIRA study will determine the effectiveness and cost-effectiveness of a complex multiple risk intervention and will provide a better understanding of implementation processes of health promotion interventions in PHC setting. It may contribute to increase knowledge about the individual and structural barriers that affect implementation of these interventions and to quantify the contextual factors that moderate the effectiveness of implementation. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03136211 .Retrospectively registered on May 2, 2017.

Effect of comprehensive smoke-free legislation on asthma and coronary disease trends in Spanish primary care patients.

Background: To examine the impact of comprehensive smoke-free legislation (SFL) (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in primary health care (PHC) patients from three Spanish regions, overall and stratified by sex. Methods: Longitudinal observational study conducted between 2007 and 2013 in the population over 15 years of age assigned to 66 PHC teams in Catalonia, Navarre and the Balearic Islands. Crude rates and age-standardized (truncated: asthma ≥ 16 years and coronary disease ≥ 35 years) incidence and prevalence rates using the direct method based on the European Standard Population were estimated based on data from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardized incidence and prevalence rates. Trends were expressed as annual percentage change and average annual percent change (AAPC). Results: The standardized asthma incidence rate showed a non-significant downward trend and the standardized prevalence rates rose significantly in the three regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. The standardized coronary disease incidence rates in Catalonia (AAPC: -8.00%, 95% CI: -10.46; -5.47) and Navarre (AAPC: -3.66%, 95% CI: -4.95;-2.35) showed a significant downward trend from 2007 to 2013, overall and by sex. The standardized coronary disease prevalence trend rate increased significantly in the whole period in Catalonia and the Balearic Islands, although a non-significant downward trend was observed from 2010 in Catalonia. Conclusion: No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL.

Smokefree legislation effects on respiratory and sensory disorders: A systematic review and meta-analysis.

AIMS: The aim of this systematic review and meta-analysis is to synthesize the available evidence in scientific papers of smokefree legislation effects on respiratory diseases and sensory and respiratory symptoms (cough, phlegm, red eyes, runny nose) among all populations. MATERIALS AND METHODS: Systematic review and meta-analysis were carried out. A search between January 1995 and February 2015 was performed in PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, and Google Scholar databases. Inclusion criteria were: 1) original scientific studies about smokefree legislation, 2) Data before and after legislation were collected, and 3) Impact on respiratory and sensory outcomes were assessed. Paired reviewers independently carried out the screening of titles and abstracts, data extraction from full-text articles, and methodological quality assessment. RESULTS: A total number of 1606 papers were identified. 50 papers were selected, 26 were related to symptoms (23 concerned workers). Most outcomes presented significant decreases in the percentage of people suffering from them, especially in locations with comprehensive measures and during the immediate post-ban period (within the first six months). Four (50%) of the papers concerning pulmonary function reported some significant improvement in expiratory parameters. Significant decreases were described in 13 of the 17 papers evaluating asthma hospital admissions, and there were fewer significant reductions in chronic obstructive pulmonary disease admissions (range 1-36%) than for asthma (5-31%). Six studies regarding different respiratory diseases showed discrepant results, and four papers about mortality reported significant declines in subgroups. Low bias risk was present in 23 (46%) of the studies. CONCLUSIONS: Smokefree legislation appears to improve respiratory and sensory symptoms at short term in workers (the overall effect being greater in comprehensive smokefree legislation in sensory symptoms) and, to a lesser degree, rates of hospitalization for asthma.

Pharmacological control of diabetes and hypertension comorbidity in the elderly: A study of "real world" data.

AIMS: The study aimed to determine which drug combinations achieve better control in comorbid diabetes and hypertension in a pragmatic sample of primary health care patients. METHODS: Cross-sectional study. SETTING: 251 primary health care centres in Catalonia, Spain. PARTICIPANTS: individuals ≥65 years old with a dual diagnosis of hypertension and diabetes. MAIN OUTCOME MEASURES: good control criteria were established as glycated haemoglobin ≤7% and blood pressure <140/90mmHg. Antihypertensive and hypoglycaemic drugs and treatment adherence were analysed in relation to their association with good control. RESULTS: 27,637 patients (58.0% women) had hypertension and diabetes and met selection criteria. Mean age was 75.9 years (standard deviation [SD]: 6.7). Both diseases were well controlled simultaneously in 34.2% of patients. The combination of biguanides and diuretics achieved the highest association with good control. Adherence to pharmacological treatment was more difficult in diabetes than in hypertension. Lack of control was associated significantly with non-adherence to treatment, 0-12 PHC visits, obesity and increasing number of diabetes prescriptions. CONCLUSIONS: Good control of diabetes and hypertension comorbidity with pharmacological treatment in elderly patients is challenging. Some drug combinations achieved better control than others. The greatest effort should focus on improving the low adherence to diabetes treatment.

The burden of cardiovascular morbidity in a European Mediterranean population with multimorbidity: a cross-sectional study.

BACKGROUND: Cardiovascular diseases are highly represented in multimorbidity patterns. Nevertheless, few studies have analysed the burden of these diseases in the population with multimorbidity. The objective of this study was to identify and describe the cardiovascular diseases among the patients with multimorbidity. METHODS: We designed a cross-sectional study in patients ≥19 years old assigned to 251 primary health care centres in Catalonia, Spain. The main outcome was cardiovascular morbidity burden, defined as the presence of one or more of 24 chronic cardiovascular diseases in multimorbid patients (≥2 chronic conditions). Two groups were defined, with and without multimorbidity; the multimorbidity group was further divided into cardiovascular and non-cardiovascular subgroups. The secondary outcomes were: modifiable major cardiovascular risk factors (smoking, hypertension, hypercholesterolaemia, diabetes) and cardiovascular risk score (REGICOR, Registre Gironí del Cor). Other variables analysed were: sex, age (19-24, 25-44, 45-64, 65-79, and 80+ years), number of chronic diseases, urban setting, active toxic habits (smoking and alcohol), physical parameters and laboratory tests. RESULTS: A total of 1,749,710 individuals were included (mean age, 47.4 years [SD: 17.8]; 50.7 % women), of which nearly half (46.8 %) had multimorbidity (95 % CI: 46.9-47.1). In patients with multimorbidity,, the cardiovascular burden was 54.1 % of morbidity (95 % CI: 54.0-54.2) and the four most prevalent cardiovascular diseases were uncomplicated hypertension (75.3 %), varicose veins of leg (20.6 %), "other" heart disease (10.5 %) and atrial fibrillation/flutter (6.7 %). In the cardiovascular morbidity subgroup, 38.2 % had more than one cardiovascular disease. The most prevalent duet and triplet combinations were uncomplicated hypertension & lipid disorder (38.8 %) and uncomplicated hypertension & lipid disorder & non-insulin dependent diabetes (11.3 %), respectively. By age groups, the same duet was the most prevalent in patients aged 45-80 years and in men aged 25-44 years. In women aged 19-44, varicose veins of leg & anxiety disorder/anxiety was the most prevalent; in men aged 19-24, it was uncomplicated hypertension & obesity. Patients with multimorbidity showed a higher cardiovascular risk profile than the non-multimorbidity group. CONCLUSIONS: More than 50 % percent of patients with multimorbidity had cardiovascular diseases, the most frequent being hypertension. The presence of cardiovascular risk factors and the cardiovascular risk profile were higher in the multimorbidity group than the non-multimorbidity group. Hypertension, diabetes and dyslipidaemia constituted the most prevalent multimorbidity pattern.

[Multimorbidity patterns in young adults in Catalonia: an analysis of clusters]. / Patrones de multimorbilidad en adultos jóvenes en Cataluña: un análisis de clústeres.

OBJECTIVE: The aim of this study was to identify multimorbidity patterns in patients from 19 to 44 years attended in primary care in Catalonia in 2010. DESIGN: Cross-sectional study. SETTING: 251 primary care centres. PARTICIPANTS: 530,798 people with multimorbidity, aged 19 to 44 years. MAIN OUTCOME MEASURES: Multimorbidity was defined as the coexistence of ≥2 more International Classification system (ICD-10) registered in the electronic health record. Multimorbidity patterns were identified using hierarchical cluster analysis and by sex and age group (19-24 and 25-44). RESULTS: Of the 882,708 people from initial population, 530,798 (60.1%) accomplished multimorbidity criterion. Mean age was 33.0 years (SD: 7.0) and 53.3% were women. Multimorbidity was higher in the 25-to 44-years-old group with respect the younger group (60.5 vs. 58.1%, p<0.001), being higher in women. Most prevalent cluster in all groups included, among others, by dental caries, smoking, dorsalgia, common cold and other anxiety disorders. For both sexes in the 25-to 44-years-old group appeared the cardiovascular-endocrine-metabolic pattern (obesity, lipid disorders and arterial hypertension). CONCLUSIONS: Multimorbidity affects more than half of persons between 19 to 44-years-old. The most prevalent cluster is formed by grouping common diseases (dental caries, common cold, smoking, anxiety disorders and dorsalgias). Another pattern to highlight is the cardiovascular-endocrine-metabolic pattern in the 25- to 44 years-old group. Knowledge of patterns of multimorbidity in young adults could be used to design individualized preventive strategies.

Variability in screening prevention activities in primary care in Spain: a multilevel analysis.

BACKGROUND: Despite evidence of the benefits of prevention activities, studies have reported only partial integration and great variability of screening in daily clinical practice. The study objectives were: 1) To describe Primary Health Care (PHC) screening for arterial hypertension, dyslipidaemia, obesity, tobacco use, and excessive alcohol consumption in 2008 in 2 regions of Spain, based on electronic health records, and 2) To assess and quantify variability in screening, and identify factors (of patient, general practitioners and PHC team) associated with being screened, that are common throughout the PHC population. METHODS: Multicentre, cross-sectional study of individuals aged ≥ 16 years (N = 468,940) who visited the 426 general practitioners (GPs) in 44 PHC teams in Catalonia and Navarre in 2008. OUTCOMES: screening for hypertension, dyslipidaemia, obesity, tobacco use, and excessive alcohol consumption. Other variables were considered at the individual (sociodemographics, visits, health problems), GP and PHC team (region among others). Individual and contextual factors associated with the odds of being screened and the variance attributable to each level were identified using the SAS PROC GLIMMIX macro. RESULTS: The most prevalent screenings were for dyslipidaemia (64.4%) and hypertension (50.8%); the least prevalent was tobacco use (36.6%). Overall, the odds of being screened were higher for women, older patients, those with more comorbidities, more cardiovascular risk factors, and more frequent office visits, and those assigned to a female GP, a GP with a lower patient load, or a PHC team with a lower percentage of patients older than 65 years. On average, individuals in Navarre were less likely to be screened than those in Catalonia. Hypertension and dyslipidaemia screenings had the least unexplained variability between PHC teams and GPs, respectively, after adjusting for individual and contextual factors. CONCLUSIONS: Of the studied screenings, those for obesity, tobacco, and alcohol use were the least prevalent. Attention to screening, especially for tobacco and alcohol, can be greatly improved in the PHC setting.

Country of origin and prevention of breast cancer: beliefs, knowledge and barriers.

This study describes the concept of prevention and identifies the knowledge, perceived benefits and barriers, as well as the practices of early detection of breast cancer among women from different cultural backgrounds and socioeconomic levels. A socioconstructivist qualitative study was conducted in Barcelona. The study population consisted of women who were either native (Spanish) or immigrants from low income countries, aged 40 to 69 years. Narrations of the 68 informants were subjected to sociological discourse analysis. Place and culture of origin, social class and the migratory process can either facilitate or constitute barriers to breast cancer prevention.

Knowledge, attitude and perceptions of breast cancer screening among native and immigrant women in Barcelona, Spain.

OBJECTIVE: Inequalities between immigrant and native populations in terms of access and use of health services have been described. The objective is to compare knowledge, attitudes, vulnerabilities, benefits and barriers related to breast cancer (BC) and screening mammography among women from different countries resident in Barcelona. METHODS: A cross-sectional survey carried out in Barcelona in 2009. The study population consisted of female residents in Barcelona between 45 and 69 years of age; participants were Spanish nationals or immigrants from low-income countries. 960 participants were asked 72 questions, mainly with Likert responses. The dependent variables were five quantitative scales: (1) knowledge of BC and early detection, (2) attitude towards health and BC, (3) vulnerability to BC, (4) barriers to mammography, (5) benefits of mammography. The independent variables were country of origin, social class, setting, cohabitation, age, mammography use, length of residence and fluency of the language. Analyses compared scale scores stratified by the independent variables. Multivariable linear regression models were fitted to determine the relationship between the scales and the independent variables. RESULTS: We observed inequalities according to country of origin on all scales after adjustment for independent variables. Chinese women presented the greatest differences with respect to native women, followed by Maghrebi and Filipino women. Inequalities exist on the vulnerability and barriers scales according to social class and urban/rural setting, and on the attitude scale according to social class. CONCLUSIONS: Country of origin, social class and urban/rural setting are key contributors to inequality in these scales.

Preventive control of breast and cervical cancer in immigrant and native women in Spain: the role of country of origin and social class.

The study describes the periodic use of cervical and breast cancer screening by women residing in Spain, according to their country of origin, and analyzes whether the observed associations are modified by social class. A cross-sectional design was used, with the study population consisting of women residing in Spain in 2006, ages 25-65 years (N = 10,093) and 40-69 years (N = 6674) in the cervical and breast cancer screening groups, respectively. The information source was Spain's National Health Survey of 2006. The dependent variables were: undergoing periodic cervical cancer screening (every 5 years or less) and breast cancer screening (every 2 years or less). The independent variables were: country of origin, social class, health care coverage, cohabitation, and age. A descriptive analysis was carried out, and robust Poisson regression models were fitted. Women from low-income countries underwent fewer periodic screening exams for cervical cancer and breast cancer. Independent of country of origin, women from the manual classes underwent fewer screening exams than those from the non-manual classes. In the 50-69 years age group, it was mainly women from the manual classes from low-income countries who underwent fewer periodic mammograms. Having only public health care coverage and not cohabiting with a partner were also associated with lower prevalences of use.

Evolution of inequalities in breast and cervical cancer screening in Barcelona: population surveys 1992, 2001, and 2006.

OBJECTIVE: To describe and compare breast and cervical cancer screening among women in Barcelona in 1992, 2001, and 2006 by social class, age, and screening approach. METHODS: This was a study of trends based on analysis of Barcelona health interview surveys for the years 1992 (n=5,003), 2001 (n=10,030), and 2006 (n=6,050). Dependent variables were having regular mammographies (at least every 2 years) and having regular cytologic testing (at least every 3 years). Independent variables were age, social class, and survey year. A descriptive analysis was carried out. To compare prevalence in terms of social class and the years studied, we calculated prevalence differences (PD) and prevalence ratios (PR) by fitting robust Poisson regression models. RESULTS: In 1992, women aged 40?49 had more regular mammographies than those aged 50?69, with social class inequalities in both age groups. Having cervical cancer screening was more common than having breast cancer screening, with prevalence varying from 46.4% in the low social classes to 59.2% in the high classes. In 2001, breast cancer screening had risen, particularly in women aged 50?69, a tendency that had stabilized by 2006. Inequalities diminished over the period, more markedly in women aged 50?69; PRs of 1.22 and 1.58, respectively, for high and middle social classes with respect to the lowest class in 1992 fell to PRs of 1.07 and 1.08, respectively, in 2006. In the case of cervical cancer screening, inequalities also diminished but not to the same extent. CONCLUSIONS: Preventive screening for breast and cervical cancer has increased, and the population screening program for breast cancer among women aged 50?69 years appears to contribute more than opportunistic screening for cervical cancer in reducing social class inequalities.

Socio-economic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program.

BACKGROUND: The aim of this study was to describe inequalities in the use of breast and cervical cancer screening services according to educational level in European countries in 2002, and to determine the influence of the type of screening program on the extent of inequality. METHODS: A cross-sectional study was performed using individual-level data from the WHO World Health Survey (2002) and data regarding the implementation of cancer screening programmes. The study population consisted of women from 22 European countries, aged 25-69 years for cervical cancer screening (n =11 770) and 50-69 years for breast cancer screening (n = 4784). Dependent variables were having had a PAP smear and having had a mammography during the previous 3 years. The main independent variables were socio-economic position (SEP) and the type of screening program in the country. For each country the prevalence of screening was calculated, overall and for each level of education, and indices of relative (RII) and absolute (SII) inequality were computed by educational level. Multilevel logistic regression models were fitted. RESULTS: SEP inequalities in screening were found in countries with opportunistic screening [comparing highest with lowest educational level: RII = 1.28, 95% confidence interval (CI) 1.12-1.48 for cervical cancer; and RII = 3.11, 95% CI 1.78-5.42 for breast cancer] but not in countries with nationwide population-based programmes. Inequalities were also observed in countries with regional screening programs (RII = 1.35, 95% CI 1.10-1.65 for cervical cancer; and RII = 1.58, 95% CI 1.26-1.98 for breast cancer). CONCLUSIONS: Inequalities in the use of cancer screening according to SEP are higher in countries without population-based cancer screening programmes. These results highlight the potential benefits of population-based screening programmes.

[Satisfaction and expectations of the women participants and not participants in the breast cancer screening programme in Barcelona after 10 years of operation]. / Satisfacción y expectativas de las mujeres participantes y no participantes en el programa de detección precoz de cáncer de mama de Barcelona tras 10 años de funcionamiento.

BACKGROUND: In order to improve the strategies of communication and to increase the participation in the screening program, one considers to describe the sociodemographic characteristics of participants and nonparticipants of the Breast Cancer Screening Program (BCSP) in Barcelona (2007), to analyse the degree of satisfaction and knowledge with the programme, and to know the expectations of nonparticipants with respect to the programme. METHODS: Cross-sectional study in a sample of 600 women between 50 and 69 years of age registered in Barcelona. A telephone interview was carried out using a questionnaire composed of 35 questions, grouped in: knowledge of the disease and the programme, satisfaction with the programme, expectations (characteristics which might increase participation) and sociodemographic characteristics. The association between knowledge and satisfaction with the sociodemographic characteristics was analysed by means of bivariate and multivariate analysis (robust poisson models). A descriptive analysis of the expectations of nonparticipants was carried out. RESULTS: Among the 244 nonparticipants interviewed, 160 (65,6%) had middle or superior studies, and 163 (66,8%) were of a privileged social class. Of 356 women that indicated to be participants in the PDPCM 340 (95,5 %) were satisfied with the PDPCM in global. CONCLUSIONS: The degree of satisfaction and knowledge with the programme is very high. The expectations indicated suggest that women receive contradictory messages with regard to periodicity (annual respect biannual) and age range (40-69 respect 50-69).