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  • 1.
    Cordoba-Dona, Juan Antonio
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. 1Delegación Territorial de Igualdad, Salud y Políticas Sociales de Andalucía.
    Escolar-Pujolar, Antonio
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Socialmedicin.
    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 unemployment2016Ingår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 16, artikel-id 267Artikel i tidskrift (Refereegranskat)
    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.

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  • 2.
    Córdoba Doña, Juan Antonio
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Withstanding austerity: economic crisis and health inequalities in Spain2017Doktorsavhandling, 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.

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  • 3.
    Córdoba-Doña, Juan Antonio
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Delegación Territorial de la Consejería de Salud de la Junta de Andalucía, Cádiz, Spain.
    Escolar-Pujolar, Antonio
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Withstanding austerity: equity in health services utilisation in the first stage of the economic recession in Southern Spain2018Ingår i: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, nr 3, artikel-id e0195293Artikel i tidskrift (Refereegranskat)
    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.

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  • 4.
    Córdoba-Doña, Juan Antonio
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Delegación Territorial de Igualdad, Salud y Políticas Sociales de Cádiz, Cádiz, Spain.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Escolar-Pujolar, Antonio
    Delegación Territorial de Igualdad, Salud y Políticas Sociales de Cádiz, Cádiz, Spain.
    Martínez-Faure, Jesús Enrique
    Empresa Pública de Emergencias Sanitarias, Cádiz, Spain.
    Gustafsson, Per E.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin.
    Economic crisis and suicidal behaviour: the role of unemployment, sex and age in Andalusia, Southern Spain2014Ingår i: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 13, artikel-id 55Artikel i tidskrift (Refereegranskat)
    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.

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  • 5.
    Jesus Rodriguez, Gabriel
    et al.
    Servicio de Medicina Preventiva, Salud Pública y Promoción de la Salud, Hospital Universitario Puerta del Mar, Cádiz, España.
    Escolar-Pujolar, Antonio
    Servicio de Medicina Preventiva, Salud Pública y Promoción de la Salud, Hospital Universitario Puerta del Mar, Cádiz, España and Delegación Territorial de Igualdad, Salud y Políticas Sociales, Cádiz, España.
    Cordoba-Dona, Juan Antonio
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Delegación Territorial de Igualdad, Salud y Políticas Sociales, Cádiz, España.
    Trends in socioeconomic inequalities in general mortality in the city of Cadiz, Spain (1992-2007)2014Ingår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 28, nr 4, s. 313-315Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: To analyze trends in socioeconomic inequality in mortality in the city of Cadiz (Spain) from 1992 to 2007. Methods: An ecological study was performed of trends over 3 cross-sections, with the census tract as the unit of analysis. Deaths were grouped into three periods: 1992-1996, 1997-2001 and 2002-2007 and were then classified according to a deprivation index of the census tract. We calculated adjusted rates by the direct method and three measures of health inequality. Results: Of 18,586 deaths, 96.7% was geocoded to a census tract. The population-attributable risk decreased in men and women, respectively, from 15.4% and 12.2% in 1992-1996 to 9.3% and 5.6% in 2002-2007. The other measures, slope index and the relative index also showed a decline in inequality but only among women. Conclusions: Despite a decreasing trend, social inequalities are a substantial component in the distribution of overall mortality in the city of Cadiz. 

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  • 6. Perez-Alonso, Aranzazu
    et al.
    Córdoba-Doña, Juan Antonio
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Luis Millares-Lorenzo, Jose
    Figueroa-Murillo, Estrella
    Garcia-Vadillo, Cristina
    Romero-Morillo, Jose
    Outbreak of silicosis in Spanish quartz conglomerate workers2014Ingår i: International journal of occupational and environmental health, ISSN 1077-3525, E-ISSN 2049-3967, Vol. 20, nr 1, s. 26-32Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: To describe the epidemiological and clinical characteristics of an outbreak of occupational silicosis and the associated working conditions. Methods: Cases were defined as men working in the stone cutting, shaping, and finishing industry in the province of Cadiz, diagnosed with silicosis between July 2009 and May 2012, and were identified and diagnosed by the department of pulmonology of the University Hospital of Puerto Real (Cadiz). A census of workplaces using quartz conglomerates was carried out to determine total numbers of potentially exposed workers. A patient telephone survey on occupational exposures and a review of medical records for all participants were conducted. Results: Silicosis was diagnosed in 46 men with a median age of 33 years and a median of 11 years working in the manufacturing of countertops. Of these cases, 91.3% were diagnosed with simple chronic silicosis, with an abnormal high-resolution computerized tomography (HRCT) scan. One patient died during the study period. Employer non-compliance in prevention and control measures was frequently reported, as were environmental and individual protection failures. Conclusions: The use of new construction materials such as quartz conglomerates has increased silicosis incidence due to intensive occupational exposures, in the context of high demand fuelled by the housing boom. This widespread exposure poses a risk if appropriate preventive measures are not undertaken.

  • 7. Quizhpe, Edy
    et al.
    Nauta, Gladys
    Cordoba-Dona, Juan Antonio
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Consejeria Salud, Junta Andalucia, Cadiz, Spain.
    Teran, Enrique
    Five-Year Eradication of Hepatitis B Infection after an Outreach Immunization Program in the Waorani Population in the Ecuadorian Amazon2016Ingår i: American Journal of Tropical Medicine and Hygiene, ISSN 0002-9637, E-ISSN 1476-1645, Vol. 95, nr 3, s. 670-673Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    In Waorani communities of the Amazon basin of Ecuador, hepatitis B (HB) surface antigen was found in 14% of asymptomatic persons. The aim of this study was to identify the Waorani population in Ecuador and obtain an epidemiologically adequate coverage of vaccination against hepatitis B virus (HBV) among them. Between February and September 2010, three vaccination campaigns were completed as part of a collaborative activity between the Ecuadorian Ministry of Public Health and the community leaders in the intervention areas. In addition, in 10 of the 22 Waorani communities, during first contact, a questionnaire about risk factors for HBV infection was administered. A total of 16 Waorani communities were registered before the beginning of this intervention, but during the actual process, six additional communities were identified. In total, 1,251 community members were registered, 92.7% of which received all three doses of the vaccine. Among them, 83% of survey respondents reported having been vaccinated, but only 22% were able to show proof. Only 1% of respondents were intravenous drug users, whereas 22% had at least one tattoo. All self-identified as heterosexual, but only 32% reported using condoms during sexual intercourse. By March 2015, no new cases of HB were been reported in any of the Waorani communities. Herein, we report the importance of intersectoral collaboration to strengthen health interventions in an isolated population like the Waorani area.

  • 8. Rodríguez, Gabriel Jesús
    et al.
    Córdoba-Doña, Juan Antonio
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Consejería de Salud de la Junta de Andalucía. Delegación Territorial de Cádiz, Espana.
    Escolar-Pujolar, Antonio
    Aguilar-Diosdado, Manuel
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Familia, economía y servicios sanitarios: claves de los cuidados en pacientes con diabetes y amputación de miembros inferiores. Estudio cualitativo en Andalucía: [Family, socioeconomic status and health services: Clues to health care in diabetic patients with lower limb amputations in Andalusia. A qualitative study]2018Ingår i: Atención Primaria, ISSN 0212-6567, E-ISSN 1578-1275, Vol. 50, nr 10, s. 611-620Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Aim: To examine the experience of diabetic care in patients undergoing lower limb amputation.

    Design: A qualitative study using the phenomenological approach.

    Setting: Cadiz Health District.

    Participants: A total of 16 patients (11 men and 5 women) diagnosed with diabetes mellitus type 2 and with non-traumatic lower limb amputation.

    Methods: Semi-structured interviews were performed, followed by a content analysis according Graneheim and Lundman.

    Results: Four categories were identified: 1. The family is the cornerstone for diabetic care. 2. The socio-economic and working conditions determine the quality of self-care. 3. The patient-health professional interaction facilitates patient care. 4. Limitations in the provision of health services.

    Conclusion: Family, economic and working conditions, along with health system-related factors are the most important elements in the care of patients with diabetes and amputations. Social, economic and working conditions determine diabetic complications. In order to enhance health care impact on the prevention of diabetes mellitus complications, health system policy makers must take these facts seriously into consideration and in a more personalised manner.

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  • 9. Ruiz-Ramos, Miguel
    et al.
    Córdoba-Doña, Juan Antonio
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Bacigalupe, Amaia
    Juárez, Sol
    Escolar-Pujolar, Antonio
    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].2014Ingår i: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 28 (Suppl 1), s. 89-96Artikel i tidskrift (Refereegranskat)
    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.

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