Health literacy: association with socioeconomic determinants and the use of health services in Spain.

Background: Health literacy (HL) is the set of social and cognitive skills that determine person's level of motivation and the ability to access, understand and use information to promote and maintain good health. The aim of this study is to assess the level of health literacy, and to analyze its relationship with sociodemographic variables, state of health, and use of health services in the population aged 15 and over in the Valencian Community (Spain). Methods: Cross-sectional study based on a sample of 5,485 subjects participating in the Health Survey of the Valencia Community. The HLS-EU-Q16 was used. As outcome variables we considered HL categorized into 2 levels: Inadequate or Problematic HL and Sufficient HL and the standardized literacy index. Prevalence rates and HL means were estimated and OR were calculated to analyze the association between variables. Results: A total of 12.8% of the subjects surveyed presented an inadequate or problematic degree of HL. This percentage was higher in people >85 years (63.1%), with a low level of education (46.5%), in retired people (27.4%) or in other work situations (25.0%), in foreigners (18.1%), in low-income people (16.2%), with a perception of poor health status (26.9%), chronic disease (18.5%) or with activity limitations (56.4% severe, 19.7% not severe). Significant differences were found. With the exception of chronic disease, all the variables analyzed were associated with HL. Low HL was associated with a lower consumption of medicines, a greater use of health services, general medical consultations, poorer knowledge of new health technologies and fewer preventive health visits. Conclusion: The percentage of inadequate or problematic HL was globally not very high, but certain population subgroups notably presented a high degree of inadequate or problematic HL. Raising the HL level of such groups should be regarded as a priority. HL was shown to be associated with the service use and new health technology use. Enhancing the population's HL should lead to the following: a greater probability of adopting preventive practices; improving the use of the health system; and boosting people's abilities to manage and to improve their own health.

Determinants of Disability in Minority Populations in Spain: A Nationwide Study.

Some population groups could be especially vulnerable to the effects of population ageing. The Global Activity Limitation Indicator (GALI) has been proposed as a measure of disability, but it has not been used in minority groups. The aim of this study is to estimate the prevalence of disability using the GALI and to analyse its determinants in immigrant and Roma populations. Data from the Spanish National Health Survey 2017 and the National Health Survey of the Roma Population 2014 were used, including adults aged 50 and above. Prevalence of disability was estimated, and odds ratios were calculated using logistic regression models to assess the association between disability and demographic, socioeconomic, and health variables. The prevalence of disability was estimated at 39.4%, 30.6%, and 58.7% in the native, immigrant, and Roma populations, respectively. Gender was a common determinant for the native and Roma populations. On the other hand, among immigrants, the risk of disability increased over the time residing in Spain. There were significant interactions with age and gender in the native population. Disability has different determinants in the three population groups. Public health measures to protect the Roma population and immigrants' health should be considered.

Socioeconomic inequalities in the place of death in urban small areas of three Mediterranean cities.

BACKGROUND: Dying at home is the most frequent preference of patients with advanced chronic conditions, their caregivers, and the general population. However, most deaths continue to occur in hospitals. The objective of this study was to analyse the socioeconomic inequalities in the place of death in urban areas of Mediterranean cities during the period 2010-2015, and to assess if such inequalities are related to palliative or non-palliative conditions. METHODS: This is a cross-sectional study of the population aged 15 years or over. The response variable was the place of death (home, hospital, residential care). The explanatory variables were: sex, age, marital status, country of birth, basic cause of death coded according to the International Classification of Diseases, 10th revision, and the deprivation level for each census tract based on a deprivation index calculated using 5 socioeconomic indicators. Multinomial logistic regression models were adjusted in order to analyse the association between the place of death and the explanatory variables. RESULTS: We analysed a total of 60,748 deaths, 58.5% occurred in hospitals, 32.4% at home, and 9.1% in residential care. Death in hospital was 80% more frequent than at home while death in a nursing home was more than 70% lower than at home. All the variables considered were significantly associated with the place of death, except country of birth, which was not significantly associated with death in residential care. In hospital, the deprivation level of the census tract presented a significant association (p < 0.05) so that the probability of death in hospital vs. home increased as the deprivation level increased. The deprivation level was also significantly associated with death in residential care, but there was no clear trend, showing a more complex association pattern. No significant interaction for deprivation level with cause of death (palliative, not palliative) was detected. CONCLUSIONS: The probability of dying in hospital, as compared to dying at home, increases as the socioeconomic deprivation of the urban area of residence rises, both for palliative and non-palliative causes. Further qualitative research is required to explore the needs and preferences of low-income families who have a terminally-ill family member and, in particular, their attitudes towards home-based and hospital-based death.

Changes in Socioeconomic Inequalities in Amenable Mortality after the Economic Crisis in Cities of the Spanish Mediterranean Coast.

Several studies have described a decreasing trend in amenable mortality, as well as the existence of socioeconomic inequalities that affect it. However, their evolution, particularly in small urban areas, has largely been overlooked. The aim of this study is to analyse the socioeconomic inequalities in amenable mortality in three cities of the Valencian Community, namely, Alicante, Castellon, and Valencia, as well as their evolution before and after the start of the economic crisis (2000-2007 and 2008-2015). The units of analysis have been the census tracts and a deprivation index has been calculated to classify them according to their level of socioeconomic deprivation. Deaths and population were also grouped by sex, age group, period, and five levels of deprivation. The specific rates by sex, age group, deprivation level, and period were calculated for the total number of deaths due to all causes and amenable mortality and Poisson regression models were adjusted in order to estimate the relative risk. This study confirms that the inequalities between areas of greater and lesser deprivation in both all-cause mortality and amenable mortality persisted along the two study periods in the three cities. It also shows that these inequalities appear with greater risk of death in the areas of greatest deprivation, although not uniformly. In general, the risks of death from all causes and amenable mortality have decreased significantly from one period to the other, although not in all the groups studied. The evolution of death risks from before the onset of the crisis to the period after presented, overall, a general pro-cyclical trend. However, there are population subgroups for which the trend was counter-cyclical. The use of the deprivation index has made it possible to identify specific geographical areas with vulnerable populations in all three cities and, at the same time, to identify the change in the level of deprivation (ascending or descending) of the geographical areas throughout the two periods. It is precisely these areas where more attention is needed in order to reduce inequalities.

Socioeconomic Inequalities in Mortality among Foreign-Born and Spanish-Born in Small Areas in Cities of the Mediterranean Coast in Spain, 2009-2015.

Many studies have analysed socioeconomic inequalities and its association with mortality in urban areas. However, few of them have differentiated between native and immigrant populations. This study is an ecological study of mortality by overall mortality and analyses the inequalities in mortality in these populations according to the level of deprivation in small areas of large cities in the Valencian Community, from 2009 to 2015. The census tract was classified into five deprivation levels using an index based on socioeconomic indicators from the 2011 census. Rates and relative risks of death were calculated by sex, age, level of deprivation and country of birth. Poisson regression models have been used. In general, there was a higher risk of death in natives at the levels of greatest deprivation, which did not happen in immigrants. During the 2009-2015 period, there were socioeconomic inequalities in mortality, particularly in natives, who presented a higher risk of death than immigrants. Future interventions and social policies should be implemented in order to reduce inequalities in mortality amongst socioeconomic levels and to maintain the advantage that the immigrant population enjoys.

Heterogeneity/granularity in ethnicity classifications project: the need for refining assessment of health status.

BACKGROUND: Identifying ethnic inequalities in health requires data with sufficiently 'granular' (fine detailed) classifications of ethnicity to capture sub-group variation in healthcare use, risk factors and health behaviors. The Robert Wood Johnson Foundation (RWJF), in the USA, commissioned us to explore granular approaches to ethnicity data collection outside of the USA, commencing with the European Union. METHODS: We examined official data sources (population censuses/registers) within the EU-28 to determine the granularity of their approach to ethnicity. When ethnic information was not available, related variables were sought (e.g. country of birth). RESULTS: Within the EU-28, we found 55% of countries collected data on ethnicity. However, only 26% of these countries (England, Wales, Northern Ireland, Scotland, Republic of Ireland, Hungary, Poland and Slovakia) had a granular approach, with half of these being within the UK. Estonia, Lithuania, Croatia, Bulgaria, Republic of Cyprus and Slovenia collected one to six categories. A 'write-in' option only was found in Latvia, Romania and the Czech Republic. Forty-five percent of countries did not collect ethnicity data but collected other related variables. CONCLUSIONS: (i) Although there is reasonable attention to the diversity of ethnic groups in data collection, a granular approach does not predominate within EU-28 classifications. (ii) Where ethnicity is collected, it is conceptualized in different ways and diverse terminology is used. (iii) A write-in option provides the most granular approach. (iv) Almost half of the countries did not collect data on ethnicity, but did collect related variables that could be used as a proxy.

[Mortality due to medical and surgical complications, economic crisis and health spending in Spain, 2002-2013]. / Mortalidad por complicaciones médicas y quirúrgicas, impacto de la crisis y gasto sanitario en España, 2002-2013.

OBJECTIVE: To describe the evolution of mortality risks for complications due to medical care or surgery between the periods prior to (2002-2007) and after (2008-2013) the beginning of the economic crisis for Spain and by autonomous region, and to analyse the relationship between the changes in the risks of death and the socioeconomic impact of the crisis and the variation in health spending. METHOD: Ecological study based on age-standardized mortality rates, synthetic index of vulnerability as a socioeconomic indicator and variation in health expenditure as an indicator of health expenditure. The relative risk of death between periods was estimated with Poisson regression models. RESULTS: The number of deaths increased for Spain in the period studied. Although the relationship between the increase in public investment in health and the decrease in mortality due to this cause has not been clearly demonstrated, it was possible to determine that the autonomous regions with the lowest increase in health expenditure had rates higher than the rest throughout the period, and that the most vulnerable to the crisis and with the lowest increase in spending presented the greatest increase in the risk of death between the periods. CONCLUSIONS: Given the increase in these deaths, due to avoidable failures of the system, it is necessary to continue investigating this cause of mortality.

Contribution of the Economic Crisis to the Risk Increase of Poor Mental Health in a Region of Spain.

Previous research suggests that the economic crisis can affect mental health. The purpose of this study was to analyse the association of risk of poor mental health with various socioeconomic, demographic, health, quality of life, and social support variables; and to evaluate the contribution of socioeconomic variables most affected by the beginning of the economic crisis (employment situation and income) on the changes in the prevalence of the risk of poor mental health between 2005 and 2010. A study of prevalence evolution in adult population residents of the Valencian Community in the Spanish Mediterranean was conducted. We studied 5781 subjects in 2005 and 3479 in 2010. Logistic regression models have been adjusted to analyse the association between variables. A standardisation procedure was carried out to evaluate which part of the changes in overall prevalence could be attributed to variations in the population structure by age, sex, employment status, and income between the years under study. The prevalence of GHQ+ increased from 2005 to 2010, in both men and women. Several variables were closely associated with the risk of poor mental health (sex, age, country of birth, number of nonmental chronic diseases, social support, disability, cohabitation in couple, employment status, and income). The changes produced as a result of the onset of the economic crisis in income and unemployment (increase in low income and in unemployment rates) contributed to the increase of poor mental health risk. This could confirm the sensitivity of mental health to the economic deterioration caused by the crisis.

Economic Crisis and Amenable Mortality in Spain.

Background: Both overall mortality and avoidable mortality have decreased in recent years in most European countries. It has become clear that less privileged socioeconomic groups have an increased risk of death. In 2008, most countries went into a severe economic recession, whose effects on the health of the population are still ongoing. While on the one hand, some evidence associates the economic crisis with positive health outcomes (pro-cyclical effect), on the other hand, some other evidence suggests that the economic crisis may pose serious public health problems (counter-cyclical effect), which has given rise to controversy. Objectives: To describe the evolution of overall mortality and amenable mortality in Spain between 2002⁻2007 (before the economic crisis) and 2008⁻2013 (during the economic crisis), nationally and by province, as well as to analyse trends in the risks of death and their association with indicators of the impact of the crisis. Methods: Ecological study of overall mortality and amenable mortality describing the evolution of the risks of death between 2002⁻2007 and 2008⁻2013. Age Standardised Rates were calculated, as well as their percentage change between periods. The association between percentage changes and provincial indicators of the impact of the crisis was analysed. Amenable mortality was studied both overall and categorised into five groups. Results: Amenable mortality represented 8.25% of overall mortality in 2002⁻2007, and 6.93% in 2008⁻2013. Age Standardised Rates for overall mortality and global amenable mortality generally declined, with the sharpest decline in amenable mortality. Decreases in overall mortality and amenable mortality were directly related to vulnerability indicators. The most significant decreases were registered in ischaemic heart disease, cerebrovascular disease, and other amenable causes. The relationship with vulnerability indices varied from direct (cancer) to inverse (hypertensive disease). Conclusions: Amenable mortality shows a more significant decrease than overall mortality between both study periods, albeit unevenly between provinces causes of death. Higher vulnerability indicators entail greater declines, although this trend varied for different causes. Mortality trends and their relationship with socioeconomic indicators in a situation of crisis must be conducted cautiously, taking into consideration a possible pro-cyclical effect.

Is recession bad for your mental health? The answer could be complex: evidence from the 2008 crisis in Spain.

BACKGROUND: We explored the impact of 2008 recession on the prevalence of mental health problems in Spain. METHODS: Repeated cross-sectional survey design. Datasets from 2006 and 2011 were used, and temporal change was examined. The study was conducted on the economically active population (16-64 years old). The two surveys included 29,478 and 21,007 people, obtaining a 96 and 89.6% response rate, respectively. Multiple logistic regression models were adjusted to identify poor mental health risk factors. A standardisation analysis was performed to estimate the prevalence of people at risk of poor mental health (GHQ+). RESULTS: The prevalence of GHQ+ following the crisis increased in men and decreased in women. Two logistic regression analyses identified GHQ+ risk factors. From 2006 to 2011, unemployment rose and income fell for both men and women, and there was a decline in the prevalence of somatic illness and limitations, factors associated with a higher prevalence of GHQ+. After controlling for age, the change in employment and income among men prompted an increase in the prevalence of GHQ+, while the change in somatic illness and limitations tended to mitigate this effect. After the recession, unemployed men showed a better level of somatic health. The same effects were not detected in women. CONCLUSIONS: The economic recession exerted a complex effect on mental health problems in men. The reduction of prevalence in women was not associated with changes in socioeconomic factors related to the economic crisis nor with changes in somatic health.

Self-rated health and hospital services use in the Spanish National Health System: a longitudinal study.

BACKGROUND: Self-rated health is a subjective measure that has been related to indicators such as mortality, morbidity, functional capacity, and the use of health services. In Spain, there are few longitudinal studies associating self-rated health with hospital services use. The purpose of this study is to analyze the association between self-rated health and socioeconomic, demographic, and health variables, and the use of hospital services among the general population in the Region of Valencia, Spain. METHODS: Longitudinal study of 5,275 adults who were included in the 2005 Region of Valencia Health Survey and linked to the Minimum Hospital Data Set between 2006 and 2009. Logistic regression models were used to calculate the odds ratios between use of hospital services and self-rated health, sex, age, educational level, employment status, income, country of birth, chronic conditions, disability and previous use of hospital services. RESULTS: By the end of a 4-year follow-up period, 1,184 participants (22.4%) had used hospital services. Use of hospital services was associated with poor self-rated health among both men and women. In men, it was also associated with unemployment, low income, and the presence of a chronic disease. In women, it was associated with low educational level, the presence of a disability, previous hospital services use, and the presence of chronic disease. Interactions were detected between self-rated health and chronic disease in men and between self-rated health and educational level in women. CONCLUSIONS: Self-rated health acts as a predictor of hospital services use. Various health and socioeconomic variables provide additional predictive capacity. Interactions were detected between self-rated health and other variables that may reflect different complex predictive models, by gender.

Trends in socioeconomic inequalities in preventable mortality in urban areas of 33 Spanish cities, 1996-2007 (MEDEA project).

BACKGROUND: Preventable mortality is a good indicator of possible problems to be investigated in the primary prevention chain, making it also a useful tool with which to evaluate health policies particularly public health policies. This study describes inequalities in preventable avoidable mortality in relation to socioeconomic status in small urban areas of thirty three Spanish cities, and analyses their evolution over the course of the periods 1996-2001 and 2002-2007. METHODS: We analysed census tracts and all deaths occurring in the population residing in these cities from 1996 to 2007 were taken into account. The causes included in the study were lung cancer, cirrhosis, AIDS/HIV, motor vehicle traffic accidents injuries, suicide and homicide. The census tracts were classified into three groups, according their socioeconomic level. To analyse inequalities in mortality risks between the highest and lowest socioeconomic levels and over different periods, for each city and separating by sex, Poisson regression were used. RESULTS: Preventable avoidable mortality made a significant contribution to general mortality (around 7.5%, higher among men), having decreased over time in men (12.7 in 1996-2001 and 10.9 in 2002-2007), though not so clearly among women (3.3% in 1996-2001 and 2.9% in 2002-2007). It has been observed in men that the risks of death are higher in areas of greater deprivation, and that these excesses have not modified over time. The result in women is different and differences in mortality risks by socioeconomic level could not be established in many cities. CONCLUSIONS: Preventable mortality decreased between the 1996-2001 and 2002-2007 periods, more markedly in men than in women. There were socioeconomic inequalities in mortality in most cities analysed, associating a higher risk of death with higher levels of deprivation. Inequalities have remained over the two periods analysed. This study makes it possible to identify those areas where excess preventable mortality was associated with more deprived zones. It is in these deprived zones where actions to reduce and monitor health inequalities should be put into place. Primary healthcare may play an important role in this process.

Trends in socioeconomic inequalities in amenable mortality in urban areas of Spanish cities, 1996-2007.

BACKGROUND: While research continues into indicators such as preventable and amenable mortality in order to evaluate quality, access, and equity in the healthcare, it is also necessary to continue identifying the areas of greatest risk owing to these causes of death in urban areas of large cities, where a large part of the population is concentrated, in order to carry out specific actions and reduce inequalities in mortality. This study describes inequalities in amenable mortality in relation to socioeconomic status in small urban areas, and analyses their evolution over the course of the periods 1996-99, 2000-2003 and 2004-2007 in three major cities in the Spanish Mediterranean coast (Alicante, Castellón, and Valencia). METHODS: All deaths attributed to amenable causes were analysed among non-institutionalised residents in the three cities studied over the course of the study periods. Census tracts for the cities were grouped into 3 socioeconomic status levels, from higher to lower levels of deprivation, using 5 indicators obtained from the 2001 Spanish Population Census. For each city, the relative risks of death were estimated between socioeconomic status levels using Poisson's Regression models, adjusted for age and study period, and distinguishing between genders. RESULTS: Amenable mortality contributes significantly to general mortality (around 10%, higher among men), having decreased over time in the three cities studied for men and women. In the three cities studied, with a high degree of consistency, it has been seen that the risks of mortality are greater in areas of higher deprivation, and that these excesses have not significantly modified over time. CONCLUSIONS: Although amenable mortality decreases over the time period studied, the socioeconomic inequalities observed are maintained in the three cities. Areas have been identified that display excesses in amenable mortality, potentially attributable to differences in the healthcare system, associated with areas of greater deprivation. Action must be taken in these areas of greater inequality in order to reduce the health inequalities detected. The causes behind socioeconomic inequalities in amenable mortality must be studied in depth.

[Malnutrition and inequalities in Francoist Spain: the impact of a milk supplement on the growth of Spanish schoolchildren (1954-1978)]. / Malnutrición y desigualdades en la España del franquismo: el impacto del complemento alimenticio lácteo en el crecimiento de los escolares españoles (1954-1978).

The Spanish nutritional and food transition was consolidated over the course of the twentieth century. In the pre-transition stage, a renewed interest emerged in the deficiencies presented by children''s diets, and food and nutritional education was considered the best course of action to correct them. The aim of this study was to analyse the changes over time and regional differences in the nutritional status of Spanish schoolchildren in rural areas in the 1950s and 1970s, using their height as an anthropometric parameter. The results revealed the existence of two categories at the beginning of the 1960s: a first group in which the height of children from the Cantabrian coast, the Levante, Catalonia and the Balea - ric Islands was similar to that of well-nourished children, and a second group from the regions of Andalusia, Extremadura and Galicia, who were not as tall. Between 1954 and 1977, the height of well-nourished children rose, particularly between 1954 and the first half of the 1960s. There was also a significant increase in the height of children attending national schools in rural areas, and the regional differences that had existed at the beginning of the 1960s disappeared. These advances were undoubtedly influenced both by the milk supplement and the food and nutritional education activities carried out within the framework of the Spanish Diet and Nutrition Education programme (EDALNU).

A lo largo del siglo XX, la población española fue consolidando su proceso de transición nutricional y alimentaria. En la etapa pre-transicional, se produjo un renovado interés por las deficiencias que mostraba la alimentación de los niños y se apostó por la educación alimentaria-nutricional para superarlas. El objetivo del trabajo es analizar el estado nutricional, a través de la talla como parámetro antropométrico, que mostraba la población escolar del ámbito rural español, entre las décadas de 1950 y 1970, su evolución y las diferencias que existían entre regiones. Los resultados ponen de manifiesto que al inicio de la década de 1960 se apreciaban dos patrones: un primer grupo donde la estatura de los niños de la costa cantábrica, zona de Levante, Cataluña y Baleares, mostraba niveles similares a los de niños bien alimentados; y un segundo grupo donde las tallas eran inferiores, en el que se encontraban las regiones de Andalucía, Extremadura y Galicia. Entre 1954 y 1977, las tallas de los niños bien alimentados mostraron un incremento que fue especialmente intenso entre 1954 y la primera mitad de la década de 1960. En el caso de los niños y niñas que acudían a las escuelas nacionales del ámbito rural, también se produjo un significativo incremento en la talla, además de corregirse las diferencias regionales que existían al principio de los años sesenta. En todos aquellos avances habrían influido tanto el complemento alimenticio, como las actividades de educación alimentación y nutrición que se llevaron a cabo en el marco del Programa EDALNU.

Diseño y análisis comparativo de un inventario de indicadores de mortalidad evitable adaptado a las condiciones sanitarias de Colombia / Design and comparative analysis of an inventory of avoidable mortality indicators specific to health conditions in Colombia

OBJETIVOS: Elaborar un inventario de indicadores de mortalidad evitable (INIME) que permita analizar las fallas en el control de los riesgos de mortalidad predominantes en Colombia y comparar los resultados de su aplicación con los obtenidos mediante dos enfoques ampliamente utilizados. MÉTODOS: Se revisaron los registros oficiales de mortalidad de Colombia de 1985 a 2001; las causas básicas de muerte se clasificaron según la CIE-9. Se seleccionaron los indicadores de mortalidad evitable (ME) mediante un algoritmo que combinó las listas de Holland y de Taucher, la definición de Rutstein y colaboradores y el principio de Uemura. Se compararon las proporciones de muertes evitables resultantes de aplicar el INIME y las dos listas de ME a una base de datos con los registros oficiales de defunciones de Colombia de 1993 a 1996. RESULTADOS: De las 680617 defunciones registradas en el período de estudio, se clasificaron como evitables 18,2 por ciento según la lista de Holland y 51,3 por ciento según la lista de Taucher. La ME según el INIME ascendió a 76,7 por ciento. Este patrón se mantuvo relativamente estable entre 1993 y 1996. Las diferencias observadas en la proporción de muertes evitables según el INIME y las dos listas de ME se relacionaron con el perfil epidemiológico local y el enfoque conceptual de cada lista. CONCLUSIONES: Las diferencias entre el INIME y las listas de ME de Holland y de Taucher muestran las consecuencias de usar una u otra clasificación en el contexto colombiano. El INIME puede constituir un recurso valioso para fundamentar y evaluar políticas sanitarias, pero debe ajustarse a la situación específica en que se aplique.

OBJECTIVES: To develop a list of indicators of avoidable mortality (LIAM) in order to analyze failed efforts to control the mortality risks prevalent in Colombia, and to compare its results to those of two widely-used approaches. METHODS: The official mortality records of Colombia for 1985-2001 were reviewed; the basic causes of death were classified according to the ICD-9. Indicators of avoidable mortality (AM) were selected using an algorithm that combined the lists of Holland and Taucher, the definition of Rutstein and colleagues, and the principle of Uemura. The proportions of avoidable deaths that resulted from applying the LIAM and the two AM lists were compared to a database containing Colombia's official death records from 1993-1996. RESULTS: Of the 680 617 deaths registered during the study period, 18.2 percent were classified as avoidable according to Holland's list, and 51.3 percent, by Taucher's list. According to the LIAM, avoidable mortality rose to 76.7 percent. This pattern remained relatively stable in 1993-1996. The differences observed between the proportions of avoidable deaths according to the LIAM and that of the two other lists were related to the local epidemiological profile and the conceptual approach of each list. CONCLUSIONS: The differences between the LIAM and the AM lists of Taucher and of Holland attest to the consequences of using one or another classification in the Colombian context. The LIAM can be a valuable resource for undergirding and evaluating health policies, but must be adjusted to the specific situation in which it is applied.

Preventable avoidable mortality: evolution of socioeconomic inequalities in urban areas in Spain, 1996-2003.

This study describes the inequalities in preventable avoidable mortality in relation to socioeconomic levels and analyses their evolution during the period 1996-2003 in the cities of Alicante, Castellon and Valencia. Four causes of preventable avoidable mortality were analysed according to sex: malignant tumour of the trachea, bronchus and lung, cirrhosis and other chronic diseases of the liver, motor vehicle accidents and AIDS, which had caused the death of non-institutionalised residents in the three cities during the period 1996-2003. The different census tracts were grouped into three socioeconomic levels. In general, socioeconomic inequalities in preventable avoidable mortality remain constant in time, except the ones caused by AIDS in Valencia, where they increase for men. Some census tracts in the three cities where the study was carried out were found to have significantly higher preventable mortality rates, and therefore require intervention.