Health equity in Somalia? An evaluation of the progress made from 2006 to 2019 in reducing inequities in maternal and newborn health.

BACKGROUND: Every human being has the right to affordable, high-quality health services. However, mothers and children in wealthier households worldwide have better access to healthcare and lower mortality rates than those in lower-income ones. Despite Somalia's fragile health system and the under-5 mortality rate being among the highest worldwide, it has made progress in increasing reproductive, maternal, and child health care coverage. However, evidence suggests that not all groups have benefited equally. We analysed secondary 2006 and 2018-19 data to monitor disparities in reproductive, maternal, and child health care in Somalia. METHODS: The study's variables of interest are the percentage of contraceptive prevalence through modern methods, adolescent fertility rate, prenatal care, the rate of births attended by midwives, the rate of births in a health care facility, the rate of early initiation of breastfeeding, stunting and wasting prevalence and care-seeking for children under-five. As the outcome variable, we analysed the under-five mortality rate. Using reliable data from secondary sources, we calculated the difference and ratio of the best and worst-performing groups for 2006 and 2018-19 in Somalia and measured the changes between the two. RESULTS: Between 2006 and 2018-19, An increase in the difference between women with high and low incomes was noticed in terms of attended labours. Little change was noted regarding socioeconomic inequities in breastfeeding. The difference in the stunting prevalence between the highest and lowest income children decreased by 20.5 points, and the difference in the wasting prevalence of the highest and the lowest income children decreased by 9% points. Care-seeking increased by 31.1% points. Finally, although under-five mortality rates have decreased in the study period, a marked income slope remains. CONCLUSIONS: The study's findings indicate that Somalia achieved significant progress in reducing malnutrition inequalities in children, a positive development that may have also contributed to the decrease in under-five mortality rate inequities also reported in this study. However, an increase in inequalities related to access to contraception and healthcare for mothers is shown, as well as for care-seeking for sick children under the age of five. To ensure that all mothers and children have equal access to healthcare, it is crucial to enhance efforts in providing essential quality healthcare services and distributing them fairly and equitably across Somalia.

Population health trends and disease profile in Somalia 1990-2019, and projection to 2030: will the country achieve sustainable development goals 2 and 3?

OBJECTIVES: This study aims to evaluate whether Somalia will reach Sustainable Development Goals 2 and 3 by 2030 and what the country requires to advance closer to these objectives. SETTING: Somalia. PARTICIPANTS: We carried out analyses of secondary data obtained from the following open-access databases: Global Burden of Disease 2019 study; United Nations (UN) Department of Economic and Social Affairs Population Division; World Bank World Development Indicators; United Nations Children's Fund (UNICEF); UNICEF/World Health Organisation (WHO)/World Bank Joint Child Malnutrition Estimates; and UN Interagency Group for Child Mortality Estimation (UN IGME), disaggregated by sex. PRIMARY OUTCOME MEASURES: stillbirth, neonatal, infant, under-five, maternal and child mortality; under-five malnutrition; life expectancy; health-adjusted life expectancy; age-standardised all-cause mortality; age-standardised cause-specific mortality for the leading causes of death; disability-adjusted life years. SECONDARY OUTCOME MEASURES: vitamin A coverage; stunting, overweight in children under 5; top risk factors contributing to cause-specific mortality. RESULTS: life expectancy in Somalia will increase to 65.42 years (95% UI 62.30-68.54) for females and 58.54 years (95% UI 54.89-62.19) for males in 2030. Stunting will continue to decline to 25.2% (90% UI 13.9-39.5%), and the under-five mortality rate will drop to 85.9 per 1000 live births (90% UI 22.0-228.1 per 1000 live births) for females and 96.4 per 1000 live births (90% UI 24.8-255.3 per 1000 live births) for males in 2030. This study's analyses predict that the maternal mortality ratio in Somalia will decline to 696.42 deaths per 100,000 live births in 2030. CONCLUSIONS: there has been progress towards SDG targets in Somalia since 1990. To achieve these, Somalia requires greater health improvements than observed between 1990 and 2019.

Socioeconomic Inequalities in Chronic Liver Diseases and Cirrhosis Mortality in European Urban Areas before and after the Onset of the 2008 Economic Recession.

OBJECTIVE: To analyse the trends in chronic liver diseases and cirrhosis mortality, and the associated socioeconomic inequalities, in nine European cities and urban areas before and after the onset of the 2008 financial crisis. METHODS: This is an ecological study of trends in three periods of time: two before (2000-2003 and 2004-2008), and one after (2009-2014) the onset of the economic crisis. The units of analysis were the geographical areas of nine cities or urban areas in Europe. We analysed chronic liver diseases and cirrhosis standardised mortality ratios, smoothing them with a hierarchical Bayesian model by each city, area, and sex. An ecological regression model was fitted to analyse the trends in socioeconomic inequalities, and included the socioeconomic deprivation index, the period, and their interaction. RESULTS: In general, chronic liver diseases and cirrhosis mortality rates were higher in men than in women. These rates decreased in all cities during the financial crisis, except among men in Athens (rates increased from 8.50 per 100,000 inhabitants during the second period to 9.42 during the third). Socioeconomic inequalities in chronic liver diseases and cirrhosis mortality were found in six cities/metropolitan areas among men, and in four among women. Finally, in the periods studied, such inequalities did not significantly change. However, among men they increased in Turin and Barcelona and among women, several cities had lower inequalities in the third period. CONCLUSIONS: There are geographical socioeconomic inequalities in chronic liver diseases and cirrhosis mortality, mainly among men, that did not change during the 2008 financial crisis. These results should be monitored in the long term.

Socio-economic inequalities on cancer mortality in nine European areas: The effect of the last economic recession.

BACKGROUND: The effect of inequalities aggravated by economic recessions in the mortality rates of certain diseases has been previously described. In this study, we analyzed the relationship between socio-economic deprivation and cancer mortality. We focused on lung, colon, prostate, and breast cancers in nine European urban areas over three periods: two before (2000-2003 and 2004-2008) and one after (2009-2014) the onset of the 2008 financial crisis. METHODS: This is an ecological study of trends. The units of analysis were small areas within nine European urban areas. We used a composite deprivation index as a socio-economic indicator. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyze the evolution of socio-economic inequalities, we fitted an ecological regression model that included the socio-economic indicator, the period of time, and the interaction between these terms. RESULTS: In men, socio-economic inequalities in all-cancer and lung cancer mortality were observed in most of the cities studied, but did not increase after the onset of the economic crisis. In women, only two cities (Stockholm and London) showed socio-economic inequalities in all-cancer and lung cancer mortality; there was also no increase in inequalities. CONCLUSIONS: Our results did not validate our hypothesis that inequalities increase in times of crisis. However, they emphasize the importance of socio-economic measurements for understanding mortality inequalities, and can be used to inform prevention strategies and help plan local health programs aimed at reducing health inequalities.

Effect of the recent economic crisis on socioeconomic inequalities in mortality in nine urban areas in Europe / Efecto de la reciente crisis económica en las desigualdades socioeconómicas en la mortalidad en nueve áreas urbanas europeas

OBJECTIVE: To analyse socioeconomic inequalities in all-cause mortality among men and women in nine European urban areas during the recent economic crisis, and to compare the results to those from two periods before the crisis. METHOD: This is an ecological study of trends based on three time periods (2000-2003, 2004-2008 and 2009-2014). The units of analysis were the small areas of nine European urban areas. We used a composite deprivation index as a socioeconomic indicator, along with other single indicators. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyse the evolution of socioeconomic inequalities, we fitted an ecological regression model that included the socioeconomic indicator, the period of time, and the interaction between these terms. RESULTS: We observed significant inequalities in mortality among men for almost all the socioeconomic indicators, periods, and urban areas studied. However, no significant changes occurred during the period of the economic crisis. While inequalities among women were less common, there was a statistically significant increase in inequality during the crisis period in terms of unemployment and the deprivation index in Prague and Stockholm, respectively. CONCLUSIONS: Future analyses should also consider time-lag in the effect of crises on mortality and specific causes of death, and differential effects between genders

OBJETIVO: Analizar las desigualdades socioeconómicas en la mortalidad por todas las causas en hombres y mujeres de nueve áreas urbanas europeas durante la reciente crisis económica, y comparar los resultados con dos periodos previos a la crisis. MÉTODO: Estudio ecológico de tendencias basado en tres periodos (2000-2003, 2004-2008 y 2009-2014). Las unidades de análisis fueron las áreas pequeñas de nueve zonas urbanas europeas. Se utilizaron un índice compuesto de privación socioeconómica como indicador socioeconómico y otros indicadores simples. Como indicador de mortalidad se usó la razón de mortalidad estandarizada suavizada, calculada utilizando el modelo jerárquico bayesiano propuesto por Besag, York y Mollié. Para analizar la evolución de las desigualdades socioeconómicas se utilizó un modelo de regresión ecológico que incluía el indicador socioeconómico, el periodo y la interacción de ambos. RESULTADOS: Se observaron desigualdades significativas en la mortalidad en los hombres para casi todos los indicadores socioeconómicos, periodos y áreas urbanas. Sin embargo, no hubo cambios significativos en las desigualdades en el periodo de crisis. Aunque las desigualdades entre las mujeres fueron menos comunes, hubo un incremento significativo en las desigualdades en mortalidad en el periodo de crisis en términos de desempleo y del índice de privación en Praga y Estocolmo, respectivamente. CONCLUSIONES: Futuros análisis deberán tener en cuenta el tiempo transcurrido entre la crisis y su efecto en la mortalidad, así como diferentes causas de mortalidad y el efecto diferencial entre géneros

Effect of the recent economic crisis on socioeconomic inequalities in mortality in nine urban areas in Europe.

OBJECTIVE: To analyse socioeconomic inequalities in all-cause mortality among men and women in nine European urban areas during the recent economic crisis, and to compare the results to those from two periods before the crisis. METHOD: This is an ecological study of trends based on three time periods (2000-2003, 2004-2008 and 2009-2014). The units of analysis were the small areas of nine European urban areas. We used a composite deprivation index as a socioeconomic indicator, along with other single indicators. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyse the evolution of socioeconomic inequalities, we fitted an ecological regression model that included the socioeconomic indicator, the period of time, and the interaction between these terms. RESULTS: We observed significant inequalities in mortality among men for almost all the socioeconomic indicators, periods, and urban areas studied. However, no significant changes occurred during the period of the economic crisis. While inequalities among women were less common, there was a statistically significant increase in inequality during the crisis period in terms of unemployment and the deprivation index in Prague and Stockholm, respectively. CONCLUSIONS: Future analyses should also consider time-lag in the effect of crises on mortality and specific causes of death, and differential effects between genders.

Evaluation of data availability on population health indicators at the regional level across the European Union.

BACKGROUND: The ability to measure regional health inequalities across Europe and to build adequate population health indices depends significantly on the availability of reliable and comparable data at the regional level. Within the scope of the EU-funded project EURO-HEALTHY, a Population Health Index (PHI) was built. This model aggregates 39 indicators considered relevant by experts and stakeholders to evaluate and monitor population health on the regional level within the European Union (269 regions). The aim of this research was to assess the data availability for those indicators. As a subsequent aim, an adequate protocol to overcome issues arising from missing data will be presented, as well as key messages for both national and European statistical authorities meant to improve data collection on population health. METHODS: The methodology for the study includes three consecutive phases: (i) assessing the data availability for the respective indicators at the regional level for the last year available (ii) applying a protocol for missing data and completing the database and (iii) developing a scoring system ranging from 0 (no data available; worst) to 1 (all data available; best) to evaluate the availability of data by indicator and EU region. RESULTS: Although the missing data on the set of the PHI indicators was significant, the mean availability score for the EURO-HEALTHY PHI indicators is 0.8 and the regional availability score is 0.7, which reveal the strength of the indicators as well as the data completeness protocol for missing data. CONCLUSIONS: This study provides a comprehensive data availability assessment for population health indicators from multiple areas of concern, at the EU regional level. The results highlight that the data completeness protocol and availability scores are suitable tools to apply on any indicator's data source mapping. It also raises awareness to the urgent need for sub-national data in several domains and for closing the data gaps between and within countries. This will require policies clearly focused on improving equity between regions and a coordinated effort from the producers of data (the EU28 national statistics offices and EUROSTAT) and the stakeholders who design policies at EU, regional and local level.

Does adiposity mediate the relationship between socioeconomic position and non-allergic asthma in childhood?

BACKGROUND: Despite its high prevalence, early onset and chronic nature, the causes of asthma are not clearly established. The present study examined a plausible but untested relationship in the development of non-allergic asthma; an asthma phenotype closely linked to deprivation and other preventable risk factors. Our aim was to determine the mediating role of adiposity in the relationship between socioeconomic position in infancy and non-allergic asthma emergence in mid-childhood. METHODS: To estimate the causal indirect effect of adiposity we applied the parametric g-computational procedure to 6203 singleton children from the UK Millennium Cohort Study. Adiposity was measured at age 7 by body mass index, waist circumference and waist circumference-to-height ratio. Children who developed non-allergic asthma between the age of 7 and 14 were compared with children without allergies or allergic asthma at these ages. RESULTS: We found no evidence to suggest that adiposity is a mediator in the relationship between socioeconomic position and the development of non-allergic asthma in mid-childhood. After adjustment for risk factors, the direct effect of socioeconomic position remained; children in the lowest tertile of socioeconomic position had a 43% (OR 1.43, 95% CI 1.38 to 1.49) greater odds of developing non-allergic asthma compared with the highest tertile. CONCLUSIONS: Adiposity at age 7 does not mediate the relationship between socioeconomic position and non-allergic asthma. The results suggest that improving socioeconomic conditions and promoting healthy weight are both important in reducing the development of non-allergic asthma in early to mid-childhood.

Mother's education and offspring asthma risk in 10 European cohort studies.

Highly prevalent and typically beginning in childhood, asthma is a burdensome disease, yet the risk factors for this condition are not clarified. To enhance understanding, this study assessed the cohort-specific and pooled risk of maternal education on asthma in children aged 3-8 across 10 European countries. Data on 47,099 children were obtained from prospective birth cohort studies across 10 European countries. We calculated cohort-specific prevalence difference in asthma outcomes using the relative index of inequality (RII) and slope index of inequality (SII). Results from all countries were pooled using random-effects meta-analysis procedures to obtain mean RII and SII scores at the European level. Final models were adjusted for child sex, smoking during pregnancy, parity, mother's age and ethnicity. The higher the score the greater the magnitude of relative (RII, reference 1) and absolute (SII, reference 0) inequity. The pooled RII estimate for asthma risk across all cohorts was 1.46 (95% CI 1.26, 1.71) and the pooled SII estimate was 1.90 (95% CI 0.26, 3.54). Of the countries examined, France, the United Kingdom and the Netherlands had the highest prevalence's of childhood asthma and the largest inequity in asthma risk. Smaller inverse associations were noted for all other countries except Italy, which presented contradictory scores, but with small effect sizes. Tests for heterogeneity yielded significant results for SII scores. Overall, offspring of mothers with a low level of education had an increased relative and absolute risk of asthma compared to offspring of high-educated mothers.

Interventions to reduce inequalities in health and early child development in Europe from a qualitative perspective.

BACKGROUND: Early childhood is a critical stage of development. Inequalities in experiences affect children's wellbeing and determine their development. Early years interventions focusing on children and their parents may help address inequalities during this critical period. Understanding the experiences and perceptions of parents receiving early years programmes and staff providing these may help service development and delivery. The objective of this study was to describe staff and parents' accounts of how early childhood programmes in different European country contexts improved child development. METHODS: Five early years programmes were selected using pre-set criteria out of ten proposed ones. Twenty-five individual interviews and six focus groups were carried out with staff running interventions and with users, children and their families in different EU countries. Investigations of the studies were carried out using qualitative research methods. Data were collected by collaborating partner institutions included in the project. RESULTS: Participants described programmes which aimed to provide activities to stimulate children's learning through structured play and which provided support and assistance for parents. In these, parents were actively involved in activities. Parents and staff referred to establishing long-term trust based relationships as a key element for programmes to improve parents' self-esteem and reduce their stress levels which in turn helped improve their children's development. CONCLUSIONS: Programmes described by staff as being successful, delivered services tailored to parents and their children. Adapting to and understanding the families' circumstances and involving parents was seen by staff as important. Staff also described establishing trust based relationships as a key enabler in programme delivery; their perceptions were that parents should be empowered to develop their own capacities thus strengthening their abilities to assist in their children's learning, which had a positive effect on children.

Impact of Low Maternal Education on Early Childhood Overweight and Obesity in Europe.

BACKGROUND: Comparable evidence on adiposity inequalities in early life is lacking across a range of European countries. This study investigates whether low maternal education is associated with overweight and obesity risk in children from distinct European settings during early childhood. METHODS: Prospective data of 45 413 children from 11 European cohorts were used. Children's height and weight obtained at ages 4-7 years were used to assess prevalent overweight and obesity according to the International Obesity Task Force definition. The Relative/Slope Indices of Inequality (RII/SII) were estimated within each cohort and by gender to investigate adiposity risk among children born to mothers with low education as compared to counterparts born to mothers with high education. Individual-data meta-analyses were conducted to obtain aggregate estimates and to assess heterogeneity between cohorts. RESULTS: Low maternal education yielded a substantial risk of early childhood adiposity across 11 European countries. Low maternal education yielded a mean risk ratio of 1.58 (95% confidence interval (CI) 1.34, 1.85) and a mean risk difference of 7.78% (5.34, 10.22) in early childhood overweight, respectively, measured by the RII and SII. Early childhood obesity risk by low maternal education was as substantial for all cohorts combined (RII = 2.61 (2.10, 3.23)) and (SII = 4.01% (3.14, 4.88)). Inequalities in early childhood adiposity were consistent among boys, but varied among girls in a few cohorts. CONCLUSIONS: Considerable inequalities in overweight and obesity are evident among European children in early life. Tackling early childhood adiposity is necessary to promote children's immediate health and well-being and throughout the life course.

Perceptions and beliefs of public policymakers in a Southern European city.

INTRODUCTION: Socio-economic inequalities in health are large in urban areas; however, local municipal governments may plan, manage and provide services and policies which can reduce these. The objective of this study was to describe the beliefs and perceptions of public policymakers in a European city, Barcelona. They are the key actors in designing and implementing urban public policies. METHODS: A qualitative research study describing policymakers' beliefs on health inequalities. The study population were twelve policymakers. These were politicians or officers from the city council. Informant profiles were selected using a theoretical sample. Semi-structured individual interviews were performed to collect the data and a thematic content analysis was carried out. RESULTS: Politicians were aware of health inequalities in their city and identified diverse social causes. They viewed reducing inequalities as a priority for the city's government. Officers were less knowledgeable and described less efforts in addressing health inequalities. It was stated by some that reducing inequalities in non-health sectors helped to reduce health inequalities indirectly and there was some collaboration between two sectors. The most frequent barriers encountered when implementing policies were funding and the cities' limited authority. CONCLUSIONS: Officers and policymakers had different levels of awareness and access to information on health and its social determinants. Officers referred to specific causes of health inequalities and policies which related to their sectors and politicians were more familiar with upstream determinants and policies. Some participants explained that policies and programmes needed to be evaluated and very little intersectoral action was said to be carried out. More efforts should be made to provide all policymakers with information on the social determinants of health inequalities. Research on health inequalities and policy should engage with policymakers and promote health as a cross cutting issue in the city council in liaison with the third sector.

Mother's education and the risk of preterm and small for gestational age birth: a DRIVERS meta-analysis of 12 European cohorts.

BACKGROUND: A healthy start to life is a major priority in efforts to reduce health inequalities across Europe, with important implications for the health of future generations. There is limited combined evidence on inequalities in health among newborns across a range of European countries. METHODS: Prospective cohort data of 75 296 newborns from 12 European countries were used. Maternal education, preterm and small for gestational age births were determined at baseline along with covariate data. Regression models were estimated within each cohort and meta-analyses were conducted to compare and measure heterogeneity between cohorts. RESULTS: Mother's education was linked to an appreciable risk of preterm and small for gestational age (SGA) births across 12 European countries. The excess risk of preterm births associated with low maternal education was 1.48 (1.29 to 1.69) and 1.84 (0.99 to 2.69) in relative and absolute terms (Relative/Slope Index of Inequality, RII/SII) for all cohorts combined. Similar effects were found for SGA births, but absolute inequalities were greater, with an SII score of 3.64 (1.74 to 5.54). Inequalities at birth were strong in the Netherlands, the UK, Sweden and Spain and marginal in other countries studied. CONCLUSIONS: This study highlights the value of comparative cohort analysis to better understand the relationship between maternal education and markers of fetal growth in different settings across Europe.

Systematic review of parenting interventions in European countries aiming to reduce social inequalities in children's health and development.

BACKGROUND: Early child development influences many aspects of wellbeing, health, competence in literacy and numeracy, criminality, and social and economic participation throughout the life course. Children from disadvantaged groups have less possibilities of achieving full development. By providing a positive start for all children across the social gradient, improved developmental outcomes will be seen during later childhood and throughout their lives. The objective of this systematic review was to identify interventions during early childhood in countries from the World Health Organisation European Region in 1999-2013 which reduced inequalities in children's health and development. METHODS: A systematic review was carried out adhering to the PRISMA guidelines. The review examined universal, targeted and proportionate universalism interventions, programs and services using an electronic search strategy in PubMed and the International Bibliography of the Social Sciences [IBSS] databases. A further search was performed in the grey literature. Interventions were included only if they were aimed at children or their parents and had been evaluated. RESULTS: We identified 23 interventions in total: 6 in the PubMed data base, 5 in IBSS and 12 in grey literature. All but 1 intervention-delivered in Sweden-were carried out in the United Kingdom and the Republic of Ireland. These aimed to improve parenting abilities, however, some had additional components such as: day-care provision, improving housing conditions and speech or psychological therapies. Programmes offering intensive support, information and home visits using a psycho-educational approach and aimed at developing parent's and children's skills showed more favourable outcomes. These were parenting behaviours, overall children's health and higher level of fine motor skills and cognitive functioning. Child injuries and abuse were also reduced. Two interventions were universally proportionate and all others were aimed at a specific target population. CONCLUSIONS: Interventions with better outcomes and a higher level of evidence combined workshops and educational programmes for both parents and children beginning during early pregnancy and included home visits by specialised staff. Further evaluation and publication of early years interventions should be carried out also within a wider range of countries than just the UK and Ireland.

Social inequalities in early childhood health and development: a European-wide systematic review.

The evidence examining the relationship between specific social factors and early childhood health and developmental outcomes has never been systematically collated or synthesized. This review aims to identify the key social factors operating at the household, neighborhood, and country levels that drive inequalities in child health and development. Medline and CHICOS (a European child-cohort inventory) were systematically searched to identify all European studies published within the past 10 y. 13,270 Medline articles and 77 European child cohorts were searched, identifying 201 studies from 32 European countries. Neighborhood deprivation, lower parental income/wealth, educational attainment, and occupational social class, higher parental job strain, parental unemployment, lack of housing tenure, and household material deprivation were identified as the key social factors associated with a wide range of adverse child health and developmental outcomes. Similar association trends were observed across most European countries, with only minor country-level differences. Multiple adverse social factors operating at both the household and neighborhood levels are independently associated with a range of adverse health and developmental outcomes throughout early childhood. The social gradient in health and developmental outcomes observed throughout the remaining life course may be partly explained by gradients initiated in early childhood.

Health inequalities in European cities: perceptions and beliefs among local policymakers.

OBJECTIVE: To describe the knowledge and beliefs of public policymakers on social inequalities in health and policies to reduce them in cities from different parts of Europe during 2010 and 2011. DESIGN: Phenomenological qualitative study. SETTING: 13 European cities. PARTICIPANTS: 19 elected politicians and officers with a directive status from 13 European cities. MAIN OUTCOME: Policymaker's knowledge and beliefs. RESULTS: Three emerging discourses were identified among the interviewees, depending on the city of the interviewee. Health inequalities were perceived by most policymakers as differences in life-expectancy between population with economic, social and geographical differences. Reducing health inequalities was a priority for the majority of cities which use surveys as sources of information to analyse these. Bureaucracy, funding and population beliefs were the main barriers. CONCLUSIONS: The majority of the interviewed policymakers gave an account of interventions focusing on the immediate determinants and aimed at modifying lifestyles and behaviours in the more disadvantaged classes. More funding should be put towards academic research on effective universal policies, evaluation of their impact and training policymakers and officers on health inequalities in city governments.

Municipal interventions against inequalities in health: The view of their managers.

BACKGROUND: European city councils are increasingly developing interventions against health inequalities. There is little knowledge about how they are perceived. This study describes and analyses good practices and challenges for local interventions on inequalities in health through the narratives of European city managers. METHODS: A qualitative study was conducted. Each participating city (Amsterdam, Barcelona, Cluj-Napoca, Helsinki, Lisbon, London, Madrid, Rotterdam) selected interventions following these criteria: at least 6 months of implementation; an evaluation performed or foreseen; the reduction of health inequalities among their objectives, and only one of the interventions selected could be based on health care. Managers of these local interventions were interviewed following an outline. Eleven individual in-depth interviews describing nine local interventions were obtained. A thematic content analysis was performed. RESULTS: One or more local interventions against health inequalities were identified in each city. Most relied on quantitative data and were linked to national strategies. Few interventions addressed socio-economic determinants. Health care, employment and education were the main determinants addressed. With variable depth, evidence-base, participation and intersectorality were regular components of the interventions. Half of them targeted the city and half some deprived neighbourhoods. Few interventions had been evaluated. Scarcity of funding and sustainability of the projects were the main perceived barriers by the managers. CONCLUSIONS: City intervention managers were familiar with health inequalities and concepts as intersectorality, participation and evidence-based action, but others such as socioeconomic aims, gradient approach, evaluation and sustainability were not so widely applied. Managers' capacities and political leadership in governance for health should be reinforced.

El proyecto Ineq-Cities de investigación en desigualdades urbanas en salud: diseminación y transferencia de conocimiento en España / The Ineq-Cities research project on urban health inequalities: knowledge dissemination and transfer in Spain

El proyecto Ineq-Cities analizó en 16 ciudades europeas las desigualdades en mortalidad en áreas pequeñas y describió intervenciones para reducir las desigualdades en salud. Esta nota de campo describe la diseminación del proyecto en España. De acuerdo con las recomendaciones del proyecto, se pretendió trasladar a actores clave, principalmente personas técnicas y responsables municipales y agentes sociales locales, algunos de los resultados, junto a una introducción a las desigualdades urbanas en salud y las estrategias para abordarlas. Se realizaron 24 talleres a los que asistieron más de 350 profesionales de 92 municipios, un libro-resumen, tres artículos en medios no especializados, una propuesta de moción municipal y actividades de difusión en redes sociales. Los receptores lo valoraron positivamente y destacaron la necesidad de sistematizar estos productos. Este proceso puede haber contribuido a la inclusión de las desigualdades en salud en la agenda política y a la capacitación del personal técnico para afrontarlas (AU)

The Ineq-Cities project analyzed inequalities in mortality in small areas and described interventions to reduce inequalities in health in 16 European cities. This field note describes the dissemination of the project in Spain. In accordance with the recommendations of the project, the objective was to translate relevant results to key stakeholders - mainly technical staff, municipal officers and local social agents - and to provide an introduction to urban inequalities in health and strategies to address them. Twenty-four workshops were given, attended by more than 350 professionals from 92 municipalities. Knowledge dissemination consisted of the publication of a short book on inequalities in health and the approach to this problem in cities and three articles in nonspecialized media, a proposal for a municipal motion, and knowledge dissemination activities in social networks. Users rated these activities highly and stressed the need to systematize these products. This process may have contributed to the inclusion of health inequalities in the political agenda and to the training of officers to correct them (AU)

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.

Socioeconomic inequalities in mortality in 16 European cities.

AIMS: To explore inequalities in total mortality between small areas of 16 European cities for men and women, as well as to analyse the relationship between these geographical inequalities and their socioeconomic indicators. METHODS: A cross-sectional ecological design was used to analyse small areas in 16 European cities (26,229,104 inhabitants). Most cities had mortality data for a period between 2000 and 2008 and population size data for the same period. Socioeconomic indicators included an index of socioeconomic deprivation, unemployment, and educational level. We estimated standardised mortality ratios and controlled for their variability using Bayesian models. We estimated relative risk of mortality and excess number of deaths according to socioeconomic indicators. RESULTS: We observed a consistent pattern of inequality in mortality in almost all cities, with mortality increasing in parallel with socioeconomic deprivation. Socioeconomic inequalities in mortality were more pronounced for men than women, and relative inequalities were greater in Eastern and Northern European cities, and lower in some Western (men) and Southern (women) European cities. The pattern of excess number of deaths was slightly different, with greater inequality in some Western and Northern European cities and also in Budapest, and lower among women in Madrid and Barcelona. CONCLUSIONS: In this study, we report a consistent pattern of socioeconomic inequalities in mortality in 16 European cities. Future studies should further explore specific causes of death, in order to determine whether the general pattern observed is consistent for each cause of death.