Social class inequalities in the use of and access to health services in Catalonia, Spain: what is the influence of supplemental private health insurance?

OBJECTIVE: To analyse social class inequalities in the access to and utilization of health services in Catalonia (Spain), and the influence of having private health insurance supplementing the National Health System (NHS) coverage. DESIGN: 1994 Catalan Health Interview Survey, a cross-sectional survey conducted in 1994. SETTING: Catalonia (Spain). STUDY PARTICIPANTS: The participants were a representative sample of people aged over 14 years from the non-institutionalized population of Catalonia (n = 12,245). MAIN OUTCOME MEASURES: Health services utilization, perceived health, having only NHS or NHS plus a private health insurance, and social class. RESULTS: Although one-quarter of the population of Catalonia had a supplemental private health insurance, percentages were very different according to social class, ranging from almost 50% for classes I and II to 16% for classes IV and V in both sexes. No inequalities by social class were observed for the utilization of non-preventive health care services (consultation with a health professional in the last 2 weeks and hospitalization in the last year) among persons with poor self-perceived health status, i.e. those in most need. However, social inequalities still remain in the use of health services provided only partially by the NHS, and when characteristics of last consultation are taken into account. Subjects who paid for a private service waited an average of 18.8 minutes less than those attending the NHS. Within the NHS, social classes IV and V waited longer (35.5 minutes) than social classes I and II (28.4 minutes). CONCLUSION: The NHS in Catalonia, Spain, has reduced inequalities in the use of health services. Social inequalities remain in the use of those health services provided only partially by the NHS.

Quality of life in children and adolescents: a European public health perspective.

OBJECTIVES: The measurement of health-related quality of life (HRQOL) is increasingly important as a means of monitoring population health status over time, of detecting sub-groups within the general population with poor HRQOL, and of assessing the impact of public health interventions within a given population. At present, no standardised instrument exists which can be applied with equal relevance in pediatric populations in different European populations. The collaborative European KIDSCREEN project aims to develop a standardised screening instrument for children's quality of life which will be used in representative national and European health surveys. Participants of the project are centres from Austria, France, Germany, Netherlands, Spain, Switzerland, and United Kingdom. By including the instrument in health services research and health reporting, it also aims at identifying children at risk in terms of their subjective health, thereby allowing the possibility of early intervention. METHODS: Instrument development will be based on constructing a psychometrically sound HRQOL instrument taking into account the existing state of the art. Development will centre on literature searches, expert consultation (Delphi Methods) and focus groups with children and adolescents (8-17 years). According to international guidelines, items will be translated into the languages of the seven participating countries for a pilot test with 2,100 children and their parents in Europe. The final instrument will be used in representative mail and telephone surveys of HRQOL in 1,800 children and their parents per country (total n = 25,200) and normative data will be produced. The potential for implementing the measurement tool in health services and health reporting will also be evaluated in several different research and public health settings. The final analysis will involve national and cross cultural-analysis of the instrument. RESULTS: The international, collaborative nature of the KIDSCREEN project means it is likely to provide many challenges in terms of producing an instrument which is conceptually and linguistically appropriate for use in many different countries, but it will also provide the opportunity to develop, test and implement the first truly cross-national HRQOL instrument developed for use in children and adolescents. This will help to contribute to a better understanding of perceived health in children and adolescents and to identify populations at risk.

The quality of care and influence of double health care coverage in Catalonia (Spain).

AIMS: To analyse inequalities by social class in children's access to and utilisation of health services in Catalonia (Spain), private health insurance coverage, and certain aspects of the quality of care received. DESIGN: Cross sectional study using data from the 1994 Catalan Health Interview Survey. SETTING: Child population of Catalonia. PARTICIPANTS: A representative sample of non-institutionalised children younger than 15 years (n = 2433). MAIN OUTCOME MEASURES: Health services utilisation, perceived health, type of health insurance (only National Health System (NHS) or both NHS and private health insurance), and social class. RESULTS: No inequalities by social class were found for the utilisation of health care services provided by the NHS among children in most need. Double health care coverage does not influence the social pattern of visits. Nevertheless, social inequalities still remain in the use of those health services provided only partially by the NHS (dentist) and when characteristics of the last consultation are taken into account. That is, subjects who paid for a private service waited an average of 14.8 minutes less than those whose visit was paid for by the NHS only. CONCLUSION: Equitable access and use of medical care services in relation to need, regardless of the type of insurance and social class of their children and families, has been achieved in this region of Spain; differences by social class remain for those services incompletely covered by national health insurance and aspects of the quality of care provided.

[Determinants of quitting smoking in Catalonia, Spain]. / El abandono del hábito tabáquico en Cataluña.

OBJECTIVE: While trends in the prevalence of smoking and ex-smoking in Catalonia, Spain have been monitored, the characteristics of those smokers who quit have not been investigated. The aim of this investigation was to analyze the prevalence of cessation, or quit ratio, in Catalonia and to study its sociodemographic, life-style, and smoking correlates. SUBJECTS AND METHODS: We analyzed data collected in the Catalan Health Interview Survey conducted in 1994. This is a cross-sectional study based on a representative sample of the non-institutionalized population of Catalonia. We included for analysis a total of 5,424 subjects (3,649 males and 1,775 females) who declared to be current smokers (2,335 males and 1,331 females) or past smokers (1,314 males and 444 females). We computed the crude and age-standardized quit ratios (QR) or prevalence of cessation, as well as the odds ratio (OR) of quitting smoking, according to gender and the variables studied. RESULTS: The age-standardized QR was 31. 8% for males and 30.9% for females and increased with age. The QR was, both in males and females, greater among married subjects, with higher socioeconomic status, and with healthy life-styles (moderate and heavy leisure physical activity and moderate alcohol consumption). The OR of quitting smoking was higher in heavy smokers (OR = 2.9; 95% CI: 2.2-3.8; smokers of > 30 cigarettes/day vs. 1-10 cigarettes/day) in males, while it was < 1 for females of medium intensity, conforming a shaped curve rather than a linear trend (OR = 1.7; 95% CI: 1.0-2.9, in heavy smokers). CONCLUSIONS: This study confirms a positive association in males and females between quitting smoking and increasing age, a higher socioeconomic level, heavy smoking, and healthy life-styles. The identification of these groups should facilitate the planning of successful interventions. Further effort is also necessary to target groups with low cessation rates, such as individuals in disadvantaged social classes and light smokers.

Age at starting smoking and number of cigarettes smoked in Catalonia, Spain.

BACKGROUND: Few studies have investigated the association between age at starting smoking and the average number of cigarettes smoked per day in adulthood. To provide further evidence on this issue, we analyzed data from the Catalan Health Interview Survey (CHIS). METHODS: The CHIS was conducted in 1994 on a randomly selected sample (N = 15,000) of the population of Catalonia, Spain. A total of 4,897 current or exsmokers (3,276 males and 1,621 females) were included for analysis. Age-standardized proportions of subjects smoking <15, 15-24, and >/=25 cigarettes/day, age-standardized mean number of cigarettes smoked per day, and multivariate odds ratios (OR) of being a heavy smoker (>/=25 cigarettes/day) according to age at starting smoking (<15, 15-17, 18-19, >/=20 years) were computed. RESULTS: Men who started smoking before the age of 15 smoked on average 5.5 cigarettes more than those who started at age 19 or over. Women who started smoking early in life smoked, on average, 6.8 cigarettes/day more than women who started later. The proportion of smokers of <15 cigarettes/day was higher among subjects who started smoking later. Both for males and for females, the OR of being a heavy smoker significantly increased with decreasing age at starting smoking (OR = 2.4 for males and 4.5 for females who started at age <15 versus >/=20 years). The level of education did not modify the relationship in males, whereas the association with age at starting was only apparent for more educated women. CONCLUSIONS: This study confirms that age at starting smoking is inversely and strongly associated to the number of cigarettes smoked per day. Thus, actions aimed at the prevention or delay of smoking onset among adolescents would have an important beneficial effect.

The consequences of universalizing health services: children's use of health services in Catalonia.

The purpose of this study was to assess the role of needs and social factors in the use of health services among children under age 15 in Catalonia, Spain, where health care reform was explicitly designed to facilitate universal access to primary care according to health needs. Data from the Catalan Health Interview Survey of 1994, a multistage probability sample (2,433 children under 15 years old), were analyzed. Multiple regression examined the relationship between health needs and number of visits in the last year, controlling for the effect of sociodemographic characteristics. Two logistic regression equations were selected to predict heavy (more than seven visits per year) and light (less than two visits) utilization of services. The multiple regression model explained 14.3 percent of the variance in number of visits, with health status perception, disability, reported chronic condition, restriction of activities, and having had a recent accident by far the most important determinants. No familial socioeconomic characteristics, including social class, education, or family size, influenced the extent of use. In contrast to health systems not designed to achieve either universal access according to need or strong primary care, universal access to health services in Catalonia appears to enhance the use of services among children with health needs, regardless of socioeconomic characteristics.

[The incidence of occupational diseases: a study of medical evaluations for work incapacity in Barcelona (1987-1991)]. / Incidencia de enfermedades profesionales: estudio de las valoraciones médicas por incapacidad laboral en Barcelona (1987-1991).

BACKGROUND: The number of professional diseases (PD) declared in Spain is low. The existence of diseases of labor etiology treated as a common disease is recognized, thus disregarding important labor health risks. METHODS: The incidence of PD in the province of Barcelona from 1987-1991 was prospectively studied by the Units of Medical Evaluation of Incapacities (UMEI). The sociodemographic, medical and administrative data of the cases of PD were reported by a protocol of data collection. The cases of PD are described and the annual incidence in relation with the active working population calculated. RESULTS: The UMEI of Barcelona confirmed 554 cases of PD of which 331 were evaluated as permanent invalidity over the five years of the study. The most frequent diagnoses of PD were pneumoconiosis, skin diseases, diseases causing tendinous fatigue and hypoacusis or deafness. Eleven neoplasms were reported, 9 being caused by asbestos. During the five years the incidence of PD increased from 76 cases to 144 per 100,000 active workers. The procedure of information probably underreported the incidence of PD. CONCLUSIONS: A low incidence of professional disease was observed. The clinical-labor history is generally not carried out. The way in which the Units of Medical Evaluation of Incapacities report data concerning incidence may contribute to greater detection of professional diseases on registration being integrated into a system of epidemiologic surveillance in which all the health care, labor and administrative centers were effectively coordinated.