Erosion of universal health coverage in Spain

Whereas the recent UN resolution urges governments to accelerate progress towards universal access to affordable and quality health-care services, the Spanish Government, bypassing the parliamentary procedure, enacted a Royal Decree to limit access to free services at the point of delivery for all-undermining the principle of universal coverage. Spanish health and social service budgets have been subjected to large cuts (13,7% in 2012 and 16,2% in 2013) with some regions imposing additional budget cuts.

Special Tax on Real Estate belonging to Non-resident Corporations in Spain

Análisis del impuesto español sobre bienes inmuebles de no residentes.

How Does Intimate Partner Violence Differ Depending on Level of Rurality of Residential Area in Spain?

Intimate partner violence (IPV) is recognized as a worldwide public health problem. Most theories ascribe IPV to individual, family, or cultural factors. Authors analyzed different residential areas in Spain in terms of IPV frequency as well as its impact on health and the use of services. A standardized self-administered cross-sectional survey was administered to ever-partnered adult women ages 18 to 70 years receiving care at primary health care centers (N = 10,322). Logistic regression analyzed the association between the level of rurality and health indicators, IPV, and use of services. The lowest frequency of IPV among women is reflected in higher rurality. Women of medium and low rurality presented a poorer self-perceived health and more physical health problems. Women from medium and low rurality areas declared seeking health services more frequently. These results show the importance of the environment in health and indicate the need for research on urban–rural differences in health problems to develop specific public health programs for each country.

Factors Associated with the Cessation of Intimate Partner Violence in Women Attending Primary Care in Spain

This study aimed to identify factors associated with the likelihood of IPV cessation among women attending Spanish primary healthcare. Of the 2465 women who reported lifetime IPV, 36.1 % stated that violence had ceased. Those women not currently abused had higher levels of education and social support, were workers or students, and had no dependent children. When IPV duration was less than 5 years, the likelihood of cessation was two times higher than when IPV continued beyond 5 years. For women who have experienced physical IPV, the probability of ending the violent relationship was 10 times higher than for those suffering from psychological IPV. The implications of the findings regarding clinical significance and future research are discussed.

Economic crisis and tourism competitiveness in Spain: permanent effects or transitory shocks?

This paper considers the influence of business cycles and economic crises on Spain's tourism competitiveness. This competitiveness is measured by its share in world tourism. Analysing the presence of unit roots in the market share series from 1958 to 2010, the permanent effects of economic crises on competitiveness are evaluated. The evidence from standard linear unit root tests indicates that crises on Spanish market shares are highly persistent. When we account for endogenously determined structural breaks, we obtain greater support for stationarity, but breakpoints are identified with major economic crises. Therefore the main conclusion obtained is that the effects of the economic shocks are not neutral on competitiveness, with the negative effects being more persistent in highly intensive crises. These crises reinforce a natural downward trend of the Spanish world tourism market share caused by the natural emergence of new competing destinations and by the maturity of the Spain's principal tourism product.

From the boom to the crisis: changes in employment conditions of immigrants in Spain and their effects on mental health

Background: Migrant workers have been one of the groups most affected by the economic crisis. This study evaluates the influence of changes in employment conditions on the incidence of poor mental health of immigrant workers in Spain, after a period of 3 years, in context of economic crisis. Methods: Follow-up survey was conducted at two time points, 2008 and 2011, with a reference population of 318 workers from Colombia, Ecuador, Morocco and Romania residing in Spain. Individuals from this population who reported good mental health in the 2008 survey (n = 214) were interviewed again in 2011 to evaluate their mental health status and the effects of their different employment situations since 2008 by calculating crude and adjusted odds ratios (aORs) for sociodemographic and employment characteristics. Findings: There was an increased risk of poor mental health in workers who lost their jobs (aOR = 3.62, 95%CI: 1.64–7.96), whose number of working hours increased (aOR = 2.35, 95%CI: 1.02–5.44), whose monthly income decreased (aOR = 2.75, 95%CI: 1.08–7.00) or who remained within the low-income bracket. This was also the case for people whose legal status (permission for working and residing in Spain) was temporary or permanent compared with those with Spanish nationality (aOR = 3.32, 95%CI: 1.15–9.58) or illegal (aOR = 17.34, 95%CI: 1.96–153.23). In contrast, a decreased risk was observed among those who attained their registration under Spanish Social Security system (aOR = 0.10, 95%CI: 0.02–0.48). Conclusion: There was an increase in poor mental health among immigrant workers who experienced deterioration in their employment conditions, probably influenced by the economic crisis.

A qualitative exploration of the impact of the economic recession in Spain on working, living and health conditions: reflections based on immigrant workers' experiences

Background: This study aimed to analyse how immigrant workers in Spain experienced changes in their working and employment conditions brought about Spain's economic recession and the impact of these changes on their living conditions and health status. Method: We conducted a grounded theory study. Data were obtained through six focus group discussions with immigrant workers (n = 44) from Colombia, Ecuador and Morocco, and two individual interviews with key informants from Romania living in Spain, selected by theoretical sample. Results: Three categories related to the crisis emerged – previous labour experiences, employment consequences and individual consequences – that show how immigrant workers in Spain (i) understand the change in employment and working conditions conditioned by their experiences in the period prior to the crisis, and (ii) experienced the deterioration in their quality of life and health as consequences of the worsening of employment and working conditions during times of economic recession. Conclusion: The negative impact of the financial crisis on immigrant workers may increase their social vulnerability, potentially leading to the failure of their migratory project and a return to their home countries. Policy makers should take measures to minimize the negative impact of economic crisis on the occupational health of migrant workers in order to strengthen social protection and promote health and well-being.

Violence against young women attending primary care services in Spain: prevalence and health consequences

Background. There are a significant number of studies assessing the negative health consequences of violence against women. However, a limited number of studies analyse the health consequences of violence committed against young women by different types of aggressors. Objectives. The goal of this study is to assess the prevalence of interpersonal violence against young women in Spain and analyse its impact on the physical and mental health of the victims. Methods. A total of 1076 women aged 18–25 years attending Spanish primary care services were selected. We estimated the prevalence of interpersonal violence and compared the health data and demographic characteristics of abused and non-abused young women, multi-logistic regression models were fitted. The Wald test was used to assess whether there were differences in the negative health consequences of intimate partner (IPV) versus non-IPV. Results. As many as 27.6% young women reported a history of abuse, of whom 42.7% had been assaulted by their partner, 41.1% by someone other than their partner and 16.2% both by their partner and another person. The distribution of social and demographic characteristics was similar for IPV and non-IPV victims. Young abused women were three times more likely to suffer psychological distress and have somatic complaints, and they were four times more likely to use medication as compared to non-abused women. Conclusion. Our results suggest that all forms of violence compromise young women’s health seriously. Including patients’ history of abuse in their health record may help make more informed clinical decisions and provide a more integrated care.

Health inequality between immigrants and natives in Spain: the loss of the healthy immigrant effect in times of economic crisis

Background: The immigrant population living in Spain grew exponentially in the early 2000s but has been particularly affected by the economic crisis. This study aims to analyse health inequalities between immigrants born in middle- or low-income countries and natives in Spain, in 2006 and 2012, taking into account gender, year of arrival and socioeconomic exposures. Methods: Study of trends using two cross-sections, the 2006 and 2012 editions of the Spanish National Health Survey, including residents in Spain aged 15–64 years (20 810 natives and 2950 immigrants in 2006, 14 291 natives and 2448 immigrants in 2012). Fair/poor self-rated health, poor mental health (GHQ-12 > 2), chronic activity limitation and use of psychotropic drugs were compared between natives and immigrants who arrived in Spain before 2006, adjusting robust Poisson regression models for age and socioeconomic variables to obtain prevalence ratios (PR) and 95% confidence interval (CI). Results: Inequalities in poor self-rated health between immigrants and natives tend to increase among women (age-adjusted PR2006 = 1.39; 95% CI: 1.24–1.56, PR2012 = 1.56; 95% CI: 1.33–1.82). Among men, there is a new onset of inequalities in poor mental health (PR2006 = 1.10; 95% CI: 0.86–1.40, PR2012 = 1.34; 95% CI: 1.06–1.69) and an equalization of the previously lower use of psychotropic drugs (PR2006 = 0.22; 95% CI: 0.11–0.43, PR2012 = 1.20; 95% CI: 0.73–2.01). Conclusions: Between 2006 and 2012, immigrants who arrived in Spain before 2006 appeared to worsen their health status when compared with natives. The loss of the healthy immigrant effect in the context of a worse impact of the economic crisis on immigrants appears as potential explanation. Employment, social protection and re-universalization of healthcare would prevent further deterioration of immigrants’ health status.

Intimate partner violence among women in Spain: the impact of regional-level male unemployment and income inequality

Background: Intimate partner violence (IPV) against women is a complex worldwide public health problem. There is scarce research on the independent effect on IPV exerted by structural factors such as labour and economic policies, economic inequalities and gender inequality. Objective: To analyse the association, in Spain, between contextual variables of regional unemployment and income inequality and individual women’s likelihood of IPV, independently of the women’s characteristics. Method: We conducted multilevel logistic regression to analyse cross-sectional data from the 2011 Spanish Macrosurvey of Gender-based Violence which included 7898 adult women. The first level of analyses was the individual women’ characteristics and the second level was the region of residence. Results: Of the survey participants, 12.2% reported lifetime IPV. The region of residence accounted for 3.5% of the total variability in IPV prevalence. We determined a direct association between regional male long-term unemployment and IPV likelihood (P = 0.007) and between the Gini Index for the regional income inequality and IPV likelihood (P < 0.001). Women residing in a region with higher gender-based income discrimination are at a lower likelihood of IPV than those residing in a region with low gender-based income discrimination (odds ratio = 0.64, 95% confidence intervals: 0.55–0.75). Conclusions: Growing regional unemployment rates and income inequalities increase women’s likelihood of IPV. In times of economic downturn, like the current one in Spain, this association may translate into an increase in women’s vulnerability to IPV.

Mechanisms that Trigger a Good Health-Care Response to Intimate Partner Violence in Spain. Combining Realist Evaluation and Qualitative Comparative Analysis Approaches

Background. Health care professionals, especially those working in primary health-care services, can play a key role in preventing and responding to intimate partner violence. However, there are huge variations in the way health care professionals and primary health care teams respond to intimate partner violence. In this study we tested a previously developed programme theory on 15 primary health care center teams located in four different Spanish regions: Murcia, C Valenciana, Castilla-León and Cantabria. The aim was to identify the key combinations of contextual factors and mechanisms that trigger a good primary health care center team response to intimate partner violence. Methods. A multiple case-study design was used. Qualitative and quantitative information was collected from each of the 15 centers (cases). In order to handle the large amount of information without losing familiarity with each case, qualitative comparative analysis was undertaken. Conditions (context and mechanisms) and outcomes, were identified and assessed for each of the 15 cases, and solution formulae were calculated using qualitative comparative analysis software. Results. The emerging programme theory highlighted the importance of the combination of each team’s self-efficacy, perceived preparation and women-centredness in generating a good team response to intimate partner violence. The use of the protocol and accumulated experience in primary health care were the most relevant contextual/intervention conditions to trigger a good response. However in order to achieve this, they must be combined with other conditions, such as an enabling team climate, having a champion social worker and having staff with training in intimate partner violence. Conclusions. Interventions to improve primary health care teams’ response to intimate partner violence should focus on strengthening team’s self-efficacy, perceived preparation and the implementation of a woman-centred approach. The use of the protocol combined with a large working experience in primary health care, and other factors such as training, a good team climate, and having a champion social worker on the team, also played a key role. Measures to sustain such interventions and promote these contextual factors should be encouraged.

No effect of unemployment on intimate partner-related femicide during the financial crisis: a longitudinal ecological study in Spain

Background: Spain’s financial crisis has been characterized by an increase in unemployment. This increase could have produced an increase in deaths of women due to intimate partner-related femicides (IPF). This study aims to determine whether the increase in unemployment among both sexes in different regions in Spain is related to an increase in the rates of IPF during the current financial crisis period. Methods: An ecological longitudinal study was carried out in Spain’s 17 regions. Two study periods were defined: pre-crisis period (2005–2007) and crisis period (2008–2013). IPF rates adjusted by age and unemployment rates for men and women were calculated. We fitted multilevel linear regression models in which observations at level 1 were nested within regions according to a repeated measurements design. Results: Rates of unemployment have progressively increased in Spain, rising above 20 % from 2008 to 2013 in some regions. IPF rates decreased in some regions during crisis period with respect to pre-crisis period. The multilevel analysis does not support the existence of a significant relationship between the increase in unemployment in men and women and the decrease in IPF since 2008. Discussion: The increase in unemployment in men and women in Spain does not appear to have an effect on IPF. The results of the multilevel analysis discard the hypothesis that the increase in the rates of unemployment in women and men are related to an increase in IPF rates. Conclusions: The decline in IPF since 2008 might be interpreted as the result of exposure to other factors such as the lower frequency of divorces in recent years or the medium term effects of the integral protection measures of the law on gender violence that began in 2005.

A Unique Prestressed Concrete Pedestrian Bridge in Spain

This paper describes the so-called Kiss Bridge. This structure resembles a kiss, a subtle touch of structures. The beams have been structurally designed to adapt the Japanese art of paper folding called "origami." The material used for constructing the floating beams is white reinforced concrete in the form of folded shells. The two geometrically different parts have distinct structural behaviors. The length of the main pathway of both structures is over 60 m. The pedestrian bridge crosses an artificial rainwater channel with a skew of 45° with respect to the referred channel. The joint between the cantilever structure and the Y-shaped one is located over the middle of the channel. Each stretch has different transversal sections. The pedestrian bridge is made with prestressed self-compacting reinforced concrete of 60 MPa. The foundation is shallow, comprising footings and footing beams made of 25 MPa conventional concrete. The cantilever structure with its foundations is designed as a semi-integral bridge whereas the Y-shaped one is an integral structure. The dynamic behavior of the structure was carefully studied to ensure that the dynamic loads generated by pedestrians do not cause excessive vibrations, especially to the cantilever structure, which could present dynamic interactions with the pedestrians walking. The bridge was recognized, in the 2014 edition of the fib Awards for Outstanding Concrete Structures, for having made a valuable contribution to the image and promotion of concrete structures.

Using realist evaluation to assess primary healthcare teams’ responses to intimate partner violence in Spain

Objective: Few evaluations have assessed the factors triggering an adequate health care response to intimate partner violence. This article aimed to: 1) describe a realist evaluation carried out in Spain to ascertain why, how and under what circumstances primary health care teams respond to intimate partner violence, and 2) discuss the strengths and challenges of its application. Methods: We carried out a series of case studies in four steps. First, we developed an initial programme theory (PT1), based on interviews with managers. Second, we refined PT1 into PT2 by testing it in a primary healthcare team that was actively responding to violence. Third, we tested the refined PT2 by incorporating three other cases located in the same region. Qualitative and quantitative data were collected and thick descriptions were produced and analysed using a retroduction approach. Fourth, we analysed a total of 15 cases, and identified combinations of contextual factors and mechanisms that triggered an adequate response to violence by using qualitative comparative analysis. Results: There were several key mechanisms —the teams’ self-efficacy, perceived preparation, women-centred care—, and contextual factors —an enabling team environment and managerial style, the presence of motivated professionals, the use of the protocol and accumulated experience in primary health care—that should be considered to develop adequate primary health-care responses to violence. Conclusion: The full application of this realist evaluation was demanding, but also well suited to explore a complex intervention reflecting the situation in natural settings.

Trends and Disparities in Mortality Among Spanish-Born and Foreign-Born Populations Residing in Spain, 1999–2008

Spain’s immigrant population has increased 380 % in the last decade, accounting for 13.1 % of the total population. This fact has led her to become during 2009 the eighth recipient country of international immigrants in the world. The aim of this article is to describe the evolution of mortality and the main causes of death among the Spanish-born and foreign-born populations residing in Spain between 1999 and 2008. Age-standardised mortality rates (ASRs), average age and comparative mortality ratios among foreign-born and Spanish-born populations residing in Spain were computed for every year and sub-period by sex, cause of death and place of birth as well as by the ASR percentage change. During 1999–2008 the ASR showed a progressive decrease in the risk of death in the Spanish-born population (−17.8 % for men and −16.6 % for women) as well as in the foreign-born one (−45.9 % for men and −35.7 % for women). ASR also showed a progressive decrease for practically all the causes of death, in both populations. It has been observed that the risk of death due to neoplasms and respiratory diseases among immigrants is lower than that of their Spanish-born counterparts, but risk due to external causes is higher. Places of birth with the greater decreases are Northern Europe, Eastern Europe, Western Europe, Southern Europe, and Latin America and the Caribbean. The research shows the differences in the reduction of death risk between Spanish-born and immigrant inhabitants between 1999 and 2008. These results could contribute to the ability of central and local governments to create effective health policy. Further research is necessary to examine changes in mortality trends among immigrant populations as a consequence of the economic crisis and the reforms in the Spanish health system. Spanish data sources should incorporate into their records information that enables them to find out the immigrant duration of permanence and the possible impact of this on mortality indicators.