Evolución y desigualdades en el estilo de vida relacionado con la salud de la población adulta española durante el periodo 2006-2017

Abstract

Background: The third Sustainable Development Goal (SDG), on well-being and health, is among the main lines of action of the SDGs established by the United Nations Organization and its project to raise awareness and impact on the 17 SDGs. In line with this, considering the surveillance and monitoring of equity in health and its social determinants among the main challenges of political action of the Commission on Social Determinants of Health, this doctoral thesis covers different scenarios of inequality during the period 2006-2017, mainly in health-related lifestyles of the adult population. Objective: The general objective is to analyze the evolution and social inequalities in health-related lifestyles and health indicators of the Spanish adult population during the period 2006-2017. For this purpose, three specific objectives are considered: (a) to analyze socioeconomic inequalities in health-related lifestyles and health indicators in the Spanish adult population in the period 2006-2017, as well as the association between lifestyle behaviors and socioeconomic gradient in some health indicators, including health-related quality of life and obesity; (b) to examine factors and circumstances that deepen inequalities in health-related lifestyles and health indicators in the period 2006-2017, including intermediate determinants such as place of residence and informal care, and also the influence of morbidity; and (c) to determine plausible interventions (i.e., laws for the control and regulation of behaviors such as smoking and the effects of educational attainment) that potentially have been able or could influence health-related lifestyles and reduce lifestyle-related socioeconomic inequalities. Methods: The sample consisted of 118,604 people (52.4% women) from the Spanish population who participated in the Spanish National Health Survey (2006, 2011/12 and 2017 editions) and the European Health Survey (2009 and 2014 editions) for Spain; and a population affiliated to the Madeira Association of Sport for All in the Autonomous Region of Madeira (Funchal, Portugal) of 2017, 381 people (61.2% women). Socioeconomic and sociodemographic variables, lifestyle-related variables and health indicators were measured from these surveys. Logistic regression analysis, mediation, latent classes, generalized estimating equations to fit logistic regression models and correlation matrices were performed as the main statistical analyses. Results: During the period analyzed, an increase in socioeconomic inequality was observed in health-related lifestyle habits, such as physical activity, smoking, and daily fruit and vegetable intake. Regarding the socioeconomic gradient in certain health indicators (obesity and health-related quality of life), physical activity and eating habits partially explained the socioeconomic gradient in obesity. Furthermore, in terms of physical activity domains, physical activity in sport was the modality that partially explained the socio-economic gradient in health-related quality of life. Differences in lifestyle and health indicators were observed between urban and rural areas that persisted throughout the period analyzed, including a higher weight status and alcohol consumption in rural men and a lower probability of cytological examination in rural women. In turn, in these years, informal caregivers indicated a more active lifestyle and higher daily intake of fruits and vegetables compared to non-caregivers, although they also had higher smoking and alcohol consumption. In addition, certain groups of people with chronic diseases were also more likely to have poorer health and lifestyle habits compared to people without these diseases. Finally, following the introduction of Law 42/2010, aimed at reducing smoking, there was a gradual decrease in the smoking population and, in this period analyzed, attaining a high educational level (university studies or more), proved to be an indicator associated with a better overall lifestyle, independent of occupational social class. Conclusions: Despite more favorable trends in some lifestyle habits, e.g., smoking, socioeconomic inequality increases in some of the main healthy lifestyle behaviors, demonstrating that the public health policies implemented in this period have not effectively reduced the socioeconomic gradient in health-related behaviors. Given this problem, education could play an additional and independent role in achieving health equity through its effects on health-related behaviors, regardless of occupational status. However, the results reinforce the importance of not considering only behavioral factors in the socioeconomic gradient of health, as these only partially contribute to its explanation. Therefore, public policies should consider other intermediate factors that could mediate this health gradient, including material circumstances, psychosocial factors, and biological processes that derive from the lifestyle behaviors themselves.