[From face-to-face consultation to teleconsultation: Primary health care professionals' experiences in the Basque Country during the pandemic]. / De la consulta presencial a la teleconsulta: experiencias de profesionales de atención primaria del País Vasco durante la pandemia.

OBJECTIVE: To explore the perceptions of Primary Health Care (PHC) professionals on changes in consultation modalities and their impact on PHC fundamentals during the pandemic. DESIGN: Qualitative exploratory research conducted between October and November, 2021. LOCATION: Four urban and one rural primary health care centers with different socioeconomic profiles in the threeterritories of the Basque Country. PARTICIPANTS: Forty-six professionals from different categories of the PHC team and health centre directors. METHOD: Purposive sampling. Five focus groups and fourin-depth interviews. Thematic analysis with the support of the Atlas.ti programme. Triangulation of results among the research team. RESULTS: Experiences with the development of teleconsultation appear to be directly conditioned by the pandemic context in its different phases and by the PC situation. The professionals identified communication barriers, as well as potentialities of its use that require adequate training and evaluation. Risks of inequity were perceived in the use of teleconsultations that could be affecting the quality of care. Longitudinality was assessed as a facilitating factor and problems of coordination and communication through teleconsultation between care levels were identified. CONCLUSIONS: The replacement of face-to-face consultation by teleconsultation had an impact on fundamental aspects of PHC such as quality, accessibility, equity, coordination and longitudinality. Teleconsultation in PHC should always be evaluated considering the specific circumstances and contexts of its implementation.

[Gender inequality and mental health medicalization: Sociocultural determining factors from the analysis of expert perceptions]. / Desigualdad de género y medicalización de la salud mental: factores socioculturales determinantes desde el análisis de percepciones expertas.

To identify the sociocultural roots that explain the higher frequency of diagnoses of depression and/or anxiety and the prescription of psychotropic drugs in women, in order to propose a preliminary explanatory framework for the investigation of gender inequalities in mental health and its medicalization. Qualitative study with a descriptive-interpretive design, through in-depth interviews conducted in January and February 2021. Interviews were held in various cities of the Basque Country, Barcelona and Madrid. 12 experts in gender and mental health from the clinical (Primary Care and Mental Health), academic and associative fields. Intentional sampling, following the snowball technique, until covering the diversity of previously identified profiles and the saturation of the discourse. An analysis of thematic content was carried out starting from a critical-realistic epistemological perspective. The main dimensions to explain gender inequalities in diagnoses of depression or anxiety and prescription of psychoactive drugs were: 1) the material and symbolic subordination of women, 2) the role of «psi¼ sciences in the pathologization of the feminine identity, 3) the epistemological and androcentric biases of biomedicine, and 4) the active agency of women in medicalization processes. The reduction of gender inequalities in the diagnoses and prescription of psychotropic drugs will require joint intervention at the clinical, community and structural levels that, from a feminist perspective, manage to reverse the socioeconomic, symbolic and epistemic vulnerability of women.

The role of birthplace and educational attainment on induced abortion inequalities.

BACKGROUND: Induced abortion (IA) has shown social inequality related to birthplace and education with higher rates of IAs in immigrant and in less educated women relative to their native and highly educated counterparts. This study examined the independent and joint effects of birthplace and education on IA, repeated and IA performed during the 2nd trimester of pregnancy among women residing in the Basque Country, Spain. METHODS: We conducted a cross-sectional population-based study of IA among women aged 25-49 years residing in the Basque Country, Spain, between 2011 and 2013. Log-binomial regression was used to quantify the independent and joint effects of birthplace and education attainment on all outcomes. RESULTS: Immigrant women exhibited higher probability of having an IAs (PR: 5.31), a repeated (PR: 7.23) or a 2nd trimester IAs (PR: 4.07) than women born in Spain. We observed higher probabilities for all outcomes among women with a primary or less education relative to those with a graduate education (All IAs PR: 2.51; repeated PR: 6.00; 2nd trimester PR: 3.08). However, no significant heterogeneity was observed for the effect of education on the association of birthplace with IAs, repeated or 2nd trimester IAs. CONCLUSIONS: Birthplace and education are key factors to explain not only an IA decision but also having a repeated or a 2nd trimester IA. However, the effects of birthplace and education may be independent from each other on these outcomes. A better understanding of these factors on IAs is needed when designing programs for sexual and reproductive health aimed to reduce inequalities among women.

Self-rated health, time of residence and social determinants of health in immigrant populations: A complex relationship in groups of different origins in a Southern European region.

Health of immigrant population changes with time of residence and under the effect of social determinants of health. This study analyses the health status of the immigrant population in the Basque Country according to groups of origin assessing the effect of time of residence on health in the different origin groups considering social and migration-related determinants of health. A cross-sectional study of the immigrant population in the Basque Country using the Foreign Origin Population Survey was conducted. A descriptive analysis is performed of each group of origin and Poisson models are applied. The main variable is self-rated health, and the independent variables are divided into three groups: demographic, socioeconomic and migration-related. For the study, immigrants are divided into six origin groups. Results show that the health and the effects of socioeconomic and migratory variables on health vary according to origin. Immigrants with greater economic difficulties present poorer health, though to different extents and the effects on health of educational level and perception of discrimination differ according to origin. Finally, the relation between time of residence and self-rated health varies according to origin: Colombian, Ecuadorian, Peruvian, Eastern EU and sub-Saharan immigrants living in Spain for 10 or more years report poorer health even when controlling for socioeconomic and migration-related variables, while people from the Maghreb and Asia do not. Therefore, the effects on health of time of residence, living conditions and the migratory experience differ according to migrant group, leading to the importance of analysing the health of immigrants as a heterogeneous group.

The lived experience of receiving and providing antenatal care during the Covid-19 crisis in Southern Europe: An exploratory qualitative study.

OBJECTIVE: The Covid-19 pandemic led to a reorganization of antenatal care including the cancellation or shift into telemedicine of consultations and restrictions to the presence of an accompanying person. The aim was to explore healthcare professionals' and women's lived experience of such reorganisation consequences on the quality of care and specific challenges they faced, with a particular emphasis on telemedicine and equity. METHODS: Exploratory qualitative study using semi-structured interviews and focus group discussions of women and healthcare providers in New Aquitaine (France) and in the Basque Country (Spain). We collected data from a purposive sampling of women (n = 33) and professionals (n = 19) who had received or provided antenatal care in hospitals and ambulatory facilities between March 2020 and December 2021. Participants' narratives were thematically analysed to identify themes that were subsequently contextualised to the two territories. RESULTS: Antenatal care professionals and pregnant women experienced strong emotions and suffered from organizational changes that compromised the quality and equity of care. The pandemic and associated restrictions were sources of emotional distress, fear and loneliness, especially among more disadvantaged and isolated women. Among professionals, the lack of adequate means of protection and the multiple changes in caring protocols generated burnout, feeling of abandonment and emotional distress. CONCLUSIONS: The Covid-19 experience should serve to critically consider the unexpected consequences of reorganising healthcare services and the need to meet patients' needs, with a particular consideration for disadvantaged groups. Future scenarios of telemedicine generalisation should consider a combination of in presence and remote consultations ensuring antenatal care quality and equity.

Trends and determinants of social inequities in cardiovascular risk factors in Spain: a mixed-methods study.

This sequential mixed-methods study aims to: 1) assess spatial and temporal trends in cardiovascular risk factors by socioeconomic position from 2001 to 2020 in Spain; 2) explore public health professionals' perspectives regarding interventions that might have impacted these inequities; and 3) analyze determinants on social inequities in cardiovascular risk factors. First, we will measure the change in absolute and relative social inequities in eight cardiovascular risk factors through time trend analysis using repeated cross-sectional data from both National and European Health Surveys for Spain from 2001 to 2020. Second, we will interview key informants -both at the regional and national level-, to contextualize data obtained in phase 1 and capture the content and variation of policies across regions. Third, we will use econometric methods to analyze how these identified interventions have impacted these social inequities within and across regions.

Social Inequalities in Health Determinants in Spanish Children during the COVID-19 Lockdown.

The COVID-19 lockdown was imposed in a context of notable inequalities in the distribution of the social determinants of health. It is possible that the housing conditions in which children and their families experienced the confinement, and the adoption of healthy behaviors, may have followed unequal patterns. The aim was to describe social inequalities in housing conditions and in health-related behaviors among children during the lockdown in Spain. This cross-sectional study was based on data from an online survey collecting information on the child population (3-12 years) living in Spain (n = 10,765). The outcome variables used were several housing conditions and health-related behaviors. The socioeconomic variables used were financial difficulties and parents' educational level. Crude prevalence and prevalence ratios estimated using Poisson models were calculated. During lockdown, children from families with low educational levels and financial difficulties not only tended to live in poor housing conditions, but were also exposed to negative health determinants such as noise and tobacco smoke; they took less physical exercise, had a poorer diet, spent more time in front of screens and had less social contact. A notable social gradient was found in most of the variables analyzed. The results point to the need to incorporate the perspective of equity in the adoption of policies in order to avoid the increase of pre-existing social inequalities in the context of a pandemic.

[Unwanted loneliness, health and social inequalities throughout the life cycle]. / Soledad no deseada, salud y desigualdades sociales a lo largo del ciclo vital.

OBJECTIVE: To analyse the prevalence of unwanted loneliness in our context and its association with health from a life cycle and social inequalities perspective. METHOD: Cross-sectional study based on data from the Health Survey of the Basque Country (n = 7.228; response rate 79%). The prevalence of unwanted loneliness, its association with perceived health and mental health, and social inequalities according to social class were analysed. To analyse the association, age-adjusted prevalence ratios (PR) calculated from robust Poisson models were calculated. RESULTS: The feeling of unwanted loneliness affects 23.3% of men and 29.7% of women, being higher in older people and young adults, and in the most disadvantaged social classes. Feeling alone is associated with worse health, both general (PRa men 2.11, 95% confidence interval [95%CI] 1.77-2.51; PRa women 2.10, 95%CI 1.83-2.41) and mental (PRa men 3.95, 95%CI 3.15-4.95; RPa women 3.50, 95%CI 2.99-4.12). Social inequalities in loneliness, as well as the association between it and poor health, was greater among young adults. CONCLUSIONS: The results of the study have important implications for intervention in the reduction and prevention of unwanted loneliness, underlining the importance of the life cycle and social inequalities.

[How to measure the migration status of the child and young population? Studies on health and inequalities in health in Europe]. / ¿Cómo medir el estatus migratorio de la población infantil y juvenil? Estudios sobre salud y desigualdades en salud en Europa.

OBJECTIVE: To analyse how the migration status of the child and young population is measured in the scientific literature on health and social inequalities in health in Europe. METHOD: A systematic search of the literature published in Spanish, English and French between 2007 and 2017 in PubMed and Social Sciences Citation Index was carried out. The included studies analysed health and social inequalities in health of a population under 18 years old according to its migration origin in Europe. The variables used to measure the migration status were described. RESULTS: 50 articles were included. Twenty studies analysed perinatal health, eleven mental health, nine dental health, and ten studies other variables. The main variables to define migration status were the country of birth (32 studies), either of the child, the mother, or one of the parents, and sometimes in a complementary way. Less frequent was the use of nationality (15 studies), of the child, or of the parents, especially the mother. Migration status is referred to in very different ways, not always comparable and sometimes the variable used is not clearly explained. CONCLUSIONS: There is a great diversity of ways to measure migration status in the child and young population. A better definition and consensus is needed to improve the temporal and geographical comparability of knowledge in this area, which will help to design public policies aimed at reducing social inequalities in health from childhood.

[Health and determinants of health in second generations of international immigrants: Social inequalities in health since childhood?] / Salud y determinantes sociales de la salud en hijos e hijas de personas inmigrantes internacionales: ¿desigualdades sociales en salud desde la infancia?

OBJECTIVE: To analyse the social inequalities in health between children and youth population of an immigrant origin from low-income countries and those of native origin in the Basque Country. METHOD: Cross-sectional descriptive study using data from the Basque Country Health Survey 2013. Variables of health, behaviours and life conditions were used as the outcome variables. Prevalence ratios were calculated using robust Poisson models. RESULTS: The children with immigrant parents had poorer self-rated health, a higher prevalence of obesity, spent more hours in sedentary activities and lived in households with greater economic difficulties. The differences persisted even after adjusting for social class and educational level of parents. CONCLUSIONS: A migrant background is a highly relevant axis of health inequalities and has an influence beyond a generation. Given this reality, it is necessary to implement effective and suitable measures to ensure life with good health conditions and to reduce social inequalities in health, not only in childhood but through the entire life cycle.

The Impact of Fiscal Policies on the Socioeconomic Determinants of Health.

There has been considerable recent debate around the alleged impact of discretionary fiscal policies - especially austerity policies - on health and health inequalities. Assuming that most of the impact will have to run via the effect of fiscal policies on socioeconomic determinants of health (SDH), it is of interest to gain a further understanding of the relationship between fiscal policies and SDH. Therefore, the aim of this article is to review the recent evidence on the impact of discretionary fiscal policies on key SDH, i.e. income, poverty, education, and employment, in high income OECD countries. We find that there are no simple answers as to how fiscal policy affects those determinants of health. The effects of contractionary and expansionary fiscal policies on the analyzed SDH vary considerably across countries and will largely depend on the pre-crisis situation. Contractionary fiscal policies seem to have increased poverty, while their impact on income inequality will be influenced by the composition of the implemented measures. More empirical research trying to directly link fiscal policies to health outcomes, while taking into account of some of the mechanisms encountered here, would be worthwhile.

Perceived discrimination and self-rated health in the immigrant population of the Basque Country, Spain.

OBJECTIVE: To examine the effect of perceived discrimination and self-rated health among the immigrant population in the Basque Country, Spain, and determine whether this effect varies according to region of origin, age, sex and education. METHODS: Descriptive cross-sectional study. The study population included immigrants aged 18 and older residing in the Basque Country. Data from the 2014 Foreign Immigrant Population Survey (n=3,456) were used. Log-binomial regression was used to quantify the association between perceived discrimination and self-rated health before and after checking for the selected characteristics. RESULTS: Almost 1 in 10 immigrant adults reports perceiving discrimination. In adjusted analyses, the immigrants perceiving discrimination were almost were 1.92 more likely to rate their health as poor (prevalence ratio: 1.92; 95% CI: 1.44-2.56) than those who did not report discrimination. This association did not vary according to region of origin, age, sex or educational level. CONCLUSIONS: Perceived discrimination shows a consistent relationship with perceived health. Moreover, this association did not depend on the region of origin, age, sex or educational level of immigrants. These results show the need for implementing inclusive policies to eliminate individual and institutional discrimination and reduce health inequalities between the immigrant and native populations.

[Austerity and healthcare privatization in times of crisis: are there any differences among autonomous communities?]. / Austeridad y privatización sanitaria en época de crisis: ¿existen diferencias entre las comunidades autónomas?

OBJECTIVE: To analyse the differences between autonomous communities in Spain according to their policies of austerity and healthcare privatization during the economic crisis. METHODS: Changes in the application of legal reforms, healthcare privatization and healthcare financing/resources in the autonomous communities were analysed, and a summary indicator of each dimension was constructed. RESULTS: The Basque Country showed the clearest behaviour towards a weak policy of austerity and privatization, as opposed to La Rioja, Madrid, and the Balearic Islands. CONCLUSIONS: The three classifications will enable analysis of the mediating effect of policies of austerity and privatization in the relationship between the economic crisis and health in the Spanish context.

Induced abortion in a Southern European region: examining inequalities between native and immigrant women.

OBJECTIVES: To examine induced abortion (IA) inequalities between native and immigrant women in a Southern European region and whether these inequalities depend on a 2010 Law facilitating IA. METHODS: We conducted two analyses: (1) prevalence of total IAs, repeat and second trimester IA, in native and immigrant women aged 12-49 years for years 2009-2013 according to country of origin; and (2) log-binomial regression was used to quantify the association of place of origin with repeat and second trimester IAs among women with IAs. RESULTS: Immigrants were more likely to have an IA than Spanish women, with the highest probability in Sub-Saharan Africa (PR 8.32 95 % CI 3.66-18.92). Immigrant women with an IA from countries other than Maghreb and Asia have higher probabilities of a repeat IA than women from Spain. Women from Europe non-EU/Romania were 50 % (95 % CI 0.30-0.79) less likely to have a second trimester IA, while women from Central America/Caribbean were 45 % (95 % CI 1.11-1.89) more likely than Spanish women. The 2010 Law did not affect these associations. CONCLUSIONS: There is a need for parenthood planning programs and more information and access to contraception methods especially in immigrant women to help decrease IAs.

[Participation and representation of the immigrant population in the Spanish National Health Survey 2011-2012]. / Participación y representatividad de la población inmigrante en la Encuesta Nacional de Salud de España 2011-2012.

OBJECTIVE: Population health surveys have been the main data source for analysis of immigrants' health status in Spain. The aim of this study was to analyze the representation of this population in the Spanish National Health Survey (SNHS) 2011-2012. METHODS: We analyzed methodological publications and data from the SNHS 2011-2012 and the population registry. Differences in the participation rate between the national and foreign populations and the causes for these differences were analyzed, as well as the representation of 11 countries of birth in the survey with respect to the general population, with and without weighting. RESULTS: Households with any foreign person had a lower participation rate, either due to a higher error in the sampling frame or to a higher non-response rate. In each country of birth, the sample was smaller than would be expected according to the population registry, especially among the Chinese population. When we applied the sample weights to the 11 countries of birth, the estimated population volume was closer to the estimated volume of the population registry for all the countries considered, although globally both the underrepresentation and the intranational bias remained. CONCLUSIONS: The lower participation of the immigrant population and differences in participation depending on the country of origin suggest the existence of a potential bias in the SNHS, which should be taken into account in studies analyzing the health of this population. The lower participation rate should be studied in greater depth in order to take appropriate measures to increase the representativeness of health surveys.

[Immigration and health: Social inequalities between native and immigrant populations in the Basque Country (Spain)]. / Inmigración y salud: desigualdades entre la población autóctona e inmigrante en el País Vasco.

OBJECTIVE: To analyze health inequalities between native and immigrant populations in the Basque Country (Spain) and the role of several mediating determinants in explaining these differences. METHODS: A cross-sectional study was performed in the population aged 18 to 64 years in the Basque Country. We used data from the Basque Health Survey 2007 (n=4,270) and the Basque Health Survey for Immigrants 2009 (n=745). We calculated differences in health inequalities in poor perceived health between the native population and immigrant populations from distinct regions (China, Latin America, the Maghreb and Senegal). To measure the association between poor perceived health and place of origin, and to adjust this association by several mediating variables, odds ratios (OR) were calculated through logistic regression models. RESULTS: Immigrants had poorer perceived health than natives in the Basque Country, regardless of age. These differences could be explained by the lower educational level, worse employment status, lower social support, and perceived discrimination among immigrants, both in men and women. After adjustment was performed for all the variables, health status was better among men from China (OR: 0.18; 95% confidence interval [CI95%]: 0.04-0.91) and Maghreb (OR: 0.26; 95% CI: 0.08-0.91) and among Latin American women (OR: 0.36; 95% CI: 0.14-0.92) than in the native population. CONCLUSIONS: These results show the need to continue to monitor social and health inequalities between the native and immigrant populations, as well as to support the policies that improve the socioeconomic conditions of immigrants.