Socioeconomic inequalities in mortality in Barcelona: a study based on census tracts (MEDEA Project).

The aim of this study is to describe inequalities in socioeconomic indicators and in mortality by sex in the census tracts of Barcelona city during the period 1996-2003. The results show that there is excess mortality in coastal and northern areas. This distribution is similar to that of socioeconomic deprivation and therefore there is an association between mortality and socioeconomic indicators, not only for total mortality but also for the specific causes of death studied. This type of analysis can be useful for planning of public health policy since it allows small areas with high mortality risk to be detected.

[Constructing a deprivation index based on census data in large Spanish cities(the MEDEA project)]. / Construcción de un índice de privación a partir de datos censales en grandes ciudades españolas (Proyecto MEDEA).

OBJECTIVES: a) To describe the methodology used to construct a deprivation index by census tract in cities, to identify the tracts with the least favorable socioeconomic conditions, and b) to analyze the association between this index and overall mortality. METHODS: Several socioeconomic indicators (Census 2001) were defined by the census tracts of the following cities: Barcelona, Bilbao, Madrid, Seville and Valencia. The correlations with the standardized mortality ratio (1996-2003), and the dimensionality of the socioeconomic indicators were studied. Finally, the selected indicators were aggregated in an index, in which the results of the factor loadings from extraction of a factor by principal components were used as weighting values. RESULTS: The indicators with the strongest correlations with overall mortality were those related to work, education, housing conditions and single parent homes. In the analysis of dimensionality, a first dimension appeared that contained indicators related to work (unemployment, manual and eventual workers) and education (insufficient education overall and in young people). In all the cities studied, the index created with these 5 indicators explained more than 75% of their variability. The correlations between this index and mortality generally showed higher values than those obtained with each indicator separately. CONCLUSIONS: The deprivation index proposed could be a useful instrument for health planning as it detects small areas of large cities with unfavorable socioeconomic characteristics and is associated with mortality. This index could contribute to the study of social inequalities in health in Spain.

[Methods to smooth mortality indicators: application to analysis of inequalities in mortality in Spanish cities [the MEDEA Project]]. / Métodos para la suavización de indicadores de mortalidad: aplicación al análisis de desigualdades en mortalidad en ciudades del Estado español (Proyecto MEDEA).

Although there is some experience in the study of mortality inequalities in Spanish cities, there are large urban centers that have not yet been investigated using the census tract as the unit of territorial analysis. The coordinated project <> was designed to fill this gap, with the participation of 10 groups of researchers in Andalusia, Aragon, Catalonia, Galicia, Madrid, Valencia, and the Basque Country. The MEDEA project has four distinguishing features: a) the census tract is used as the basic geographical area; b) statistical methods that include the geographical structure of the region under study are employed for risk estimation; c) data are drawn from three complementary data sources (information on air pollution, information on industrial pollution, and the records of mortality registrars), and d) a coordinated, large-scale analysis, favored by the implantation of coordinated research networks, is carried out. The main objective of the present study was to explain the methods for smoothing mortality indicators in the context of the MEDEA project. This study focusses on the methodology and the results of the Besag, York and Mollié model (BYM) in disease mapping. In the MEDEA project, standardized mortality ratios (SMR), corresponding to 17 large groups of causes of death and 28 specific causes, were smoothed by means of the BYM model; however, in the present study this methodology was applied to mortality due to cancer of the trachea, bronchi and lung in men and women in the city of Barcelona from 1996 to 2003. As a result of smoothing, a different geographical pattern for SMR in both genders was observed. In men, a SMR higher than unity was found in highly deprived areas. In contrast, in women, this pattern was observed in more affluent areas.

[Trends in social inequalities in pregnancy care in Barcelona (Spain), 1994-97 versus 2000-03]. / Evolución de las desigualdades según la clase social en el control del embarazo en Barcelona (1994-97 frente a 2000-03).

OBJECTIVE: To describe and compare social inequalities in pregnancy care among pregnant women living in Barcelona (Spain) in 2 periods. METHODS: Two 4-year periods were compared: 1994-1997 and 2000-2003. The study population consisted of pregnant women living in Barcelona and the control sample was drawn from the Barcelona Birth Defects Registry (n = 905 in 1994-1997; n = 927 in 2000-2003). Medical records and personal interviews with the mothers were used as information sources. The dependent variables were pregnancy planning, prenatal use of folic acid, smoking, the number of obstetric visits, trimester of the first visit, the number of obstetric ultrasound scans, fifth-month diagnostic ultrasound scan, invasive procedures, and smoking cessation. The independent variables were maternal age and social class. Maternal age-adjusted logistic regression models for each dependent variable according to social class were calculated and the results for both 4-year periods were compared. RESULTS: Pregnant women in both manual and non-manual occupational classes showed better results in the second period in 7 out of 10 variables (although the results were not identical in the 2 occupational classes). However, when interclass variations between the 2 periods were compared, differences in 8 out of 10 variables were found: 7 indicators were more favorable in the more privileged classes and only one was more favorable in the less privileged classes. CONCLUSIONS: Except for one of the variables analyzed (more than 3 ultrasound scans), the less privileged classes showed poorer results than the more privileged classes when the tendencies in indicators were compared between the two periods. The gap between social classes in pregnancy care is increasing over time.

[Socioeconomic inequalities in the provision and uptake of prenatal care]. / Desigualdades socioeconómicas relacionadas con el cuidado y el control del embarazo.

OBJECTIVE: To describe socioeconomic inequalities in the provision and uptake of prenatal care among women in Barcelona (Spain) between 1994 and 2003. METHODS: Cross-sectional study of women in Barcelona who delivered a child without birth defects. Information was obtained from hospital medical records and a personal interview with women included in the Barcelona Birth Defects Registry, containing a random sample of 2% of all pregnant women in the city (n = 2299). DEPENDENT VARIABLES: number of obstetric visits, the trimester of the first visit, the number of obstetric ultrasound scans, the fifth-month diagnostic ultrasound scan, invasive procedures, prenatal folic acid intake, pregnancy planning, smoking and smoking cessation. The independent variables were maternal age and social class. Logistic regression models were filted for each dependent variable. RESULTS: In social classes with manual occupations, there was a higher proportion of pregnant women who attended less than six obstetric visits and who attended the first obstetric visit after the first trimester. Moreover, these women were less likely to have undergone an invasive procedure, to have taken folic acid supplements, to have planned the pregnancy, to be non-smokers and to stop smoking. In the more privileged classes, there was a higher proportion of women who attended more than 12 obstetric visits and who underwent more than three ultrasound scans. CONCLUSIONS: Socioeconomic inequalities were found in the provision and uptake of prenatal care in Barcelona. Uptake was greater in the more advantaged social classes but excessive medicalization was found in all classes. Rationalizing the use of healthcare resources and reducing excessive medicalization would reduce inequalities in prenatal care in Barcelona.

Breast cancer mortality in Barcelona following implementation of a city breast cancer-screening program.

BACKGROUND: To assess the impact that the Barcelona city breast cancer-screening program has had in the decline of mortality due to breast cancer among women aged 50-74 years, in the city of Barcelona. METHODS: A quasi-experimental study based on breast cancer deaths among women aged between 50 and 74 years residing in Barcelona between 1984 and 2004. The variables used were: age, year, and Primary Health Care District (ABS) grouped into four zones according to the year of implementation of the screening program. We carried out a descriptive analysis of mortality by year and age and fitted Poisson models to calculate the relative risk of dying prior to the existence of the program, after its implementation, and as a function of its degree of implementation. The models are adjusted for ABS socioeconomic level. RESULTS: Between 1984 and 2004, 3733 women aged between 50 and 74 years died of breast cancer. The mortality rate fluctuated, reaching its highest level in 1991, having declined since. Prior to implementation of the program, mortality was falling by 1% annually (RR=0.99 95 CI%=0.98-0.99), and since then by 5% (RR=0.95 95 CI%=0.92-0.99). There are no significant differences in mortality reduction between zones where the program was implemented earlier and those where it came in later, even though mortality in the final phase of complete implementation is significantly lower by 17%, with respect to the period prior to its introduction. CONCLUSIONS: The results show a reduction in mortality due to breast cancer over the entire period studied, the decline being more marked after the program was introduced. Opportunistic screening and the greater efficacy of the treatment of initial cancers have both influenced the findings. A longer follow up time will be needed in order to obtain more conclusive results.

Maternal smoking, social class and outcomes of pregnancy.

Exposure to tobacco during pregnancy is an important risk factor for infant health. Recently the prevalence of smoking during pregnancy has declined in our area. The objective of this study was to analyse the association between several social variables and the fetal exposure to smoking, as well as the association between maternal smoking and some adverse gestational outcomes. Data collection was cross-sectional. The study population were women in the city of Barcelona (Catalonia, Spain) delivering a child without birth defects. The sample corresponded to the controls of the Birth Defects Registry of Barcelona, 2% of all pregnancy deliveries in the city from 1994 to 2003 (n = 2297). Information sources were hospital records and a personal interview of mothers. The analysis measured first the association between independent variables (instruction level, social class, occupation, nationality, planned pregnancy, parity, hospital funding and smoking status of the mother's partner) with two dependent variables: smoking at the initiation of pregnancy and quitting during pregnancy. Second, the persistence of smoking over pregnancy and all independent variables were studied with three variables indicating adverse outcomes of pregnancy: low gestation, low birthweight and intrauterine growth restriction (IUGR). Finally, the joint association between the persistence of smoking over pregnancy and social class taken as independent variables was determined with the three variables indicating adverse outcomes of pregnancy. Logistic regression models were fitted, adjusting for maternal age. Results are presented as odds ratios with their 95% confidence intervals. The prevalence of smoking at the onset of gestation was 41%, and 40% of these women quit during pregnancy, so that 25% delivered as active smokers. Fewer women with higher educational levels and from families with non-manual jobs smoked, as did immigrants, those planning pregnancy and women whose partner did not smoke. Smoking immigrants quit more frequently than nationals, as did those planning pregnancy, primiparae, and women whose partner did not smoke. Low gestation, low birthweight and IUGR were more frequent among smokers and women with a manual occupation, but manual occupation lost its significance when adjusting for smoking. The association between smoking and adverse results was higher for IUGR. In conclusion, the prevalence of smoking and quitting during pregnancy varied according to social factors. The influence of social factors on the outcome of pregnancy was mediated strongly by smoking in a country that provides access to health care free of cost. A priority in reducing inequalities in health is to help women from manual work backgrounds quit smoking.

[Evaluation of the primary health care reform: preventive practices and inequalities]. / Evaluación de la reforma de la atención primaria de salud: prácticas preventivas y desigualdades.

OBJECTIVE: To evaluate primary care reform (PCR) in Barcelona during the year 2000 using 3 preventive practices: anti-smoking advice, blood pressure measurement, and flu vaccination. Any inequalities of gender, age, or social class in receiving these practices are also assessed. DESIGN: Cross-sectional, descriptive, observational study. SETTING: Barcelona Health Survey, primary health care, Spain, year 2000. PARTICIPANTS: Non-institutionalised residents of the city of Barcelona over 15 years old in the year 2000 (N=10,000 people). MAIN MEASUREMENTS: The indicators used were the prevalences of receiving the 3 practices. Descriptive and multivariate logistic regression analyses were performed. RESULTS: Receiving the preventive practices studied is greater in areas where PCR was established longer, compared to the centres that had not begun the reforms (63.7% as opposed to 53.2%, respectively). Anti-smoking advice, for women, is less frequent in the more disadvantaged classes (odds ratio [OR] =0.72; 95% confidence interval [CI], 0.55-1). CONCLUSIONS: PCR is a factor associated with carrying out preventive practices. No significant disparities between social class or gender were found for those who received the preventive practices.