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Withstanding austerity: economic crisis and health inequalities in Spain
Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
2017 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Background: Along with the austerity measures introduced in many countries, the economic crisis affecting Europe since 2008 seems to have impacted many aspects of the health of the Spanish population and has had a negative effect on the provision health services. An increasing body of knowledge has shown a clear impact of the current crisis on suicidal behaviour and mental health, and a less consistent effect on physical health and access to healthcare. However, little is known about the impact of the crisis on social inequalities in health and healthcare access, an area on which the present study seeks to shed light in the context of Spain, and specifically Andalusia, a region hit very hard by the crisis.

Objective: To study the impact of the economic crisis starting in 2008 on health, health inequalities and health service utilisation in Spain and Andalusia and the roles of socio-demographic factors in these associations.

Methods: Death rates were analysed to study the annual percent change in overall and cause-specific mortality in Spain between 1999 and 2011, and the Longitudinal Database of the Andalusian Population was used to study educational inequalities in overall mortality from 2002 to 2010 (study 1). To calculate suicide attempt rates, information from 2003 to 2012 on 11,494 men and 12,886 women provided by the Health Emergencies Public Enterprise Information System in Andalusia was utilised. The association between unemployment and suicide attempts was studied through linear regression models (study 2). Two waves of the Andalusian Health Survey (2007 and 2011–12) provided data for the third and fourth studies of this thesis. Educational and employment status inequalities in poor mental health in relation with the crisis were analysed through Poisson regression models (study 3). The change in inequalities (pre-crisis–crisis) in health care utilisation outcomes (general practitioner, specialist, hospitalisation and emergency attendance) was measured by the change in horizontal inequality indices. A decomposition analysis of change in inequality between periods was performed using the Oaxaca approach (study 4).

Results: Study 1: Overall mortality in Spain decreased steadily during the period, with annual percent changes of -2.44% in men and -2.20% in women. An increase in educational inequality in mortality was observed in men in Andalusia. In women, the inequalities instead remained stable. Suicide mortality showed a downward trend in both sexes in Spain. Study 2: A sharp increase in suicide attempts in Andalusia was detected after the onset of the crisis in both sexes, with adults aged 35 to 54 years being the most affected. Suicide attempts were associated with unemployment rates only in men. Study 3: Poor mental health increased in working individuals with secondary and primary studies during the crisis compared to the pre-crisis period, while it decreased in the university study group. However, in unemployed individuals poor mental health increased only in the secondary studies group. Financial strain could partly explain the crisis effect on mental health among the unemployed. Study 4: Horizontal inequality in utilisation changed to a greater equality or a more pro-poor inequality in both sexes. In the decomposition analysis, socioeconomic position and health status showed greater contributions to the changes in inequalities.

Conclusion: This thesis illustrates the complexity of the influences of the current economic crisis on health inequalities in a Southern European region. Specifically, no noticeable effects of the crisis on overall and suicide mortality were detected; instead, increasing educational inequalities in mortality in men and a large increase in suicide attempts in middle aged men and women were observed. The deterioration in poor mental health was mainly detected in those of intermediate educational level. Economic conditions such as unemployment and financial strain proved to be relevant. Finally, in the light of no increased inequalities in healthcare utilisation, the universal coverage health system seems to buffer the deleterious effect of the crisis and austerity policies in this context.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå universitet , 2017. , s. 83
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 1875
Nyckelord [en]
Economic crisis, mental health, socioeconomic inequalities, health determinants, health care utilisation, Spain, Andalusia
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Forskningsämne
epidemiologi
Identifikatorer
URN: urn:nbn:se:umu:diva-130950ISBN: 978-91-7601-645-9 (digital)OAI: oai:DiVA.org:umu-130950DiVA, id: diva2:1070449
Disputation
2017-02-24, Sal 135, By 9A, Allmänmedicin, ingång X5, Norrlands universitetssjukhus, Umeå, 09:00 (Engelska)
Opponent
Handledare
Tillgänglig från: 2017-02-03 Skapad: 2017-02-01 Senast uppdaterad: 2018-06-09Bibliografiskt granskad
Delarbeten
1. Crisis económica al inicio del siglo xxi y mortalidad en Espana. ˜ Tendencia e impacto sobre las desigualdades sociales. Informe SESPAS 2014 [The economic crisis at the beginning of the XXI century and mortality in Spain. Trend and impact on social inequalities. SESPAS Report 2014].
Öppna denna publikation i ny flik eller fönster >>Crisis económica al inicio del siglo xxi y mortalidad en Espana. ˜ Tendencia e impacto sobre las desigualdades sociales. Informe SESPAS 2014 [The economic crisis at the beginning of the XXI century and mortality in Spain. Trend and impact on social inequalities. SESPAS Report 2014].
Visa övriga...
2014 (Spanska)Ingår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 28 (Suppl 1), s. 89-96Artikel i tidskrift (Refereegranskat) Published
Abstract [es]

El objetivo de este estudio es analizar el impacto de la actual crisis económica en la evolución de la mortalidad en Espana˜ y sus efectos sobre las desigualdades sociales en la mortalidad en Andalucía. Se han utilizado las defunciones procedentes de las estadísticas vitales del Instituto Nacional de Estadística para los anos ˜ 1999 a 2011, así como la población correspondiente del padrón municipal de habitantes. Se calcularon tasas ajustadas de mortalidad general y específica por sexo y edad. Para estimar las tasas de mortalidad general y las razones de tasas según el nivel de estudios, entre 2002 y 2010 se utilizó la Base de Datos Longitudinal de Población de Andalucía (cohorte censal del 2001). Los porcentajes de cambio anuales y las tendencias se calcularon mediante regresión joinpoint. En Espana˜ no se observa ningún cambio de tendencia significativo en la mortalidad a partir de 2008. Desde 1999 se mantiene una tendencia descendente, en ambos sexos y por todas las causas, excepto en las enfermedades del sistema nervioso. La mortalidad por accidentes de tráfico acelera su decrecimiento desde 2003. Los suicidios no modifican su tendencia negativa a lo largo del periodo. En Andalucía, las desigualdades sociales en la mortalidad general aumentaron en los hombres desde el inicio de la crisis, en el ano˜ 2008, fundamentalmente por un mayor descenso en la mortalidad en los de mayor nivel de estudios que en el resto, en un contexto de descenso de la mortalidad. En las mujeres no se observan cambios en el patrón de desigualdad.

Abstract [en]

This study aimed to assess the impact of the current economic crisis on mortality trends in Spain and its effect on social inequalities in mortality in Andalusia. We used data from vital statistics and the Population Register for 1999 to 2011, as provided by the Spanish Institute of Statistics, to estimate general and sex- and age-specific mortality rates. The Longitudinal Database of the Andalusian Population (2001 census cohort) was used to estimate general mortality rates and ratios by educational level. The annual percentages of change and trends were calculated using Joinpoint regressions. No significant change in the mortality trend was observed in Spain from 2008 onward. A downward trend after 1999 was confirmed for all causes and both sexes, with the exception of nervous system-related diseases. The reduction in mortality due to traffic accidents accelerated after 2003, while the negative trend in suicide was unchanged throughout the period studied. In Andalusia, social inequalities in mortality have increased among men since the beginning of the crisis, mainly due to a more intense reduction in mortality among persons with a higher educational level. Among women, no changes were observed in the pattern of inequality.

Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Identifikatorer
urn:nbn:se:umu:diva-130573 (URN)10.1016/j.gaceta.2014.01.005 (DOI)24612790 (PubMedID)
Tillgänglig från: 2017-01-24 Skapad: 2017-01-24 Senast uppdaterad: 2018-06-09Bibliografiskt granskad
2. Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, Southern Spain
Öppna denna publikation i ny flik eller fönster >>Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, Southern Spain
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2014 (Engelska)Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 13, artikel-id 55Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

INTRODUCTION: Although suicide rates have increased in some European countries in relation to the current economic crisis and austerity policies, that trend has not been observed in Spain. This study examines the impact of the economic crisis on suicide attempts, the previously neglected endpoint of the suicidal process, and its relation to unemployment, age and sex.

METHODS: The study was carried out in Andalusia, the most populated region of Spain, and which has a high level of unemployment. Information on suicide attempts attended by emergency services was extracted from the Health Emergencies Public Enterprise Information System (SIEPES). Suicide attempts occurring between 2003 and 2012 were included, in order to cover five years prior to the crisis (2003-2007) and five years after its onset (2008-2012). Information was retrieved from 24,380 cases (11,494 men and 12,886 women) on sex, age, address, and type of attention provided. Age-adjusted suicide attempt rates were calculated. Excess numbers of attempts from 2008 to 2012 were estimated for each sex using historical trends of the five previous years, through time regression models using negative binomial regression analysis. To assess the association between unemployment and suicide attempts rates, linear regression models with fixed effects were performed.

RESULTS: A sharp increase in suicide attempt rates in Andalusia was detected after the onset of the crisis, both in men and in women. Adults aged 35 to 54 years were the most affected in both sexes. Suicide attempt rates were associated with unemployment rates in men, accounting for almost half of the cases during the five initial years of the crisis. Women were also affected during the recession period but this association could not be specifically attributed to unemployment.

CONCLUSIONS: This study enhances our understanding of the potential effects of the economic crisis on the rapidly increasing suicide attempt rates in women and men, and the association of unemployment with growing suicidal behaviour in men. Research on the suicide effects of the economic crisis may need to take into account earlier stages of the suicidal process, and that this effect may differ by age and sex.

Ort, förlag, år, upplaga, sidor
BioMed Central, 2014
Nyckelord
Suicide attempts, Economic crisis, Unemployment, Spain, Andalusia
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Identifikatorer
urn:nbn:se:umu:diva-91951 (URN)10.1186/1475-9276-13-55 (DOI)000340006000001 ()25062772 (PubMedID)
Tillgänglig från: 2014-08-18 Skapad: 2014-08-18 Senast uppdaterad: 2018-06-07Bibliografiskt granskad
3. How are the employed and unemployed affected by the economic crisis in Spain?: Educational inequalities, life conditions and mental health in a context of high unemployment
Öppna denna publikation i ny flik eller fönster >>How are the employed and unemployed affected by the economic crisis in Spain?: Educational inequalities, life conditions and mental health in a context of high unemployment
2016 (Engelska)Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, artikel-id 267Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Despite an increasing number of studies on the factors mediating the impact of the economic recession on mental health, research beyond the individual employment status is scarce. Our objectives were to investigate in which ways the mental health of employed and unemployed populations is differently affected by the current economic recession along the educational scale and to examine whether financial strain and social support explain these effects of the crisis. Methods: A repeated cross-sectional study, using two waves of the Andalusian Health Survey in 2007 (pre-crisis) and 2011-2012 (crisis). A population aged between 19 and 64 years was selected. The dependent variable was the Mental Component Summary of the SF-12 questionnaire. We performed Poisson regression models stratified by working status, with period, educational level, financial strain and social support as independent variables. We examined interactions between period and educational level. Age, sex, main earner, cohabitation and partner's working status were considered as covariates. Results: The study included 3210 individuals (1185 women) in 2007 and 3633 individuals (1486 women) in 2011-2012. In working individuals the prevalence of poor mental health increased for secondary and complete primary studies groups during crisis compared to the pre-crisis period, while it decreased significantly in the university study group (PR = 0.76, 95 % CI: 0.58-0.99). However, in unemployed individuals prevalence ratios for poor mental health increased significantly only in the secondary studies group (PR = 1.73, 95 % CI: 1.06-2.83). Financial strain and social support yielded consistent associations with mental health in all subgroups. Only financial strain could partly explain the crisis effect on mental health among the unemployed. Conclusions: Our study supports the finding that current economic recession is associated with poorer mental health differentially according to labour market status and educational level. Those with secondary studies may be at risk in times of economic recession. In connection with this, emerging educational inequalities in mental health among the employed population were observed. Our research also suggests a partial mediating role of financial strain for the effects of crisis on poor mental health among the unemployed. Good social support appears to buffer poor mental health in all subgroups but not specifically during crisis period.

Nyckelord
Economic crisis, Mental health, Employment status, Educational inequalities, Financial strain, Social support, Spain
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Identifikatorer
urn:nbn:se:umu:diva-119284 (URN)10.1186/s12889-016-2934-z (DOI)000372494400001 ()26979336 (PubMedID)
Tillgänglig från: 2016-05-16 Skapad: 2016-04-15 Senast uppdaterad: 2019-04-26Bibliografiskt granskad
4. Withstanding austerity: equity in health services utilisation in the first stage of the economic recession in Southern Spain
Öppna denna publikation i ny flik eller fönster >>Withstanding austerity: equity in health services utilisation in the first stage of the economic recession in Southern Spain
2018 (Engelska)Ingår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, nr 3, artikel-id e0195293Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Scant research is available on the impact of the current economic crisis and austerity policies on inequality in health services utilisation in Europe. This study aimed to describe the trends in horizontal inequity in the use of health services in Andalusia, Spain, during the early years of the Great Recession, and the contribution of demographic, economic and social factors. Consultation with a general practitioner (GP) and specialist, hospitalisation and emergency care were studied through the Andalusian Health Survey 2007 (pre-crisis) and 2011-2012 (crisis), using a composite income index as socioeconomic status (SES) indicator. Horizontal inequity indices (HII) were calculated to take differential healthcare needs into account, and a decomposition analysis of change in inequality between periods was performed. Results showed that before the crisis, the HII was positive (greater access for people with higher SES) for specialist visits but negative (greater access for people with lower SES) in the other three utilisation models. During the crisis no change was observed in inequalities in GP visits, but a pro-poor development was seen for the other types of utilisation, with hospital and emergency care showing significant inequality in favour of low income groups. Overall, the main contributors to pro-poor changes in utilisation were socioeconomic variables and poor mental health, due to changes in their elasticities. Our findings show that inequalities in healthcare utilisation largely remained in favour of the less well-off, despite the cuts in welfare benefits and health services provision during the early years of the recession in Andalusia. Further research is needed to monitor the potential impact of such measures in subsequent years.

Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Identifikatorer
urn:nbn:se:umu:diva-130574 (URN)10.1371/journal.pone.0195293 (DOI)000428845900026 ()29601609 (PubMedID)2-s2.0-85044858050 (Scopus ID)
Forskningsfinansiär
Forte, Forskningsrådet för hälsa, arbetsliv och välfärd, 2006-1512; 2014-0451
Anmärkning

Originally included in thesis in manuscript form with title: Withstanding austerity: equity in access to health services in the first stage of the economic recession in southern Spain

Tillgänglig från: 2017-01-24 Skapad: 2017-01-24 Senast uppdaterad: 2018-06-25Bibliografiskt granskad

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