Inequities in hospitalisation in a South European country: Lessons learned from the last European recession.

In Spain, regional health systems (universal access) depend on each Autonomous Communities (ACs). The management of the 2008 economic crisis has been different in the ACs, which may have led to an increase in inequities in the use of health services. The objective of this study was to analyse the impact of individual and regional characteristics on public hospitalisation inequities in Spain for the period 2003-2017. We developed a repeated cross-sectional study through Spanish National Health Surveys (2003, 2006, 2011 and 2017) and the Spanish European Health Survey (2014; n = 118,499 subjects). Multilevel and Oaxaca decomposition analyses were conducted to analyse the effect of individual and regional factors in hospitalisation inequities. The results showed that the prevalence of hospitalisation was higher for women (2003: 11.2%; 2017: 9.0%) than for men (2003: 10.7%; 2017: 8.8%) and it decreased with time. Multilevel analyses showed that, after adjustment for variables related to healthcare demand, there were inequities in the probability of hospitalisation, mainly in women. The decomposition analyses showed a higher effect of the number of hospital beds available on hospitalisation in men than in women. There is a direct relationship between the number of hospital beds and the probability of hospitalisation in both sexes. In conclusion, a progressive decrease in hospitalisation use was observed in Spain in the context of the economic recession. Individual-level and regional-level factors were associated with hospitalisation inequities. It is necessary to guarantee equitable access to health services according to the need even in recession times.

The use of health care services in the Great Recession: evaluating inequalities in the Spanish context / El uso de los servicios sanitarios durante la Gran Recesión: evaluación de las desigualdades en el contexto español

OBJECTIVE: To analyse the effect of the Great Recession (2008) on primary care (PC) and secondary care (SC) inequalities in Spain. METHOD: Repeated cross-sectional study using Spanish Health Surveys from 2001 to 2017 (n=139,566). Prevalence of PC and SC utilization were calculated standardized by age. Chi square tests for trend were conducted to explore the evolution. We performed logistic regression analyses adjusted by the Andersen's model of demand for care to explore inequalities prior to, during and following the recession. All the analyses were stratified by sex. RESULTS: Healthcare use trends changed from a rapid increase in the pre-recession period to a plateau during the recession and a decrease in the post-recession period. Healthcare use was higher in women (PC: 15.8% to 32.5%; SC: 8.2% to 16.2%) than in men (PC: 11.3% to 24.1%; SC: 5.4% to 11.6%) and the gender gap increased. During the recession the likelihood of PC use was higher in disadvantaged groups, while SC had greater usage amongst more advantaged social groups. Inequalities in SC use increased during the recession and could not be attributed to factors of need. CONCLUSIONS: Healthcare use trends changed as a result of the recession. There are socioeconomic inequalities in the use of PC and SC in Spain, which increased in secondary care, during the recession and in the post-recession period. It is necessary to take into account socioeconomic determinants in health planning, in order to achieve equity in healthcare services

OBJETIVO: Analizar el efecto de la Gran Recesión en las desigualdades en el uso de atención primaria (AP) y atención especializada (AE) en España. MÉTODO: Análisis transversal repetido (Encuestas Nacionales de Salud 2001-2017; n=139.566). Se calcularon las prevalencias de utilización estandarizadas por edad y se realizó el cálculo de tendencias para explorar la evolución. Se llevaron a cabo análisis de regresión logística ajustados por el Modelo de demanda asistencial de Andersen para estudiar las desigualdades en los periodos anterior, durante y posterior a la crisis. Todos los análisis se estratificaron por sexo. RESULTADOS: La tendencia en la utilización de los servicios sanitarios pasó de un rápido incremento en el periodo anterior a la crisis a una estabilización durante la crisis y un posterior descenso. La utilización de los servicios sanitarios fue mayor en las mujeres (AP: 15,8% a 32,5%; AE: 8,2% a 16,2%) que en los hombres (AP: 11,3% a 24,1%; AE: 5,4% a 11,6%), aumentando las diferencias. Durante la crisis, la probabilidad de usar la AP fue mayor en los grupos más desfavorecidos, mientras que en la AE se observa la tendencia contraria. Las desigualdades en la AE aumentaron durante la recesión, pero ello no puede atribuirse a factores de necesidad. CONCLUSIONES: La tendencia de la utilización de los servicios sanitarios cambió en la Gran Recesión. Existen desigualdades en la utilización de servicios sanitarios en España, que han aumentado en AE durante el periodo de crisis y poscrisis. Es necesario considerar los factores socioeconómicos en planificación sanitaria con el fin de lograr la equidad

The use of health care services in the Great Recession: evaluating inequalities in the Spanish context.

OBJECTIVE: To analyse the effect of the Great Recession (2008) on primary care (PC) and secondary care (SC) inequalities in Spain. METHOD: Repeated cross-sectional study using Spanish Health Surveys from 2001 to 2017 (n=139,566). Prevalence of PC and SC utilization were calculated standardized by age. Chi square tests for trend were conducted to explore the evolution. We performed logistic regression analyses adjusted by the Andersen's model of demand for care to explore inequalities prior to, during and following the recession. All the analyses were stratified by sex. RESULTS: Healthcare use trends changed from a rapid increase in the pre-recession period to a plateau during the recession and a decrease in the post-recession period. Healthcare use was higher in women (PC: 15.8% to 32.5%; SC: 8.2% to 16.2%) than in men (PC: 11.3% to 24.1%; SC: 5.4% to 11.6%) and the gender gap increased. During the recession the likelihood of PC use was higher in disadvantaged groups, while SC had greater usage amongst more advantaged social groups. Inequalities in SC use increased during the recession and could not be attributed to factors of need. CONCLUSIONS: Healthcare use trends changed as a result of the recession. There are socioeconomic inequalities in the use of PC and SC in Spain, which increased in secondary care, during the recession and in the post-recession period. It is necessary to take into account socioeconomic determinants in health planning, in order to achieve equity in healthcare services.

Vigilancia en salud pública: una necesidad inaplazable / Public health surveillance: a pressing need

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Bayesian analysis of the geographical variation of type 1 diabetes mellitus in under 15 yr olds in northeast Spain, 1991-2009.

OBJECTIVE: High variability has been observed in type 1 diabetes mellitus (DM1) incidence rates (IRs) in childhood. The aim of this study was to characterize DM1 in Aragón and to identify variations in the geographical pattern by gender. METHODS: A descriptive and ecological study was conducted to determine geographical variations in the DM1 incidence for the period 1991-2009. The source of information was the registry of DM1. To determine data completeness, a capture-recapture analysis was performed. Cases were georeferenced according to the Basic Healthcare Area (BHA) of residence. IRs for both genders, age group, 5 yr of diagnosis, and 95% confidence intervals (95% CIs) were calculated. Geographical pattern was studied applying Bayesian statistical model. The standardized incidence ratios (SIRs), smoothed SIR, and the posteriori risk probability (PRP) were represented cartographically for BHA stratified by gender. RESULTS: The completeness was 93.5%. The global IR was 19.2 cases/10(5) person-years (95% CI: 17.6-20.8), boys 21.4 (95% CI: 19.0-23.8) and girls 16.8 (95% CI: 14.7-19.1). The age-specific rates were significantly lower in the 0-4 year age group with respect to the groups of 5-9 and 10-14 years. For boys, areas with a statistically significant excess of risk were found in the north [smoothed SIR: 118-167.9 and PRP of what the smoothed SIR would be greater than 100 (PRP) above 0.8] and below average risk in the south (smoothed SIR: 65.9-79.1 and PRP less than 0.2). CONCLUSIONS: DM1 IR presented a north-south geographical pattern in boys. This pattern was not observed in girls or when both genders were considered together. Later studies should include gender as an essential variable.

Evaluation of a health promotion intervention for skin cancer prevention in Spain: the SolSano program.

The incidence of skin cancer is increasing worldwide, and Spain is no exception. SolSano is the first Spanish health education program for sun safety directed at elementary school children. The objective was to evaluate SolSano's effects on students' knowledge, attitudes and practices about sun safety. A non-randomized, before/after, community intervention without control group, with schools as the unit of intervention, was used for the study. Five thousand eight hundred and forty-five children from 215 Aragonese Primary Schools (Grades 1-2) participated in the program in their classes during the 2004-2005 academic year. The educational package contained an activity guide for teachers, a workbook for each pupil, a poster and an informative pamphlet for families. The pre-test and post-test surveys were similar and were composed of two parts: the first part uses the 'Draw and Write research strategy' and the second part was a questionnaire. One thousand five hundred and twenty-two students completed both questionnaires, 49.2% were boys, and the mean age was 6.6; 45.7% self-reported pale skin and easy sunburn and 48% dark skin and rarely sunburn; 72.3% of the children reported having dark hair and eyes, and 51.6% freckles or moles. The mean score for the complete survey significantly increased by 1.55 points (1.38-1.72) after the intervention (p < 0.001), and girls did better than boys. Sunscreens were the most-commonly employed sun protection strategy while strategies such as seeking shadow and wearing clothes exhibited the greatest increase after the SolSano program [percentage increase of 19.3% (16.4-22.3) and 26.8% (23.4-30.3), respectively]. At baseline, 35.8% of children reported sunburns during the previous summer compared with 23.5% after the program. SolSano also achieved a slight reduction in the percentage of students who desired to be tanned. Our study demonstrates that significant knowledge can be acquired, attitudes regarding the healthiness of a tan can be modified and intentions to change sun protection behaviour can be promoted by well-designed educational programs.