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The European Journal of Public Health, Vol. 28, No. 3, 553–559
ß The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/cky010 Advance Access published on 1 February 2018
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Effect of comprehensive smoke-free legislation on
asthma and coronary disease trends in Spanish primary care patients
Yolanda Rando-Matos1,2, Mariona Pons-Vigue´s2,3,4, Teresa Rodriguez-Blanco2,3, Joana Ripoll5,6, Joan Llobera5,6, Julio Mora´n7, Josep Lluı´s Ballve´-Moreno1,2, Concepcio´ Viola´n2,3,
Bonaventura Bolı´bar2,3
1 Centre d’Atencio´ Prima`ria (CAP) Florida Nord. Gere`ncia d’A`mbit d’Atencio´ Prima`ria Metropolitana Sud, Institut Catala`
de la Salut (ICS), Hospitalet de Llobregat, Barcelona, Spain
2 Institut Universitari d’Investigacio´ en Atencio´ Prima`ria Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain 3 Universitat Auto`noma de Barcelona, Bellaterra (Cerdanyola del Valle`s), Spain
4 Universitat de Girona, Girona, Spain
5 Primary Care Research Unit of Mallorca, Baleares Health Services-Ibsalut, Palma, Spain
6 Instituto de Investigacio´n Sanitaria les Illes Balears (IdSBA), Hospital Universitario Son Espases, Palma, Spain 7 Consultorio de Bara´soain (Equipo de Atencio´n Primaria de Tafalla), Servicio Navarro de Salud, Navarra, Spain This article will be included in the doctoral dissertation of Yolanda Rando-Matos at the Universitat Auto`noma de Barcelona.
Correspondence:Mariona Pons-Vigue´s, Institut Universitari d’Investigacio´ en Atencio´ Prima`ria Jordi Gol (IDIAP Jordi Gol), Av. Gran Via de les Corts Catalanes 587, A`tic, 08007, Barcelona, Spain, Tel: + 34 93 48 24253, e-mail:
Background:To examine the impact of comprehensive smoke-free legislation (SFL) (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in primary health care (PHC) patients from three Spanish regions, overall and stratified by sex.Methods:Longitudinal observational study conducted between 2007 and 2013 in the population over 15 years of age assigned to 66 PHC teams in Catalonia, Navarre and the Balearic Islands. Crude rates and age-standardized (truncated: asthma 16 years and coronary disease 35 years) incidence and prevalence rates using the direct method based on the European Standard Population were estimated based on data from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardized incidence and prevalence rates. Trends were expressed as annual percentage change and average annual percent change (AAPC).Results:The standardized asthma incidence rate showed a non-significant downward trend and the standardized prevalence rates rose significantly in the three regions. Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. The standardized coronary disease incidence rates in Catalonia (AAPC:8.00%, 95% CI:10.46;5.47) and Navarre (AAPC: 3.66%, 95% CI: 4.95;-2.35) showed a significant downward trend from 2007 to 2013, overall and by sex. The standardized coronary disease prevalence trend rate increased significantly in the whole period in Catalonia and the Balearic Islands, although a non-significant downward trend was observed from 2010 in Catalonia.Conclusion:No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of comprehensive SFL.
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Introduction
E
vidence shows that secondhand smoke (SHS) exposure is causally associated with conditions such as asthma and acute coronary syndrome.1Consequently, legislative measures have been adopted to protect people’s health in public areas and workplaces.2,3Since the introduction of smoke-free legislation (SFL), various studies have assessed its repercussions from different points of view. For instance, a decrease in the number of hospital admissions for coronary disease in adults has been observed following the imple- mentation of this legislation4–6and a meta-analysis showed a 13%decrease in hospital admissions for acute myocardial infarction (AMI).7
According to a Cochrane review, results on the impact of SFL on hospital admissions for asthma remains inconsistent,8although a meta-analysis showed a 24% decrease in hospital admissions for respiratory conditions.9 We should underscore that most studies on the impact of SFL in asthma and coronary disease have analysed hospital data and that few studies address the impact of
the legislation in primary health care (PHC) patients. For instance, Kalkhoran et al.10analysed non-hospital emergency visits for asthma (Uruguay) and observed a 15% decrease in the incidence rate ratio.
In contrast, Been et al.11did not find any reduction in new diagnoses of asthma in children after SFL implementation (UK).
On 1 January 2006, the Spanish government introduced a smoking law (Law 28/2005)12 which included regulations on the sale, supply, consumption and advertising of tobacco products.
Smoking was banned in all enclosed public and private workplaces with the exception of the hospitality sector, where partial restrictions were established depending on the size of the establishment. This law was expanded in January 2011 (Law 42/2010)13 and as a result smoking was forbidden in all enclosed public places, including bars, restaurants and nightclubs, and in some open-air public places such as playgrounds.
The studies that analysed the effect of the Spanish partial law on hospital admissions for asthma and coronary disease showed a decrease in the incidence of AMI and inconclusive results for asthma.14–16To our knowledge, no studies have been published on
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the impact of the comprehensive law on asthma (in PHC) and heart disease, although some studies evaluate the effect of this law on smoking and exposure to SHS.17,18
The aim of this study was to examine the impact of the Spanish comprehensive SFL (Law 42/2010) on the incidence and prevalence of adult asthma and coronary disease in PHC patients in three regions (Catalonia, Navarre and the Balearic Islands) during the period 2007–13, overall and stratified by sex.
Methods
Study design, participants and source of information This is a longitudinal observational study of the population assigned to 66 PHC teams (PHCTs) in three Spanish regions: Catalonia, Navarre and the Balearic Islands (22 PHCT per region). Inclusion criteria of the PHCT were: (i) use of electronic health records (EHRs) by 1 January 2005, in Catalonia and Navarre, and 2008 in the Balearic Islands; and (ii) agreement to participate in the study by over 80% health-care professionals of the PHCT. Random cluster sampling was stratified by region, with the PHCT as randomization unit.19In each PHCT, general practitioners (GPs) with a patient list between 400–3000 were selected. GP with shorter patient lists were accepted if it was their first year in the PHCT.
The study period was from 2007 to 2013 in Catalonia and Navarre.
In the Balearic Islands it was from 2010 to 2013 because EHR were not sufficiently reliable before 2010. Inclusion criteria for patients were: (i) Population allocated to the selected PHCT for each year of the period in Catalonia and Navarre (80% patients entered in 2007). Some patients died or moved during the study period. In the Balearic Islands, data from 2010 to 2013 of patients allocated to the selected PHCT in 2013 were analysed retrospectively (no annual comprehensive register of patients was available); (ii) Aged between16 and100 years when entering the study and (iii) A minimum of one visit with the PHCT during the study period (in order to have data in the EHR collected during this period). In the case of coronary disease, the population was restricted to those35 years to allow the use of the Framingham and REGICOR equations to calculate coronary risk.20 Supplementary figure S1 shows the flowchart of the study.
Data were extracted from the REGIPREV database.19It contains encrypted and anonymized clinical information recorded in the EHR from these 66 PHCT. An algorithm was applied to obtain equivalent data from the health records software used in each region. An equivalence table based on that created by WONCA21,22 was formulated by the research team matching the codes of the International Classification of Diseases, 10th revision (ICD-10)23used in Catalonia and the International Classification of Diseases, 9th revision (ICD-9) codes used in the Balearic Islands with the International Classification of Primary Care, Second edition (ICPC-2) used in Navarre.
Variables
For each year of the study (at 31st of December), the dichotomous dependent variables were:
(i) Diagnosis of coronary episode: any register (1) of the diagnosis codes of coronary disease (codes I-20 to I-25 of the ICD-10 codes, 410-413 and 429.7 of ICD-9 and K74-76 of the ICPC-2).
(ii) Diagnosis of asthma episode: any register (1) of the diagnosis codes of asthma (codes J-45 and J-46 of the ICD- 10, codes 493 of the ICD-9 and R96 of the ICPC-2).
The following variables of each patient were collected when entering the study: age, sex, number of health problems and number of PHC visits during the year considered. The number of health problems was used as a morbidity indicator; it was calculated
as the sum of the number of different active health problems (all chronic and acute problems, coded by ICPC-2).
Data analyses
Descriptive statistics were used to summarize overall information.
Categorical variables were expressed as percentage, and continuous variables as mean (standard deviation) or median (interquartile range [IQR]).
We performed a stratified analysis per region, overall and by sex.
Crude rates and age-standardized (truncated: asthma,16 years and coronary disease, 35 years) incidence and prevalence rates were calculated for each year using the direct method, and based on the European Standard Population. These were expressed as rates per 10 000 inhabitants.
To analyse the trends of age-standardized incidence and prevalence rates, the joinpoint analysis was used to identify the best-fitting points (the ‘joinpoints’, in calendar years) where the rate changes significantly over time. Significant changes include changes in direction or in the rate of increase or decrease.24 Temporal trends were expressed as the annual percentage change (APC), computed over each specified time interval and the average annual percent change (AAPC), computed to summarize and compare these trends over the entire time period. Ninety-five percent confidence intervals (95% CI) of APC and AAPC were calculated.
Analyses were performed using Stata/SE version 14.2 for Windows (Stata Corp.LP, College Station, TX). The joinpoint regression analysis was carried out using the joinpoint software from the Surveillance Research Programme of the US National Cancer Institute.25
Ethical aspects
The study was approved by the Research Ethics Committee of the IDIAP Jordi Gol. Confidentiality was guaranteed by data encryption and anonymization.
Results
The asthma study population consisted of 472 348 patients in Catalonia, 272 415 in Navarre and 302 281 in the Balearic Islands.
At the onset of the study, the mean age in years of the asthma and coronary disease populations was circa 45 and 55, respectively. In both populations more than half were women (>51%). Catalonia presented the highest median number of visits for the asthma (6, IQR: 2–13) and coronary disease populations (7, IQR: 2–15).
The Balearic Islands recorded the highest number of active health problems per patient for both populations (asthma population median 8, IQR: 4–14; coronary disease population median 9, IQR:
5–15) (table 1).
The asthma incidence rate reached 0.40% in Catalonia in 2009, 0.55% in Navarre in 2008 and 0.69% in the Balearic Islands in 2010.
The Balearic Islands presented the highest overall and standardized rates between 2010 and 2013. Navarre showed a higher incidence rate than Catalonia over the entire study period. The same patterns were observed for both sexes. Navarre showed the highest overall and standardized asthma prevalence rate throughout the study period (range: 3.92–5.87%). The crude and standardized prevalence rates were higher for women than for men in the three regions (table 2, Supplementary table S1).
The standardized asthma incidence rates showed a non-significant downward trend in the three regions. This trend was more pronounced in the Balearic Islands (AAPC:4.99% per year, 95%
CI: 13.76; 4.68). In Navarre and the Balearic Islands there was a higher decrease for men than for women. No region presented sig- nificant points of change (‘joinpoint’). The standardized asthma prevalence rates rose significantly in the three regions over the study period. Catalonia and Navarre showed two distinct time
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periods, 2007–09 and 2009–13, overall and by sex, with the exception of males in Catalonia. After 2009, increases in prevalence rates were smaller than in the previous period in these two regions. The Balearic Islands observed the highest steady and significant increase (AAPC: 8.87%, 95% CI: 7.49; 10.28), followed by Navarre (AAPC: 7.07%, 95% CI: 6.36; 7.77) over the study period (table 3).
On the whole, the incidence of coronary disease rates was decreasing both in Catalonia and Navarre. However, this reduction was higher in Catalonia (range: 0.43–0.61%) than in Navarre (range: 0.36–0.40%). Conversely, it increased over the considered period in the Balearic Islands (range: 0.38%-0.51%).
Navarre presented the highest coronary disease prevalence rate (range: 4.01–4.85%) and the Balearic Islands the lowest (range:
2.13–3.28%) in each year. Crude and standardized coronary
disease incidence and prevalence rates were considerably higher for men than for women in all regions. Specifically, prevalence rates were over two-fold higher for men than for women (table 2, Supplementary table S2).
The standardized coronary disease incidence rates in Catalonia and Navarre showed a significant downward trend from 2007 to 2013, overall and by sex, with higher AAPC in Catalonia (AAPC:
8.00%, 95% CI:10.46;5.47) than in Navarre (AAPC:3.66%, 95% CI:4.95;2.35). In contrast, the Balearic Islands presented a non-significant upward trend (AAPC: 4.45%) over the study period with an AAPC of 6.78% per year in women. In Catalonia, the overall standardized coronary disease prevalence rate showed a significant upward trend of 1.52% per year between 2007 and 2010, and sub- sequently a downward trend of 0.52% per year between 2010 and 2013, although this decline was not significant. Male trends were of Table 2 Overall crudeaand age-standardizeda,basthma and coronary disease incidence and prevalence rates for each year by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13
Asthma Coronary disease
Year Total Incidence rates Prevalence rates Total Incidence rates Prevalence rates
Overall crude
Female Male Overall crude
Female Male Overall
crude
Female Male Overall crude
Female Male
% Rate/
10 000 Rate/
10 000
% Rate/
10 000 Rate/
10 000
% Rate/
10 000 Rate/
10 000
% Rate/
10 000 Rate/
10 000 Catalonia
2007 376 971 0.35 42.03 25.40 3.51 422.69 278.02 25 3837 0.61 38.14 95.68 3.91 251.06 621.34
2008 381 351 0.35 41.98 26.13 3.73 449.53 299.69 253 701 0.55 32.60 87.74 4.09 254.01 636.09
2009 382 650 0.40 48.13 31.26 3.97 479.58 325.70 252 141 0.57 34.46 86.38 4.24 255.69 649.79
2010 381 100 0.35 43.08 27.03 4.17 499.29 344.46 249 823 0.53 33.22 77.35 4.38 258.27 657.57
2011 376 892 0.29 34.62 23.66 4.36 516.22 349.88 246 620 0.45 25.66 65.66 4.47 255.74 657.82
2012 371 809 0.28 34.43 20.85 4.55 538.08 365.23 243 229 0.43 22.48 62.01 4.55 249.89 655.02
2013 362 918 0.32 38.28 25.95 4.81 567.24 392.15 236 557 0.43 24.22 59.69 4.61 250.08 655.82
Navarre
2007 222 920 0.52 59.94 44 .73 3 .92 444.67 347.40 155 302 0.40 24.77 63.41 4.01 245.40 653.38
2008 229 529 0.55 67.95 43 .44 4 .28 488.99 378.59 156 006 0.39 23.63 59.77 4.19 248.87 671.87
2009 232 847 0.52 61.27 43 .03 4 .62 523.16 417.67 155 370 0.38 26.00 52.90 4.35 256.17 674.07
2010 234 957 0.52 66.16 40 .04 4 .95 557.36 450.45 154 500 0.37 20.52 54.91 4.49 254.76 678.41
2011 234 154 0.45 56.76 32 .74 5 .22 586.21 478.70 152 454 0.36 21.66 50.84 4.62 253.98 679.97
2012 233 702 0.44 53.36 36 .69 5 .50 610.88 511.84 150 514 0.38 20.51 54.98 4.73 249.29 680.14
2013 229 459 0.49 60.28 39 .53 5 .87 649.70 551.66 146 768 0.37 18.83 50.54 4.85 244.03 676.01
Balearic Islands
2010 302 281 0.69 82.41 51.07 4.12 475.59 346.72 203 532 0.38 29.94 65.27 2.13 157.73 379.72
2011 302 281 0.58 74.61 41.13 4.47 520.82 380.81 203 532 0.47 33.62 76.91 2.50 177.71 423.60
2012 302 281 0.59 72.32 45.48 4.85 565.59 419.60 203 532 0.51 39.03 73.23 2.89 200.52 458.21
2013 302 281 0.57 72.56 41.78 5.19 607.29 454.11 203 532 0.51 35.85 73.42 3.28 217.86 492.69
a: Truncated crude rate (16-years old, 17 age groups).
b: Rates are per 10 000 inhabitants and age-standardized on the European Standard Population (direct method).
Table 1 Characteristics of the asthma and coronary disease study population by region (Catalonia, Navarre, Balearic Islands-Spain) at the onset of the study
Asthma (16 years) Coronary disease (35 years)
Catalonia (n=472 348)
Navarre (n= 272 415)
Balearic Islands (n=302 281)
Catalonia (n= 301 403)
Navarre (n=172 809)
Balearic Islands (n=203 532) Age (years), SD 45.45 (18.78) 44.87 (19.37) 45.51 (17.73) 55.95 (15.25) 56.07 (15.08) 54.62 (14.08) Sex (female), number (%) 243590 (51.57) 139513 (51.21) 157538 (52.12) 157011 (52.09) 89321 (51.68) 106339 (52.25) Number of visits, mean (SD);
median (IQR)
9.12 (11.30); 6.00 (2.00–13.00)
6.41 (8.62); 4.00 (1.00–9.00)
9.05 (12.10); 5.00 (1.00–12.00)
10.78 (12.65); 7.00 (2.00–15.00)
7.89 (9.89); 5.00 (2.00–11.00)
10.49 (13.15); 7.00 (2.00–14.00) Number of health problems,
mean (SD);
median IQR)
4.50 (4.44); 3.00 (1.00–6.00)
7.40 (5.05); 6.00 (4.00–10.00)
9.70 (7.68); 8.00 (4.00–14.00)
5.25 (4.75); 4.00 (2.00–7.00)
8.12 (5.28); 7.00 (4.00–11.00)
10.51 (8.00); 9.00 (5.00–15.00)
Abbreviation:SD, standard deviation; IQR, interquartile range.
Patients belonged to 22 PHC Team in each region.
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similar magnitude to the overall trends in both periods. In Navarre, the overall prevalence trends were similar to Catalonia but non-sig- nificant, with a ‘joinpoint’ in 2009. In the Balearic Islands, sharp and significant increases were observed, overall (AAPC: 10.01%, 95% CI:
7.30; 12.78) as well as in both sexes (AAPC: female: 11.38%, 95% CI:
8.21; 14.65; male: 8.85%, 95% CI: 6.11; 11.67) from 2010 to 2013 (table 4).
Discussion
Although a small, non-significant decrease in trends of standardized asthma incidence rates in patients over 15 years of age was observed in the three Spanish regions, the reduction was more pronounced in the Balearic Islands. In contrast, standardized asthma prevalence rates trends increased significantly in the three regions. This increase was smaller during the 2009–13 period in Catalonia and Navarre, and higher for men than women in all regions.
Standardized coronary disease incidence and prevalence rates were considerably higher for men than for women in all regions. In Catalonia and Navarre, standardized coronary disease incidence rates showed a significant downward trend throughout the period studied. Conversely, trends of standardized coronary disease prevalence rates significantly increased in Catalonia from 2007 to 2010 overall and in males and also in the Balearic Islands throughout the study period. However, a non-significant downward trend was also observed after 2010 in Catalonia.
Few published studies evaluate the impact of SFL on asthma and coronary disease from a PHC perspective. In addition, the method- ology of these studies varies greatly further complicating comparison. We should also highlight that the effect of SFL on asthma is as yet unclear in the populations and settings where it has been analysed. Been et al.11found no association between the
introduction of SFL and the number of new wheezing/asthma cases among children 12 years visited by GP in UK.11 A quasiexperimental study in the US concluded that SFL reduced asthmatic symptoms in non-smoking children (3–15 years), but no association was found with self-reported asthma rates.26 A Spanish study that assessed the effects of partial SFL on asthma admissions rates at any age in Barcelona and Madrid failed to detect significant changes from 2003 to 2006 with fully adjusted models.15 Nevertheless, same authors found that asthma-related hospital admission rates increased by 12.1% immediately after the partial SFL in five Spanish regions, but decreased by 7.4% (95% CI:
0.2, 14.2) immediately after the comprehensive SFL, although the 1-year decrease was sustained only among men (9.9%, 95% CI: 3.9, 15.6).27Kalkhoran et al.10found a significant 15% decrease in the incidence of non-hospital emergency visits for bronchospasm in in- dividuals aged 15 years following the implementation of Uruguay’s SFL compared with prior period.
To our knowledge, no studies evaluate the impact of SFL on coronary disease in primary care, although data on the effect of SFL are available from hospital settings.28–30Three studies evaluate the 2005 Spanish partial SFL with hospital data on coronary disease.
Agu¨ero et al.14found a significant decrease of 11% in AMI incidence rates in the post-ban period compared with the previous period in Catalonia, particularly in women. In the city of Barcelona, Villalbı´
et al.31analysed annual AMI hospitalization rates and found lower rates in 2006 than in 2005 for all age groups except in males under 45 years of age, i.e. an age-adjusted decrease of 10.68% in males and of 8.76% in women in 2006 compared with 2004. Using fully adjusted models, Gala´n et al.15did not detect significant changes in hospital admission rates for AMI in Barcelona and Madrid in 2006 compared with the previous period. However, a significant AMI percentage rate change of—8.6% was observed in Barcelona Table 3Trends in age-standardizedaasthma incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands-Spain) and sex, 2007–13
Trend 1 Trend 2 AAPC (95% CI)
Years APC (95% CI) P value Years APC (95% CI) P value 2007–13 P value
Catalonia Incidence
Overall 2007–13 –2.71 (–8.12; 3.01) 0.271 –2.71 (–8.12; 3.01) 0.271
Female 2007–13 –3.09 (–8.21; 2.31) 0.197 –3.09 (–8.21; 2.31) 0.197
Male 2007–13 –1.97 (–8.10; 4.57) 0.464 –1.97 (–8.10; 4.57) 0.464
Prevalence
Overall 2007–09 7.13 (0.14; 14.61) 0.048 2009 – 2013 4.22 (1.88; 6.62) 0.016 5.18 (3.89; 6.49) <0.001 Female 2007–09 6.41 (2.42; 10.55) 0.020 2009 – 2013 4.17 (2.84; 5.53) 0.005 4.91 (4.18; 5.65) <0.001
Male 2007–13 5.53 (4.33; 6.75) <0.001 5.53 (4.33; 6.75) <0.001
Navarre Incidence
Overall 2007–13 –2.49 (–5.58; 0.71) 0.101 –2.49 (–5.58; 0.71) 0.101
Female 2007–13 –1.93 (–5.65; 1.94) 0.252 –1.93 (–5.65; 1.94) 0.252
Male 2007–13 –3.38 (–7.14; 0.52) 0.076 –3.38 (–7.14; 0.52) 0.076
Prevalence
Overall 2007–09 9.09 (5.02; 13.31) 0.010 2009–2013 6.07 (4.98; 7.17) 0.002 7.07 (6.36; 7.77) <0.001 Female 2007–09 8.61 (3.97; 13.45) 0.015 2009–2013 5.31 (4.05; 6.58) 0.003 6.40 (5.60; 7.20) <0.001 Male 2007–09 9.83 (5.94; 13.87) 0.008 2009–2013 7.13 (6.10; 8.17) 0.001 8.02 (7.35; 8.70) <0.001 Balearic Islands
Incidence
Overall 2010–13 –4.99 (–13.76; 4.68) 0.151 –4.99 (–13.76; 4.68) 0.151
Female 2010–13 –4.32 (–10.92; 2.78) 0.118 –4.32 (–10.92; 2.78) 0.118
Male 2010–l13 –5.32 (–20.91; 13.34) 0.321 –5.32 (–20.91; 13.34) 0.321
Prevalence
Overall 2010–13 8.87 (7.49; 10.28) 0.001 8.87 (7.49; 10.28) 0.001
Female 2010–13 8.50 (7.02; 9.99) 0.002 8.50 (7.02; 9.99) 0.002
Male 2010–13 9.50 (8.17; 10.85) 0.001 9.50 (8.17; 10.85) 0.001
Abbreviations:CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis.
a: Truncated (16-years old, 17 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method).
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compared with the period before the implementation of the SFL.
Despite this, primary care records are considered the single most complete source of non-fatal myocardial infarction.32In comparison with the abovementioned articles that present the percentage of change that occurs between two periods, the current study shows a significant decrease of 8% per year in the APC for men and women in Catalonia. Otherwise, a non-significant increase in the incidence of coronary disease was observed in the Balearic Islands, where data were only available for the last four years of the study. We hypothe- size that this increase might respond to a higher registration of the condition for prescription purposes and not to changes in the char- acteristics of the population.
Even though comprehensive SFL was introduced in Spain in 1 January 2011 and therefore its impact on the incidence of asthma and coronary disease should have been observed from this date onwards, no change in the trends of asthma and coronary disease were detected. It is likely that the prior effect of the 2005 Spanish partial SFL implemented on 1 January 2006 had weakened the impact of the comprehensive SFL, since a significant decrease in AMI hospital rates14,31 had already been observed. The lack of EHR in the period prior the partial SFL precludes the study of a larger period. Other factors that might have influenced these results are: immature computerization of EHR in the initial stages of im- plementation; changes in the software over time33–35; incentives to PHC providers to improve the management of hypertension, hyper- lipidaemia and diabetes; and the programmes for quitting smoking prior to the implementation of the comprehensive SFL.
Incidence rate trends have been use to analyse the impact of SFL.
However, we have considered also relevant the trends in the prevalence of asthma and coronary disease as indirect indicators of the increase or decrease of these conditions. The prevalence rates show the year in which trends changed in Catalonia and
Navarre, which do not coincide with the introduction of the new legislation.
Limitations and strengths
The evaluation of this public health law can be further complicated by factors not contemplated in this study that could influence the incidence and prevalence of asthma and coronary disease. Since the only variables collected were age, sex, number of health problems and number of PHC visits, no analyses adjusted by other variables known to be associated with the study conditions has been carried out. In addition, variation in the register of diagnostics in each region might generate differences in the number of active health problems for each patient and in the rates of asthma and coronary disease, for instance, the underregistration of asthma exacerbations in all regions, linking the diagnose with the episode in Navarre and the lack of integration of diagnostic data with electronic prescrip- tions in the Balearic Islands before 2012. As a result of these limita- tions and also due to the shorter study period in the Balearic Islands, the analysis was stratified by region. Otherwise, variations in study population size in Catalonia and Navarre along the study period were small and consistent with the variations in the whole population. Although rates of childhood asthma are usually considered to be more sensitive to SHS than rates of asthma in adults, this study only focuses on adult population as children data weren’t available.
This is the first study that evaluates the effect of the Spanish comprehensive SFL on adult asthma and coronary disease in PHC patients. It is crucial to analyse the effect of a public health law in PHC patients under real conditions.36–38The participation of three different Spanish regions and the use of EHR provides a wide range of valuable data. In addition, the use of joinpoint analysis evaluates Table 4 Trends in age-standardizedacoronary disease incidence and prevalence rates by region (Catalonia, Navarre and Balearic Islands- Spain) and Sex, 2007–13
Trend 1 Trend 2 AAPC (95% IC)
Years APC (95% CI) P-value Years APC (95% CI) P-value 2007–13 P-value
Catalonia Incidence
Overall 2007–13 –8.00 (–10.46; –5.47) 0.001 –8.00 (–10.46; –5.47) 0.001
Female 2007–13 –8.09 (–12.02; –3.98) 0.004 –8.09 (–12.02; –3.98) 0.004
Male 2007–13 –8.14 (–9.90; –6.34) <0.001 –8.14 (–9.90; –6.34) <0.001
Prevalence
Overall 2007–10 1.52 (0.22; 2.83) 0.037 2010–2013 –0.52 (–1.76; 0.73) 0.213 0.49 (0.08; 0.90) 0.019 Female 2007–10 0.89 (–1.28; 3.11) 0.220 2010–2013 –1.20 (–3.30; 0.94) 0.137 –0.16 (–0.85; 0.54) 0.654 Male 2007–10 1.90 (1.36; 2.45) 0.004 2010–2013 –0.22 (–0.74; 0.29) 0.204 0.83 (0.66; 1.01) <0.001 Navarre
Incidence
Overall 2007–13 –3.66 (–4.95; –2.35) 0.001 –3.66 (–4.95; –2.35) 0.001
Female 2007–13 –4.50 (–7.65; –1.24) 0.017 –4.50 (–7.65; –1.24) 0.017
Male 2007–13 –3.22 (–5.58; –0.80) 0.019 –3.22 (–5.58; –0.80) 0.019
Prevalence
Overall 2007–09 1.95(–0.72; 4.69) 0.088 2009–2013 –0.27 (–1.07, 0.55) 0.293 0.47 (–0.01; 0.94) 0.053 Female 2007–09 2.56 (–1.70, 6.99) 0.124 2009–2013 –1.11 (–2.39, 0.18) 0.065 0.10 (–0.66; 0.85) 0.806
Male 2007–13 0.47 (–0.03; 0.97) 0.059 0.47 (–0.03; 0.97) 0.059
Balearic Islands Incidence
Overall 2010–13 4.45 (–8.16; 18.79) 0.283 4.45 (–8.16; 18.79) 0.283
Female 2010–13 6.78 (–10.11; 26.84) 0.243 6.78 (–10.11; 26.84) 0.243
Male 2010–13 2.59 (–10.53; 17.63) 0.506 2.59 (–10.53; 17.63) 0.506
Prevalence
Overall 2010–13 10.01 (7.30; 12.78) 0.004 10.01 (7.30; 12.78) 0.004
Female 2010–13 11.38 (8.21; 14.65) 0.004 11.38 (8.21; 14.65) 0.004
Male 2010–13 8.85 (6.11; 11.67) 0.005 8.85 (6.11; 11.67) 0.005
Abbreviations:CI, confidence interval; APC, annual percentage change and AAPC, average annual percent change estimated by joinpoint regression analysis.
a: Truncated (35-years old, 13 age groups) rates per 10 000 inhabitants, age-standardized on the European Standard Population (direct method).
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longitudinal trends instead of just comparing two different periods, obtaining a more accurate analysis.
Conclusions
No changes in the trends of adult asthma and coronary disease in PHC Spanish patients were detected after the introduction of com- prehensive SFL. The impact of the comprehensive SFL might have been lessened by the effect of the previous implementation of the partial SFL. This article provides baseline data for future research into the effectiveness of this law. In addition to specific factors associated with asthma and coronary disease, future studies should consider cigarette consumption, socio-economic status and asthma in children.
Supplementary data
Supplementary data are available atEURPUBonline.
Acknowledgements
We thank all professionals of the 66 PHCTs who volunteered to participate in the study. The authors would also like to thank Josep M Elorza-Ricart, Magdalena Rosell-Murphy, Lluı´s Martı´nez, Javier Baquedano, Javier Arranz and Ma A´ngeles Nuin for their assistance.
Funding
This work was supported by the Carlos III Health Institute (Ministry of Economy and Competitiveness, Spain) with a grant for research projects on health (PI11/01413) through the Network for Prevention and Health Promotion in Primary Care (redIAPP, RD12/0005/0001;
RD16/0007/001), and by European Union ERDF funds.
Conflicts of interest: None declared.
Key points
Trend of asthma incidence rates decreased non-significantly over the study period.
Coronary disease incidence rates decreased significantly in Catalonia and Navarre.
Incidence trends for asthma and coronary disease remained unchanged.
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The European Journal of Public Health, Vol. 28, No. 3, 559–564
ß The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckx138 Advance Access published on 27 September 2017
...
Country of residence, gender equality and victim
blaming attitudes about partner violence: a multilevel analysis in EU
Anna-Karin Ivert1,2, Juan Merlo2, Enrique Gracia3
1 Department of Criminology, Faculty of Health and Society, Malmo¨ University, Malmo¨, Sweden
2 Unit of Social Epidemiology, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmo¨, Sweden 3 Department of Social Psychology, Faculty of Psychology, University of Valencia, Valencia, Spain
Correspondence:Anna-Karin Ivert, Department of Criminology, Malmo¨ University, SE-205 06 Malmo¨, Sweden, Tel: +46 40 665 76 47, e-mail: [email protected]
Background: Intimate partner violence against women (IPVAW) is a global and preventable public health problem.
Public attitudes, such as victim-blaming, are important for our understanding of differences in the occurrence of IPVAW, as they contribute to its justification. In this paper, we focus on victim-blaming attitudes regarding IPVAW within the EU and we apply multilevel analyses to identify contextual determinants of victim-blaming attitudes.
We investigate both the general contextual effect of the country and the specific association between country level of gender equality and individual victim-blaming attitudes, as well as to what extend a possible general contextual effect was explained by county level gender equality.Methods: We analyzed data from 26 800 re- spondents from 27 member states of the European Union who responded to a survey on public perceptions of domestic violence. We applied multilevel logistic regression analysis and measures of variance (intra-class correl- ation (ICC)) were calculated, as well as the discriminatory accuracy by calculating the area under the receiver operator characteristic curve. Results: Over and above individual characteristics, about 15% of the individual variance in the propensity for having victim-blaming attitudes was found at the country level, and country level of gender equality did not affect the general contextual effect (i.e. ICC) of the country on individual victim-blaming attitudes.Conclusion: The present study shows that there are important between-country differ- ences in victim-blaming attitudes that cannot be explained by differences in individual-level demographics or in gender equality at the country level. More research on attitudes towards IPVAW is needed.
...
Introduction
I
ntimate partner violence against women (hereafter IPVAW) is a global and preventable public health problem of unjustifiable size.1,2 A study by the European Union Agency for Fundamental Rights (FRA) in 2012 indicated that about 22% of the European women had experienced physical and/or sexual violence by a partner since age 15, with a range between 13% (e.g. Austria and Spain) and 32% (Denmark and Latvia).3IPVAW is a complex phenomenon and in addition to explanations and risk factors at the individual level,4,5 contextual factors at the community or country levels can also be important for our under- standing of IPVAW. As far as we know, however, there are only a few studies trying to identify contextual effects on IPVAW6,7 but only two8,9 have applied appropriate multilevel analysis. From this multilevel perspective, over and above individual characteristics, differ- ences at the country level in legislation or in cultural norms, attitudes and beliefs might explain differences in the individual probability of
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