Evaluation of the Biases in the Studies that Assess the Effects of the Great Recession on Health. A Systematic Review.

BACKGROUND: Our main objective was to evaluate the fundamental biases detected in studies assessing the effects the Great Recession had on health for the case of Spain. As secondary objectives we presented methods to control these biases and to discuss the results of the studies in question if they had controlled for them. METHODS: We carried out a systematic review of the literature published up to June 2018. We evaluated the biases that could have happened in all the eligible studies. RESULTS: From the review, we finally selected 53 studies. Of the studies we reviewed, 60.38% or 32 out of 53, were evaluated as having a high risk of bias. The main biases our review revealed were problems with evaluation, time bias, lack of control of unobserved confounding, and non-exogeneity when defining the onset of the Great Recession. CONCLUSIONS: The results from the studies that controlled the biases were quite consistent. Summing up, the studies reviewed found that the Great Recession increased the risk of declaring poor self-rated health and the deterioration of mental health. Both the mortality rate and the suicide rate may well have increased after the Great Recession, probably after a three- to four-year delay.

Did psychotropic drug consumption increase during the 2008 financial crisis? A cross-sectional population-based study in Spain.

OBJECTIVES AND SETTING: Although psychotropic drugs are used to treat mental health disorders, little evidence analyses the effects the 2008 economic downturn had on psychotropic drug consumption in the case of Spain. We analyse these effects, considering both gender and employment situation. PARTICIPANTS: We used the microdata from the face-to-face cross-sectional population-based Spanish National Health Survey for two periods: 2006-2007 (n=28 954) and 2011-2012 (n=20 509). Our samples included adults (>15 years old). METHODS: The response variables are consumption (or not) of antidepressants or sedatives and the explanatory variables are the year of the survey, gender and employment status. Covariates are mental health problems, mental health index General Health Questionnaire (GHQ-12) and self-reported health outcome variables such as self-rated health, chronic diseases, smoking behaviour, sleeping hours, body mass index, physical activity in the workplace, medical visits during the past year, age, region of residence (autonomous communities), educational level, marital status and social class of the reference person. Finally, we include interactions between time period, gender and employment status. We specify random effects logistic regressions and use Bayesian methods for the inference. RESULTS: The economic crisis did not significantly change the probability of taking antidepressant drugs (OR=0.56, 95% CI 0.18 to 2.56) nor sedatives (OR=1.21, 95% CI 0.26 to 5.49). In general, the probability of consuming antidepressants among men and women decreases, but there are differences depending on employment status. The probability of consuming sedatives also depends on the employment status. CONCLUSIONS: While the year of the financial crisis is not associated with the consumption of antidepressants nor sedatives, it has widened the gap in consumption differences between men and women. Although antidepressant use dropped, the difference in consumption levels between men and women grew significantly among the retired, and in the case of sedatives, risk of women taking sedatives increased in all groups except students.

Influence maternal background has on children's mental health.

BACKGROUND: In this paper, we aim to discern how a mother's health and her socioeconomic determinants may influence her children's mental health. In addition to this, we also evaluate the influence of other household characteristics and whether or not the economic downturn has heightened the effect a parent's social gradient has on their children's mental health. METHODS: We use samples comprised of 4-14-year-old minors from the 2006 Spanish National Health Survey (SNHS), undertaken prior to the crisis, and the 2011 SNHS, carried out during the crisis. The participating children's mental health is assessed using the Strengths and Difficulties Questionnaire (SDQ). Mixed models are used to evaluate the influence a mother's health and her socioeconomic status may have on her children's mental health. We also add interactions to observe the effect specific socioeconomic determinants may have had during the economic downturn. RESULTS: The risk of a child suffering from mental health disorders increases when their mother has mental health problems. Socioeconomic determinants also play a role, as a low socioeconomic status (SES) increases the risk of a child exhibiting behavioural problems, being hyperactive or antisocial, whereas when a mother has attained a high level of education, this significantly reduces the probability of a child having mental health problems. 'Homemaker' is the activity status most positively related to children's mental health. The findings show that the Spanish economic downturn has not significantly changed children's mental health problems and the negative effects of low maternal SES are no greater than they were before the crisis. The main difference in 2011, with respect to 2006, is that the risk of children suffering from mental health problems is higher when their parents are (long or short-term) unemployed. CONCLUSIONS: In conclusion, both a mother's health and her socioeconomic status, as well as other household characteristics, are found to be related to her children's mental well-being. Although the crisis has not significantly changed mental health disorders in children or the social gradient of parents in general, at-risk children are the most negatively affected in the Spanish economic downturn.

[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.

Inequalities in suicide mortality rates and the economic recession in the municipalities of Catalonia, Spain.

INTRODUCTION: While previous research already exists on the impact of the current economic crisis and whether it leads to an increase in mortality by suicide, our objective in this paper is to determine if the increase in the suicide rate in Catalonia, Spain from 2010 onwards has been statistically significant and whether it is associated with rising unemployment. METHODS: We used hierarchical mixed models, separately considering the crude death rate of suicides for municipalities with more than and less than 10,000 inhabitants as dependent variables both unstratified and stratified according to gender and/or age group. RESULTS: In municipalities with 10,000 or more inhabitants there was an increase in the relative risk of suicide from 2009 onwards. This increase was only statistically significant for working-aged women (16-64 years). In municipalities with less than 10,000 inhabitants the relative risk showed a decreasing trend even after 2009. In no case did we find the unemployment rate to be associated (statistically significant) with the suicide rate. CONCLUSIONS: The increase in the suicide rate from 2010 in Catalonia was not statistically significant as a whole, with the exception of working-aged women (16-64 years) living in municipalities with 10,000 or more inhabitants. We have not found this increase to be associated with rising unemployment in any of the cases. Future research into the effects of economic recessions on suicide mortality should take into account inequalities by age, sex and size of municipalities.

Social differences in avoidable mortality between small areas of 15 European cities: an ecological study.

BACKGROUND: Health and inequalities in health among inhabitants of European cities are of major importance for European public health and there is great interest in how different health care systems in Europe perform in the reduction of health inequalities. However, evidence on the spatial distribution of cause-specific mortality across neighbourhoods of European cities is scarce. This study presents maps of avoidable mortality in European cities and analyses differences in avoidable mortality between neighbourhoods with different levels of deprivation. METHODS: We determined the level of mortality from 14 avoidable causes of death for each neighbourhood of 15 large cities in different European regions. To address the problems associated with Standardised Mortality Ratios for small areas we smooth them using the Bayesian model proposed by Besag, York and Mollié. Ecological regression analysis was used to assess the association between social deprivation and mortality. RESULTS: Mortality from avoidable causes of death is higher in deprived neighbourhoods and mortality rate ratios between areas with different levels of deprivation differ between gender and cities. In most cases rate ratios are lower among women. While Eastern and Southern European cities show higher levels of avoidable mortality, the association of mortality with social deprivation tends to be higher in Northern and lower in Southern Europe. CONCLUSIONS: There are marked differences in the level of avoidable mortality between neighbourhoods of European cities and the level of avoidable mortality is associated with social deprivation. There is no systematic difference in the magnitude of this association between European cities or regions. Spatial patterns of avoidable mortality across small city areas can point to possible local problems and specific strategies to reduce health inequality which is important for the development of urban areas and the well-being of their inhabitants.

A conditional model for estimating the increase in suicides associated with the 2008-2010 economic recession in England.

BACKGROUND: Although evidence of the effects of the economic crisis on suicides is quite low, a recent article shows that the increase in suicides in England between 2008 and 2010 could be associated with the rise in unemployment. Our study analysed whether this effect was the same for all regions of England, using a conditional model which explicitly allows estimation of regional time trends and the effects of unemployment on suicides at the regional level. METHODS: Hierarchical mixed models were used to assess both, suicides attributable to the financial crisis and the association between unemployment and suicides. The number and the (age-standardised) rate of suicides, for men and women separately, were the dependent variables. We considered the nine English regions based on the NUTS 2 level. RESULTS: There was an (not statistically significant) increase in the number of suicides between 2008 and 2010. The variation in rates was not statistically significant in England as a whole but there were statistically significant increases and decreases in some regions. Statistically significant associations between unemployment and suicides were only found at regional level. For men, statistically significant unemployment rates were positively associated with age-standardised suicide rates in the South West (0.384), North West (0.260) and North East (0.136), and negatively associated in the East of England (-0.444), East Midlands (-0.236) and London (-0.168). CONCLUSIONS: The study provides evidence that, even with statistically significant associations, finding variability, but no clear pattern, between trends and associations and/or numbers and rates might in fact suggest relatively spurious relationships; this is a result of not controlling for confounders.

[Measurement of the importance of user satisfaction dimensions in healthcare provision]. / Medida de la importancia de las dimensiones de la satisfacción en la provisión de servicios de salud.

OBJECTIVE: Identifying users' perceptions of the quality of care is essential to improve health services delivery. The main objective of this article was to describe the application of a methodology to identify factors that facilitate the identification of areas for improvement. METHOD: A questionnaire was applied in three health areas in Catalonia (Spain) (primary care [n=332], outpatient specialty care [n=410] and hospital emergency care [n=413]) to measure user satisfaction and assess the importance given to the aspects analyzed. RESULTS: The main areas for improvement in primary care identified by an importance-performance analysis involved the time devoted to patients as well as health professionals' willingness to listen to their views. In hospital emergency care, the main area of improvement was related to the hospital's physical conditions. CONCLUSIONS: The tools designed and implemented by the Catalan Health Service (Spain) have proved to be valid for the detection of priority areas to improve service delivery and promote regional equity.

Factors determining family planning in Catalonia. Sources of inequity.

INTRODUCTION: In recent decades, the foreign population in Spain has increased significantly, particularly for Catalonia, an autonomous region of Spain (2.90% in 2000 and 15.95% in 2010) and in particular Girona province (6.18% in 2000 and 21.55% in 2010). Several studies have shown a lower use of family planning methods by immigrants. This same trend is observed in Spain. The objective of this paper is to determine the existence of differences and possible sources of inequity in the use of family planning methods among health service users in Catalonia (Spain) by sex, health status, place of birth and socioeconomic conditions. METHODS: Data were taken from an ad-hoc questionnaire which was compiled following a qualitative stage of individual interviews. Said questionnaire was administered to 1094 Catalan public health service users during 2007. A complete descriptive analysis was carried out for variables related to public health service users' sociodemographic characteristics and variables indicating knowledge and use of family planning methods, and bivariate relationships were analysed by means of chi-square contrasts. Considering the use (or non-use) of family planning methods as a dependent variable and a set of demographic, socioeconomic and health status variables as explanatory factors, the relationship was modelled using mixed models. RESULTS: The analysed sample is comprised of 54.3% women and 45.7% men, with 74.3% natives (or from the EU) and 25.7% economic immigrants. 54.8% use some method of family planning, the condom (46.7%) and the pill (28.0%) being the two most frequently used methods. Statistical modelling indicates that those factors which most influence the use of family planning methods are level of education (30.59% and 39.29% more likelihood) and having children over 14 (35.35% more likelihood). With regard to the origin of the user, we observe that patients from North Africa,sub. Saharan Africa and Asia are less likely to use family planning methods (36.68%, 38.59% and 70.51%, respectively). CONCLUSIONS: The use of family planning methods is positively related to a higher level of education and having children over 14. Factors such as sex, age, income and self-perceived health do not appear to influence their use. Furthermore, being a native of this country, the European Union or Central/South America represents a greater likelihood of use than being African or Asian. Although no general differences in use were found between sexes, the difference found in the case of Asian women stands out, with a higher likelihood of use.

Factors determining access to and use of primary health care services in the Girona Health Region (Spain).

BACKGROUND: Increased population flowing from abroad has generated an intense debate regarding the economic consequences of migration in public services such as health, where new and specific demands are being created. This new demand for health care gives rise to the need to identify those factors which influence the user's decision to contact the health services and those which determine the quantity of services consumed. The aim of this study is to identify which variables affect these two stages of the use of such services in the Girona Health Region (RSG), where immigrant population represents 21.96% of the total population. METHODS: Specification of a Hurdle model with a count response variable related to primary health care service visits in the RSG for 2006. The study data is based on a sample of users (immigrants and natives) taken from the population assigned to primary health care services in eight Basic Health Areas (ABS) of the RSG. RESULTS: Contacting primary health care services is associated with variables that ought to affect use of health care such as chronic illness and taking prescribed medication as well as being aged between 46 and 55. Using primary health care services once makes users more likely to make further visits. The number of visits is related not only with variables that ought affect use of health care but also with variables that ought not to affect use of health care such as working without a contract, living in rented accommodation, or being unemployed. Additionally, if we consider the birthplace of the user, we observe the same pattern, with different directions and intensities, depending on the origin of the patient. For example, a higher likelihood of first contact is shown in Eastern Europeans, South Americans, and North Africans that suffer from cholesterol. A higher attendance is observed in natives and Eastern Europeans that take prescribed medication as well as natives, Eastern Europeans, and North Africans living in rented accommodation. On the other hand, working without a contract supposes a higher attendance in natives but a lower attendance in Eastern Europeans and sub-Saharan Africans. CONCLUSIONS: We do not detect any socioeconomic barriers associated with making a first contact with primary health services for the users analyzed. However, we do note evidence of horizontal inequity in terms of attending health services, related to variables that ought to affect use of health care as well as socioeconomic factors (variables that ought not to affect use of health care). The user's origin is an important key in detecting different intensities of access and regular visits to primary health care services.

Spatial variability in mortality inequalities, socioeconomic deprivation, and air pollution in small areas of the Barcelona Metropolitan Region, Spain.

BACKGROUND: There is evidence that geographic variability of social health inequalities continues to exist even after individual risk factors have been taken into account. However, relatively few studies have examined the contribution of exposure to air pollutants to those inequalities. OBJECTIVES: To study the geographic variability of inequalities in mortality and their associations with socioeconomic and environmental inequalities in small areas of the metropolitan of Barcelona during the period 1994 to 2003. METHODS: As in the MEDEA Project, the small area unit was the census tract. Study population consisted of the residents of the metropolitan area of Barcelona. Response variables were all-cause and specific-cause standardized mortality ratio (SMR). Explanatory variables were deprivation index, summarizing socioeconomic variables of the census tracts, and estimates of air pollutant exposures. Bayesian hierarchical models were used in order to reduce the extra variability when using SMR and to assess associations between mortality and deprivation and air pollution. RESULTS: Statistically significant associations with deprivation were found for the causes of death related to consumption of tobacco and alcohol for men and, besides lung cancer, diet-related causes for women. Statistically significant pollution coefficients were only found in the metropolitan area of Barcelona and in men. A positive interaction between pollutants and the deprivation index was statistically significant for respiratory mortality and PM(10), and ischemic disease mortality and NO(2), both for men. CONCLUSIONS: We found deprivation to be associated in a statistically significant way with the geographical variation in mortality in the census tracts of the metropolitan area of Barcelona, in the period 1994 to 2003. Those air pollutants more directly related with traffic modify some of these associations.

[Methods to smooth mortality indicators: application to analysis of inequalities in mortality in Spanish cities [the MEDEA Project]]. / Métodos para la suavización de indicadores de mortalidad: aplicación al análisis de desigualdades en mortalidad en ciudades del Estado español (Proyecto MEDEA).

Although there is some experience in the study of mortality inequalities in Spanish cities, there are large urban centers that have not yet been investigated using the census tract as the unit of territorial analysis. The coordinated project <> was designed to fill this gap, with the participation of 10 groups of researchers in Andalusia, Aragon, Catalonia, Galicia, Madrid, Valencia, and the Basque Country. The MEDEA project has four distinguishing features: a) the census tract is used as the basic geographical area; b) statistical methods that include the geographical structure of the region under study are employed for risk estimation; c) data are drawn from three complementary data sources (information on air pollution, information on industrial pollution, and the records of mortality registrars), and d) a coordinated, large-scale analysis, favored by the implantation of coordinated research networks, is carried out. The main objective of the present study was to explain the methods for smoothing mortality indicators in the context of the MEDEA project. This study focusses on the methodology and the results of the Besag, York and Mollié model (BYM) in disease mapping. In the MEDEA project, standardized mortality ratios (SMR), corresponding to 17 large groups of causes of death and 28 specific causes, were smoothed by means of the BYM model; however, in the present study this methodology was applied to mortality due to cancer of the trachea, bronchi and lung in men and women in the city of Barcelona from 1996 to 2003. As a result of smoothing, a different geographical pattern for SMR in both genders was observed. In men, a SMR higher than unity was found in highly deprived areas. In contrast, in women, this pattern was observed in more affluent areas.

[Constructing a deprivation index based on census data in large Spanish cities(the MEDEA project)]. / Construcción de un índice de privación a partir de datos censales en grandes ciudades españolas (Proyecto MEDEA).

OBJECTIVES: a) To describe the methodology used to construct a deprivation index by census tract in cities, to identify the tracts with the least favorable socioeconomic conditions, and b) to analyze the association between this index and overall mortality. METHODS: Several socioeconomic indicators (Census 2001) were defined by the census tracts of the following cities: Barcelona, Bilbao, Madrid, Seville and Valencia. The correlations with the standardized mortality ratio (1996-2003), and the dimensionality of the socioeconomic indicators were studied. Finally, the selected indicators were aggregated in an index, in which the results of the factor loadings from extraction of a factor by principal components were used as weighting values. RESULTS: The indicators with the strongest correlations with overall mortality were those related to work, education, housing conditions and single parent homes. In the analysis of dimensionality, a first dimension appeared that contained indicators related to work (unemployment, manual and eventual workers) and education (insufficient education overall and in young people). In all the cities studied, the index created with these 5 indicators explained more than 75% of their variability. The correlations between this index and mortality generally showed higher values than those obtained with each indicator separately. CONCLUSIONS: The deprivation index proposed could be a useful instrument for health planning as it detects small areas of large cities with unfavorable socioeconomic characteristics and is associated with mortality. This index could contribute to the study of social inequalities in health in Spain.

[Research protocol for the mortality atlas of the provincial capitals of Andalusia and Catalonia (AMCAC Project)]. / Protocolo de investigación del atlas de mortalidad de las capitales de provincia de andalucía y cataluña (Proyecto AMCAC).

The aim of this work is to make known the multicentric project AMCAC, whose objective is to describe the geographical distribution of mortality from all causes in census groups of the provincial capitals of Andalusia and Catalonia during 1992-2002 and 1994-2000 respectively, and to study the relationship between the sociodemographic characteristics of the census groups and mortality. This is an ecological study in which the analytical unit is the census group. The data correspond to 298,731 individuals (152,913 men and 145,818 women) who died during the study periods in the towns of Almeria, Barcelona, Cadiz, Cordoba, Girona, Granada, Huelva, Jaen, Lleida, Malaga, Seville and Tarragona during the study periods. The dependent variable is the number of deaths observed per census group. The independent variables are the percentage of unemployment, illiteracy and manual workers. Estimation of the moderated relative risk and the study of the associations among the sociodemographic characteristics of the census groups and the mortality will be done for each town and each sex using the Besag-York-Mollie model. Dissemination of the results will help to improve and broaden knowledge about the population's health, and will provide an important starting point to establish the influence of contextual variables on the health of urban populations.