Background The economic recession starting in 2008 may be having negative effects on health.
Purpose We aimed to identify and characterise changes in trends in 15 health indicators in Spain during the recession.
Methods Joinpoint regression and average annual percent change (AAPC) were used to compare trends.
Results Premature mortality rates from several causes of death, except from cancer, showed statistically significant downward trends during the recession, as did poor self-reported health. HIV incidence was stable. No indicator declined significantly more slowly during the recession than in the preceding 4-year period, and two declined significantly faster.
Conclusion Health in Spain has continued to improve during the first four years of the economic recession at a rate equal to or higher than in previous years.
- Epidemiological methods
- HEALTH POLICY
- HEALTH STATUS
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Some southern European countries, including Spain, have been strongly affected by the economic crisis that began in 2008. These countries offer a valuable natural experiment to augment the empirical evidence on the effects of economic cycles on population health. A number of studies have looked at this topic in industrialised countries.1 ,2 The findings generally show that total mortality decreases in periods of recession and increases in periods of economic expansion. The variations are particularly important in mortality from traffic injuries and other unintentional causes of death. Mortality from cardiovascular disease also shows a similar variation with the economic cycle, whereas cancer mortality is not related to macroeconomic conditions.3 ,4 In contrast, the evidence is less consistent regarding mortality from suicide, which suggests that the effect of macroeconomic conditions on mortality from this cause may differ across countries.5–8
However, many people, even those who are well informed, think that the economic crisis must have a negative impact on health. The idea that economic hardship would fail to have a negative effect on health is counterintuitive, which probably explains why it is generally believed that pathology increases when the economy declines. Except for suicide indicators, the only country to date for which trend estimates have been published for various population health indicators before and during the current economic recession is Greece.9 Specifically, whereas the total mortality rate in Greece has continued its downward trend during the crisis period, mortality from suicide and infectious diseases increased between 2007 and 2009, as did the prevalence of poor self-reported health. Moreover, between 2010 and 2011, the incidence of infectious diseases was found to be on the rise. This increase was primarily due to worsening trends in HIV infection resulting from the increasing number of new cases of HIV infection in injecting drug users and from outbreaks of West Nile virus infection and malaria.
Between 1996 and 2007, Spain experienced sustained economic growth, followed by the onset of the crisis in 2008. The objective of the present work is to describe time trends in various health indicators in Spain during 1995 to 2011 and to identify changes in trends during the recession period suggesting a worsening of health.
We calculated the annual rate of premature (0–74 years) mortality, both overall and from selected specific causes of death, between 1995 and 2011. We also estimated the prevalence of self-reported poor health among the population aged 16–74 for 1995–2011, as well as the incidence of diagnosed HIV infections in the whole population for 2004–2011. To characterise macroeconomic conditions, the gross domestic product adjusted for purchasing power parity (GDP-PPP) was used. Details on data sources, definitions and the specific causes of death included in each broad category are shown in the online supplementary web table. Main data for the indicators come from national registries (mortality rates, HIV incidence) and the National Health Survey (prevalence of self-reported poor health).
Mortality rates and prevalence of poor health were directly standardised by age using weights from the European standard population stratified into 5-year age groups. To compare time trends of health indicators after and before the onset of the economic crisis, the average annual percent change (AAPC) in the 4-year period 2008–2011 and three similar previous periods was used. AAPCs were estimated by fitting joinpoint regression models, which characterise trends using joined linear segments on a logarithmic scale. Each segment slope is associated with an AAPC, which is estimated as a geometric weighted average of the annual percent change for each period considered. The annual values of indicators and the corresponding SEs were entered in the models, except for GDP-PPP, where a constant variance over the period was assumed. A maximum number of two joinpoints was established. For each indicator, the model estimates the possible joinpoints (significant change of trend) and displays the results as a straight or segmented line built with the modelled annual values of the indicator. However, to simplify the presentation of results in this paper, the graphics are not shown but the AAPCs calculated for 4-year periods, as this was the duration of the economic recession in 2011. A positive AAPC indicates an upward trend, while a negative one indicates a downward trend, with significance set as p<0.05. Student t test was used to determine if the AAPC in the period 2008–2011 differed significantly from previous periods. The joinpoint analysis was performed using Joinpoint v 220.127.116.11
In 2008, macroeconomic conditions in Spain changed rather abruptly: the estimated average growth rate of GDP-PPP dropped from 3.8% in 2003–2007 to −1% in 2008–2011, as can be seen in table 1. These results also show that all the indicators considered, except cancer mortality and HIV incidence, showed statistically significant downward trends during the economic recession (2008–2011). The greatest decreases were observed for mortality from traffic injuries (−14.2%), infectious diseases other than HIV (−8.7%) and illicit drug-induced deaths (−8.6%).
No indicator declined significantly more slowly during the recession than in the preceding 4-year period. Although cancer mortality declined more slowly, the differences with respect to the decline in the previous period were not statistically significant. Two indicators, mortality from infectious diseases other than HIV and prevalence of poor self-reported health, decreased significantly faster during the recession period.
Our findings suggest that Spanish health has continued to improve during the first four years of economic recession at a rate equal to or higher than occurred in previous years. Of the selected health indicators (mortality from different causes, HIV incidence and prevalence of self-reported poor health), none was worse during the first four years of the economic recession than in the previous 4-year period. All indicators, except cancer mortality and HIV incidence, show a significant downward trend (improvement) during the recession period, and some indicators have even moved from a stable to a downward trend.
Some authors have suggested that other southern European countries could be experiencing trends in several health indicators similar to what has been observed in Greece.11 An increase in mental health problems has also been reported among patients visiting primary care settings in Spain during the economic recession.12 However, our results for Spain differ from those of Greece and show that during the first four years of the economic recession, mortality from suicide and infectious diseases decreased, as did the prevalence of poor self-reported health. Illicit drug-induced mortality—another indicator related to mental health—has also declined.
Our findings apparently support the results of studies conducted on the effects of economic cycles on mortality.1 ,2 However, some of the largest declines in mortality found in Spain during the current economic recession are probably also related to causes other than macroeconomic conditions or changes in GDP. For example, the decline in mortality from traffic injuries may be primarily attributable to the effectiveness of road safety policies introduced in the years before or during the crisis,13 ,14 and the decline in drug-induced mortality is probably mainly related to the declining prevalence of drug injection and the sustained high coverage of harm reduction interventions15—factors that are not clearly related to changes in GDP.
The economic crisis in Spain is associated with increased income inequality16 and has given rise to a new law restricting universal access to healthcare for illegal immigrants.11 However, it may still be too early for some possible effects of the economic crisis on health, mediated by declining living conditions, to be reflected in the indicators of mortality and self-reported poor health. Thus, it seems prudent to conclude that the relationship between changes in macroeconomic conditions and health are complex since many other structural and contextual variables may be involved. Probably, in rich countries, the achievements of the health of the population, as a result of public health improvements and increased material welfare, resist well the threat of economic recession cycles. In any case, much more research is needed to clarify this relationship and to determine whether economic cycles manifest their effects on health in a delayed manner.
What is already known on this subject?
In the 4-year period 2008-2011 of economic recession premature mortality rates from several causes of death, except from cancer, showed statistically significant downward trends.
The greatest decrease was observed for mortality from traffic injuries.
Poor self-reported health decreased significantly faster during the recession period.
The health of the Spanish population has continued to improve during the first four years of economic recession at a rate equal to or higher than occurred in previous years.
What this study adds?
In Spain, all the indicators considered, except cancer mortality and HIV incidence, showed statistically significant downward trends during the economic recession.
No indicator declined significantly more slowly during the recession than in the preceding 4-year period.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online table
Contributors ER originated the study and coordinated the writing of the paper. GB contributed to the analysis of this study and to the drafting of the paper. MJB and LF contributed to the interpretation of the results and to the drafting of the paper. All authors contributed to the final version of the paper. All authors have seen and approved the final version.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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