Objective: Comparison of mortality amenable to medical intervention (avoidable mortality) in small geographical areas provides a useful tool to analyse quality of health care services. Currently there are no studies that analyse avoidable mortality by geographical distribution in small areas for the whole of Spain. The aim of this study is to describe the geographical distribution of avoidable and non-avoidable mortality in small areas in Spain by sex for the period 1990-2001. Methods: The 2.218 small areas considered consisted of municipalities or aggregated municipalities in the entirety of the Spanish territory. Avoidable deaths were analysed for the period 1990¿2001. Empirical Bayes model-based estimates of age-adjusted relative risk were displayed in small-area maps for each group of causes of death by sex. Results: There is an heterogeneous geographical distribution of avoidable mortality for both sexes. Areas with greater mortality are located in the south and northwest of Spain. Especially for hypertension, cerebrovascular disease and ischaemic heart disease in men there is a clear aggregation of deaths in these areas. Geographical distribution of non avoidable mortality in both sexes is similar to that described for these three causes. Conclusions: Geographical study of avoidable mortality in small areas for the whole of Spain permits the identification of areas with elevated mortality. Further research is necessary to clarify those factors related to avoidable mortality distribution.

Infant size at birth is a useful indicator to evaluate fetal growth in relation to gestational age. There is no standard model to create anthropometric reference curves in neonates, but the method chosen could determine the reference values estimated. We describe the methods used to construct population-based reference curves of birth weight for gestational age in Catalonia, Spain. These methods included detection of implausible values of birth weight for gestational age by a probabilistic cluster model, utilization of the Generalized Additive Model for Location and Scale method to obtain smoothed percentiles and z-scores, and calculation of 95% confidence intervals by bootstrapping. To our knowledge, these are the first reference curves in neonates constructed through a method allowing asymmetric distributions with kurtosis to be modelled. Estimation of confidence intervals is useful to determine which reference intervals can be employed to assess newborn size.

Objective: To determine the effect of an intervention in secondary schools on visible tobacco use, the prevalence and intensity of smoking, and the attitudes and behaviors of teachers and students. Methods: We performed a quasiexperimental study in 18 public secondary schools that carried out the program and in 18 that did not (control group). Information was obtained on visible tobacco use and the number of ashtrays and smokefree posters through direct observation. Data were collected on tobacco use, the number of heavy smokers, smoking in schools, opinions on smokefree schools, smoking in front of the students, and attempts to quit smoking through questionnaires to teachers and students in the third year of compulsory secondary education (15-year-olds) and in the final year of secondary school (18-year-olds). Results: Visible tobacco use was lower in the intervention group (27.9 vs. 45.6%) and twice as many posters were displayed. No differences were found in the prevalence of daily tobacco use, but the percentage of heavy smokers was lower in teachers and students in the intervention group. Smoking was lower in students in the third year of compulsory secondary education in schools carrying out the program. Opinions about smokefree schools were favorable in both groups. Conclusions: The program contributed to reducing visible tobacco use and in decreasing the number of heavy smokers among teachers and students.

Objective: To determine the causes of non-participation in a breast cancer early detection program for women in the northern area of Almería (Spain). Methods: We performed a case-control study. A sample of women included in a breast cancer early detection program between October 2002 and February 2004 was chosen. Participants were interviewed about family, sociodemographic and program-related variables (knowledge, accessibility, attitudes), family and personal history, and health status. Possible differences among women who attended the program and those who did not were analyzed through bivariate analysis and multivariate logistic regression. Odds ratio (OR) and 95% confidence interval (95%CI) were calculated. Results: A total of 720 questionnaires were completed (350 cases and 370 controls) and 291 women (40.4% of the sample) were replaced. The variables found to be independently associated with non-participation in the program were as follows: not receiving a letter (OR=11.2; 95%CI: 4.6-26.9), undergoing mammography outside the program (OR=4.4; 95%CI: 2.8-6.9), not having illnesses requiring medical examinations (OR=2; 95%CI: 1.3-3), and expressing fear of the result of mammography (OR=1.8; 95%CI: 1.2-2.6). Conclusions Women who did not receive a letter or who underwent mammography outside the program had a greater risk of not attending the program, hence the need to improve the quality of the database. Awareness of the program should be increased among women and health education should be provided to women fearing the outcome.

Interventions implemented by governments are very frequently related to the determinants of health. Health impact assessment (HIA) is used as a predictive tool to include health in nonhealth policymaking. This paper defines HIA, describes its methods, procedures and applications, and discusses opportunities and challenges associated with HIA. Doing a HIA implies studying the intervention, profiling the target population, and estimating its impacts on health by means of combining quantitative and qualitative evidence. HIA has been used in different kinds of policies (transports, urban regeneration, culture, energy development etc.), at different levels (local, national, European) and in many countries. Despite its scarce use in Spain, HIA allows to consider health in sectorial policymaking, taking into account social inequalities in health, so that healthier public policies can be designed. On the other hand, HIA is a tool under methodological development which use is hindered due to the existing narrow biomedical perspective on the determinants of health, and to the difficulties in working in public policy-making with multisectorial and participative perspectives.

Objective: To assess the impact of codification of nursing activities and procedures on a hospital's weighting and finance. Methods: Codification was performed in two inpatient settings using discharge data. Nurses' procedures and patient conditions falling within nurses' responsibilities were codified. New mean weights for diagnosisrelated groups (DRGs) and hospital complexity units (HCU) were calculated, as were their effects on finance. Results: In January and February, 2006, the mean weighting in the medical admission unit increased by 0.0655, representing 7.2727 more HCU and a rise in the monthly budget of 13,092.25€. On January of 2006, the mean weighting in the surgical admission unit increased by 0.0747 representing 10.8315 HCU and an increase in the monthly budget of 19,498.76€. Conclusions: Codification of nursing activities has improved the case mix and has had a positive effect on the hospital's finance.

The evolution of public health in Spain during the 19th century can be divided into three stages. In the first stage (1812-1833), the reign of Fernando VII prevented the development of the liberal postulates: «the autonomy of the city councils in the matter of hygiene and public health». The second stage (1833-1873), was characterized by the legislative development of sanitary organization in Spain. As a result of this new legislative framework, and in the context of social hygiene («social inequality as the origin of disease»), the figures of municipal health professionals appeared, engaged by the city councils to be in charge of the medical assistance of the poor (municipal physician), of the pharmaceutical assistance of the poor (municipal pharmacist), and of the health inspection of meat from the slaughterhouses (municipal veterinarian). The third stage (1873-1904), marked the beginning of a new age (microbiology) and the beginning of the scientific method. Microbiology prompted the creation of municipal laboratories throughout the state and laid the foundations for the creation of the Healthcare Services of Medicine, Pharmacy and Veterinary Science at the beginning of the xx century. These organizations would have a well-defined organizational structure with wider functions.

Introduction: Understanding the quality, costs and outcomes of healthcare services requires precise determination of the morbidity in a population. Measurement of morbidity in a population and its association with the services provided remains to be performed. The aim of this article was to present our experience of using clinical risk groups (CRGs) to measure morbidity in an integrated healthcare organization (IHO). Methods: We studied the population attended by an IHO in a county (approximately 120,000 patients) from 2002 to 2005. CRGs were used to measure morbidity. A descriptive analysis was performed of the population's distribution in CRG categories and utilization rates. Results: One or more chronic diseases was found in 15.5% of the population, significant acute illness was found in 9%, minor chronic diseases was found in 7% and very severe diseases was found in 0.5%. Between 2002 and 2005, the number of individuals with chronic disease increased by 8%. The burden of illness increased with age. However, at all ages, at least 40% of the population remained healthy. Comorbidity in chronic illnesses was a crucial factor in explaining healthcare resource utilization. Conclusions: The CRG grouping system aids analysis at different levels for clinical administration. Due to its composition, this system allows better understanding of the use, costs and quality of the set of services received by a population.

Introduction: The aim of this study was to determine the weeks of high rotavirus circulation in Valladolid (Spain) and to compare the characteristics of hospitalizations and emergencies in epidemic and nonepidemic periods. Methods: The information sources consisted of the weekly notifications to the Microbiological Information System, the Minimum Data Set, and the Emergency Registry. Expected cases for 2006 were calculated using a previously developed model. Weeks with observed cases over the upper limit of the 95% confidence interval for expected cases were considered epidemic periods. Hospitalization and emergencies in epidemic and nonepidemic periods were compared. Results: The number of cases in 2006 was 42% less than the expected number. The mean number of daily admissions was higher in epidemic periods (d=1.49; p=0.01) and the length of admissions was longer. Conclusion: The activity of the paediatric service increased during the epidemic period. Consequently, implementation of surveillance activities and prevention and control programs for rotavirus in hospitals would seem advisable.

Objectives: To identify dietary patterns in pregnancy and describe their relationship with sociodemographic factors, smoking, and body mass index. As a secondary objective, intakes were evaluated relative to current dietary recommendations for pregnant women. Methods: Cross-sectional assessment of dietary intakes in 473 pregnant women from the Island of Menorca (Spain) was performed. Dietary patterns were identified using a principal components analysis, and dietary quality was assessed by comparing food group intakes with recommended intakes in pregnancy. Results: Two dietary patterns were identified, one characterized by high intakes of energy-dense foods and low intakes of fruits and vegetables («caloric»), and the other by high intakes of vegetables, legumes, fish, meat, rice and pasta («healthy»). Scores for the caloric pattern were higher in immigrants, smokers, parous women and women with only primary school education (p<0,05). Scores for the healthy pattern were higher in women originally from other parts of Spain and immigrants (p<0,05). No associations were found with the remaining variables. Adherence to dietary recommendations was high for fruit, meat and especially dairy products, while intakes of vegetables, cereals and legumes were only one-third of recommended levels. Conclusions: Dietary patterns during pregnancy were similar to previously reported patterns in the general population, showing consistent associations with sociodemographic factors and smoking. There were substantial deficiencies in intakes of cereals, legumes and vegetables in all women, suggesting the need for educational interventions and monitoring during prenatal care to improve the quality of dietary habits during pregnancy.

Health crises shock the population and overwhelm the health services. This article analyzes 30 years of health crises in Spain from a multifaceted perspective: population, patients, clinicians, public health practitioners, politicians, the media and other groups involved. The interaction among all stakeholders shapes the response and management of any health crisis. Heterogeneity of management and of health effects-contributing to inequalities in health-is common. The participation and coordination of the health services is crucial in detection of the crisis and in modulating the population reactions. Public health services characterized by their low public profile could gain public influence by their role in coordinating politicians and the media when solving important health problems. Analyzing the mistakes and successes in previous crises together with risk and vulnerability assessments, research and drills are essential to give a quick and adequate response to future crises.

Objective: To assess the psychometric quality of an instrument designed to measure functional independence (Functional Independence Scale [FIS]) in several activities of daily living domains and to be applied by trained non-health-related interviewers. The study was carried out in the autonomous region of Madrid in community-dwelling elders. Methods: We performed a cross-sectional validation study. In addition to the FIS, Pfeiffer's questionnaire, the Depression Subscale of the Hospital Anxiety and Depression Scale, the Comorbidity Index, the Barthel Index, and EQ-5D were used. These measures were cross-sectionally applied to community-dwelling elders (n=500) and outpatients in a general hospital (n=100) aged =65 years. The following FIS psychometric attributes were analyzed: acceptability, scaling assumptions, internal consistency, construct validity, and precision. Results: A fully computable FIS total score was obtained in 94.3% of the subjects. A ceiling effect (60.65%), but no floor effect (0.22%) was evident in the community-dwelling elders. No floor or ceiling effects were detected in the hospital sample. Scaling assumptions and internal consistency were satisfactory (item-total correlations: 0.57-0.91; Cronbach's alpha: 0.94). Factor analysis identified three factors that explained 74.3% of the variance. Indexes of convergent, internal, and known-groups validity were satisfactory. The scale's precision, determined by the standard error of measurement (2.49; 95%CI=4.88), was also satisfactory. Conclusion: The FIS is an easy-to-use instrument with appropriate metric attributes. This scale can be usefully applied in broad samples of non-institutionalized elders by non-health related personnel.

Objective: To conform a frame of reference for the organization of the public health teaching in university degrees in Spain, in agreement with the directives of the European Space for Higher Education. Methods Specific professional competencies in public health have been extracted from the Libros blancos published by the ANECA (National Agency of Quality Evaluation) for the degrees on medicine, pharmacy, nursing, human nutrition and dietetics, optics and optometry, veterinary, social work, occupational relations, teacher training, and environmental sciences. Following the framework proposed by the Working Group on professional competencies in public health in Spain, we have selected those competences that enable future professionals to participate in the development of the public health from their field of activity. We have also identified and correlated the specific competences of each degree with the corresponding activities and functions. Results All the studied degrees have competences in public health functions. The majority has also defined activities in community health analysis, design and implementation of health interventions and programmes, promotion of social participation and citizen's control of their own health. Conclusions There is academic space for the multidisciplinary development of the public health in Spain beyond the health professions. The identification of the specific competencies of each degree related with activities on public health reveal what are the contents to be in included in each syllabus.