Socioeconomic inequalities in COVID-19 incidence during the first six waves in Barcelona.

BACKGROUND: The emergence of SARS-CoV-2 affected urban areas. In Barcelona, six waves of COVID-19 hit the city between March 2020 and March 2022. Inequalities in the incidence of COVID-19 have been described. However, no studies have examined the daily trends of socioeconomic inequalities and how they changed during the different phases of the pandemic. The aim of this study is to analyse the dynamic socioeconomic inequalities in the incidence of COVID-19 during the six waves in Barcelona. METHODS: We examined the proportion of daily cases observed in the census tracts in the lower income tercile compared with the proportion of daily cases observed in the sum of the lower and higher income terciles. Daily differences in these proportions were assessed as a function of the epidemic waves, sex, age group, daily incidence and daily change in the incidence. A logistic regression model with an autoregressive term was used for statistical analysis. RESULTS: A time-dynamic effect was found for socioeconomic inequalities in the incidence of COVID-19. In fact, belonging to a lower-income area changed from being a risk factor (Waves 1, 2, 4 and 5) to being a protective factor in the sixth wave of the pandemic. Age also had a significant effect on incidence, which also changed over the different waves of the pandemic. Finally, the lower-income areas showed a comparatively lower incidence during the ascending phase of the epidemic waves. CONCLUSION: Socioeconomic inequalities in COVID-19 changed by wave, age group and wave phase.

A City Surveillance System for Social Health Inequalities: The Case of Barcelona.

INTRODUCTION: In the past, health inequalities were not prioritised in the political agenda of Barcelona. The change of city government (2015) was an opportunity to develop a Surveillance System for Social Health Inequalities in the city, which is described in this article. METHODS: The design of the Surveillance System formed part of the Joint Action for Health Equity in Europe (JAHEE), funded by the European Union. Various steps were considered by the experts to set up the System: define its objectives, target population, domains and indicators, and sources of information; perform data analysis; implement and disseminate the system; define the evaluation; and perform regular data updates. RESULTS: The System considers the following domains: social determinants of health, health-related with behaviours, use of healthcare, and health outcomes, and includes eight indicators. As axes of inequality, the experts chose sex, age, social class, country of origin, and geographical area. The Surveillance System for Social Health Inequalities is presented on a website including different types of figures. CONCLUSION: The methodology used to implement the Surveillance System can be used to implement similar systems in other urban areas around the world.

Inequalities in life expectancy by educational level and its decomposition in Barcelona, 2004-2018 / Desigualdades en la esperanza de vida por nivel educativo y su descomposición en Barcelona, 2004-2018

Objective: To analyse the gap in life expectancy by educational level in the city of Barcelona from 2004 to 2018 and to decompose this gap by age and causes of death. Method: We computed abridged life tables at the age of 25 years by sex from 2004 to 2018 using standard methods. Educational level was categorised in two groups (lower secondary or less vs. upper secondary or higher education). The life expectancy gap was further decomposed by age and by causes of death based in Arriaga's method in 5-year age blocks up to the age of ≥ 90 years and broad causes of death using ICD-10 codes. Results: The life expectancy gap at 25 years by educational level oscillated without trend at around 3.08 years for men and 1.93 years for women. Decomposition by age showed a favourable significant shift in the contribution to this gap from young to older ages for men, with few changes for women. Decomposition by causes of death showed that the diseases concentrating the largest share of the contribution were neoplasms and respiratory and circulatory disease. There was a significant downward trend in external causes for men and in infectious diseases for both men and women but a significant upward trend for respiratory disease for both sexes. Conclusions: The stability of the life expectancy gap by educational level during the period analysed resulted from a combination of divergent trends by age and causes of death among high and low educational levels. (AU)

Objetivo: Analizar la brecha en la esperanza de vida por nivel educativo en la ciudad de Barcelona desde 2004 hasta 2018, y descomponer esta brecha por edad y causas de muerte. Método: Se calcularon tablas de vida abreviadas a la edad de 25 años por sexo desde 2004 hasta 2018 utilizando métodos estándar. El nivel educativo se clasificó en dos grupos: secundaria inferior o menor frente a secundaria superior o educación superior. La brecha de la esperanza de vida se descompuso además por edad y por causas de muerte según el método de Arriaga en bloques de edad de 5 años hasta la edad de ≥90 años y causas amplias de muerte utilizando los códigos de la CIE-10. Resultados: La brecha de la esperanza de vida a los 25 años por nivel educativo osciló sin tendencia en torno a los 3,08 años para los hombres y 1,93 años para las mujeres. La descomposición por edad mostró un cambio favorable a esta brecha desde las edades jóvenes a las mayores en los hombres, con pocos cambios en las mujeres. La descomposición por causas de muerte mostró una mayor contribución de las neoplasias y las enfermedades respiratorias y circulatorias. Hubo una tendencia a la baja en las causas externas en los hombres, y en las enfermedades infecciosas tanto en los hombres como en las mujeres, pero al alza en las enfermedades respiratorias para ambos sexos. Conclusiones: La estabilidad de la brecha de la esperanza de vida por nivel educativo durante el periodo analizado fue el resultado de una combinación de tendencias divergentes por edad y causas de muerte entre los niveles educativos altos y bajos. (AU)

Tackling health inequalities in a public health organization: the case of the Barcelona Public Health Agency.

BACKGROUND: Municipalities are important actors in the implementation of policies to tackle health inequalities, which requires political will, the availability of financial support, and technical and human resources. With the aim of aligning with local government political priorities, in 2017 the Barcelona Public Health Agency (Agència de Salut Pública de Barcelona, henceforth ASPB), which is responsible for the public health functions of the city, launched a strategy to improve the approach to tackling health inequalities in all its services. The objectives of this study were to show how social health inequalities were addressed in the ASPB from 2017 to 19 and to describe which actions were proposed after a participatory process aiming to create a plan to systematically incorporate health inequalities in ASPB actions. METHODS: The ASPB has 304 workers, 8 directors and 20 services or departments. Participatory methodologies were carried out: 1) semi-structured interviews with department heads (N = 12, 60%); 2) world cafe workshops open to a group of workers (N = 63, 37%); 3) a Quick and Colorful voting session open to a group of workers (N = 108, 63%); and 4) Hanlon matrix with 19 actions to be prioritized (N = 12 services, 60%). RESULTS: Semi-structured interviews and world cafe workshops provided 40 potential actions. After a step by step process of participatory prioritization, seven lines of action emerged: 1) to make progress in collaborative networking; 2) to promote policy evaluation; 3) to increase the ability of the ASPB to evaluate policies to reduce health inequalities; 4) to incorporate the axes of inequalities in all ASPB products; 5) to improve information on vulnerable groups; 6) to incorporate the gender perspective; and 7) to participate in an internal training plan to address health inequalities. CONCLUSIONS: The participation of ASPB public health professionals and staff allowed the organization to design a shared plan of actions to address health inequalities. This experience could be useful for other municipalities whose political agendas include tackling inequalities in health.

Inequalities in life expectancy by educational level and its decomposition in Barcelona, 2004-2018.

OBJECTIVE: To analyse the gap in life expectancy by educational level in the city of Barcelona from 2004 to 2018 and to decompose this gap by age and causes of death. METHOD: We computed abridged life tables at the age of 25 years by sex from 2004 to 2018 using standard methods. Educational level was categorised in two groups (lower secondary or less vs. upper secondary or higher education). The life expectancy gap was further decomposed by age and by causes of death based in Arriaga's method in 5-year age blocks up to the age of ≥ 90 years and broad causes of death using ICD-10 codes. RESULTS: The life expectancy gap at 25 years by educational level oscillated without trend at around 3.08 years for men and 1.93 years for women. Decomposition by age showed a favourable significant shift in the contribution to this gap from young to older ages for men, with few changes for women. Decomposition by causes of death showed that the diseases concentrating the largest share of the contribution were neoplasms and respiratory and circulatory disease. There was a significant downward trend in external causes for men and in infectious diseases for both men and women but a significant upward trend for respiratory disease for both sexes. CONCLUSIONS: The stability of the life expectancy gap by educational level during the period analysed resulted from a combination of divergent trends by age and causes of death among high and low educational levels.

Multi-level policy responses to tackle socioeconomic inequalities in the incidence of COVID-19 in a European urban area.

BACKGROUND: Spain has been hit hard by COVID-19 since March 2020, especially in its metropolitan areas. We share experiences from Barcelona in measuring socioeconomic inequalities in the incidence of COVID-19 in the different waves, and in implementing coordinated and equity-oriented public health policy responses. METHODS: We collected daily data on confirmed COVID-19 cases, geocoded the address of residence to assign each case to one of the 73 neighborhoods and 1068 census tracts, and calculated the cumulative incidence of COVID-19 by neighborhood and five income groups (quintiles of census tracts) by sex across four waves of the pandemic. We adjusted hierarchical Bayesian spatial models to obtain the relative risk (RR) of cumulative incidences in each quintile compared with the richest areas. A variety of public health policies implemented to tackle the pandemic and especially these inequalities in COVID-19 incidence and vaccination are selected and described. RESULTS: Area-level income inequalities in the incidence of COVID-19 were present at different degree in all four waves. In the second wave (10/1/2020 to 12/6/2020), RR for the poorest income quintile census tracts compared with the richest was 1.43 (95% credible interval-CI-: 1.22-1.67) for men and 1.58 (95% CI: 1.35-1.83) for women. Later, inequalities in vaccination coverage also arose. Equity-oriented policy responses included: "health hotels" or home delivery of basic products for individuals with COVID-19 and without adequate conditions for isolation; new emergency facilities for homeless people, including those with active drug use; mass screening in high incidence areas; contingency plans for nursing homes and schools; adapting community health programs for their early reactivation; digital self-appointment support points and community vaccination days. CONCLUSION: COVID-19 hit Barcelona neighborhoods unequally, with variations between waves. The rapid availability of geolocalized data and by socioeconomic level helped public authorities to implement targeted policies and collaborative interventions for the most vulnerable populations. Further studies would be needed to evaluate their impact.

Geographical Variability in Mortality in Urban Areas: A Joint Analysis of 16 Causes of Death.

The geographical distribution of mortality has frequently been studied. Nevertheless, those studies often consider isolated causes of death. In this work, we aim to study the geographical distribution of mortality in urban areas, in particular, in 26 Spanish cities. We perform an overall study of 16 causes of death, considering that their geographical patterns could be dependent and estimating the dependence between the causes of death. We study the deaths in these 26 cities during the period 1996-2015 at the census tract level. A multivariate disease mapping model is used in order to solve the potential small area estimation problems that these data could show. We find that most of the geographical patterns found show positive correlations. This suggests the existence of a transversal geographical pattern, common to most causes of deaths, which determines those patterns to a higher/lower extent depending on each disease. The causes of death that exhibit that underlying pattern in a more prominent manner are chronic obstructive pulmonary disease (COPD), lung cancer, and cirrhosis for men and cardiovascular diseases and dementias for women. Such findings are quite consistent for most of the cities in the study. The high positive correlation found between geographical patterns reflects the existence of both high and low-risk areas in urban settings, in general terms for nearly all the causes of death. Moreover, the high-risk areas found often coincide with neighborhoods known for their high deprivation. Our results suggest that dependence among causes of death is a key aspect to be taken into account when mapping mortality, at least in urban contexts.

Socioeconomic Inequalities in COVID-19 in a European Urban Area: Two Waves, Two Patterns.

Background: The objective of this paper is to analyze social inequalities in COVID-19 incidence, stratified by age, sex, geographical area, and income in Barcelona during the first two waves of the pandemic. Methods: We collected data on COVID-19 cases confirmed by laboratory tests during the first two waves of the pandemic (1 March to 15 July and 16 July to 30 November, 2020) in Barcelona. For each wave and sex, we calculated smooth cumulative incidence by census tract using a hierarchical Bayesian model. We analyzed income inequalities in the incidence of COVID-19, categorizing the census tracts into quintiles based on the income indicator. Results: During the two waves, women showed higher COVID-19 cumulative incidence under 64 years, while the trend was reversed after that threshold. The incidence of the disease was higher in some poor neighborhoods. The risk ratio (RR) increased in the poorest groups compared to the richest ones, mainly in the second wave, with RR being 1.67 (95% Credible Interval-CI-: 1.41-1.96) in the fifth quintile income group for men and 1.71 (95% CI: 1.44-1.99) for women. Conclusion: Our results indicate the existence of inequalities in the incidence of COVID-19 in an urban area of Southern Europe.

Smoking and inequalities in mortality in 11 European countries: a birth cohort analysis.

PURPOSE: To study the trends of smoking-attributable mortality among the low and high educated in consecutive birth cohorts in 11 European countries. METHODS: Register-based mortality data were collected among adults aged 30 to 79 years in 11 European countries between 1971 and 2012. Smoking-attributable deaths were estimated indirectly from lung cancer mortality rates using the Preston-Glei-Wilmoth method. Rate ratios and rate differences among the low and high-educated were estimated and used to estimate the contribution of inequality in smoking-attributable mortality to inequality in total mortality. RESULTS: In most countries, smoking-attributable mortality decreased in consecutive birth cohorts born between 1906 and 1961 among low- and high-educated men and high-educated women, but not among low-educated women among whom it increased. Relative educational inequalities in smoking-attributable mortality increased among both men and women with no signs of turning points. Absolute inequalities were stable among men but slightly increased among women. The contribution of inequality in smoking-attributable mortality to inequality in total mortality decreased in consecutive generations among men but increased among women. CONCLUSIONS: Smoking might become less important as a driver of inequalities in total mortality among men in the future. However, among women, smoking threatens to further widen inequalities in total mortality.

Evaluación de la atención primaria, versión modificada del instrumento PCAT-A10 / Modified version of the PCAT-A10 tool for the evaluation of primary care

OBJETIVO: Evaluar las características métricas del índice Primary Care Assessment Tool de 10 ítems, para adultos (PCAT-A10), versión en castellano y catalán, reducida del original Primary Care Assessment Tool-Adult Edition (PCAT-AE), habiendo modificado el ítem de salud mental. DISEÑO: Estudio observacional transversal. Emplazamiento: Población residente en la ciudad de Barcelona. PARTICIPANTES: De los 3.496 participantes mayores de 14 años de la muestra aleatoria representativa de la población de Barcelona, de la Encuesta de Salud de Barcelona 2016-17, se seleccionaron los que declararon tener un médico/a de cabecera, que alguna vez en la vida habían realizado una visita a algún especialista y que habían contestado más del 50% de ítems del PCAT-A10 (n = 3.107). Mediciones principales: Descriptiva de los ítems, análisis de consistencia interna y de correlación ítem-total corregida del índice PCAT-A10 modificado y los 10 ítems que lo conforman. Se analizan tres escenarios de tratamiento de las no respuestas: sustitución por 0, por el valor intermedio (2,5) y excluyendo las personas que no contestaron algún ítem. RESULTADOS: El índice PCAT-A10 obtuvo alfa de Cronbach de 0,73, 0,79 y 0,85 en los tres escenarios nombrados, correlaciones ítem-total corregida entre 0,41 y 0,66, y 20,8% de no respuesta al ítem de salud mental. CONCLUSIONES: La nueva versión del PCAT-A10 presenta una alta fiabilidad con una mayor respuesta en el ítem de salud mental respecto a la versión anterior

OBJECTIVE: To evaluate the measurement characteristics of the Spanish and Catalan versions of the 10-Item Primary Care Assessment Tool for adults (PCAT-A10), shortened from the original Primary Care Assessment Tool (PCAT), with a new mental health item. DESIGN: Cross-sectional observational study. LOCATION: The city of Barcelona. PARTICIPANTS: Of the 3,496 people over 14 years of age from the representative random sample of the Barcelona population, from the 2016-17 Barcelona Health Survey, those who declared they had a family doctor, and had visited a specialist at some time in their lives, and had answered more than 50% of PCAT-A10 items were selected (n = 3,107). MAIN MEASUREMENTS: Item descriptive analysis, analysis of internal consistency, corrected item - total correlation, of the PCAT-A10 index and the 10 items that make it up. Three scenarios for non-response to treatment were analysed: substitution by 0, by the intermediate value, and excluding people who did not answer any item. RESULTS: The PCAT-A10 index obtained Cronbach alphas of 0.73, 0.79, and 0.85 in the three mentioned scenarios, correlation item total corrected between 0.41 and 0.66, and 20.8% non-responses to the mental health item. CONCLUSIONS: The new version of PCAT-A10 has a high reliability with a higher response in the mental health item compared to the previous version

[Modified version of the PCAT-A10 tool for the evaluation of primary care]. / Evaluación de la atención primaria, versión modificada del instrumento PCAT-A10.

OBJECTIVE: To evaluate the measurement characteristics of the Spanish and Catalan versions of the 10-Item Primary Care Assessment Tool for adults (PCAT-A10), shortened from the original Primary Care Assessment Tool (PCAT), with a new mental health item. DESIGN: Cross-sectional observational study. LOCATION: The city of Barcelona. PARTICIPANTS: Of the 3,496 people over 14 years of age from the representative random sample of the Barcelona population, from the 2016-17 Barcelona Health Survey, those who declared they had a family doctor, and had visited a specialist at some time in their lives, and had answered more than 50% of PCAT-A10 items were selected (n=3,107). MAIN MEASUREMENTS: Item descriptive analysis, analysis of internal consistency, corrected item - total correlation, of the PCAT-A10 index and the 10 items that make it up. Three scenarios for non-response to treatment were analysed: substitution by 0, by the intermediate value, and excluding people who did not answer any item. RESULTS: The PCAT-A10 index obtained Cronbach alphas of 0.73, 0.79, and 0.85 in the three mentioned scenarios, correlation item total corrected between 0.41 and 0.66, and 20.8% non-responses to the mental health item. CONCLUSIONS: The new version of PCAT-A10 has a high reliability with a higher response in the mental health item compared to the previous version.

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.

Decline in fertility induced by economic recession in Spain / Disminución de la fertilidad inducida por la crisis económica en España

OBJECTIVE: To describe trends in fertility in Spain before (pre-recession; 1998-2008) and during (recession period; 2009-2013) the economic crisis of 2008, taking into account women's age and regional unemployment in 2010. METHOD: The study consisted of a panel design including cross-sectional ecological data for the 17 regions of Spain. We describe fertility trends in Spain in two time periods, pre-recession (1998-2008) and recession (2009-2013). We used a cross-sectional, ecological study of Spanish-born women to calculate changes in fertility rates for each period using a linear regression model adjusted for year, period, and interaction between them. RESULTS: We found that compared to the pre-recession period, the fertility rate in Spain generally decreased during the economic recession. However, in some regions, such as the Canary Islands, this decrease began before the onset of the recession, while in other regions, such as the Basque country, the fertility rate continued to grow until 2011. The effects of the recession on the fertility rate are clearly observed in women aged 30-34 years. CONCLUSIONS: The current economic recession has disrupted the positive trend in fertility that began at the start of this century. Since Spain already had very low fertility rates, the further decline caused by the economic recession could jeopardize the sustainability of welfare-state systems

OBJETIVO: Describir las tendencias de la fecundidad en España en la época precrisis (1998-2008) y durante la crisis (2009-2013) económica, teniendo en cuenta la edad de las mujeres y el desempleo regional en 2010. MÉTODO: Se utiliza un diseño panel que incluye datos ecológicos transversales para las 17 comunidades autónomas de España. Se describen las tendencias de fecundidad en los dos periodos. Para calcular los cambios en las tasas de fecundidad se utiliza un modelo de regresión lineal ajustado por año, periodo e interacción de ellas. RESULTADOS: En comparación con el periodo anterior, la tasa de fecundidad global en España disminuyó durante la crisis económica. Sin embargo, en algunas comunidades, como las Islas Canarias, esta disminución comenzó antes del inicio de la crisis, mientras que en otras, como el País Vasco, la tasa de fecundidad continuó creciendo hasta 2011. Los efectos de la crisis en la fecundidad se observan claramente en mujeres de 30 a 34 años. CONCLUSIONES: La crisis económica actual ha interrumpido la tendencia positiva en la fecundidad que comenzó a principios de este siglo. Dado que España ya tenía tasas de fecundidad muy bajas, el descenso causado por la crisis económica podría poner en peligro la sostenibilidad de los sistemas de bienestar social

Spatial Variability of Heat-Related Mortality in Barcelona from 1992-2015: A Case Crossover Study Design.

Numerous studies have demonstrated the relationship between summer temperatures and increased heat-related deaths. Epidemiological analyses of the health effects of climate exposures usually rely on observations from the nearest weather station to assess exposure-response associations for geographically diverse populations. Urban climate models provide high-resolution spatial data that may potentially improve exposure estimates, but to date, they have not been extensively applied in epidemiological research. We investigated temperature-mortality relationships in the city of Barcelona, and whether estimates vary among districts. We considered georeferenced individual (natural) mortality data during the summer months (June-September) for the period 1992-2015. We extracted daily summer mean temperatures from a 100-m resolution simulation of the urban climate model (UrbClim). Summer hot days (above percentile 70) and reference (below percentile 30) temperatures were compared by using a conditional logistic regression model in a case crossover study design applied to all districts of Barcelona. Relative Risks (RR), and 95% Confidence Intervals (CI), of all-cause (natural) mortality and summer temperature were calculated for several population subgroups (age, sex and education level by districts). Hot days were associated with an increased risk of death (RR = 1.13; 95% CI = 1.10-1.16) and were significant in all population subgroups compared to the non-hot days. The risk ratio was higher among women (RR = 1.16; 95% CI= 1.12-1.21) and the elderly (RR = 1.18; 95% CI = 1.13-1.22). Individuals with primary education had similar risk (RR = 1.13; 95% CI = 1.08-1.18) than those without education (RR = 1.10; 95% CI= 1.05-1.15). Moreover, 6 out of 10 districts showed statistically significant associations, varying the risk ratio between 1.12 (95% CI = 1.03-1.21) in Sants-Montjuïc and 1.25 (95% CI = 1.14-1.38) in Sant Andreu. Findings identified vulnerable districts and suggested new insights to public health policy makers on how to develop district-specific strategies to reduce risks.

Decline in fertility induced by economic recession in Spain.

OBJECTIVE: To describe trends in fertility in Spain before (pre-recession; 1998-2008) and during (recession period; 2009-2013) the economic crisis of 2008, taking into account women's age and regional unemployment in 2010. METHOD: The study consisted of a panel design including cross-sectional ecological data for the 17 regions of Spain. We describe fertility trends in Spain in two time periods, pre-recession (1998-2008) and recession (2009-2013). We used a cross-sectional, ecological study of Spanish-born women to calculate changes in fertility rates for each period using a linear regression model adjusted for year, period, and interaction between them. RESULTS: We found that compared to the pre-recession period, the fertility rate in Spain generally decreased during the economic recession. However, in some regions, such as the Canary Islands, this decrease began before the onset of the recession, while in other regions, such as the Basque country, the fertility rate continued to grow until 2011. The effects of the recession on the fertility rate are clearly observed in women aged 30-34 years. CONCLUSIONS: The current economic recession has disrupted the positive trend in fertility that began at the start of this century. Since Spain already had very low fertility rates, the further decline caused by the economic recession could jeopardize the sustainability of welfare-state systems.

Socioeconomic inequalities in suicide mortality in European urban areas before and during the economic recession.

BACKGROUND: Few studies have assessed the impact of the financial crisis on inequalities in suicide mortality in European urban areas. The objective of the study was to analyse the trend in area socioeconomic inequalities in suicide mortality in nine European urban areas before and after the beginning of the financial crisis. METHODS: This ecological study of trends was based on three periods, two before the economic crisis (2000-2003, 2004-2008) and one during the crisis (2009-2014). The units of analysis were the small areas of nine European cities or metropolitan areas, with a median population ranging from 271 (Turin) to 193 630 (Berlin). For each small area and sex, we analysed smoothed standardized mortality ratios of suicide mortality and their relationship with a socioeconomic deprivation index using a hierarchical Bayesian model. RESULTS: Among men, the relative risk (RR) comparing suicide mortality of the 95th percentile value of socioeconomic deprivation (severe deprivation) to its 5th percentile value (low deprivation) were higher than 1 in Stockholm and Lisbon in the three periods. In Barcelona, the RR was 2.06 (95% credible interval: 1.24-3.21) in the first period, decreasing in the other periods. No significant changes were observed across the periods. Among women, a positive significant association was identified only in Stockholm (RR around 2 in the three periods). There were no significant changes across the periods except in London with a RR of 0.49 (95% CI: 0.35-0.68) in the third period. CONCLUSIONS: Area socioeconomic inequalities in suicide mortality did not change significantly after the onset of the crisis in the areas studied.

Progress against inequalities in mortality: register-based study of 15 European countries between 1990 and 2015.

Socioeconomic inequalities in mortality are a challenge for public health around the world, but appear to be resistant to policy-making. We aimed to identify European countries which have been more successful than others in narrowing inequalities in mortality, and the factors associated with narrowing inequalities. We collected and harmonised mortality data by educational level in 15 European countries over the last 25 years, and quantified changes in inequalities in mortality using a range of measures capturing different perspectives on inequality (e.g., 'relative' and 'absolute' inequalities, inequalities in 'attainment' and 'shortfall'). We determined which causes of death contributed to narrowing of inequalities, and conducted country- and period-fixed effects analyses to assess which country-level factors were associated with narrowing of inequalities in mortality. Mortality among the low educated has declined rapidly in all European countries, and a narrowing of absolute, but not relative inequalities was seen in many countries. Best performers were Austria, Italy (Turin) and Switzerland among men, and Spain (Barcelona), England and Wales, and Austria among women. Ischemic heart disease, smoking-related causes (men) and amenable causes often contributed to narrowing inequalities. Trends in income inequality, level of democracy and smoking were associated with widening inequalities, but rising health care expenditure was associated with narrowing inequalities. Trends in inequalities in mortality have not been as unfavourable as often claimed. Our results suggest that health care expansion has counteracted the inequalities widening effect of other influences.

Socioeconomic inequalities in suicide mortality in Barcelona during the economic crisis (2006-2016): a time trend study.

OBJECTIVES: This study aimed to analyse trends in socioeconomic inequalities in suicide mortality in Barcelona before and after the start of the economic crisis that started at the end of 2008, including both individual factors and contextual factors of the deceased's neighbourhood of residence. DESIGN: This is a trend study of three time periods: pre-economic crisis (2006-2008), early crisis (2009-2012) and late crisis (2013-2016). SETTING: Total Barcelona residents between 2006 and 2016 (≥25 years of age) and death data derived from the Judicial Mortality Registry of Barcelona. PARTICIPANTS: 996 deaths by suicide between 2006 and 2016 were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES: The outcomes were age-standardised suicide mortality rates and the associations (relative and absolute risk) between suicide mortality and individual and contextual characteristics for the three time periods. RESULTS: From 2006 to 2008, men with a lower educational level were more likely to commit suicide than better educated men (relative risk (RR)=1.46; 95% CI 1.11 to 1.91). This difference disappeared after the onset of the crisis. We found no differences among women. From 2013 to 2016, suicide risk increased among men living in neighbourhoods with higher unemployment levels (RR=1.57; 95% CI 1.09 to 2.25) and among women living in neighbourhoods with a higher proportion of elderly people living alone (RR=2.13; 95% CI 1.15 to 3.93). CONCLUSIONS: We observed risks for suicide among men living in neighbourhoods of Barcelona with higher unemployment levels and among women living in neighbourhoods with a higher proportion of elderly people living alone. Inequalities in suicide mortality according to educational level tended to disappear during the crisis among men. Thus, it is important to continue to monitor suicide determinants especially in times of economic crisis.

Trends in cancer mortality in Spain: the influence of the financial crisis / Evolución de la mortalidad por cáncer en España: influencia de la crisis económica

Objective: To determine if the onset of the economic crisis in Spain affected cancer mortality and mortality trends. Method: We conducted a longitudinal ecological study based on all cancer-related deaths and on specific types of cancer (lung, colon, breast and prostate) in Spain between 2000 and 2013. We computed age-standardised mortality rates in men and women, and fit mixed Poisson models to analyse the effect of the crisis on cancer mortality and trends therein. Results: After the onset of the economic crisis, cancer mortality continued to decline, but with a significant slowing of the yearly rate of decline (men: RR = 0.987, 95%CI = 0.985-0.990, before the crisis, and RR = 0.993, 95%CI = 0.991-0.996, afterwards; women: RR = 0.990, 95%CI = 0.988-0.993, before, and RR = 1.002, 95%CI = 0.998-1.006, afterwards). In men, lung cancer mortality was reduced, continuing the trend observed in the pre-crisis period; the trend in colon cancer mortality did not change significantly and continued to increase; and the yearly decline in prostate cancer mortality slowed significantly. In women, lung cancer mortality continued to increase each year, as before the crisis; colon cancer continued to decease; and the previous yearly downward trend in breast cancer mortality slowed down following the onset of the crisis. Conclusions: Since the onset of the economic crisis in Spain the rate of decline in cancer mortality has slowed significantly, and this situation could be exacerbated by the current austerity measures in healthcare

Objetivo: Determinar si el inicio de la crisis económica en España afectó a la mortalidad por cáncer y sus tendencias. Método: Estudio ecológico longitudinal que analiza todas las muertes por cáncer y por tipos específicos de cáncer (pulmón, colon, mama y próstata) en España entre 2000 y 2013. Se estimaron las tasas de mortalidad estandarizadas por edad en hombres y mujeres, y se ajustaron modelos mixtos de Poisson para analizar el efecto de la crisis sobre la mortalidad por cáncer y sus tendencias. Resultados: Después del inicio de la crisis económica, la mortalidad por cáncer continuó su tendencia a la baja, pero con una disminución significativa del decrecimiento anual (hombres: riesgo relativo [RR] = 0,987, intervalo de confianza del 95% [IC95%] = 0,985-0,990, antes de la crisis, y RR = 0,993, IC95% = 0,991-0,996 después; mujeres: RR = 0,990, IC95% = 0,988-0,993, antes, y RR = 1,002, IC95% = 0,998-1,006 después). En los hombres, la mortalidad por cáncer de pulmón se redujo, continuando la tendencia observada en el periodo anterior a la crisis; la tendencia en la mortalidad por cáncer de colon no cambió significativamente y siguió aumentando; y la disminución anual de la mortalidad por cáncer de próstata se desaceleró significativamente. En las mujeres, la mortalidad por cáncer de pulmón continuó aumentando cada año, como antes de la crisis; el cáncer de colon continuó disminuyendo; y la tendencia a la disminución de la mortalidad por cáncer de mama se desaceleró después del inicio de la crisis. Conclusiones: Desde el inicio de la crisis económica en España, la disminución de la tasa de mortalidad por cáncer se ha desacelerado significativamente y esta situación podría verse exacerbada por las actuales medidas de austeridad en el sistema sanitario