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      Social inequality in morbidity, framed within the current economic crisis in Spain


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          Inspired by the ‘Fundamental Cause Theory (FCT)’ we explore social inequalities in preventable versus relatively less-preventable illnesses in Spain. The focus is on the education-health gradient, as education is one of the most important components of an individual’s socioeconomic status (SES). Framed in the context of the recent economic crisis, we investigate the education gradient in depression, diabetes, and myocardial infarction (relatively highly preventable illnesses) and malignant tumors (less preventable), and whether this educational gradient varies across the regional-economic context and changes therein.


          We use data from three waves of the Spanish National Health Survey (2003–2004, 2006–2007, and 2011–2012), and from the 2009–2010 wave of the European Health Survey in Spain, which results in a repeated cross-sectional design. Logistic multilevel regressions are performed with depression, diabetes, myocardial infarction, and malignant tumors as dependent variables. The multilevel design has three levels (the individual, period-regional, and regional level), which allows us to estimate both longitudinal and cross-sectional macro effects. The regional-economic context and changes therein are assessed using the real GDP growth rate and the low work intensity indicator.


          Education gradients in more-preventable illness are observed, while this is far less the case in our less-preventable disease group. Regional economic conditions seem to have a direct impact on depression among Spanish men (y-stand. OR = 1.04 [95 % CI: 1.01–1.07]). Diabetes is associated with cross-regional differences in low work intensity among men (y-stand. OR = 1.02 [95 % CI: 1.00–1.05]) and women (y-stand. OR = 1.04 [95 % CI: 1.01–1.06]). Economic contraction increases the likelihood of having diabetes among men (y-stand. OR = 1.04 [95 % CI: 1.01–1.06]), and smaller decreases in the real GDP growth rate are associated with lower likelihood of myocardial infarction among women (y-stand. OR = 0.83 [95 % CI: 0.69–1.00]). Finally, there are interesting associations between the macroeconomic changes across the crisis period and the likelihood of suffering from myocardial infarction among lower educated groups, and the likelihood of having depression and diabetes among less-educated women.


          Our findings partially support the predictions of the FCT for Spain. The crisis effects on health emerge especially in the case of our more-preventable illnesses and among lower educated groups. Health inequalities in Spain could increase rapidly in the coming years due to the differential effects of recession on socioeconomic groups

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12939-015-0217-4) contains supplementary material, which is available to authorized users.

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          Agreement between self-report questionnaires and medical record data was substantial for diabetes, hypertension, myocardial infarction and stroke but not for heart failure.

          Questionnaires are used to estimate disease burden. Agreement between questionnaire responses and a criterion standard is important for optimal disease prevalence estimates. We measured the agreement between self-reported disease and medical record diagnosis of disease. A total of 2,037 Olmsted County, Minnesota residents > or =45 years of age were randomly selected. Questionnaires asked if subjects had ever had heart failure, diabetes, hypertension, myocardial infarction (MI), or stroke. Medical records were abstracted. Self-report of disease showed >90% specificity for all these diseases, but sensitivity was low for heart failure (69%) and diabetes (66%). Agreement between self-report and medical record was substantial (kappa 0.71-0.80) for diabetes, hypertension, MI, and stroke but not for heart failure (kappa 0.46). Factors associated with high total agreement by multivariate analysis were age 12 years, and zero Charlson Index score (P < .05). Questionnaire data are of greatest value in life-threatening, acute-onset diseases (e.g., MI and stroke) and chronic disorders requiring ongoing management (e.g.,diabetes and hypertension). They are more accurate in young women and better-educated subjects.
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            Gender differences in depression in 23 European countries. Cross-national variation in the gender gap in depression.

            One of the most consistent findings in the social epidemiology of mental health is the gender gap in depression. Depression is approximately twice as prevalent among women as it is among men. However, the absence of comparable data hampers cross-national comparisons of the prevalence of depression in general populations. Using information about the frequency and severity of depressive symptoms from the third wave of the European Social Survey (ESS-3), we are able to fill the gap the absence of comparable data leaves. In the ESS-3, depression is measured with an eight-item version of the Center for Epidemiological Studies-Depression Scale. In the current study, we examine depression among men and women aged 18-75 in 23 European countries. Our results indicate that women report higher levels of depression than men do in all countries, but there is significant cross-national variation in this gender gap. Gender differences in depression are largest in some of the Eastern and Southern European countries and smallest in Ireland, Slovakia and some Nordic countries. Hierarchical linear models show that socioeconomic as well as family-related factors moderate the relationship between gender and depression. Lower risk of depression is associated in both genders with marriage and cohabiting with a partner as well as with having a generally good socioeconomic position. In a majority of countries, socioeconomic factors have the strongest association with depression in both men and women. This research contributes new findings, expanding the small existing body of literature that presents highly comparable data on the prevalence of depression in women and men in Europe. Copyright 2010 Elsevier Ltd. All rights reserved.
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              How Many Countries for Multilevel Modeling? A Comparison of Frequentist and Bayesian Approaches


                Author and article information

                Int J Equity Health
                Int J Equity Health
                International Journal for Equity in Health
                BioMed Central (London )
                14 November 2015
                14 November 2015
                : 14
                : 131
                [ ]Centre for Urban Political Sociology and Policies, Universidad Pablo de Olavide, ES-41013 Seville, Spain
                [ ]Health and Demographic Research (HeDeRa), Department of Sociology, Ghent University, Korte Meer 5, 9000 Ghent, Belgium
                [ ]Centre for Urban Political Sociology and Policies, Department of Sociology, Pablo de Olavide University, Ctra. de Utrera, km. 1, 41013 Seville, Spain
                © Zapata Moya et al. 2015

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 14 April 2015
                : 17 September 2015
                Custom metadata
                © The Author(s) 2015

                Health & Social care
                crisis,fundamental cause theory,macroeconomic changes,influence on health,morbidity,spain


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