[Gender perspectives in mental health plans in Spain: a pending task?] / Perspectiva de género en los planes de salud mental en España: ¿una asignatura pendiente?

OBJECTIVE: To develop a gender sensitivity index and analyse the regional mental health plans in force in 2021 in terms of their gender sensitivity. METHOD: We reviewed the regional mental health plans in force in 2021 using an ad hoc questionnaire design based on a review of documents and reports on gender sensitivity in health policies. We construct an index based on both the symbolic and operative sensibility of plans. RESULTS: Of the seven plans reviewed, four scored less than 13 out of 26. The maximum score was 18 and the minimum 2. Symbolic gender sensitivity was higher than operational sensitivity. CONCLUSIONS: Mental health plans have a low or very low degree of gender sensitivity. Not considering gender as a determinant of mental health in the formulation of specific health plans may reduce the effectiveness of interventions aimed at reducing gender inequalities in mental health.

Gender Inequalities in Publications about COVID-19 in Spain: Authorship and Sex-Disaggregated Data.

Gender inequalities in biomedical literature have been widely reported in authorship as well as the scarcity of results that are stratified by sex in the studies. We conducted a bibliometric review of articles on COVID-19 published in the main Spanish medical journals between April 2020 and May 2021. The purpose of this study was to analyse differences in authorship order and composition by sex and their evolution over time, as well as the frequency of sex-disaggregated empirical results and its relationship with the author sex in articles on COVID-19 in the main Spanish biomedical journals. We identified 914 articles and 4921 authors, 57.5% men and 42.5% women. Women accounted for 36.7% of first authors and for 33.7% of last authors. Monthly variation in authorship over the course of the pandemic indicates that women were always less likely to publish as first authors. Only 1.0% of the articles broke down empirical results by sex. Disaggregation of results by sex was significantly more frequent when women were first authors and when women were the majority in the authorship. It is important to make gender inequalities visible in scientific dissemination and to promote gender-sensitive research, which can help to reduce gender bias in clinical studies as well as to design public policies for post-pandemic recovery that are more gender-equitable.

[Socioeconomic inequalities and COVID-19 in Spain. SESPAS Report 2022]. / Desigualdades socioeconómicas y COVID-19 en España. Informe SESPAS 2022.

The COVID-19 pandemic has shown its syndemic nature where the contagion by coronavirus joins the high prevalence of chronic diseases in a context of great social inequality and a clear gradient of those pathologies. The objectives of this article are: 1) to show a conceptual framework of the determinants of social inequality in the COVID-19; 2) to review the available literature on socioeconomic inequalities in various aspects related to COVID-19 in Spain; and 3) propose recommendations to monitor, intervene with policies and communication guides to reduce social inequalities in COVID-19, showing examples developed in Spain. The conceptual framework includes structural and intermediate determinants reflecting the different axes of inequality that characterize the syndemic nature of COVID-19. The literature review published up to July 2021 in Spain describes a socioeconomic gradient of COVID-19, not always consistent among studies, as well as an uneven impact of many measures to control the pandemic. Finally, the proposals for reducing social inequalities in COVID-19 include: 1) to guarantee information systems and research with an equity perspective; 2) to reduce inequalities in COVID-19 through its intermediate, and economic and political determinants; and 3) to design communication models and understanding frameworks that break with hegemonies that hide the relevance of social inequality in the pandemic. Given the syndemic nature of COVID-19 and accumulated knowledge, surveillance systems, interventions and communication must include a clear perspective of health equity.

[Gender inequality and mental health medicalization: Sociocultural determining factors from the analysis of expert perceptions]. / Desigualdad de género y medicalización de la salud mental: factores socioculturales determinantes desde el análisis de percepciones expertas.

To identify the sociocultural roots that explain the higher frequency of diagnoses of depression and/or anxiety and the prescription of psychotropic drugs in women, in order to propose a preliminary explanatory framework for the investigation of gender inequalities in mental health and its medicalization. Qualitative study with a descriptive-interpretive design, through in-depth interviews conducted in January and February 2021. Interviews were held in various cities of the Basque Country, Barcelona and Madrid. 12 experts in gender and mental health from the clinical (Primary Care and Mental Health), academic and associative fields. Intentional sampling, following the snowball technique, until covering the diversity of previously identified profiles and the saturation of the discourse. An analysis of thematic content was carried out starting from a critical-realistic epistemological perspective. The main dimensions to explain gender inequalities in diagnoses of depression or anxiety and prescription of psychoactive drugs were: 1) the material and symbolic subordination of women, 2) the role of «psi¼ sciences in the pathologization of the feminine identity, 3) the epistemological and androcentric biases of biomedicine, and 4) the active agency of women in medicalization processes. The reduction of gender inequalities in the diagnoses and prescription of psychotropic drugs will require joint intervention at the clinical, community and structural levels that, from a feminist perspective, manage to reverse the socioeconomic, symbolic and epistemic vulnerability of women.

Occupational health, frontline workers and COVID-19 lockdown: new gender-related inequalities?

INTRODUCTION: The abrupt onset of COVID-19, with its rapid spread, has had brutal consequences in all areas of society, including the workplace. In this paper, we report the working conditions, health, and tranquilisers and opioid analgesics use of workers during the first months of the ensuing pandemic, according to whether they were frontline workers or not and also according to sex. METHODS: Our analysis is based on cross-sectional survey data (collected during April and May 2020) from the wage-earning population in Spain (n=15 070). We estimate prevalences, adjusted prevalence differences and adjusted prevalence ratios by sex and according to whether the worker is a frontline worker or not. RESULTS: Employment and working conditions, exposure to psychosocial risks, as well as health status and the consumption of tranquilisers and opioid analgesics all showed sex and sectoral (frontline vs non-frontline) inequalities, which placed essential women workers in a particularly vulnerable position. Moreover, the consumption of tranquilisers and opioid analgesics increased during the pandemic and health worsened significantly among frontline women workers. CONCLUSIONS: The exceptional situation caused by the COVID-19 pandemic provides an opportunity to revalue essential sectors and to dignify such employment and working conditions, especially among women. There is an urgent need to improve working conditions and reduce occupational risk, particularly among frontline workers. In addition, this study highlights the public health problem posed by tranquilisers and opioid analgesics consumption, especially among frontline women.

Which are the intermediate determinants of gender inequalities in mental health?: A scoping review.

BACKGROUND: Gender segmentation in the labour market and women's greater burden of domestic work and caregiving increase their risk of developing mental health problems, especially in vulnerable social groups. AIMS: The objectives of this study were to identify and describe the role of working and labour conditions, domestic work and caregiving and social support in gender inequalities in mental health, as well as to assess whether studies have taken an intersectional approach, describing its role in gender inequalities in mental health. METHODS: We carried out a systematic review of scientific articles published between 2010 and 2019 in PubMed, Scopus, WoS and PsycInfo, in Spanish and English, conducted in the European Economic Area in populations aged between 25 and 65 years. Studies were excluded if they were qualitative, focused on sexual identity or factors based on biological differences, or considered use of medical services, medicalisation or suicide as the outcome variable. RESULTS: A total of 30 articles were included, of which only four concerned studies in which intersectional analysis had been performed. The mental health of men was seen to be more influenced by employment conditions and that of women by working conditions, the double presence and civil status. Further, depending on the size of the household (women) and unemployment (men), people in lower social classes had poorer mental health outcomes. CONCLUSIONS: The results may be useful for designing policies focused on reducing gender inequalities in mental health. Additionally, they show the need for taking an intersectional perspective.

[COVID-19 and gender: certainties and uncertainties in monitoring the pandemic.] / COVID-19 y género: certezas e incertidumbres en la monitori-zación de la pandemia.

OBJECTIVE: Highlighting gender inequalities during the pandemic and its relationship with other axes of social inequality will be decisive for its adequate monitoring. The aim of this study was to assess the differences between men and women in the main measures of infection and mortality by COVID-19, considering its temporal evolution, raising awareness about the weaknesses and contradictions between sources of information. METHODS: Cross-sectional analysis based on the microdata on COVID cases notified by the National Epidemiological Surveillance Network (RENAVE), the Death Statistics of the National Statistical Institute (INE) and the estimates of excess mortality from the INE and the Daily Mortality Monitoring System (MoMo) microdata. Standardized rates, prevalences and and ratios by sex were calculated for each indicator. The percentage of excess mortality without COVID-19 diagnosis in each sex was calculated. Male/female ratios for symptoms and risk factors of COVID-19 were also calculated. RESULTS: The rate of infection by COVID-19 was higher in women in the three waves of the pandemic, reaching 65% of infections during April and May 2020. Complications were between 1.5 and 2.5 times higher in men, especially in ICU admissions, which were 2.5 times more frequent than in women. Although mortality rates and excess mortality were also higher in men (around 1.8 times), the percentage of excess mortality without COVID-19 diagnosis was higher in women (44% in men vs. 52% in women the first wave). With regard to the symptoms of COVID-19, fever, cough, and dyspnoea were more frequent in men (20%, 10% and 19% more, respectively) compared to sore throat, vomiting or diarrhea that were more prevalent in women (90%, 40% and 10% more, respectively). CONCLUSIONS: The analysis disaggregated by sex has made it possible to identify differences between men and women in the diagnosis, presentation and severity of the COVID-19 that can help a better clinical and epidemiological approach to the disease. However, official sources present important gaps when presenting information disaggregated by sex. It is therefore necessary to advance in the inclusion of a gender perspective in the statistics on COVID-19, starting with a necessary but not sufficient condition such as the disaggregation by sex of the data.

OBJETIVO: Visibilizar las desigualdades de género durante la pandemia y su relación con otros ejes de desigualdad social resultará decisivo para su adecuada monitorización. El objetivo de este estudio fue analizar las diferencias entre hombres y mujeres en las principales medidas de contagio, complicaciones y mortalidad por la COVID-19 teniendo en cuenta la evolución temporal de las mismas a lo largo de la pandemia en el estado español, visibilizando las aportaciones y carencias entre fuentes de información. METODOS: Análisis transversal en base a los casos COVID notificados por la Red Nacional de Vigilancia Epidemiológica (RENAVE); las estimaciones de mortalidad del Instituto Nacional de Estadística (INE) y las estimaciones de exceso de mortalidad del INE y los microdatos del Sistema de Monitorización de la Mortalidad diaria (MoMo). Se calcularon tasas, prevalencias y ratios por sexo de cada indicador. Se calculó el porcentaje de exceso de mortalidad sin diagnóstico COVID-19 en cada sexo. Se calcularon, así mismo, las ratios hombres/mujeres para los síntomas y factores de riesgo de la COVID-19 recogidos. RESULTADOS: La tasa de infección por la COVID-19 fue superior en mujeres en las tres olas de la pandemia, llegando a constituir un 65% de las infecciones durante abril y mayo de 2020. Las complicaciones por coronavirus fueron entre 1,5 y 2,5 veces mayores en hombres de manera constante especialmente en las admisiones en UCI que llegaron a ser 2,5 veces más frecuentes que en mujeres. Si bien las tasas de mortalidad y el exceso de mortalidad fueron también superiores en hombres (en torno a 1,8 veces), el porcentaje de exceso de mortalidad sin diagnóstico COVID-19 fue superior en mujeres (44% en hombres frente a 52% en mujeres en la primera ola). Con respecto a los síntomas de la COVID-19, la fiebre, la tos y la disnea fueron más frecuentes en hombres (un 20%, 10% y 19% más, respectivamente) frente al dolor de garganta, vómitos o diarrea que se presentó más en mujeres (90%, 40% y 10% más, respectivamente). CONCLUSIONES: El análisis desagregado por sexo ha permitido identificar diferencias entre hombres y mujeres en el diagnóstico, presentación y gravedad de la COVID-19 que ayudarán a un mejor abordaje clínico y epidemiológico de la enfermedad. Sin embargo, las fuentes oficiales presentan importantes lagunas a la hora de presentar la información desagregada por sexo. Es por ello necesario avanzar en la inclusión de la perspectiva de género en la estadística sobre el COVID-19, empezando por una condición necesaria, pero no suficiente, como la desagregación por sexo de los datos.

Gender inequalities in depression/anxiety and the consumption of psychotropic drugs: Are we medicalising women's mental health?

Aims: Clinical studies show that women are more likely to be diagnosed with depression and anxiety, and to consume prescribed psychotropic drugs. Applying an intersectional perspective that considers age, education and social class, the present study assesses gender inequalities in the diagnosis of depression/anxiety and in psychotropic consumption. Methods: We analysed data from the 2018 Basque Country Health Survey (Spain; n=8014). Prevalence rates of poor mental health, diagnosis of depression/anxiety and psychotropic consumption were calculated for each sex by age and socio-economic status. Poisson regression models were calculated to estimate PRs of these variables in women, adjusted for age, mental health status and health-care visits, and for diagnosis of depression/anxiety in the case of psychotropic drug consumption. Results: Women were 2.48 times more likely than men to be diagnosed with depression or anxiety, and this difference remained significant after adjustments (prevalence ratio (PR)=1.86; 95% confidence interval (CI) 1.40-2.47). Women also took significantly more prescribed psychotropic drugs, even controlling for their poorer mental health, their higher prevalence of diagnosis and their more frequent health-care visits (PR=1.52; 95% CI 1.28-1.82). No gender inequalities were observed in those younger than 45 or with the highest level of education. Conclusions: Gender inequalities in the diagnosis and prescription of psychotropic drugs exist, and these cannot be explained by differences in mental-health status or health-care visit frequency. It seems, then, that medicalisation of mental health is occurring among women. Further evidence about the mechanisms that underlie the results is crucial to design truly gender-sensitive health policies that reduce medicalisation of women's mental health.

Diagnosis and Treatment of Depression in Spain: Are There Gender Inequalities?

It is well known that women are more likely than men to be diagnosed with depression and to consume antidepressants. The factors related to the medicalisation of depression and their social distribution remain unclear. The aim of this study was to analyse gender inequalities in the medicalisation of depression from an intersectional perspective. This was a cross-sectional study based on data from the European Health Survey relating to Spain. Gender inequalities were calculated using prevalence ratios of women compared to men with a diagnosis of depression and antidepressant use, adjusted for age, depressive symptoms, primary care visits and diagnosis of depression in the case of antidepressant use. After adjustments, the diagnosis of depression and the use of antidepressants were more prevalent in women, especially of lower socioeconomic levels. Gender inequalities in the diagnosis of depression also increased with decreasing level of education. Regarding the use of antidepressants, gender inequalities were not significant in university graduates and people of higher social. The gender inequalities found in the diagnosis and treatment of depression cannot be completely attributed to a higher level of depressive symptoms in women or their greater frequency of visits to primary care. Inequalities are greater in more vulnerable social groups.

[Gender as a determinant of mental health and its medicalization. SESPAS Report 2020]. / El género como determinante de la salud mental y su medicalización. Informe SESPAS 2020.

Women's worse mental health has been shown using both health survey and clinical-based data. Considering that the hypothesis about a greater biological vulnerability of women is inconsistent, unequal living conditions between men and women, together with hegemonic models of hegemonic masculinity and femininity emerge as explain factors of these gender inequalities in mental health. The article shows that gender inequalities in mental health, the intersection of different axes of inequality, and the existence of a possible process of medicalization of women's mental health, by which health professionals are labeling women more frequently as depressed and anxious given similar mental health status in men and women. Prescription of psychotropic drugs is also of greater intensity in women, given equal need. This reality, moreover, seems to be unequal depending on the age and socioeconomic level of the patients. In recent years, different experiences are being developed aimed at addressing the growing medicalization of mental health from a gender perspective. Given that the phenomenon of medicalization is complex, it is necessary to act and promote changes at political-structural, cultural and health care levels that ultimately reverse gender inequalities in societies and promote non gender-biased healthcare.

Inequalities in participation in colorectal cancer screening programmes: a systematic review.

BACKGROUND: Colorectal cancer (CRC) is a major public health problem due to its incidence and mortality. Screening programmes help decrease its impact on the population through early detection. However, the uneven distribution of social determinants of health can cause inequalities. The aim of this study is to identify the social inequalities in the participation in CRC screening programmes. METHODS: A systematic review of the literature was carried out, searching in both health and social databases for papers published since 2000 in English, Spanish, Portuguese and French. The search strategies combined terms regarding screening, CRC, participation and social inequalities. Included papers were quantitative or qualitative primary studies analyzing gender and socioeconomic inequalities in the participation in CRC screening programmes implemented by public and private health-care providers and addressing 45- to 75-year-old population. RESULTS: A total of 96 studies, described in 102 articles, were included. Most were quantitative observational studies and analyzed population-based screening programmes. They were carried out mainly in the UK (n=29) and the USA (n=18). Participation in screening programmes varied from 1.1% to 82.8% using several methods. A total of 87 studies assessed participation by sex and one focussed on men, but only two provided an analysis from a gender perspective. Although men are at a higher risk of developing CRC, they generally were less likely to participate in screening programmes. Screening attendance was higher among the least deprived areas. CONCLUSIONS: Gender and socioeconomic inequalities in CRC screening participation should be addressed through the design of tailored interventions with a multidimensional focus.

[Social inequalities in health in the older population: an insight into the debate on delayed retirement age in Spain from a public health perspective]. / Desigualdades sociales en salud en población mayor: una aportación desde la salud pública al debate sobre el retraso de la edad de jubilación en España.

OBJECTIVE: To analyse the inequalities in life expectancy in the Spanish population over the age of 65 according to educational level. METHOD: Cross sectional study on the Spanish population aged 65 years and over. Life expectancy and healthy life expectancy were calculated combining mortality, health and population data. RESULTS: People aged 65 and over with a lower educational level had shorter lives, with fewer years of good health and more years of poor health. Women lived longer, but with proportionally more years of poor health. DISCUSSION: Social inequalities in health must be considered in the current debate on delaying the age of retirement.

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

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

[Contextual indicators to assess social determinants of health and the Spanish economic recession]. / Indicadores contextuales para evaluar los determinantes sociales de la salud y la crisis económica española.

OBJECTIVE: To provide indicators to assess the impact on health, its social determinants and health inequalities from a social context and the recent economic recession in Spain and its autonomous regions. METHODS: Based on the Spanish conceptual framework for determinants of social inequalities in health, we identified indicators sequentially from key documents, Web of Science, and organisations with official statistics. The information collected resulted in a large directory of indicators which was reviewed by an expert panel. We then selected a set of these indicators according to geographical (availability of data according to autonomous regions) and temporal (from at least 2006 to 2012) criteria. RESULTS: We identified 203 contextual indicators related to social determinants of health and selected 96 (47%) based on the above criteria; 16% of the identified indicators did not satisfy the geographical criteria and 35% did not satisfy the temporal criteria. At least 80% of the indicators related to dependence and healthcare services were excluded. The final selection of indicators covered all areas for social determinants of health, and 62% of these were not available on the Internet. Around 40% of the indicators were extracted from sources related to the Spanish Statistics Institute. CONCLUSIONS: We have provided an extensive directory of contextual indicators on social determinants of health and a database to facilitate assessment of the impact of the economic recession on health and health inequalities in Spain and its autonomous regions.

The Impact of Fiscal Policies on the Socioeconomic Determinants of Health.

There has been considerable recent debate around the alleged impact of discretionary fiscal policies - especially austerity policies - on health and health inequalities. Assuming that most of the impact will have to run via the effect of fiscal policies on socioeconomic determinants of health (SDH), it is of interest to gain a further understanding of the relationship between fiscal policies and SDH. Therefore, the aim of this article is to review the recent evidence on the impact of discretionary fiscal policies on key SDH, i.e. income, poverty, education, and employment, in high income OECD countries. We find that there are no simple answers as to how fiscal policy affects those determinants of health. The effects of contractionary and expansionary fiscal policies on the analyzed SDH vary considerably across countries and will largely depend on the pre-crisis situation. Contractionary fiscal policies seem to have increased poverty, while their impact on income inequality will be influenced by the composition of the implemented measures. More empirical research trying to directly link fiscal policies to health outcomes, while taking into account of some of the mechanisms encountered here, would be worthwhile.

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

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

[Study protocol on the effect of the economic crisis on mortality and reproductive health and health inequalities in Spain]. / Protocolo del estudio sobre el efecto de la crisis económica en la mortalidad, la salud reproductiva y las desigualdades en salud en España.

The aim is to present the protocol of the two sub-studies on the effect of the economic crisis on mortality and reproductive health and health inequalities in Spain. Substudy 1: describe the evolution of mortality and reproductive health between 1990 and 2013 through a longitudinal ecological study in the Autonomous Communities. This study will identify changes caused by the economic crisis in trends or reproductive health and mortality indicators using panel data (17 Autonomous Communities per study year) and adjusting Poisson models with random effects variance. Substudy 2: analyse inequalities by socioeconomic deprivation in mortality and reproductive health in several areas of Spain. An ecological study analysing trends in the pre-crisis (1999-2003 and 2004-2008) and crisis (2009-2013) periods will be performed. Random effects models Besag York and Mollié will be adjusted to estimate mortality indicators softened in reproductive health and census tracts.