[Lights and shadows in the implementation of community action for health]. / Luces y sombras en la implementación de la acción comunitaria para la salud.

OBJECTIVE: To explore the experiences of individuals who develop projects and interventions where community participation-action constitutes a strategic tool for reducing health inequalities. METHOD: Qualitative study based on semi-structured, in-depth online interviews with individuals considered experts in the development of health promotion strategies involving community participation. A total of 12 individuals from the healthcare, social healthcare, academic, and associative backgrounds were selected. The texts were analyzed following the thematic content analysis approach. RESULTS: The prominent strength of the processes involving the interviewed individuals is their participatory approach. However, there is no genuine commitment to promoting community participation from primary healthcare, and precarity has been identified as a significant weakness in the development of participatory health promotion projects. The sustainability of participatory processes relies on the transfer of knowledge to the community and their empowerment. CONCLUSIONS: Participatory processes have demonstrated their ability to reposition the community as an essential part of the healthcare system. It would be interesting to use a measurement tool for participation in all community health actions, both to guide their design and planning and to assess the depth of participation and its impact on the process. Enhancing community action expectations for health in the near future involves promoting a community-oriented approach in primary care and intersectoral collaboration, which requires a significant institutional and policy commitment.

The need for adolescents' agency in salutogenic approaches shaping physical activity in schools.

Physical activity (PA) contributes to health throughout life. In particular, young people can benefit from this. Schools can play a key role in providing learning conditions to experience meaningful PAs aimed at inspiring students to lifelong PA. In this article, we argue the need for a salutogenic approach in schools focussing on respecting and enhancing adolescents' agency with regard to their PA. This approach entails listening to adolescents' perspectives and inviting them to participate in actively designing and carrying out PA as a prerequisite for their inclusive engagement. We unpack the concept of agency by drawing on insights from the Capability Approach. This provides input for the integration of agency in health promoting schools and salutogenic approaches, to enhance PA-related agency. Finally, we outline a research agenda to, eventually, create opportunities for students in schools to expand their PA-related agency. Lay Summary Physical activity (PA) contributes to health throughout life. Schools can play a key role in fostering meaningful PA experiences to inspire students to lifelong PA. This requires schools to focus on students' personal aspirations, providing them with the space to develop their autonomy and find opportunities to decide and act upon expanding their agency with respect to the physically active lifestyles they deem meaningful.

Gaceta Sanitaria se suma a la iniciativa REWARD para mejorar la investigación biomédica y reducir el desperdicio en ciencia / Gaceta Sanitaria joins the REWARD initiative to improve biomedical research and reduce waste in science

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La salud persecutoria: los límites de la responsabilidad

Contenido: Los informes mayoritarios, la nueva salud pública y la gestión saludable de comportamientos. Estilo de vida, genómica y responsabilidad individual en salud. La promoción de estilos de vida saludables. Breve incursión al estilo de vida en Internet y en la academia. Estilos de vida: individual y colectivo. Genómica, epidemiología y salud pública. Genes y comportamientos en salud: en busca de informes responsables. Los riesgos de la responsabilidad individual en la genomización epidemiológica. La responsabilidad frente a los límites

State downsizing as a determinant of infant mortality and achievement of Millennium Development Goal 4.

The aim of this study was to evaluate the worldwide effect of state downsizing policies on achievement of U.N. Millennium Development Goal 4 (MDG4) on infant mortality rates. In an ecological retrospective cohort study of 161 countries, from 1978 to 2002, the authors analyzed changes in government consumption (GC) as determining exposure to achievement of MDG4. Descriptive methods and a multiple logistic regression were applied to adjust for changes in gross domestic product, level of democracy, and income inequality. Excess infant mortality in the exposed countries, attributable to reductions in GC, was estimated. Fifty countries were found to have reduced GC, and 111 had increased GC. The gap in infant mortality rate between these groups of countries doubled in the study period. Non-achievement of MDG4 was associated with reductions in GC and increases in income inequality. The excess infant mortality attributable to GC reductions in the exposed countries from 1990 to 2002 was 4,473,348 deaths. The probability of achieving MDG4 seems to be seriously compromised for many countries because of reduced public sector expenditure during the last 25 years of the 20th century, in response to World Bank/International Monetary Fund Washington Consensus policies. This seeming contradiction between the goals of different U.N. branches may be undermining achievement of MDG4 and should be taken into account when developing future global governance policy.

[Appraisal of the Millennium Development Goals by means of a review of the scientific literature in 2008]. / Valoración de los Objetivos de Desarrollo del Milenio mediante la revisión de la literatura científica en 2008.

The Millennium Development Goals (MDGs) are now at the midterm of their target period, as 2015 is the date scheduled by the United Nations Organisation (UN) for their attainment. The purpose of this article is to review the current situation of the MDGs worldwide and to analyse the barriers which are preventing them from being attained in each of the MDG areas, as well as to assess a number of the indicators evaluated. In order to do so, a review has been made of the scientific literature published on the MDGs in the principal health sciences and social sciences databases, as well as the most significant reports on the issue drawn up by the United Nations. The scientific studies on the 8 MDGs and their 18 Targets make it possible to undertake a critical analysis of the situation in which each of these Goals are found at the present time, identifying the determinants that are preventing the attainment of the Goals and the actions considered necessary in order to achieve progress. Although there have been improvements in some of the goals on a world level, the research carried out to date reveals barriers to the attainment of the MDGs, as well as the insufficient weight of the developing countries in the economic and political decision-making processes, together with the incoherence between the economic policies and the social and health policies. Furthermore, Sub-Saharan Africa constitutes the most disadvantaged region, which means that it will not attain the majority of the MDGs. Spain and the developed countries, in addition to contributing resources, can also contribute to the MDGs by means of the identification and eradication of the barriers preventing attainment. This involves promoting international economic relations under conditions of social justice, by supporting a greater decision-making power for developing countries and denouncing actions that increase social inequalities and the impoverishment of the population.

Valoración de los objetivos de desarrolo del milenio mediante la revisión de la literatura científica en 2008 / Appraisal of the millennium development goals by means of a review of the scientific literature in 2008

Los Objetivos de Desarrollo del Milenio (ODM) se encuentran actualmente a mitad de su periodo de ejecución, siendo el año 2015 la fecha prevista por la Organización de Naciones Unidas (ONU) para su alcance. El objetivo de este artículo es revisar la situación actual en la que se encuentran los ODM a nivel mundial y analizar las barreras que estarían impidiendo su consecución para cada uno de los ámbitos de los ODM, así como valorar algunos de los indicadores evaluados. Para ello, se ha revisado la literatura científica publicada sobre los ODM en las principales bases de datos de ciencias de la salud y ciencias sociales, así como los principales informes elaborados sobre el tema por Naciones Unidas. Los estudios científicos en torno a los 8 ODM y sus 18 Metas permiten realizar un análisis crítico sobre la situación en la que se encuentra en la actualidad cada uno de ellos, identificando los determinantes que están impidiendo su consecución y las acciones que se consideran necesarias para impulsar el avance. Aunque a nivel global ha habido mejoras en algunas de las metas, la investigación realizada hasta la fecha muestra barreras a la consecución de los ODM, como el insuficiente peso de los estados de los países en desarrollo sobre las decisiones económicas y políticas, así como la incoherencia entre las políticas económicas y las políticas sociales y de salud. Por otra parte, África Subsahariana constituye la región con mayor desventaja, lo que supone que no alcanzará la mayoría de los ODM. España y los países desarrollados, además de aportar recursos, pueden contribuir a los ODM mediante la identificación y erradicación de las barreras que impiden su alcance. Esto significa promover unas relaciones económicas internacionales en condiciones de justicia social, apoyando un mayor poder de decisión para los países en desarrollo, y denunciando las actuaciones que incrementan las desigualdades sociales y el empobrecimiento de la población (AU)

The Millennium Development Goals (MDGs) are now at the midterm of their target period, as 2015 is the date scheduled by the United Nations Organisation (UN) for their attainment. The purpose of this article is to review the current situation of the MDGs worldwide and to analyse the barriers which are preventing them from being attained in each of the MDG areas, as well as to assess a number of the indicators evaluated. In order to do so, a review has been made of the scientific literature published on the MDGs in the principal health sciences and social sciences databases, as well as the most significant reports on the issue drawn up by the United Nations. The scientific studies on the 8 MDGs and their 18 Targets make it possible to undertake a critical analysis of the situation in which each of these Goals are found at the present time, identifying the determinants that are preventing the attainment of the Goals and the actions considered necessary in order to achieve progress. Although there have been improvements in some of the goals on a world level, the research carried out to date reveals barriers to the attainment of the MDGs, as well as the insufficient weight of the developing countries in the economic and political decision-making processes, together with the incoherence between the economic policies and the social and health policies. Furthermore, Sub-Saharan Africa constitutes the most disadvantaged region, which means that it will not attain the majority of the MDGs. Spain and the developed countries, in addition to contributing resources, can also contribute to the MDGs by means of the identification and eradication of the barriers preventing attainment. This involves promoting international economic relations under conditions of social justice, by supporting a greater decision-making power for developing countries and denouncing actions that increase social inequalities and the impoverishment of the population (AU)

[Assessment criteria for public policies on obesity: the view of Spanish stakeholders]. / Criterios de valoración de políticas públicas para la obesidad en España según sus actores principales.

AIM: To explore the criteria used to assess public policy initiatives on obesity in Spain by the main stakeholders. METHODS: Multicriteria mapping was performed within the framework of the European PorGrow Project "Policy options for responding to obesity" through a structured interview with 21 stakeholders, who were leaders in the public and private sectors in Spain in the area of food and physical exercise. Qualitative and quantitative information was included in the analysis. The interviewees justified their positions for or against the various policy options with criteria that were weighted by their relative importance and documented with quotations and nuggets from the interviewees' discourse. RESULTS: We identified 93 criteria for policy selection in the 21 interviewees. The most frequent criteria and those perceived as most important were efficacy (n = 18), social benefits (n = 17) and social acceptability (n = 14). The economic impact on individuals and the public sector was not considered important by the interviewees. The economic impact on the commercial sector was not included by any of the participants. The criterion most highly valued by public sector stakeholders was societal benefits while that most valued by private sector stakeholders was efficacy. CONCLUSIONS: Spain is in the initial stages of developing public policy on obesity and, as yet, there are no winners and losers among those concerned, which may explain why economic costs seem to be relatively unimportant for the stake-holders, opening a window of opportunity for the development of regulatory policies.

Criterios de valoración de políticas públicas para la obesidad en España según sus actores principales / Assessment criteria for public policies on obesity: the view of Spanish stakeholders

Objetivos: Explorar los argumentos utilizados por los actores clave para valorar las políticas públicas en España orientadas a reducir la obesidad en la población.Métodos: Mapeo por multicriterios, en el marco del proyecto europeo Opciones de Políticas para Responder al Desafío de la Obesidad (PorGrow), mediante una entre-vista estructurada individual a 21 actores principales, líderes del sector público y privado en la alimentación y el ejercicio físico en España. Se integró en el análisis información de tipo cuantitativo y cualitativo. Los entrevistados justificaron sus posicionesen pro y en contra de las diferentes iniciativas de políticas, aspectos que se denominaron «criterios», que fueron ponderados según su importancia relativa y documentados mediante textos y «perlas» del discurso de los entrevistados.Resultados: Se identificaron 93 argumentos para la selección de políticas en los 21 entrevistados. Los argumentos más utilizados y valorados por su importancia fueron: eficacia (n = 18), beneficios sociales (n = 17) y aceptabilidad social (n = 14). Los costes económicos fueron considerados poco relevantes tanto para el sector público como para los individuos. El impactoeconómico para el sector comercial no fue incluido porninguno de los entrevistados. Según el área de actuación, los criterios más relevantes fueron la eficacia y los beneficios sociales, para el sector privado y público, respectivamente.Conclusiones: Quizá porque España se encuentra al comienzo del proceso de desarrollo de políticas de obesidad y aún no hay ni «ganadores» ni «perdedores» entre los afectados, los costes financieros aparecen como una cuestión de bajo perfil para los entrevistados, lo que abre una ventana de oportunidad para ensayar políticas de regulación

Aim: To explore the criteria used to assess public policy initiatives on obesity in Spain by the main stakeholders.Methods: Multicriteria mapping was performed within the framework of the European PorGrow Project «Policy options for responding to obesity» through a structured interview with 21 stakeholders, who were leaders in the public and private sectors in Spain in the area of food and physical exercise. Qualitative and quantitative information was included in the analysis. The interviewees justified their positions for or against thevarious policy options with criteria that were weighted by their relative importance and documented with quotations and «nuggets» from the interviewees’ discourse.Results: We identified 93 criteria for policy selection in the 21 interviewees. The most frequent criteria and those perceived as most important were efficacy (n = 18), social benefits (n = 17) and social acceptability (n = 14). The economic impact on individuals and the public sector was not considered importantby the interviewees. The economic impact on the commercial sector was not included by any of the participants. The criterion most highly valued by public sector stakeholders was societal benefits while that most valued by private sector stakeholders was efficacy.Conclusions: Spain is in the initial stages of developing public policy on obesity and, as yet, there are no winners and losers among those concerned, which may explain why economic costs seem to be relatively unimportant for the stakeholders, opening a window of opportunity for the development of regulatory policies

Epidemiología de las desigualdades del desarrollo de género en España (1990-2000) / Gender development inequalities epidemiology in Spain (1990-2000)

Fundamento: El género es un determinante de la salud importante para las Políticas de Salud Pública. Este estudio describe los cambios en las desigualdades del desarrollo de género en España y sus Comunidades Autónomas (CCAA) en la década 1990 y 2000. Métodos: Estudio ecológico del Índice de Desarrollo Humano (IDH) y el Índice de Desarrollo de Género (IDG) y sus componentes por sexo (educación, ingresos y esperanza de vida al nacer). Resultados: El IDG de España ha crecido en un 5,05% en los años 90. Pero, mientras que en 1990 el 51,5% de la población estaba ubicada por encima del IDG promedio español en 2000 disminuyó al 46,3%. Asturias: 3,37%, Cantabria: 3,68% e Islas Baleares: 3,71% son las de menor crecimiento; Madrid: 6,46% y Extremadura: 6,75% las de mayor. Todas las CCAA. tienen un valor de IDG menor que de IDH. Ambos sexos tuvieron un crecimiento promedio similar en la esperanza de vida (Hombres: 5% y Mujeres: 4%) manteniéndose las diferencias, aunque se detectan variaciones según CCAA. En educación, las mujeres mejoraron el doble que los hombres (Hombres: 3% y Mujeres: 6%), siendo Cataluña, Aragón, Madrid, Baleares y Galicia las de mayor igualdad. Pese a que las mujeres mejoraron el triple que los hombres en el índice de ingresos (Hombres: 3% y Mujeres: 9%), las diferencias persisten a favor de los hombres. Conclusiones: Las desigualdades en el desarrollo de género disminuyeron en los 90 en España, aunque la mejora de la educación, ingresos y esperanza de vida se produjo sólo en algunas CCAA, persistiendo diferencias interregionales (AU)

Background: Gender is an important health determinant for public health policies. This study describes the changes in gender development inequalities in Spain and its autonomous regions from 1990 to 2000. Methods: An ecological study using the Human Development Index (HDI) and the Gender Development Index (GDI) was done. IDG both men and women was analysed according to indexes of education, income and life expectancy at birth. Results: Although the GDI has had an increase of 5,05% in the 90´s, 51,5% of the population was located above the global GDI of Spain in 1990, moreover this number decreased to 46,3% in 2000. Gender inequalities have been reduced both at national and regional levels. The regions with the lowest increase were Asturias (3.37%), Cantabria (3.68%) and Baleares Islands (3.71%). The regions with the highest increase were Madrid (6,46%) and Extremadura (6,75%). All the autonomous regions showed a number of GDI lower than the value of HDI. Both sexes achieved similar increase in life expectancy (Men: 5% and Women: 4%). An unequal variation was detected according to the autonomous region (Basque Country; Men: 7% and Women: 3%; Madrid; Men:8% and Women:5%). Women have improved their educational level in comparison to men (Men: 3% and Women: 6%). In the 90s, men obtained more income than women, but women improved their situation three times more than men. Conclusions: Inequalities in Human Development analysed by gender have been reduced in the 90s in Spain. However, the improvement of education, income and life expectancy occurred only in some autonomous regions. This situation shows the differences among Spanish autonomous regions (AU)

El reto para la salud pública de los Objetivos de Desarrollo del Milenio: un enfoque desde la epidemiología política / The challenge to public health of the Millenium Development Goals: an approach from political epidemiology

Los Objetivos de Desarrollo del Milenio, y dentro de éstos las Metas del Milenio, constituyen un plan operativo para la consecución de logros básicos dirigidos al alcance de la salud, la erradicación de la pobreza y el cumplimiento de los derechos humanos fundamentales. Sus ámbitos de acción representan un punto de entrada histórico para una eventual política social a escala mundial, donde la intervención intersectorial es imprescindible para la eficacia de ésta. La salud pública, por su naturaleza multidisciplinar, junto a la epidemiología política, constituyen herramientas útiles para contribuir a incrementar el conocimiento científico en el ámbito de la salud con relación a los Objetivos de Desarrollo del Milenio. A pesar de la oportunidad que constituye este acuerdo internacional, se ha profundizado poco acerca de las dificultades, fundamentalmente políticas para su consecución. Por lo tanto, es necesario un cambio conceptual y metodológico basado en pasar de preguntarnos acerca de los determinantes socials de la salud a cuestionarnos acerca de los determinantes politicos de los propios determinantes sociales. Esto supondría no sólo elaborar una taxonomía de las injusticias, sino encontrar puntos de entrada efectivos en las instituciones derivadas del poder político para aminorarlas (AU)

The Millennium Development Goals, and within these the Millennium Targets, constitute a working plan that strives to achieve basic goals within the field of health, eradicate poverty, and ensure compliance with basic human rights. Its scope of action represents a historic breakthrough as a step toward a possible global social policy, in which cooperation between the different sectors is essential for its efficiency. Due to its multidisciplinary nature, public health, as well as political epidemiology, can be used to help increase scientific knowledge in the field of health with respect to the Millennium Development Goals. Despite the opportunity that this international agreement provides, insufficient in-depth study has been carried out on the potential –mainly political– difficulties that could arise during its implementation. Therefore, a conceptual and methodological change is required so that concern does not simply center on social determinants of health but instead takes into consideration the political reasons behind them. To reduce inequality, not only must injustice be classified but effective ways must also be found to encourage institutions with political power to take part in this initiative (AU)

Los sistemas de género y/en la Encuesta Nacional de Salud / Gender systems and/in the Spanish National Health Interview Survey

Objetivo: Analizar la Encuesta Nacional de Salud (ENS) desde la perspectiva de géneros, con especial énfasis en la división sexual del trabajo. Métodos: Análisis del contenido de la ENS-2003 desde la perspectiva del género, entendiéndolo como: a) base de normas sociales: responsabilidades por sexo, riesgos y problemas de salud según los roles masculinos/femeninos; b) organizador de la estructura social: división sexual del trabajo, doble carga, segregación horizontal/vertical, dedicación (horas) a tareas según tiempos sociales, acceso a recursos, y c) componente de la identidad individual: conflictos por múltiples roles, insatisfacción con la imagen corporal, autoestima, autopercepción, reconocimiento del trabajo, asimilación sexual de género, problemas de salud por diferencias sexuales. Resultados: La ENS gira alrededor del sustentador principal, en masculino. La división sexual del trabajo doméstico se identifica con sólo una pregunta general. Al utilizar el concepto «actividad principal para empleo o trabajo reproductivo», la encuesta induce a valorarla, jerarquizarla y seleccionar una; en consecuencia, se pierde información, lo que dificulta el análisis del impacto de la doble carga en la salud. No se pregunta por horas de trabajo reproductivo y ocio. En una misma pregunta se mezclan agresiones (intencionales) y accidentes (no intencionales) lo que imposibilita el estudio de la violencia de género. Conclusiones: La ENS recoge la variable sexo, pero su enfoque, más descriptivo que explicativo, limita su perspectiva de género. Se pueden medir situaciones concretas de desigualdad entre hombres y mujeres relativas al trabajo remunerado, pero no es posible determinar completamente otros indicadores de desigualdad social entre ambos sexos, como la situación de las amas de casa y de doble jornada

Objective: To analyze the Spanish National Health Interview Survey (NHIS) from a gender perspective, with special emphasis on gender division of labor. Method: We analyzed the 2003 Spanish NHIS from the perspective of the levels of gender observation, with gender understood as: a) the basis of social norms (responsibilities by sex, health risks, and problems related to masculine/feminine roles); b) the organizer of the social structure: gender division of labor, work overload, vertical/horizontal segregation, time spent in activities according to social times, access to resources), and c) a component of individual identity (conflicts due to multiple roles, body image dissatisfaction, self-esteem, self-perceived recognition of the work performed, assimilation of the sexual gender role, sex differences in health conditions). Results: The Spanish NHIS is centered on the main provider, referred to in masculine grammatical form. Gender division of domestic labor is identified only by a general question. When using the concept of main activity for productive or reproductive work, the survey requires respondents to evaluate them and select only one, thus losing information and hampering analysis of the impact of an overload of work on health. Information on time used for reproductive work and leisure is not solicited. Assaults (intentional) and accidents (non-intentional) are combined in the same question, thus preventing research on gender-related violence. Conclusions: The Spanish NHIS includes the variable of sex, but its more descriptive than analytic focus limits gender analysis. The survey allows specific circumstances of employment-related inequalities between sexes to be measured, but does not completely allow other indicators of gender inequalities, such as the situation of housewives or work overload, to be measured

[Famine in the Spanish civil war and mortality from coronary heart disease: a perspective from Barker's hypothesis]. / El hambre en la Guerra Civil española y la mortalidad por cardiopatía isquémica: una perspectiva desde la hipótesis de Barker.

OBJECTIVE: To determine whether the famine experienced during the Spanish civil war and immediate postwar period influenced mortality from coronary heart disease (CHD) in persons born in this period, following the lines of Barker's hypothesis on fetal programming of chronic diseases in adult life. METHODS: Using CHD mortality data by age and sex for 1990-2002, annual and age-adjusted rates were calculated by the direct method. Poisson regressions were used to estimate period, age and cohort effects by year of birth (1918-1957). RESULTS: During the study period, CHD mortality fell by a yearly average of -2.3% in both sexes and in all ages yearly. This trend was influenced by both cohort and period effects (p<0.001); an increased risk was observed for both sexes and in all ages in the deaths corresponding to persons born during the war and postwar years when the famine was most intense (1937, 1940, 1943 and 1945). CONCLUSIONS: The results obtained by studying yearly CHD mortality are compatible with those expected by Barker's hypothesis of the effect of nutritional stress during pregnancy. In addition to its human, economic and political costs, the Spanish civil war could also have had negative consequences for the health of persons born in this period.

El hambre en la Guerra Civil española y la mortalidad por cardiopatía isquémica: una perspectiva desde la hipótesis de Barker / Famine in the Spanish civil war and mortality from coronary heart disease: a perspective from Baker's hypothesis

Objetivo: Analizar si el hambre durante la Guerra Civil española y la inmediata posguerra influyó sobre la mortalidad por cardiopatía isquémica de las personas que nacieron en este período, según lo planteado en la hipótesis de Barker acerca de la posible programación fetal de enfermedades de la edad adulta. Métodos: Con los datos de mortalidad por edad y sexo por cardiopatía isquémica en el período 1990-2002, se calcularon las tasas anuales de mortalidad específicas y las tasas ajustadas por edad, por el método directo. Mediante análisis de regresión de Poisson se analizó el efecto de la edad, el período y la cohorte anual de nacimiento (1918-1957). Resultados: Durante el período de estudio, la mortalidad por cardiopatía isquémica ha disminuido un promedio anual de ­2,3% en ambos sexos y para todas las edades. En el descenso de mortalidad están presentes los efectos cohorte y período (p < 0,001); se observa un incremento del riesgo para todas las edades y ambos sexos en las muertes correspondientes a personas nacidas durante los años reconocidos como de mayor escasez alimentaria de la Guerra Civil y la inmediata posguerra (1937, 1940, 1943 y 1945). Conclusiones: Los resultados obtenidos al estudiar anualmente la mortalidad por cardiopatía isquémica son compatibles con la hipótesis de Barker sobre el efecto del estrés alimentario durante el embarazo en la génesis de diversas enfermedades en el adulto. La Guerra Civil española, además de costes humanos, económicos y políticos, puede haber tenido consecuencias negativas para la salud de los nacidos en esas cohortes

Objective: To determine whether the famine experienced during the Spanish civil war and immediate postwar period influenced mortality from coronary heart disease (CHD) in persons born in this period, following the lines of Barker's hypothesis on fetal programming of chronic diseases in adult life. Methods: Using CHD mortality data by age and sex for 1990-2002, annual and age-adjusted rates were calculated by the direct method. Poisson regressions were used to estimate period, age and cohort effects by year of birth (1918-1957). Results: During the study period, CHD mortality fell by a yearly average of ­2.3% in both sexes and in all ages yearly. This trend was influenced by both cohort and period effects (p < 0.001); an increased risk was observed for both sexes and in all ages in the deaths corresponding to persons born during the war and postwar years when the famine was most intense (1937, 1940, 1943 and 1945). Conclusions: The results obtained by studying yearly CHD mortality are compatible with those expected by Barker's hypothesis of the effect of nutritional stress during pregnancy. In addition to its human, economic and political costs, the Spanish civil war could also have had negative consequences for the health of persons born in this period

[Opacity of general agreements on goods and services in Spain]. / La opacidad de los acuerdos generales de bienes y servicios en España.

OBJECTIVE: To explore the intensity of the debate in the Spanish Parliament on the General Agreement on Trade in Services (GATS) developed by Spain and the World Trade Organization, and to compare it with the debate on the General Agreement on Tariffs and Trade (GATT). METHODS: A systematic search and content analysis were performed of all parliamentary initiatives on GATS and GATT undertaken from 1979 to 2004 in the Spanish Parliament and Senate. The frequency and percentages of initiatives on both issues were calculated, and the final result and kinds of initiative were analyzed. RESULTS: A total of 185 initiatives were presented in the Spanish Parliament on these agreements, of which 120 were on GATT, 8 were on GATS and 57 were on both agreements. Most of these initiatives were not discussed in parliament (GATT, 71%; GATS, 55.4%) or were the subject of political debate with low participation among parliamentary groups. CONCLUSIONS: Despite the implications of the GATS for Spanish health policy, the agreement was developed with little prior political debate, which was even less intense than that on GATT. The parliamentary function of controlling the government should be reaffirmed in Spain.

La opacidad de los acuerdos generales de bienes y servicios en España / Opacity of general agreements on goods and services in Spain

Objetivo: Explorar la intensidad del debate parlamentario sobre el Acuerdo General de Comercio de Servicios (AGCS) asumido por España ante la Organización Mundial del Comercio (OMC), y compararla con la del Acuerdo General de Bienes (GATT). Métodos: Búsqueda sistemática y análisis del contenido de todas las iniciativas parlamentarias sobre AGCS y GATT realizadas entre 1979 y 2004 en el Congreso de los Diputados y el Senado. Se calculó la frecuencia y porcentaje de iniciativas parlamentarias de ambos temas, resultado de su tramitación y tipo de iniciativa. Resultados: Se presentaron 185 iniciativas parlamentarias sobre los acuerdos multilaterales de bienes y servicios, de las que 120 se referían al GATT, 8 al AGCS y 57 a ambos acuerdos. La mayoría de las iniciativas no fueron discutidas (GATT, 71%; GATS, 55,4%) o estuvieron sujetas a un debate político en el que apenas se dieron intervenciones por parte de los grupos parlamentarios. Conclusiones: A pesar de las implicaciones del acuerdo multilateral de servicios para la política sanitaria española, éste se ha asumido con escaso debate parlamentario previo, incluso menos que en el caso de su homólogo sobre bienes. Se requiere en este tema una intensificación de la función de control al gobierno

Objective: To explore the intensity of the debate in the Spanish Parliament on the General Agreement on Trade in Services (GATS) developed by Spain and the World Trade Organization, and to compare it with the debate on the General Agreement on Tariffs and Trade (GATT). Methods: A systematic search and content analysis were performed of all parliamentary initiatives on GATS and GATT undertaken from 1979 to 2004 in the Spanish Parliament and Senate. The frequency and percentages of initiatives on both issues were calculated, and the final result and kinds of initiative were analyzed. Results: A total of 185 initiatives were presented in the Spanish Parliament on these agreements, of which 120 were on GATT, 8 were on GATS and 57 were on both agreements. Most of these initiatives were not discussed in parliament (GATT, 71%; GATS, 55.4%) or were the subject of political debate with low participation among parliamentary groups. Conclusions: Despite the implications of the GATS for Spanish health policy, the agreement was developed with little prior political debate, which was even less intense than that on GATT. The parliamentary function of controlling the government should be reaffirmed in Spain

[Gender systems and/in the Spanish National Health Interview Survey]. / Los sistemas de género y/en la Encuesta Nacional de Salud.

OBJECTIVE: To analyze the Spanish National Health Interview Survey (NHIS) from a gender perspective, with special emphasis on gender division of labor. METHOD: We analyzed the 2003 Spanish NHIS from the perspective of the levels of gender observation, with gender understood as: a) the basis of social norms (responsibilities by sex, health risks, and problems related to masculine/feminine roles); b) the organizer of the social structure: gender division of labor, work overload, vertical/horizontal segregation, time spent in activities according to social times, access to resources), and c) a component of individual identity (conflicts due to multiple roles, body image dissatisfaction, self-esteem, self-perceived recognition of the work performed, assimilation of the sexual gender role, sex differences in health conditions). RESULTS: The Spanish NHIS is centered on the main provider, referred to in masculine grammatical form. Gender division of domestic labor is identified only by a general question. When using the concept of main activity for productive or reproductive work, the survey requires respondents to evaluate them and select only one, thus losing information and hampering analysis of the impact of an overload of work on health. Information on time used for reproductive work and leisure is not solicited. Assaults (intentional) and accidents (non-intentional) are combined in the same question, thus preventing research on gender-related violence. CONCLUSIONS: The Spanish NHIS includes the variable of sex, but its more descriptive than analytic focus limits gender analysis. The survey allows specific circumstances of employment-related inequalities between sexes to be measured, but does not completely allow other indicators of gender inequalities, such as the situation of housewives or work overload, to be measured.

[The challenge to public health of the Millenium Development Goals: an approach from political epidemiology]. / El reto para la salud pública de los Objetivos de Desarrollo del Milenio: un enfoque desde la epidemiología política.

The Millennium Development Goals, and within these the Millennium Targets, constitute a working plan that strives to achieve basic goals within the field of health, eradicate poverty, and ensure compliance with basic human rights. Its scope of action represents a historic breakthrough as a step toward a possible global social policy, in which cooperation between the different sectors is essential for its efficiency. Due to its multidisciplinary nature, public health, as well as political epidemiology, can be used to help increase scientific knowledge in the field of health with respect to the Millennium Development Goals. Despite the opportunity that this international agreement provides, insufficient in-depth study has been carried out on the potential -mainly political- difficulties that could arise during its implementation. Therefore, a conceptual and methodological change is required so that concern does not simply center on social determinants of health but instead takes into consideration the political reasons behind them. To reduce inequality, not only must injustice be classified but effective ways must also be found to encourage institutions with political power to take part in this initiative.