Urban health: an example of a "health in all policies" approach in the context of SDGs implementation.

BACKGROUND: Cities are an important driving force to implement the Sustainable Development Goals (SDGs) and the New Urban Agenda. The SDGs provide an operational framework to consider urbanization globally, while providing local mechanisms for action and careful attention to closing the gaps in the distribution of health gains. While health and well-being are explicitly addressed in SDG 3, health is also present as a pre condition of SDG 11, that aims at inclusive, safe, resilient and sustainable cities. Health in All Policies (HiAP) is an approach to public policy across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. HiAP is key for local decision-making processes in the context of urban policies to promote public health interventions aimed at achieving SDG targets. HiAPs relies heavily on the use of scientific evidence and evaluation tools, such as health impact assessments (HIAs). HIAs may include city-level quantitative burden of disease, health economic assessments, and citizen and other stakeholders' involvement to inform the integration of health recommendations in urban policies. The Barcelona Institute for Global Health (ISGlobal)'s Urban Planning, Environment and Health Initiative provides an example of a successful model of translating scientific evidence into policy and practice with regards to sustainable and healthy urban development. The experiences collected through ISGlobal's participation implementing HIAs in several cities worldwide as a way to promote HiAP are the basis for this analysis. AIM: The aim of this article is threefold: to understand the links between social determinants of health, environmental exposures, behaviour, health outcomes and urban policies within the SDGs, following a HiAP rationale; to review and analyze the key elements of a HiAP approach as an accelerator of the SDGs in the context of urban and transport planning; and to describe lessons learnt from practical implementation of HIAs in cities across Europe, Africa and Latin-America. METHODS: We create a comprehensive, urban health related SDGs conceptual framework, by linking already described urban health dimensions to existing SDGs, targets and indicators. We discuss, taking into account the necessary conditions and steps to conduct HiAP, the main barriers and opportunities within the SDGs framework. We conclude by reviewing HIAs in a number of cities worldwide (based on the experiences collected by co-authors of this publication), including city-level quantitative burden of disease and health economic assessments, as practical tools to inform the integration of health recommendations in urban policies. RESULTS: A conceptual framework linking SDGs and urban and transportplanning, environmental exposures, behaviour and health outcomes, following a HiAP rationale, is designed. We found at least 38 SDG targets relevant to urban health, corresponding to 15 SDGs, while 4 important aspects contained in our proposed framework were not present in the SDGs (physical activity, noise, quality of life or social capital). Thus, a more comprehensive HiAP vision within the SDGs could be beneficial. Our analysis confirmed that the SDGs framework provides an opportunity to formulate and implement policies with a HiAP approach. Three important aspects are highlighted: 1) the importance of the intersectoral work and health equity as a cross-cutting issue in sustainable development endeavors; 2) policy coherence, health governance, and stakeholders' participation as key issues; and 3) the need for high quality data. HIAs are a practical tool to implement HiAP. Opportunities and barriers related to the political, legal and health governance context, the capacity to inform policies in other sectors, the involvement of different stakeholders, and the availability of quality data are discussed based on our experience. Quantitative assessments can provide powerful data such as: estimates of annual preventable morbidity and disability-adjusted life-years (DALYs) under compliance with international exposure recommendations for physical activity, exposure to air pollution, noise, heat, and access to green spaces; the associated economic impacts in health care costs per year; and the number of preventable premature deaths when improvements in urban and transport planning are implemented. This information has been used to support the design of policies that promote cycling, walking, public, zero and low-emitting modes of transport, and the provision of urban greening or healthy public open spaces in Barcelona (e.g. Urban Mobility, Green Infrastructure and Biodiversity Plans, or the Superblocks's model), the Bus Rapid Transit and Open Streets initiatives in several Latin American cities or targeted SDGs assessments in Morocco. CONCLUSIONS: By applying tools such as HIA, HiAP can be implemented to inform and improve transport and urban planning to achieve the 2030 SDG Agenda. Such a framework could be potentially used in cities worldwide, including those of less developed regions or countries. Data availability, taking into account equity issues, strenghtening the communication between experts, decision makers and citizens, and the involvement of all major stakeholders are crucial elements for the HiAP approach to translate knowledge into SDG implementation.

Promoting physical activity through primary health care: the case of Catalonia.

BACKGROUND: In adults, as little as 10 minutes of moderate physical activity (PA) three times a day can help prevent non-communicable diseases and prolong life expectancy. The aim of the study was to evaluate the process and impact of scaling up a complex intervention (PAFES) implemented in Catalonia, aimed to increase the proportion of adults complying with PA recommendations (especially those with cardiovascular risk factors). METHODS: The intervention, piloted in 2005, had three elements: 1) establishing clinical guidelines for PA; 2) identifying local PA resources; 3) PA screening and advice in primary health care (PHC) settings, based on stage of change. Central and local level implementation activities included training, support to municipalities, dissemination through a web page, and promotion of World Physical Activity Day (WPAD). Evaluation followed the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance), identifying 3-6 variables for annual evaluation of each dimension. These included coverage of PA screening and advice and individuals with access to a healthy exercise route (Reach), increased PA level between 2006 and 2010-15 (Effectiveness), PAFES adoption by PHC centres and municipalities (Adoption), process evaluation data (Implementation), and cost (Maintenance). RESULTS: PHC screening coverage increased from 14.4% (2008) to 69.6% (2015) and advice coverage from 8.3% (2012) to 35.6% (2015). In 2015, 82.5% patients had access to a "healthy route" (Reach). The proportion of patients with at least one cardiovascular risk factor who were "sufficiently active" increased from 2006 to 2010-2013 (Effectiveness). By 2015, PAFES was applied by all PHC teams, 8.3% municipalities and 22.7% PHC centres had organized WPAD events (Adoption). The Plan showed good penetration in all health regions by 2013, with relatively low use of resources and estimated cost (Implementation). By 2013 the Plan was embedded within the health system (Maintenance). CONCLUSIONS: In the first application of the RE-AIM framework to evaluate the scaling-up of a PA plan, PAFES showed good results for most RE-AIM indicators. Changes in priority and investment in health promotion programs affect reach, adoption, and effectiveness. It is important to maintain support until programs are strongly embedded into the health system.

European expert network on rare communicable diseases and other rare diseases linked to mobility and globalisation focused on health care provision (EURaDMoG): a feasibility study.

INTRODUCTION: In the current mobility and globalization context, there is a growing need to identify potential changes on the pattern of diseases in the European Union (EU)/European Economic Area (EEA) and provide accurate diagnosis and treatment for the population. The pattern of rare communicable diseases that can affect people returning to EU/EEA from travel abroad, visiting EU/EEA or establishing in the EU/EEA is of special relevance. The objective of this manuscript is to give an overview about the EURaDMoG study and discuss the feasibility of establishing a European network on rare communicable diseases and other rare conditions linked to mobility and globalization. METHODS: We undertook a three-steps process where we first conducted a narrative review to estimate the prevalence and incidence and to list rare communicable and non-communicable diseases linked to mobility and globalization in the EU/EEA; second, we organized an international consultation workshop with experts in the diseases previously selected; and finally, the feasibility study analysed how successful a European expert network on rare diseases linked to mobility and globalization focused on health care provision would be, accounting for different operational and also sustainability criteria. RESULTS: First, considering the areas or topics that the network should cover, it was concluded that communicable and non-communicable rare diseases linked to mobility and globalization should be differentiated. Second, since all non-communicable rare diseases linked to mobility and globalization identified are already covered by different European Reference Networks (ERNs), there is no need for them to be included in a new European network. Three scenarios were considered for establishing a potential European network for rare communicable diseases linked to Mobility and Globalisation with a focus on Health Care provision: 1) To maintain the current situation "Status Quo" scenario; 2) to create a specific European expert network (EEN) on rare communicable diseases linked to mobility and globalisation; 3) to develop a new ERN on communicable rare diseases linked to mobility and globalisation. CONCLUSIONS: Since the focus is the provision of health care, an ERN could have the potential to better boost the quality of care being facilitated by technological tools and online platforms that permit the safe and ethically acceptable exchange of data. However, this potential new network should not eclipse current existing networks and they should be complementary.

Parental knowledge of paediatric vaccination.

BACKGROUND: Although routine vaccination is a major tool in the primary prevention of some infectious diseases, there is some reluctance in a proportion of the population. Negative parental perceptions of vaccination are an important barrier to paediatric vaccination. The aim of this study was to investigate parental knowledge of paediatric vaccines and vaccination in Catalonia. METHODS: A retrospective, cross-sectional study was carried out in children aged < 3 years recruited by random sampling from municipal districts of all health regions of Catalonia. The total sample was 630 children. Parents completed a standard questionnaire for each child, which included vaccination coverage and knowledge about vaccination. The level of knowledge of vaccination was scored according to parental answers. RESULTS: An association was observed between greater vaccination coverage of the 4:4:4:3:1 schedule (defined as: 4 DTPa/w doses, 4 Hib doses, 4 OPV doses, 3 MenC doses and 1 MMR dose) and maternal age >30 years (OR: 2.30; 95% CI: 1.20-4.43) and with a knowledge of vaccination score greater than the mean (OR: 0.45; 95% CI: 0.28-0.72). The score increased with maternal educational level and in parents of vaccinated children.A total of 20.47% of parents stated that vaccines could have undesirable consequences for their children. Of these, 23.26% had no specific information and 17.83% stated that vaccines can cause adverse reactions and the same percentage stated that vaccines cause allergies and asthma. CONCLUSION: Higher vaccination coverage is associated with older maternal age and greater knowledge of vaccination.Vaccination coverage could be raised by improving information on vaccines and vaccination.

Where is the 'global' in the European Union's Health Research and Innovation Agenda?

Global Health has not featured as prominently in the European Union (EU) research agenda in recent years as it did in the first decade of the new millennium, and participation of low-income and middle-income countries (LMICs) in EU health research has declined substantially. The Horizon Europe Research and Innovation Framework adopted by the European Parliament in April 2019 for the period 2021-2027 will serve as an important funding instrument for health research, yet the proposed health research budget to be finalised towards the end of 2019 was reduced from 10% in the current framework, Horizon 2020, to 8% in Horizon Europe. Our analysis takes the evolvement of Horizon Europe from the initial framework of June 2018 to the framework agreed on in April 2019 into account. It shows that despite some improvements in terms of Global Health and reference to the Sustainable Development Goals, European industrial competitiveness continues to play a paramount role, with Global Health research needs and relevant health research for LMICs being only partially addressed. We argue that the globally interconnected nature of health and the transdisciplinary nature of health research need to be fully taken into account and acted on in the new European Research and Innovation Framework. A facilitated global research collaboration through Horizon Europe could ensure that Global Health innovations and solutions benefit all parts of the world including EU countries.

Prevalence of pertussis antibodies in umbilical cord blood samples in Catalonia, Spain.

The objective of the study was to determine the prevalence of detectable antipertussis antibodies (anti-PT) and recent pertussis infection in a representative sample (n=508) of pregnant women in Catalonia (Spain). Antipertussis (PT) antibodies were determined in cord blood samples using an in-house enzyme-linked immunosorbent assay test. The prevalence of detectable anti-PT levels was 72.8% and the prevalence of recent pertussis infection in mothers (cord blood anti-PT level of > or = 195 EU/mL was 1.8%. The (P<0.05) and the prevalence of recent pertussis infection decreased with maternal age (P< 0.01). Results obtained in this study show that it might be necessary to develop a pertussis vaccination program using acellular pertussis vaccines aimed at pregnant women to reduce the risk of pertussis infection during pregnancy and in neonates.

[Innovating the service management of public health: the experience of the Barcelona Public Health Agency (Spain)]. / Innovar en la gestión de servicios de salud pública: la experiencia de la Agencia de Salud Pública de Barcelona.

We describe the evolution of the organization of public health services in the city of Barcelona (Catalonia, Spain) until the creation of the Barcelona Public Health Agency. This Agency is a consortium created by the Barcelona City Council and the Government of Catalonia as the sole entity responsible for regional and local public health services in the city. The underlying logic for the Agency's design, as well as its mission, vision and value statements, strategy, services' portfolio, and the role of leadership in the process, are analyzed. Aspects related to the Agency's quality and communication plans, as well as the design of its processes, and its policy in terms of alliances for research and training in public health, are discussed. Finally, the main challenges for the future are described.

[Evaluation of the autochthonous transmission risk of Zika virus and other emerging mosquito-borne viral diseases in Catalonia (Spain)]. / Evaluación del riesgo de transmisión autóctona del virus Zika y otras enfermedades virales emergentes transmitidas por mosquitos en Cataluña.

The recent Zika virus epidemic has highlighted the potential risk of introducing the arbovirosis to Europe, especially within the Mediterranean region where the vector, Aedes albopictus, has become established as an invasive species. In this context, a comprehensive evaluation of the risk of introducing the Zika virus and other mosquito-borne viruses of public health importance in Catalonia (Spain) was carried out. This article summarises the results of the preliminary assessment and the recommendations for the public health preparedness and response plan against the threat posed by these emerging diseases.

Declining hepatitis A seroprevalence in adults in Catalonia (Spain): a population-based study.

BACKGROUND: One of the main uses of seroprevalence studies it to evaluate vaccination programmes. In 1998, a programme of universal vaccination of preadolescents in schools with the hepatitis A vaccine was begun in Catalonia. The objective of this study was to investigate the prevalence and risk factors of hepatitis A virus infection (HAV) in a sample of the adult population of Catalonia in 2002 and to evaluate the changes with respect to a survey carried out in 1996. METHODS: The prevalence of HAV antibodies was determined by a third generation competitive immunometric assay in a representative sample of 1292 people aged >15 years. The association between the prevalence and different sociodemographic variables was determined by multiple logistic regression analysis. RESULTS: The standardized global prevalence of HAV antibodies in 2002 was 68.2%, increased with age (p < 0.0001) and was associated with being born outside Catalonia (OR: 1.75; 95% CI 1.11-2.76) and lower social class (OR: 1.14; 95% CI 1.05-1.25). Compared with the last survey carried out in 1996 the standardized global prevalence was lower (68.2% vs 77.8%; p < 0.0001) as was the prevalence in people under 45 years. CONCLUSION: The prevalence of the hepatitis A virus is decreasing in the adult population of Catalonia, especially in the younger age groups. The programme of vaccination of adolescents begun in 1998 to control the disease can provide indirect protection to the unvaccinated population.

Foodborne Salmonella-caused outbreaks in Catalonia (Spain), 1990 to 2003.

In most developed countries, nontyphoid Salmonella is an important cause of sporadic cases and outbreaks of foodborne gastroenteritis. The aim of this study was to investigate the trend of foodborne Salmonella-caused outbreaks and number of cases, hospitalizations, and deaths and compare them with those caused by other infectious agents. The study was carried out in Catalonia, a region in northeastern Spain with a population of 6.5 million inhabitants, in 2002. All information on reported outbreaks of foodborne disease from 1990 to 2003 was reviewed. For each outbreak, the following variables were collected: year; setting (household, restaurant, school, hospital, nursing home, and others); number of cases, hospitalizations, and deaths; causal agent; and food vehicle involved. Of 1652 reported outbreaks, 1078 had a known causal agent. Among them, 871 (80.8%) were caused by Salmonella, with 14,695 cases, 1534 hospitalizations, and 4 deaths. The rate of hospitalization was higher in outbreaks due to Salmonella than in those caused by other infectious agents (rate ratio, 2.54; 95% confidence interval, 2.20 to 2.94). Forty-eight percent of Salmonella-caused outbreaks were eggborne, compared with 5.3% of those caused by other infectious agents (rate ratio, 1.40; 95% confidence interval, 1.33 to 1.48). The annual number of cases in household outbreaks of eggborne Salmonella rose over time (R2 = 0.82), but the number of outbreaks produced in other settings did not. Eggborne outbreaks caused by Salmonella in households are a major cause of disease, and increased preventive efforts are necessary, especially consumer education and awareness of the risk of eating food containing raw or slightly cooked eggs.

[Norovirus gastroenteritis outbreak by person-to-person transmission in a nursing home]. / Brote de Norovirus de transmisión persona a persona en una residencia asistida.

BACKGROUND AND OBJECTIVE: The aim of this study was to conduct an investigation into an outbreak of gastroenteritis among health workers and residents (with different grades of dependence) at a nursing home. PATIENTS AND METHOD: We detected an outbreak of gastroenteritis in a group of 52 health workers and 124 residents at a nursing home in Oliana, Lleida (Spain). A bidirectional prospective and retrospective cohort study was conducted into the consumption of water, food, grade of dependence (high, medium and low), and specific job. We studied the water supply and six food items. Faecal specimens from 30 patients were cultured and examined for Norovirus by polymerase chain reaction-reverse transcription. The possible implication of different factors associated with gastroenteritis was assessed by relative risk (RR) at 95% confidence intervals (CI). RESULTS: We interviewed 97% of the patients (172/176). The overall attack rate was 53.3% (92/172). The symptoms were: diarrhoea 68.5% (63/92), vomiting 64.1% (59/92), nausea 63.0% (58/92), fever 33.7% (31/92), abdominal pain 28.3% (26/92), and headache 14.1% (13/92). The epidemic curve highlighted transmission for 19 days. The risk factors associated with gastroenteritis were high (RR = 1.6; 95% CI, 1.0-2.6) and medium (RR = 2.8; 95% CI, 1.0-8.0) levels of dependence, health worker with high level of contact with residents (RR = 2.8; 95% CI, 1.1-7.3) and those doing cleaning work (RR = 2.8; 95% CI, 1.0-8.0). Bacterial cultures were negative for samples of food and water. Also, cultures were negative for bacteria in faecal samples but tests were positive for Norovirus in 12 faecal samples. CONCLUSIONS: We showed a Norovirus outbreak in a nursing home, person-to-person spread, associated to high and medium grades of dependence among residents, health worker with high level of contact with them and with those doing cleaning work.

Measuring the performance of health care services: a review of international experiences and their application to urban contexts.

BACKGROUND: The objective of performance assessment is to provide governments and populations with appropriate information about the state of their health care system. The objective of this paper is to present the most recent developments in performance assessment and their application in urban contexts. METHODS: Literature review in PubMed (1970-2004). We identified additional papers and grey literature from retrieved references. RESULTS: Performance assessment initiatives were identified in Australia, Canada, the United Kingdom, and New Zealand. The World Health Report 2000 is one of the best known examples of a transnational approach to performance assessment. CONCLUSION: The best developed initiatives to date are those that define precise categories, criteria and indicators with which to analyse and assess health care systems, based on a solid conceptual framework. Performance assessment fits perfectly in urban contexts, as it is a useful tool for designing and monitoring policies, assessing the quality of the services provided, and measuring the health status of city dwellers. Barcelona and Montreal are currently collaborating together on a project to assess the performance assessment of their respective health care services.

[Motor vehicle crash fatalities at 30 days in Spain]. / Fallecidos a 30 días por lesiones producidas en accidente de tráfico en España.

OBJECTIVES: To assess level of fulfillment and utility of the hospital discharge register (HDR) as a complementary source of information for estimating the number of deaths at 30 days due to motor vehicle crashes in Spain. METHODS: It is a cross-sectional study were we compared the number of people injured due to motor vehicle crashes hospitalised in a public hospital (HDR), in Spain during 2001, with the number of people severely injured or killed due to motor vehicle crashes reported by the police database (Dirección General de Tráfico, DGT) for the same year. A descriptive analysis was carried out by age, sex and region (Autonomous Community), as well as an estimation of the percentage of under-reporting of deaths by the DGT based on two assumptions. RESULTS: Police reported 27,272 severe injuries and 4,811 deaths during first 24 hours after the crash and after applying a fatality adjustment factor estimated 706 more deaths up to 30 days after the crash. The HDR reported 40,174 urgent hospitalisations. Of these, 1,099 died during the day of hospitalisation or within the following 30 days. The police only notified 68% of all cases that required hospitalisation. According to the number of deaths reported by police and contrasted with hospital register, estimations of the number of deaths at 30 days made by police could represent a level of under-reporting of between 3% and 6.6%, depending on the assumption considered. CONCLUSIONS: This study showed that the HDR is an information source that complements police statistics and is useful to estimate the number of deaths and non-fatal injuries due to motor vehicle crashes in Spain.

[Reasons for attending emergency departments. People speak out]. / Razones para acudir a los servicios de urgencias hospitalarios. La población opina.

OBJECTIVE: To ascertain why people attend hospital emergency departments (ED) for low complexity health problems. METHOD: A phenomenological, interactionist, qualitative study was performed. A theoretical sample that selected one urban and one rural area from Catalonia (Spain) was designed. In each setting, persons (n = 36) who had used the ED or a primary care emergency service 1 month before the beginning of the study were chosen. Data were obtained through 8 focus groups. An interpretative content analysis was performed, and emergent categories were constructed through research triangulation. RESULTS: Five categories emerged: symptoms, whether or not self-diagnosis was involved, perception of needs, awareness of the health services available, and the overall context of the person. Symptoms generated feelings of failing health and thus initiated care seeking. Self-diagnosis determined perceived need and the type of care sought. People contrasted their self-perception of need with their own opinion about the health services available. The decision to go to one or other service was made as a result of this contrast, but the individual's family, work, and social situations also played a part. Informants were more familiar with the service provided by the ED than with that provided by primary care. Time consumption also figured heavily in decision making. CONCLUSIONS: The presence or absence of self-diagnosis is a determining factor in attendance at EDs. Other factors that influence demand are the level of awareness of the health services available, previous experiences, and the life situation of the individual.

[Regulatory policies and public opinion: the case of smoking]. / Políticas reguladoras y opinión pública: el caso del tabaco.

BACKGROUND: Collecting and disseminating information about the public opinion on a regulatory process gives visibility to the silent social support and facilitates the process, which often confronts resistance from interest groups. This paper presents a survey about a proposed legislation on tobacco in its final stages and its results, and some considerations on the use of this sort of information in change processes. METHODS: Cross sectional descriptive study. In December 2005 a brief telephone survey was made to a population sample of 18 and more years of age (N=830) in Catalonia (Spain). The questionnaire explored opinions on the proposed regulations under discussion. We present the degree of support and the rating of nine regulatory measures, stratified by the respondents use of tobacco. RESULTS: Daily smokers are 26.3% of the surveyed population. Awareness and general support for tobacco regulation are very high. Aspects with wider support include bans on sales to minors (97.3%), smoking in enclosed public places (92.8%) and workplaces (89%), and publicity (90.8%). The aspect with less social support is banning smoking in bars and cafes (80.2%). CONCLUSIONS: The population supports widely tobacco regulation. This reinforces the process and weakens the arguments of those against it. Although smokers are less supportive, most of them accept the regulations, except for limitations in bars and cafes.

Residential green spaces and mortality: A systematic review.

BACKGROUND: A number of studies have associated natural outdoor environments with reduced mortality but there is no systematic review synthesizing the evidence. OBJECTIVES: We aimed to systematically review the available evidence on the association between long-term exposure to residential green and blue spaces and mortality in adults, and make recommendations for further research. As a secondary aim, we also conducted meta-analyses to explore the magnitude of and heterogeneity in the risk estimates. METHODS: Following the PRISMA statement guidelines for reporting systematic reviews and meta-analysis, two independent reviewers searched studies using keywords related to natural outdoor environments and mortality. DISCUSSION: Our review identified twelve eligible studies conducted in North America, Europe, and Oceania with study populations ranging from 1645 up to more than 43 million individuals. These studies are heterogeneous in design, study population, green space assessment and covariate data.We found that the majority of studies show a reduction of the risk of cardiovascular disease (CVD) mortality in areas with higher residential greenness. Evidence of a reduction of all-cause mortality is more limited, and no benefits of residential greenness on lung cancer mortality are observed. There were no studies on blue spaces. CONCLUSIONS: This review supports the hypothesis that living in areas with higher amounts of green spaces reduces mortality, mainly CVD. Further studies such as cohort studies with more and better covariate data, improved green space assessment and accounting well for socioeconomic status are needed to provide further and more complete evidence, as well as studies evaluating the benefits of blue spaces.

Individual and contextual effects in injury morbidity in Barcelona (Spain).

OBJECTIVE: To determine the relationship between socioeconomic level (measured through individual educational level and material deprivation in the areas of residence) and injury morbidity in different age groups and in males as well as in females. DESIGN: Cross-sectional survey. SETTING: Barcelona (Spain). METHODS: The study population included all cases over the age of 19 who, as a result of an injury (motor vehicles injuries, falls, hits and cuts), were admitted to the emergency departments of the six main hospitals of the city during the years 1990-1991. Age- and sex-specific morbidity rates were calculated for each educational level and each cause of injury. The contextual variable included was the proportion of unemployment in each neighbourhood. Multilevel Poisson regression models were fitted. RESULTS: Morbidity rates were higher in males, in young people and for lower educational levels. Results from the multilevel models show that, at contextual level, neighbourhoods with more unemployment present a higher risk of injuries. At individual level, after adjusting for contextual variables, the risk of sustaining injuries was higher among young men and women for all injury causes except falls among women where the risk was higher in the elderly; among both men and women, the risk of sustaining injury was higher in the population with lower educational level (RR = 1.79, 95% CI = 1.73-1.86 in men; RR = 2.12, 95% CI = 2.04-2.21 in women). This trend was also observed separately for traffic injuries, falls, hits and cuts. CONCLUSION: Our results provide information about individual and contextual social inequalities in injury morbidity, the highest risks of injury occur in individuals of lower educational level and who reside in the more private neighbourhoods. These results underscore the need to implement injury prevention strategies not only at the individual level, but also to tailor them to the socioeconomic position of the population.