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    "textoCompleto" => "<p class="elsevierStylePara"> Viernes 3 de Octubre &#47; Friday 3&#44; October<br></br> 9&#58;00&#58;00 a&#47;to 11&#58;00&#58;00</p><p class="elsevierStylePara"> Moderador&#47;Chairperson&#58;<br></br> Teresa Brugal</p><p class="elsevierStylePara"><span class="elsevierStyleBold">266 &#191;IMPORTA EL TAMA&#209;O&#63; UNA EXPLORACI&#211;N DE LA RELACI&#211;N ENTRE EL GASTO GUBERNAMENTAL TOTAL Y LA SALUD</span></p><p class="elsevierStylePara"> Alvaro Franco-Giraldo&#42;&#44; Diana Gil&#42;&#42;&#44; Carlos &#193;lvarez-Dardet&#42;&#42;&#42;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#42;Facultad Nacional de Salud P&#250;blica&#44; Universidad de Antioquia&#44; Colombia&#46; &#42;&#42;Departamento de Salud P&#250;blica&#44; Universidad de Alicante&#44; Espa&#241;a&#46; &#42;&#42;&#42;Departamento de Salud P&#250;blica&#44; Universidad de Alicante&#44; Espa&#241;a&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes&#58;</span> El tama&#241;o del Estado ha sido objeto de intenso debate pol&#237;tico y econ&#243;mico en las &#250;ltimas d&#233;cadas&#46; Diversos organismos econ&#243;micos internacionales&#44; incluso&#44; han incorporado requisitos de reducci&#243;n del gasto publico entre sus pol&#237;ticas&#46; Sin embargo&#44; todav&#237;a no existen investigaciones que traten de vincular la reducci&#243;n del gasto p&#250;blico total en un Estado y su impacto en la situaci&#243;n de salud de una poblaci&#243;n&#46; Este estudio se plantea como objetivo explorar las conexiones entre el gasto p&#250;blico estatal y las de una selecci&#243;n de indicadores de salud en una muestra de noventa pa&#237;ses de todo el mundo en la &#250;ltima d&#233;cada&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">M&#233;todos&#58;</span> Los datos correspondientes al gasto p&#250;blico como porcentaje del PIB y al PIB per c&#225;pita &#40;variables explicativas&#41; se han obtenido de las estad&#237;sticas oficiales del Fondo Monetario Internacional &#40;FMI&#41;&#46; Se incluyeron como indicadores de salud&#44; Mortalidad Infantil&#44; Mortalidad Materna y Esperanza de Vida&#44; obtenidas de los Informes de Desarrollo Humano &#40;IDH&#41; del Programa de Naciones Unidas para el Desarrollo &#40;PNUD&#41;&#46; Se encontr&#243; informaci&#243;n para todos estos indicadores circa 1990 y 2000 en un total de 90 pa&#237;ses&#46; Se realiz&#243; un an&#225;lisis descriptivo de la evoluci&#243;n del gasto p&#250;blico en estos pa&#237;ses y su distribuci&#243;n por regiones &#40;pa&#237;ses desarrollados&#44; pa&#237;ses en transici&#243;n&#44; Latinoam&#233;rica y el Caribe&#44; Asia y Ocean&#237;a y pa&#237;ses en desarrollo&#41;&#44; y comparaciones seg&#250;n cuartiles de PIB per c&#225;pita y de gasto p&#250;blico como porcentaje del PIB&#46; Posteriormente&#44; se construy&#243; un modelo de regresi&#243;n m&#250;ltiple para aislar el efecto neto del gasto p&#250;blico sobre los indicadores de salud&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Resultados&#58;</span> En la &#250;ltima d&#233;cada&#44; el tama&#241;o del Estado &#40;gasto p&#250;blico central como &#37; del PIB&#41; se ha mantenido en el mundo&#44; convergiendo hacia el final de la d&#233;cada&#44; alrededor de una media de 28&#37; &#40;s&#61; 10&#46;3&#59; cv&#61; 36&#46;8&#37;&#41;&#44; pero a&#250;n dentro de un amplio rango &#40;min&#46; 7&#46;80&#37;&#44; max&#46; 53&#46;50&#37;&#41; seg&#250;n regiones y pa&#237;ses&#46; Los indicadores de salud han mejorado significativamente&#44; con excepci&#243;n de la esperanza de vida al nacer&#46; Sin embargo&#44; hay retroceso de ellos en algunos pa&#237;ses pobres de &#193;frica y Asia&#44; afectados por el bajo gasto p&#250;blico&#46; Tanto el gasto p&#250;blico&#44; como el PIB per c&#225;pita y la regi&#243;n &#40;especialmente &#193;frica&#41; predicen significativamente los indicadores de salud&#46; El efecto del tama&#241;o del Estado tiene especial importancia sobre la mortalidad infantil &#40;r<span class="elsevierStyleSup">2</span>&#61;0&#46;16&#59; beta&#61; -0&#46;399&#59; p&#60; 0&#46;001&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusiones&#58;</span> El presente estudio tiene limitaciones como la reducida ventana temporal utilizada o no haber tenido en cuenta otras variables como el servicio de la deuda externa&#46; No obstante&#44; se ha encontrado un efecto neto del tama&#241;o del Estado&#44; aislado o asociado a otros factores&#44; sobre los indicadores de salud que debe tenerse en cuenta en el debate pol&#237;tico y epidemiol&#243;gico&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">267 SOCIOECONOMIC INEQUALITIES IN MORTALITY IN THE BASQUE COUNTRY</span></p><p class="elsevierStylePara"> Santiago Esnaola Sukia&#42;&#44; Elena Aldasoro Unamuno&#42;&#44; Rosa M&#170; Ruiz Fern&#225;ndez&#42;&#44; Covadonga Audicana Uriarte&#42;&#42;&#44; Yolanda P&#233;rez D&#237;ez&#42;&#44; Montserrat Calvo S&#225;nchez&#42;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#42;Servicio de Estudios e Investigaci&#243;n Sanitaria&#44; Departamento de Sanidad del Gobierno Vasco&#44; Vitoria-Gasteiz&#44; Espa&#241;a&#46; &#42;&#42;Servicio de Registros e Informaci&#243;n Sanitaria&#44; Departamento de Sanidad del Gobierno Vasco&#44; Vitoria-Gasteiz&#44; Espa&#241;a&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction&#58;</span> Previous studies on socioeconomic inequalities in health in the Basque country have been limited to self-perceived health&#46; The aim of this study was to describe socioeconomic inequalities in mortality in the Basque country during the 1996-1999 period&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Methods&#58;</span> Data on deaths were obtained from the mortality registry of the Basque country&#46; In view of the poor quality of socioeconomic data in death certificates&#44; the socioeconomic characteristics of the census section &#40;mean number of inhabitants&#58; 1&#44;257&#41; were assigned to each death&#46; We used principal components analysis to calculate a socioeconomic index combining the proportion of persons with less than 12 years of schooling&#44; the proportion of unemployed persons&#44; the proportion of unskilled manual workers&#44; and the proportion of households with low living standards&#46; Age-adjusted mortality rates were estimated for each sex and age group &#40;0-64 years old&#44; 65 and older&#41; for the quintiles of the socio-economic index&#46; Poisson regression models were fitted to estimate the age-adjusted rate ratios &#40;RR&#41; comparing the socioeconomic index quintiles&#44; taking the more affluent quintile as the reference category&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results&#58;</span> Inequalities in mortality according to the socioeconomic index followed a gradient in both sexes and in the two age groups&#44; with higher mortality in more deprived areas&#46; When comparing the more extreme socioeconomic quintiles&#44; the greatest inequalities were observed among men aged 0-64 &#40;RR&#58; 1&#46;56&#59; 95&#37; CI&#58; 1&#46;5-1&#46;7&#41;&#46; The RR among women aged 0-64 was 1&#46;15 &#40;95&#37; CI&#58; 1&#46;1-1&#46;2&#41;&#44; similar to those of men and women aged 65 and older&#44; which were 1&#46;10 &#40;95&#37; CI&#58; 1&#46;0-1&#46;2&#41; and 1&#46;11 &#40;95&#37; CI&#58; 1&#46;1-1&#46;2&#41; respectively&#46; With regard to the causes of death &#40;ICD-9&#41;&#44; among men aged 0-64 the RR were higher for drug overdose &#40;3&#46;64&#41;&#44; chronic obstructive pulmonary disease &#40;3&#46;53&#41; and cirrhosis &#40;2&#46;43&#41;&#59; among women 0-64 years old for cirrhosis &#40;2&#46;20&#41;&#44; ischaemic heart disease &#40;1&#46;68&#41; and cerebrovascular disease &#40;1&#46;45&#41;&#44; and an inverse association was observed for lung cancer &#40;0&#46;50&#41; and breast cancer &#40;0&#46;89&#41;&#46; After 65 years&#44; among men the main differences were for suicide &#40;1&#46;64&#41;&#44; cirrhosis &#40;1&#46;57&#41; and chronic obstructive pulmonary disease &#40;1&#46;42&#41;&#59; among women for stomach cancer &#40;1&#46;40&#41;&#44; cirrhosis &#40;1&#46;35&#41; and cerebrovascular disease &#40;1&#46;17&#41;&#44; and only breast cancer showed an inverse association &#40;0&#46;74&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions&#58;</span> This ecologic analysis could underestimate the magnitude of inequalities observed with individual level data&#46; However&#44; this study illustrates the potential utility of small-areas socioeconomic indicators both to determine the relevance of mortality inequalities and identify priorities for interventions&#46; A similar analysis with data from previous years has provided information to formulate the health policies on social inequalities in the Basque country&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">268 SOCIAL FACTORS ASSOCIATED WITH THE RENOUNCEMENT OF HEALTHCARE FOR INSUFFICIENT FINANCIAL MEANS IN UNDERPRIVILEGED URBAN AREAS IN THE PARIS REGION&#44; FRANCE&#44; 2001</span></p><p class="elsevierStylePara"> Pierre Chauvin&#44; Fabienne Bazin&#44; Isabelle Parizot</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Social determinants of health and utilization of care&#44; INSERM U444&#44; Paris&#44; France&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction&#58;</span> In France&#44; universal access to healthcare is theoretically guaranteed through the Social Security system&#46; Nevertheless&#44; 24&#37; of the population claims that they are compelled to refrain from using healthcare services for insufficient financial means&#44; according to regular national representative studies&#46; The incidence of such renouncement has been reported to be higher for the younger&#44; the poorer and&#47;or those with a less extensive Social Security coverage&#46; We aimed to estimate the role of living conditions&#44; social integration&#44; health beliefs and various other individual psychosocial characteristics&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Methods&#58;</span> 525 individuals living in 5 underprivileged areas in Paris region were enrolled in a cross-sectional multicenter representative study in 2001&#46; Statistical associations between such a renouncement and psychosocial characteristics were examined using logistic regression models adjusted on age&#44; gender&#44; household size&#44; chronic disease&#44; health insurance status&#44; income and occupation levels&#46; Bootstrap methods allowed us to evaluate the qualities of our final model&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results&#58;</span> Such a renouncement was more frequent among people who whose income was &#60;550 &#8364;&#40;OR&#61;3&#46;24 CI95&#37;&#61;1&#46;58-6&#46;67&#41;&#44; without any family doctor &#40;OR&#61;2&#46;16 CI95&#37;&#61;1&#46;09-5&#46;16&#41;&#44; with a chronic disease &#40;OR&#61;2&#46;16 CI95&#37;&#61;1&#46;13-4&#46;13&#41;&#44; any life-course experience of physical&#44; sexual or psychological abuse &#40;OR&#61;3&#46;40 CI95&#37;&#61;1&#46;68-6&#46;86&#41;&#44; a low sickness orientation &#40;OR&#61;2&#46;44 CI95&#37;&#61;1&#46;25-4&#46;75&#41;&#44; a low health priority &#40;OR&#61;3&#46;05 CI95&#37;&#61;1&#46;51-6&#46;18&#41;&#46; We observed also a dose-response relationship with the number of striking childhood events and with the level of perceived self-esteem&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusion&#58;</span> This study highlights the importance of taking into account psychosocial determinants &#40;social disruptions and integration&#44; life events&#44; health behaviors&#44; and psychological factors&#41; in addition to the socio-economic status of individuals&#44; when studying inequalities in access and utilization of healthcare services&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">269 SOCIAL CLASS AND SELF-REPORTED HEALTH STATUS AMONG MEN AND WOMEN&#58; WHAT IS THE ROLE OF WORK ORGANISATION&#44; HOUSEHOLD MATERIAL STANDARDS AND HOUSEHOLD LABOUR&#63;</span></p><p class="elsevierStylePara"> Carme Borrell<span class="elsevierStyleSup">1</span>&#44; Carles Muntaner <span class="elsevierStyleSup">2</span>&#44; Joan Benach<span class="elsevierStyleSup">3</span>&#44; Luc&#237;a Artazcoz<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleSup">1</span>Servicio de Informaci&#243;n Sanitaria&#44; Ag&#232;ncia de Salut P&#250;blica de Barcelona&#44; Barcelona&#44; Espa&#241;a&#46; <span class="elsevierStyleSup">2</span>Department of Behavioral and Community Health&#44; University of Maryland&#44; Baltimore&#44; USA&#46; <span class="elsevierStyleSup">3</span>Unidad de Investigaci&#243;n en Salud Laboral&#44; Universitat Pompeu Fabra&#44; Barcelona&#44; Espa&#241;a&#46; <span class="elsevierStyleSup">4</span>Servicio de Salud Laboral y Ambiental&#44; Ag&#232;ncia de Salut P&#250;blica de Barcelona&#44; Barcelona&#44; Espa&#241;a&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction&#58;</span> Social class understood as social relations of ownership and control over productive assets taps into parts of the social variation in health that are not captured by conventional measures of social stratification&#46; The objectives of this study are to analyse the association between self-reported health status and social class and to examine the role of work organisation&#44; material standards and household labour as potential mediating factors in explaining this association&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Methods&#58;</span> We used the Barcelona Health Interview Survey&#44; a cross-sectional survey of 10&#44;000 residents of the city&#39;s non-institutionalised population in 2000&#46; This was a stratified sample&#44; strata being the 10 districts of the city&#46; The present study was conducted on the working population&#44; aged 16-64 years &#40;2&#44;345 men and 1&#44;874 women&#41;&#46; Social class position was measured with Erik Olin Wright&#39;s indicators according to ownership and control over productive assets&#44; as well as ownership of credentials&#46; The dependent variable was self-reported health status &#40;1&#61;fair&#44; poor or very poor&#59; 0&#61;very good&#44; good&#41;&#46; The independent variables were social class&#44; age&#44; psychosocial and physical working conditions&#44; job insecurity&#44; type of labour contract&#44; number of hours worked per week&#44; possession of appliances at home&#44; as well as household labour &#40;number of hours per week&#44; to do the housework alone and having children&#44; elderly of disabled at home&#41;&#46; Several hierarchical logistic regression models were performed by adding different blocks of independent variables&#44; obtaining adjusted OR &#40;aOR&#41;&#46; The role of the potential mediating factors was studied analysing the reduction of aOR of social class after the introduction of these factors in the models&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results&#58;</span> Among men the prevalence of poor reported health was higher among small employers and petit bourgeois&#44; supervisors&#44; semi-skilled &#40;aOR&#58; 4&#46;92&#59; 95&#37; CI&#58; 1&#46;88-12&#46;88&#41; and unskilled workers &#40;aOR&#58; 7&#46;69&#59; 95&#37; CI&#58; 3&#46;01-19&#46;64&#41;&#46; Variables of work organisation were the main explanatory variables of social class inequalities in health&#44; although material standards also contributed&#46; Among women&#44; only unskilled workers had poorer health status than the referent category of manager and skilled supervisors &#40;aOR&#58; 3&#46;25&#59; 95&#37; CI&#58; 1&#46;37-7&#46;74&#41;&#46; Contrary to men&#44; the number of hours per week of household labour was associated with poor health status &#40;aOR&#58; 1&#46;02&#59; 95&#37; CI&#58; 1&#46;01-1&#46;03&#41;&#46; Although among women working conditions were the main mediating factors&#44; household material deprivation and hours of household labour per week were also important&#44; and remained associated with poor health status in the full model&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions&#58;</span> Our findings suggest that among men&#44; part of the association between social class positions and poor health can be accounted for psychosocial and physical working conditions and job insecurity&#46; Among women&#44; the association between the worker &#40;non-owner&#44; non-managerial&#44; and un-credentiated&#41; class positions and health is substantially explained by working conditions&#44; material well being at home and amount of household labour&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">270 PREVALENCIAS DE INYECCI&#211;N Y PR&#193;CTICAS DE RIESGO EN J&#211;VENES CONSUMIDORES DE HERO&#205;NA DE MADRID Y BARCELONA EN 1995 Y 2002</span></p><p class="elsevierStylePara"> Teresa Brugal&#42;&#44; Luis Royuela&#42;&#42;&#44; Estela D&#237;az de Quijano&#42;&#44; Nuria Valles&#42;&#44; Mar&#237;a Jos&#233; Bravo&#42;&#42;&#42;&#44; Gregorio Barrio&#42;&#42;&#46; Proyecto It&#237;nere</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#42;Servicio de Epidemiolog&#237;a -IMS-&#44; Agencia de Salud P&#250;blica&#44; Barcelona&#44; Espa&#241;a&#46; &#42;&#42;Observatorio Espa&#241;ol de Drogas&#44; Plan Nacional sobre Drogas&#44; Madrid&#44; Espa&#241;a&#46; &#42;&#42;&#42;Plan Nacional sobre el Sida&#44; Ministerio de Sanidad y Consumo&#44; Madrid&#44; Espa&#241;a&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes&#58;</span> En la segunda mitad de los noventa las pol&#237;ticas de reducci&#243;n de da&#241;o han experimentado un gran desarrollo&#44; por lo que se hace imprescindible evaluar su impacto en las pr&#225;cticas de riesgo&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">M&#233;todos&#58;</span> En 2001-2002 se ha llevado a cabo un estudio transversal de ingreso a una cohorte de j&#243;venes &#40;30 a&#241;os o menos&#41; consumidores de hero&#237;na captados &#237;ntegramente en la comunidad&#58; 396 en Madrid y 323 en Barcelona&#46; En 1995 se realiz&#243; otro estudio transversal en el que el 50&#37; de la muestra se reclut&#243; entre los que iniciaban tratamiento y el otro 50&#37; en la comunidad&#44; seleccion&#225;ndose los de 30 a&#241;os o menos&#58; 207 en Barcelona y 199 en Madrid&#46; En ambos casos la captaci&#243;n comunitaria se realiz&#243; mediante personas claves que conocen los escenarios de consumo y por m&#233;todos de referencia en cadena&#46; En el presente an&#225;lisis se han empleado m&#233;todos uni y bivariados&#44; evalu&#225;ndose las comparaciones con el test de Ji cuadrado y consider&#225;ndose significativas con una p &#60; 0&#44;05&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Resultados&#58;</span> En Barcelona descienden significativamente los indicadores sobre prevalencia de inyecci&#243;n&#44; mientras en Madrid no lo hacen&#58; el porcentaje de los que se han inyectado alguna vez pasa del 88&#37; al 78&#37; en Barcelona &#40;70&#37; y 65&#37; en Madrid&#41;&#44; el de los que lo han hecho en los &#250;ltimos 12 meses del 84&#37; al 75&#37; &#40;48&#37; y 49&#37; en Madrid&#41;&#44; en los &#250;ltimos 30 d&#237;as del 82 al 67 &#40;32&#37; y 40&#37; en Madrid&#41;&#44; y el de los que tienen la inyecci&#243;n como v&#237;a principal del 81&#37; al 64&#37; &#40;20&#37; en Madrid en ambos per&#237;odos&#41;&#46; Entre los que se han inyectado&#44; en ambas ciudades desciende muy significativamente el porcentaje de los que se han inyectado alguna vez con jeringas usadas por otros &#40;72&#37; y 42&#37; en Barcelona&#59; 61&#37; y 39&#37; en Madrid&#41;&#44; y el de los que lo han realizado en los &#250;ltimos 12 meses &#40;35&#37; y 20&#37; en Barcelona y 29&#37; y 17&#37; en Madrid&#41;&#44; pero el de los que lo hicieron en los &#250;ltimos 30 d&#237;as no descendi&#243; significativamente en Madrid &#40;18&#37; en 1995 y 12&#37; en 2002&#41; o incluso aument&#243; casi significativamente en Barcelona &#40;8&#37; y 13&#37;&#41;&#46; Las pr&#225;cticas indirectas de compartir material de inyecci&#243;n &#40;inyectarse o dar droga disuelta en jeringuilla usada por otros&#41; tambi&#233;n descendieron situ&#225;ndose en el 2002 por debajo del 20&#37; en los &#250;ltimos 12 meses&#44; aunque no pudo evaluarse la significaci&#243;n&#44; por haberse preguntado para los &#250;ltimos 30 d&#237;as en 1995&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusiones&#58;</span> En Barcelona ha disminuido la inyecci&#243;n entre los consumidores de hero&#237;na&#44; mientras en Madrid pr&#225;cticamente no&#46; Entre los inyectores han disminuido las pr&#225;cticas de riesgo entre los mas espor&#225;dicos&#44; mientras parece mantenerse entre los habituales&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Financiado por FIPSE 3035&#47;99&#46;</span></p>"
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Comunicaciones orales : Desigualdades sociales II
Social inequalities II
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    "textoCompleto" => "<p class="elsevierStylePara"> Viernes 3 de Octubre &#47; Friday 3&#44; October<br></br> 9&#58;00&#58;00 a&#47;to 11&#58;00&#58;00</p><p class="elsevierStylePara"> Moderador&#47;Chairperson&#58;<br></br> Teresa Brugal</p><p class="elsevierStylePara"><span class="elsevierStyleBold">266 &#191;IMPORTA EL TAMA&#209;O&#63; UNA EXPLORACI&#211;N DE LA RELACI&#211;N ENTRE EL GASTO GUBERNAMENTAL TOTAL Y LA SALUD</span></p><p class="elsevierStylePara"> Alvaro Franco-Giraldo&#42;&#44; Diana Gil&#42;&#42;&#44; Carlos &#193;lvarez-Dardet&#42;&#42;&#42;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#42;Facultad Nacional de Salud P&#250;blica&#44; Universidad de Antioquia&#44; Colombia&#46; &#42;&#42;Departamento de Salud P&#250;blica&#44; Universidad de Alicante&#44; Espa&#241;a&#46; &#42;&#42;&#42;Departamento de Salud P&#250;blica&#44; Universidad de Alicante&#44; Espa&#241;a&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes&#58;</span> El tama&#241;o del Estado ha sido objeto de intenso debate pol&#237;tico y econ&#243;mico en las &#250;ltimas d&#233;cadas&#46; Diversos organismos econ&#243;micos internacionales&#44; incluso&#44; han incorporado requisitos de reducci&#243;n del gasto publico entre sus pol&#237;ticas&#46; Sin embargo&#44; todav&#237;a no existen investigaciones que traten de vincular la reducci&#243;n del gasto p&#250;blico total en un Estado y su impacto en la situaci&#243;n de salud de una poblaci&#243;n&#46; Este estudio se plantea como objetivo explorar las conexiones entre el gasto p&#250;blico estatal y las de una selecci&#243;n de indicadores de salud en una muestra de noventa pa&#237;ses de todo el mundo en la &#250;ltima d&#233;cada&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">M&#233;todos&#58;</span> Los datos correspondientes al gasto p&#250;blico como porcentaje del PIB y al PIB per c&#225;pita &#40;variables explicativas&#41; se han obtenido de las estad&#237;sticas oficiales del Fondo Monetario Internacional &#40;FMI&#41;&#46; Se incluyeron como indicadores de salud&#44; Mortalidad Infantil&#44; Mortalidad Materna y Esperanza de Vida&#44; obtenidas de los Informes de Desarrollo Humano &#40;IDH&#41; del Programa de Naciones Unidas para el Desarrollo &#40;PNUD&#41;&#46; Se encontr&#243; informaci&#243;n para todos estos indicadores circa 1990 y 2000 en un total de 90 pa&#237;ses&#46; Se realiz&#243; un an&#225;lisis descriptivo de la evoluci&#243;n del gasto p&#250;blico en estos pa&#237;ses y su distribuci&#243;n por regiones &#40;pa&#237;ses desarrollados&#44; pa&#237;ses en transici&#243;n&#44; Latinoam&#233;rica y el Caribe&#44; Asia y Ocean&#237;a y pa&#237;ses en desarrollo&#41;&#44; y comparaciones seg&#250;n cuartiles de PIB per c&#225;pita y de gasto p&#250;blico como porcentaje del PIB&#46; Posteriormente&#44; se construy&#243; un modelo de regresi&#243;n m&#250;ltiple para aislar el efecto neto del gasto p&#250;blico sobre los indicadores de salud&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Resultados&#58;</span> En la &#250;ltima d&#233;cada&#44; el tama&#241;o del Estado &#40;gasto p&#250;blico central como &#37; del PIB&#41; se ha mantenido en el mundo&#44; convergiendo hacia el final de la d&#233;cada&#44; alrededor de una media de 28&#37; &#40;s&#61; 10&#46;3&#59; cv&#61; 36&#46;8&#37;&#41;&#44; pero a&#250;n dentro de un amplio rango &#40;min&#46; 7&#46;80&#37;&#44; max&#46; 53&#46;50&#37;&#41; seg&#250;n regiones y pa&#237;ses&#46; Los indicadores de salud han mejorado significativamente&#44; con excepci&#243;n de la esperanza de vida al nacer&#46; Sin embargo&#44; hay retroceso de ellos en algunos pa&#237;ses pobres de &#193;frica y Asia&#44; afectados por el bajo gasto p&#250;blico&#46; Tanto el gasto p&#250;blico&#44; como el PIB per c&#225;pita y la regi&#243;n &#40;especialmente &#193;frica&#41; predicen significativamente los indicadores de salud&#46; El efecto del tama&#241;o del Estado tiene especial importancia sobre la mortalidad infantil &#40;r<span class="elsevierStyleSup">2</span>&#61;0&#46;16&#59; beta&#61; -0&#46;399&#59; p&#60; 0&#46;001&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusiones&#58;</span> El presente estudio tiene limitaciones como la reducida ventana temporal utilizada o no haber tenido en cuenta otras variables como el servicio de la deuda externa&#46; No obstante&#44; se ha encontrado un efecto neto del tama&#241;o del Estado&#44; aislado o asociado a otros factores&#44; sobre los indicadores de salud que debe tenerse en cuenta en el debate pol&#237;tico y epidemiol&#243;gico&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">267 SOCIOECONOMIC INEQUALITIES IN MORTALITY IN THE BASQUE COUNTRY</span></p><p class="elsevierStylePara"> Santiago Esnaola Sukia&#42;&#44; Elena Aldasoro Unamuno&#42;&#44; Rosa M&#170; Ruiz Fern&#225;ndez&#42;&#44; Covadonga Audicana Uriarte&#42;&#42;&#44; Yolanda P&#233;rez D&#237;ez&#42;&#44; Montserrat Calvo S&#225;nchez&#42;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#42;Servicio de Estudios e Investigaci&#243;n Sanitaria&#44; Departamento de Sanidad del Gobierno Vasco&#44; Vitoria-Gasteiz&#44; Espa&#241;a&#46; &#42;&#42;Servicio de Registros e Informaci&#243;n Sanitaria&#44; Departamento de Sanidad del Gobierno Vasco&#44; Vitoria-Gasteiz&#44; Espa&#241;a&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction&#58;</span> Previous studies on socioeconomic inequalities in health in the Basque country have been limited to self-perceived health&#46; The aim of this study was to describe socioeconomic inequalities in mortality in the Basque country during the 1996-1999 period&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Methods&#58;</span> Data on deaths were obtained from the mortality registry of the Basque country&#46; In view of the poor quality of socioeconomic data in death certificates&#44; the socioeconomic characteristics of the census section &#40;mean number of inhabitants&#58; 1&#44;257&#41; were assigned to each death&#46; We used principal components analysis to calculate a socioeconomic index combining the proportion of persons with less than 12 years of schooling&#44; the proportion of unemployed persons&#44; the proportion of unskilled manual workers&#44; and the proportion of households with low living standards&#46; Age-adjusted mortality rates were estimated for each sex and age group &#40;0-64 years old&#44; 65 and older&#41; for the quintiles of the socio-economic index&#46; Poisson regression models were fitted to estimate the age-adjusted rate ratios &#40;RR&#41; comparing the socioeconomic index quintiles&#44; taking the more affluent quintile as the reference category&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results&#58;</span> Inequalities in mortality according to the socioeconomic index followed a gradient in both sexes and in the two age groups&#44; with higher mortality in more deprived areas&#46; When comparing the more extreme socioeconomic quintiles&#44; the greatest inequalities were observed among men aged 0-64 &#40;RR&#58; 1&#46;56&#59; 95&#37; CI&#58; 1&#46;5-1&#46;7&#41;&#46; The RR among women aged 0-64 was 1&#46;15 &#40;95&#37; CI&#58; 1&#46;1-1&#46;2&#41;&#44; similar to those of men and women aged 65 and older&#44; which were 1&#46;10 &#40;95&#37; CI&#58; 1&#46;0-1&#46;2&#41; and 1&#46;11 &#40;95&#37; CI&#58; 1&#46;1-1&#46;2&#41; respectively&#46; With regard to the causes of death &#40;ICD-9&#41;&#44; among men aged 0-64 the RR were higher for drug overdose &#40;3&#46;64&#41;&#44; chronic obstructive pulmonary disease &#40;3&#46;53&#41; and cirrhosis &#40;2&#46;43&#41;&#59; among women 0-64 years old for cirrhosis &#40;2&#46;20&#41;&#44; ischaemic heart disease &#40;1&#46;68&#41; and cerebrovascular disease &#40;1&#46;45&#41;&#44; and an inverse association was observed for lung cancer &#40;0&#46;50&#41; and breast cancer &#40;0&#46;89&#41;&#46; After 65 years&#44; among men the main differences were for suicide &#40;1&#46;64&#41;&#44; cirrhosis &#40;1&#46;57&#41; and chronic obstructive pulmonary disease &#40;1&#46;42&#41;&#59; among women for stomach cancer &#40;1&#46;40&#41;&#44; cirrhosis &#40;1&#46;35&#41; and cerebrovascular disease &#40;1&#46;17&#41;&#44; and only breast cancer showed an inverse association &#40;0&#46;74&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions&#58;</span> This ecologic analysis could underestimate the magnitude of inequalities observed with individual level data&#46; However&#44; this study illustrates the potential utility of small-areas socioeconomic indicators both to determine the relevance of mortality inequalities and identify priorities for interventions&#46; A similar analysis with data from previous years has provided information to formulate the health policies on social inequalities in the Basque country&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">268 SOCIAL FACTORS ASSOCIATED WITH THE RENOUNCEMENT OF HEALTHCARE FOR INSUFFICIENT FINANCIAL MEANS IN UNDERPRIVILEGED URBAN AREAS IN THE PARIS REGION&#44; FRANCE&#44; 2001</span></p><p class="elsevierStylePara"> Pierre Chauvin&#44; Fabienne Bazin&#44; Isabelle Parizot</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Social determinants of health and utilization of care&#44; INSERM U444&#44; Paris&#44; France&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction&#58;</span> In France&#44; universal access to healthcare is theoretically guaranteed through the Social Security system&#46; Nevertheless&#44; 24&#37; of the population claims that they are compelled to refrain from using healthcare services for insufficient financial means&#44; according to regular national representative studies&#46; The incidence of such renouncement has been reported to be higher for the younger&#44; the poorer and&#47;or those with a less extensive Social Security coverage&#46; We aimed to estimate the role of living conditions&#44; social integration&#44; health beliefs and various other individual psychosocial characteristics&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Methods&#58;</span> 525 individuals living in 5 underprivileged areas in Paris region were enrolled in a cross-sectional multicenter representative study in 2001&#46; Statistical associations between such a renouncement and psychosocial characteristics were examined using logistic regression models adjusted on age&#44; gender&#44; household size&#44; chronic disease&#44; health insurance status&#44; income and occupation levels&#46; Bootstrap methods allowed us to evaluate the qualities of our final model&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results&#58;</span> Such a renouncement was more frequent among people who whose income was &#60;550 &#8364;&#40;OR&#61;3&#46;24 CI95&#37;&#61;1&#46;58-6&#46;67&#41;&#44; without any family doctor &#40;OR&#61;2&#46;16 CI95&#37;&#61;1&#46;09-5&#46;16&#41;&#44; with a chronic disease &#40;OR&#61;2&#46;16 CI95&#37;&#61;1&#46;13-4&#46;13&#41;&#44; any life-course experience of physical&#44; sexual or psychological abuse &#40;OR&#61;3&#46;40 CI95&#37;&#61;1&#46;68-6&#46;86&#41;&#44; a low sickness orientation &#40;OR&#61;2&#46;44 CI95&#37;&#61;1&#46;25-4&#46;75&#41;&#44; a low health priority &#40;OR&#61;3&#46;05 CI95&#37;&#61;1&#46;51-6&#46;18&#41;&#46; We observed also a dose-response relationship with the number of striking childhood events and with the level of perceived self-esteem&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusion&#58;</span> This study highlights the importance of taking into account psychosocial determinants &#40;social disruptions and integration&#44; life events&#44; health behaviors&#44; and psychological factors&#41; in addition to the socio-economic status of individuals&#44; when studying inequalities in access and utilization of healthcare services&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">269 SOCIAL CLASS AND SELF-REPORTED HEALTH STATUS AMONG MEN AND WOMEN&#58; WHAT IS THE ROLE OF WORK ORGANISATION&#44; HOUSEHOLD MATERIAL STANDARDS AND HOUSEHOLD LABOUR&#63;</span></p><p class="elsevierStylePara"> Carme Borrell<span class="elsevierStyleSup">1</span>&#44; Carles Muntaner <span class="elsevierStyleSup">2</span>&#44; Joan Benach<span class="elsevierStyleSup">3</span>&#44; Luc&#237;a Artazcoz<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic"><span class="elsevierStyleSup">1</span>Servicio de Informaci&#243;n Sanitaria&#44; Ag&#232;ncia de Salut P&#250;blica de Barcelona&#44; Barcelona&#44; Espa&#241;a&#46; <span class="elsevierStyleSup">2</span>Department of Behavioral and Community Health&#44; University of Maryland&#44; Baltimore&#44; USA&#46; <span class="elsevierStyleSup">3</span>Unidad de Investigaci&#243;n en Salud Laboral&#44; Universitat Pompeu Fabra&#44; Barcelona&#44; Espa&#241;a&#46; <span class="elsevierStyleSup">4</span>Servicio de Salud Laboral y Ambiental&#44; Ag&#232;ncia de Salut P&#250;blica de Barcelona&#44; Barcelona&#44; Espa&#241;a&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction&#58;</span> Social class understood as social relations of ownership and control over productive assets taps into parts of the social variation in health that are not captured by conventional measures of social stratification&#46; The objectives of this study are to analyse the association between self-reported health status and social class and to examine the role of work organisation&#44; material standards and household labour as potential mediating factors in explaining this association&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Methods&#58;</span> We used the Barcelona Health Interview Survey&#44; a cross-sectional survey of 10&#44;000 residents of the city&#39;s non-institutionalised population in 2000&#46; This was a stratified sample&#44; strata being the 10 districts of the city&#46; The present study was conducted on the working population&#44; aged 16-64 years &#40;2&#44;345 men and 1&#44;874 women&#41;&#46; Social class position was measured with Erik Olin Wright&#39;s indicators according to ownership and control over productive assets&#44; as well as ownership of credentials&#46; The dependent variable was self-reported health status &#40;1&#61;fair&#44; poor or very poor&#59; 0&#61;very good&#44; good&#41;&#46; The independent variables were social class&#44; age&#44; psychosocial and physical working conditions&#44; job insecurity&#44; type of labour contract&#44; number of hours worked per week&#44; possession of appliances at home&#44; as well as household labour &#40;number of hours per week&#44; to do the housework alone and having children&#44; elderly of disabled at home&#41;&#46; Several hierarchical logistic regression models were performed by adding different blocks of independent variables&#44; obtaining adjusted OR &#40;aOR&#41;&#46; The role of the potential mediating factors was studied analysing the reduction of aOR of social class after the introduction of these factors in the models&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results&#58;</span> Among men the prevalence of poor reported health was higher among small employers and petit bourgeois&#44; supervisors&#44; semi-skilled &#40;aOR&#58; 4&#46;92&#59; 95&#37; CI&#58; 1&#46;88-12&#46;88&#41; and unskilled workers &#40;aOR&#58; 7&#46;69&#59; 95&#37; CI&#58; 3&#46;01-19&#46;64&#41;&#46; Variables of work organisation were the main explanatory variables of social class inequalities in health&#44; although material standards also contributed&#46; Among women&#44; only unskilled workers had poorer health status than the referent category of manager and skilled supervisors &#40;aOR&#58; 3&#46;25&#59; 95&#37; CI&#58; 1&#46;37-7&#46;74&#41;&#46; Contrary to men&#44; the number of hours per week of household labour was associated with poor health status &#40;aOR&#58; 1&#46;02&#59; 95&#37; CI&#58; 1&#46;01-1&#46;03&#41;&#46; Although among women working conditions were the main mediating factors&#44; household material deprivation and hours of household labour per week were also important&#44; and remained associated with poor health status in the full model&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusions&#58;</span> Our findings suggest that among men&#44; part of the association between social class positions and poor health can be accounted for psychosocial and physical working conditions and job insecurity&#46; Among women&#44; the association between the worker &#40;non-owner&#44; non-managerial&#44; and un-credentiated&#41; class positions and health is substantially explained by working conditions&#44; material well being at home and amount of household labour&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">270 PREVALENCIAS DE INYECCI&#211;N Y PR&#193;CTICAS DE RIESGO EN J&#211;VENES CONSUMIDORES DE HERO&#205;NA DE MADRID Y BARCELONA EN 1995 Y 2002</span></p><p class="elsevierStylePara"> Teresa Brugal&#42;&#44; Luis Royuela&#42;&#42;&#44; Estela D&#237;az de Quijano&#42;&#44; Nuria Valles&#42;&#44; Mar&#237;a Jos&#233; Bravo&#42;&#42;&#42;&#44; Gregorio Barrio&#42;&#42;&#46; Proyecto It&#237;nere</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#42;Servicio de Epidemiolog&#237;a -IMS-&#44; Agencia de Salud P&#250;blica&#44; Barcelona&#44; Espa&#241;a&#46; &#42;&#42;Observatorio Espa&#241;ol de Drogas&#44; Plan Nacional sobre Drogas&#44; Madrid&#44; Espa&#241;a&#46; &#42;&#42;&#42;Plan Nacional sobre el Sida&#44; Ministerio de Sanidad y Consumo&#44; Madrid&#44; Espa&#241;a&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes&#58;</span> En la segunda mitad de los noventa las pol&#237;ticas de reducci&#243;n de da&#241;o han experimentado un gran desarrollo&#44; por lo que se hace imprescindible evaluar su impacto en las pr&#225;cticas de riesgo&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">M&#233;todos&#58;</span> En 2001-2002 se ha llevado a cabo un estudio transversal de ingreso a una cohorte de j&#243;venes &#40;30 a&#241;os o menos&#41; consumidores de hero&#237;na captados &#237;ntegramente en la comunidad&#58; 396 en Madrid y 323 en Barcelona&#46; En 1995 se realiz&#243; otro estudio transversal en el que el 50&#37; de la muestra se reclut&#243; entre los que iniciaban tratamiento y el otro 50&#37; en la comunidad&#44; seleccion&#225;ndose los de 30 a&#241;os o menos&#58; 207 en Barcelona y 199 en Madrid&#46; En ambos casos la captaci&#243;n comunitaria se realiz&#243; mediante personas claves que conocen los escenarios de consumo y por m&#233;todos de referencia en cadena&#46; En el presente an&#225;lisis se han empleado m&#233;todos uni y bivariados&#44; evalu&#225;ndose las comparaciones con el test de Ji cuadrado y consider&#225;ndose significativas con una p &#60; 0&#44;05&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Resultados&#58;</span> En Barcelona descienden significativamente los indicadores sobre prevalencia de inyecci&#243;n&#44; mientras en Madrid no lo hacen&#58; el porcentaje de los que se han inyectado alguna vez pasa del 88&#37; al 78&#37; en Barcelona &#40;70&#37; y 65&#37; en Madrid&#41;&#44; el de los que lo han hecho en los &#250;ltimos 12 meses del 84&#37; al 75&#37; &#40;48&#37; y 49&#37; en Madrid&#41;&#44; en los &#250;ltimos 30 d&#237;as del 82 al 67 &#40;32&#37; y 40&#37; en Madrid&#41;&#44; y el de los que tienen la inyecci&#243;n como v&#237;a principal del 81&#37; al 64&#37; &#40;20&#37; en Madrid en ambos per&#237;odos&#41;&#46; Entre los que se han inyectado&#44; en ambas ciudades desciende muy significativamente el porcentaje de los que se han inyectado alguna vez con jeringas usadas por otros &#40;72&#37; y 42&#37; en Barcelona&#59; 61&#37; y 39&#37; en Madrid&#41;&#44; y el de los que lo han realizado en los &#250;ltimos 12 meses &#40;35&#37; y 20&#37; en Barcelona y 29&#37; y 17&#37; en Madrid&#41;&#44; pero el de los que lo hicieron en los &#250;ltimos 30 d&#237;as no descendi&#243; significativamente en Madrid &#40;18&#37; en 1995 y 12&#37; en 2002&#41; o incluso aument&#243; casi significativamente en Barcelona &#40;8&#37; y 13&#37;&#41;&#46; Las pr&#225;cticas indirectas de compartir material de inyecci&#243;n &#40;inyectarse o dar droga disuelta en jeringuilla usada por otros&#41; tambi&#233;n descendieron situ&#225;ndose en el 2002 por debajo del 20&#37; en los &#250;ltimos 12 meses&#44; aunque no pudo evaluarse la significaci&#243;n&#44; por haberse preguntado para los &#250;ltimos 30 d&#237;as en 1995&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusiones&#58;</span> En Barcelona ha disminuido la inyecci&#243;n entre los consumidores de hero&#237;na&#44; mientras en Madrid pr&#225;cticamente no&#46; Entre los inyectores han disminuido las pr&#225;cticas de riesgo entre los mas espor&#225;dicos&#44; mientras parece mantenerse entre los habituales&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Financiado por FIPSE 3035&#47;99&#46;</span></p>"
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ISSN: 02139111
Idioma original: Español
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