Decades In Spain Research Articles

Quality, acceptability and usability of self-sampling kits used by non-healthcare professionals for STI diagnosis in Spain: a single-blind study

ObjectivesSexually transmitted infections (STIs) have markedly increased over the last decade in Spain, calling for prevention and control innovative approaches. While there is evidence indicating the effectiveness of self-sampling for...

Spatiotemporal patterns and drivers of extreme fire severity in Spain for the period 1985–2018

Extreme fire severity patterns driven by climate change have deep consequences on vegetation, subsequent fire regimes and have consequences on the effectiveness of extinction. In this work, we aimed to determine if extreme fire severity defined as the 90th percentile of RdNBR has changed in Spain in the last 3 decades, if extreme fire severity patterns have differed among the different vegetation types and what drivers have influenced extreme fire severity in both summer and non-summer fires. We have used perimeters of large wildfires (≥100 ha, n = 1719) from 1985 to 2018 in four pyroregions and the main dominant vegetation types. We have analyzed time series for each pyroregion and vegetation type to determine if there were significant trends and breakpoints in extreme fire severity. We have also analyzed the effects of drought, weather, topography and vegetation on extreme fire severity in seasonal wildfires.Extreme fire severity increased in summer fires from 1985 to 2018, especially in the East and North pyroregions, while the Southwest pyroregion reached highest values in summer. There has been an increase of severity in shrubland, mosaic vegetation and conifer forests in summer. Broadleaved forests had the lowest values of fire severity and did not show any trend in the period considered. The most important drivers of extreme fire severity are, in order of importance, pyroregion, elevation, slope, vapor pressure deficit (VPD) and vegetation type for summer fires, and VPD, vegetation types, pyroregion, windspeed and drought for non-summer fires. Global change is increasing climate-related events. Our results indicate that extreme fire severity in summer has been on the rise in recent decades in Spain, suggesting that, in a climate warming context, without strategic management of these increasingly flammable landscapes, further increases may be likely.

How effective is equality regulation in reducing gender gaps in the labor market?☆

The gender gap in both employment and labour participation has narrowed markedly in recent decades in Spain. However, this decline seems to have slowed and shows a certain persistence. The solution to this problem can respond to different regulatory or non-regulatory policies. This article studies the evolution of the regulatory framework for the formulation of possible policy recommendations. We identify and quantify for the first time when, at what rate and in what regions, Spanish administrations have adopted regulations aimed at combating discrimination against women, achieving gender equality or approved measures related to the work-life balance. The study is based on a text analysis of 297,402 regulations adopted in the period 1996–2022. The indicators reveal the high degree of heterogeneity in terms of the legislation. Non-discrimination legislation was the most developed and frequent, with 11,228 regional regulations and 2590 central administration regulations adopted. We show that the volume of new regulations, mainly those related to discrimination and work-life balance, has contributed to the reduction in gender gaps. Policy actions by administrations should concentrate on these two modes of intervention. The general analysis of regulation in this area also allows for some recommendations in terms of “better regulation” policies, such as the introduction of gender equality assessments (specific regulatory impact reports).

Prediction of attention deficit hyperactivity disorder based on explainable artificial intelligence

Accurate assessment of Attention Deficit Hyperactivity Disorder (ADHD) is crucial for the effective treatment of affected individuals. Traditionally, psychometric tests such as the WISC-IV have been utilized to gather evidence and identify patterns or factors contributing to ADHD diagnosis. However, in recent years, the use of machine learning (ML) models in conjunction with post-hoc eXplainable Artificial Intelligence (XAI) techniques has improved our ability to make precise predictions and provide transparent explanations. The objective of this study is twofold: firstly, to predict the likelihood of an individual receiving an ADHD diagnosis using ML algorithms, and secondly, to offer interpretable insights into the decision-making process of the ML model. The dataset under scrutiny comprises 694 cases collected over the past decade in Spain, including information on age, gender, and WISC-IV test scores. The outcome variable is the professional diagnosis. Diverse ML algorithms representing various learning styles were rigorously evaluated through a stratified 10-fold cross-validation, with performance assessed using key metrics, including accuracy, area under the receiver operating characteristic curve, sensitivity, and specificity. Models were compared using both the full set of initial features and a well-suited wrapper-type feature selection algorithm (Boruta). Following the identification of the most suitable model, Shapley additive values were computed to assign weights to each predictor based on their additive contribution to the outcome and to elucidate the predictions. Strikingly, a reduced set of 8 out of the initial 20 variables produced results comparable to using the full feature set. Among the ML models tested, the Random Forest algorithm outperformed others on most metrics (ACC = 0.90, AUC = 0.94, Sensitivity = 0.91, Specificity = 0.92). Notably, the principal predictors, ranked by importance, included GAI – CPI, WMI, CPI, PSI, VCI, WMI – PSI, PRI, and LN. Individual case examples exhibit variations in predictions depending on unique characteristics, including instances of false positives and negatives. Our ML model adeptly predicted ADHD diagnoses in 90% of cases, with potential for further enhancement by expanding our database. Furthermore, the use of XAI techniques enables the elucidation of salient factors in individual cases, thereby aiding inexperienced professionals in the diagnostic process and facilitating comparison with expert assessments. It is important to note that this tool is designed to support the ADHD diagnostic process, where the medical professional always has the final say in decision-making.

Drivers of the time-varying heat-cold-mortality association in Spain: A longitudinal observational study

BackgroundA number of studies have reported reductions in mortality risk due to heat and cold over time. However, questions remain about the drivers of these adaptation processes to ambient temperatures. We aimed to analyse the demographic and socioeconomic drivers of the downward trends in vulnerability to heat- and cold-related mortality observed in Spain during recent decades (1980–2018). MethodsWe collected data on all-cause mortality, temperature and relevant contextual indicators for 48 provinces in mainland Spain and the Balearic Islands between Jan 1, 1980, and Dec 31, 2018. Fourteen contextual indicators were analysed representing ageing, isolation, urbanicity, heating, air conditioning (AC), house antiquity and ownership, education, life expectancy, macroeconomics, socioeconomics, and health investment. The statistical analysis was separately performed for the range of months mostly causing heat- (June-September) and cold- (October-May) related mortality. We first applied a quasi-Poisson generalised linear regression in combination with distributed lag non-linear models (DLNM) to estimate province-specific temperature-mortality associations for different periods, and then we fitted univariable and multivariable multilevel spatiotemporal meta-regression models to evaluate the effect modification of the contextual characteristics on heat- and cold-related mortality risks over time. FindingsThe average annual mean temperature has risen at an average rate of 0·36 °C per decade in Spain over 1980–2012, although the increase in temperature has been more pronounced in summer (0·40 °C per decade in June-September) than during the rest of the year (0·33 °C per decade). This warming has been observed, however, in parallel with a progressive reduction in the mortality risk associated to both hot and cold temperatures. We found independent associations for AC with heat-related mortality, and heating with cold-related mortality. AC was responsible for about 28·6% (31·5%) of the decrease in deaths due to heat (extreme heat) between 1989 and 1993 and 2009–2013, and heating for about 38·3% (50·8%) of the reductions in deaths due to cold (extreme cold) temperatures. Ageing (ie, proportion of population over 64 years) attenuated the decrease in cold-related mortality. InterpretationAC and heating are effective societal adaptive measures to heat and cold temperatures. This evidence holds important implications for climate change health adaptation policies, and for the projections of climate change impacts on human health.

Advance Care Planning in Spain

In the last decade in Spain, an important push has been given to the development of health policies that define the framework of action in the care of people with advanced chronic diseases. Respect for the autonomy of the patient, shared decision-making processes and advance care planning (ACP) are recognized into health plans as a key aspect in chronic care, frailty, and palliative care. A few but significant number of institutions, local governments, and healthcare professionals from different regions of Spain have started a rationale and roadmap for a new twist in Spain’s theoretical, ethical and policy development, promoting ACP implementation into public health care systems. In 2020, a working group founded in 2017, evolved into the “Spanish Association of Shared Care Planning” (AEPCA). The Shared Care Planning (SCP) concept grows up after the two international consensus Delphi studies in 2017 and pretends to shift from the framework of ACP programs to a person-centred care approach. In the last years, several experiences show how professionals are more sensible and interested on the ACP process, but it cannot be said, for now, that it has taken effect in the global Spanish health system. Even both ACP and SCP are being used simultaneously in Spain, each day more people and autonomous communities embrace renewed concept and foundations of SCP, supporting the work of AEPCA on spreading the value of this process into the care of people who are coping with chronic diseases, vulnerability, and frailty.

Epidemiological characteristic and prognosis changes in chronic hepatitis B in people living with HIV

IntroductionDue to hepatitis B virus (HBV) treatment and vaccination during the last decades in Spain, epidemiological and prognosis of chronic hepatitis B (CHB) may have changed. MethodsRetrospective review of CHB-HIV coinfected patients in a single reference center in Madrid until year 2019. We compared incidence, epidemiological and clinical characteristics according diagnosis period (before 2000, 2000–2004, 2005–2009, 2010–2014, 2015–2019). A retrospective longitudinal study was done to assess mortality, related risk factors and hepatic decompensation. ResultsOut of 5452 PLHIV, 160 had CHB (prevalence 2.92%; 95%CI 2.5–3.4), 85.6% were men, median age 32.1 (27−37.2). Incidence rate did not change over the years (2.4/100 patients-year). PLHIV with CHB diagnosed before year 2000 (n = 87) compared with those diagnosed between 2015 and 2019 (n = 11) were more often native-Spanish (90.8% vs. 18.2%), had infected using intravenous drugs (55.2% vs. 0), were coinfected with hepatitis C (40% vs. 9.1%) or hepatitis delta virus (30.4% vs. 0) and had more severe liver disease (cirrhosis 24.1% vs. 0). After a median follow-up of 20.4 years, 23 patients died (7.1/1000 patients-year) and 19 had liver decompensation (4.9/1000 patients-year). All deaths and liver decompensation occurred in patients diagnosed before year 2010. Mortality was associated with higher liver fibrosis in Fibroscan® (HR 1.06, 95% CI 1.03−1.09). ConclusionThe epidemiology of CHB in PLHIV in our cohort is changing with less native Spanish, more sexually transmitted cases and less coinfection with other hepatotropic virus. Patients diagnosed before 2010 have worst prognosis related to higher grades of liver fibrosis.

Vole outbreaks may induce a tularemia disease pit that prevents Iberian hare population recovery in NW Spain

Iberian hare populations have suffered severe declines during recent decades in Spain. Between 1970 and 1990s, a rapid increase in irrigation crop surface in NW Spain (Castilla-y-León region) was followed by a common vole massive range expansion and complete colonization of lowland irrigated agricultural landscapes from mountainous habitats. The subsequent large cyclic fluctuations in abundance of colonizing common voles have contributed to a periodic amplification of Francisellatularensis, the etiological agent that causes human tularemia outbreaks in the region. Tularemia is a fatal disease to lagomorphs, so we hypothesize that vole outbreaks would lead to disease spill over to Iberian hares, increasing prevalence of tularemia and declines among hare populations. Here we report on the possible effects that vole abundance fluctuations and concomitant tularemia outbreaks had on Iberian hare populations in NW Spain. We analysed hare hunting bag data for the region, which has been recurrently affected by vole outbreaks between 1996 and 2019. We also compiled data on F.tularensis prevalence in Iberian hares reported by the regional government between 2007 and 2016. Our results suggest that common vole outbreaks may limit the recovery of hare populations by amplifying and spreading tularemia in the environment. The recurrent rodent-driven outbreaks of tularemia in the region may result in a "disease pit" to Iberian hares: at low host densities, the rate of population growth in hares is lower than the rate at which disease-induced mortality increases with increased rodent host density, therefore, keeping hare populations on a low-density equilibrium. We highlight future research needs to clarify tularemia transmission pathways between voles and hares and confirm a disease pit process.

Data without reference points: collaborations in communication research in Spain are less international and publications have lower impact

Although comparisons are unpopular, they help to establish standard frames of reference to assess the situation of individuals, institutions, or countries. In the field of communication, the meta-research has been prolific in examining the current state of its production, but has ignored the need to compare what this research is with respect to what it should be, thus offering descriptions without reference points. During the last decade in Spain, have the co-authorships in communication been international? And perhaps even more importantly, has the published output been top-tier? In this study, I try to answers these gaps in the literature by comparing communication research in Spain with two broad frames of reference: the set of all sciences and the set of all social sciences. The results show that, when compared with these two macro references, communication research collaborations lack international cooperation and are quite solitary. Similarly, communication research releases fewer publications in the first quartile but more in the second, third, and fourth quartiles. The study suggests that research in terms of international collaboration and level of publication output is below the expected standard and emphasizes the need to establish comparative frameworks to assess and evaluate the state of the field beyond descriptive or headline data (as in this article).

Cambios en las características epidemiológicas y en el pronóstico de la hepatitis crónica B en personas que viven con VIH

IntroductionDue to hepatitis B virus (HBV) treatment and vaccination during the last decades in Spain, epidemiological and prognosis of chronic hepatitis B (CHB) may have changed. MethodsRetrospective review of CHB–HIV coinfected patients in a single reference center in Madrid until year 2019. We compared incidence, epidemiological and clinical characteristics according diagnosis period (before 2000, 2000–2004, 2005–2009, 2010–2014, 2015–2019). A retrospective longitudinal study was done to assess mortality, related risk factors and hepatic decompensation. ResultsOut of 5452 PLHIV, 160 had CHB (prevalence 2.92%; 95% CI: 2.5–3.4), 85.6% were men, median age 32.1 (27–37.2). Incidence rate did not change over the years (2.4/100 patients-year). PLHIV with CHB diagnosed before year 2000 (n = 87) compared with those diagnosed between 2015 and 2019 (n = 11) were more often native-Spanish (90.8% vs. 18.2%), had infected using intravenous drugs (55.2% vs. 0), were coinfected with hepatitis C (40% vs. 9.1%) or hepatitis delta virus (30.4% vs. 0) and had more severe liver disease (cirrhosis 24.1% vs. 0). After a median follow-up of 20.4 years, 23 patients died (7.1/1000 patients-year) and 19 had liver decompensation (4.9/1000 patients-year). All deaths and liver decompensation occurred in patients diagnosed before year 2010. Mortality was associated with higher liver fibrosis in Fibroscan® (HR 1.06, 95% CI: 1.03–1.09). ConclusionThe epidemiology of CHB in PLHIV in our cohort is changing with less native Spanish, more sexually transmitted cases and less coinfection with other hepatotropic virus. Patients diagnosed before 2010 have worst prognosis related to higher grades of liver fibrosis.

Trends in cardiovascular care in the National Health System in Spain. Data from the RECALCAR project 2011-2020

Introduction and objectivesThe RECALCAR project (Resources and Quality in Cardiology), an initiative of the Spanish Society of Cardiology, aims to standardize information to generate evidence on cardiovascular health outcomes. The objective of this study was to analyze trends in the resources and activity of cardiology units and/or services and to identify the results of cardiovascular care during the last decade in Spain. MethodsThe study was based on the 2 annual data sources of the RECALCAR project: a survey on resources and activity of cardiology units and/or services (2011-2020) and the minimum data set of the National Health System (2011-2019), referring to heart failure (HF), STEMI, and non-STEMI. ResultsThe survey included 70% of cardiology units and/or services in Spain. The number of hospital beds and length of stay decreased, while there was a notable increase in the number of cardiac imaging studies and percutaneous therapeutic procedures performed. Age- and sex-adjusted admissions for HF tended to decrease, despite an increase in mortality and the percentage of readmissions. In contrast, the trend in mortality and readmissions was highly favorable in STEMI; in non-STEMI, although positive, the trend was less marked. ConclusionsThe information provided by the RECALCAR project shows a favorable trend in the last decade in resources, activity and results of certain cardiovascular processes and constitutes an essential source for future improvements and decision-making in health policy.

Evolución de la asistencia cardiovascular en el Sistema Nacional de Salud de España. Datos del proyecto RECALCAR 2011-2020

Introduction and objectivesThe RECALCAR project (Resources and Quality in Cardiology), an initiative of the Spanish Society of Cardiology, aims to standardize information to generate evidence on cardiovascular health outcomes. The objective of this study was to analyze trends in the resources and activity of cardiology units and/or services and to identify the results of cardiovascular care during the last decade in Spain. MethodsThe study was based on the 2 annual data sources of the RECALCAR project: a survey on resources and activity of cardiology units and/or services (2011-2020) and the minimum data set of the National Health System (2011-2019), referring to heart failure (HF), STEMI, and non-STEMI. ResultsThe survey included 70% of cardiology units and/or services in Spain. The number of hospital beds and length of stay decreased, while there was a notable increase in the number of cardiac imaging studies and percutaneous therapeutic procedures performed. Age- and sex-adjusted admissions for HF tended to decrease, despite an increase in mortality and the percentage of readmissions. In contrast, the trend in mortality and readmissions was highly favorable in STEMI; in non-STEMI, although positive, the trend was less marked. ConclusionsThe information provided by the RECALCAR project shows a favorable trend in the last decade in resources, activity and results of certain cardiovascular processes and constitutes an essential source for future improvements and decision-making in health policy.Full English text available from:www.revespcardiol.org/en

Changes in perinatal management and outcomes in infants born at 23 weeks of gestational age during the last decade in Spain

Introduction The 2021-updated guidelines of the Spanish Society of Neonatology Guidelines have moved the zone of parental discretion to 23 + 0–23 + 6 weeks. The objective of this study was to describe the changes in perinatal management at this gestational age along the last decade and to determine if a more active perinatal management has contributed to improved outcomes. Methods Retrospective analysis of prospectively collected data from the 23-week infants included in the Spanish SEN 1500 neonatal network during the period 2010–2019. The main study outcomes were survival at discharge and survival without major morbidity of actively managed infants. Two periods were compared: 2010–2014 (Period 1) and 2015–2019 (Period 2). NICUs were classified into low activity NICUs (less than 50 admissions of very low birth weight infants per year) and high activity NICUs (50 or more admissions) Results A total of 381 infants were included, 182 in Period 1 and 199 in Period 2. In Period 2 an increase in the use of intrapartum magnesium sulfate (21.5% vs 39.9%, p .002), antenatal steroids (56.6% vs 69.3%, p .011) and active neonatal approach in delivery room (76.9% vs 86.9%, p .011) were observed. The clinical outcomes of the actively managed 313 infants were similar in both periods, except for less arterial hypotension in Period 2. Survival was 27.1% in Period 1 and 25% in Period 2 (p .068) and survival without major morbidity was 2.1% and 2.3% respectively (p .914). No difference was found between low and high activity NICUs. Conclusion A change to a more active intention to treat infants born at 23 weeks is taking place in Spain. But the survival rate of the actively-managed infants has remained stable around 25–30% during the study period. A multidisciplinary effort is needed to improve outcomes in this population.

Women’s leadership in clinical research: A retrospective observational study over two decades in Spain

Background and objectiveAvailable data support differences by gender in the leadership of clinical investigations (CI). This study analyzes to what extent women lead these investigations. Materials and methodsObservational-retrospective study in a tertiary university hospital associated with one of the most important health research institutes in Spain. We analyzed the principal investigators (PI) by gender from 2001 to 2020. Main outcome: proportion of CI led by female doctors (FD) during the study period. Secondary outcomes: differences in PI by gender according to the type of study: clinical trials (CT) or non-interventional-researches (NIR) and according to type of funding. Data sources: Research Ethics Committee (REC) and Human Resources Department registries. ResultsDuring the study, the REC approved 8466 protocols, 52% (4408/8466) were EC, the rest were NIR. Women led 39.7% (3360/8466) of the total. The gender gap was observed mainly in EC: FD were IP of 31.5% of them (1391/4408) and 48.5% (1969/4058) of NIR. This despite the increasing trend in the number of FD staff. By type of funding, when the studies were supported by private sector there was a wider gap markedly unfavorable for women. ConclusionsOur results show that there is underrepresentation of women in research leadership, mainly those with private financing. This study reinforces the idea that there is still a long way to go in this field. More studies are necessary to identify the existing differences that allow the implementation of actions at the institutional and cultural level that promote gender equality in the field of clinical research.

Energy Transition Narratives in Spain: A Case Study of As Pontes

The energy transition is one of the most important processes of the last decade in Spain, affecting all aspects of life (social, political, economic and demographic). Its main objective is to eventually replace the fossil-fuel-based energy matrix with renewable energy sources to avoid climate change and meet sustainable development goals. This transition has affected a large number of population groups and institutions in carbon-intensive regions such as As Pontes, who are the main stakeholders in this process. These stakeholders have generated different narratives around the implementation of decarbonization policies and their short- and long-term impacts on the local population and the territory. These narratives affect the acceptance and pace of implementation of decarbonization measures and policies adopted by national and regional governments. Based on a qualitative analysis of published material (press articles, policy reports published by central and regional governments, reports published by environmental groups, financial institutions and large companies), this article first identifies the different stakeholders involved in the decarbonization process and maps them according to their power and interest in the energy transition process and then highlights the prevalent energy transition narratives, with their impact on the pace of the energy transition in Spain, focusing on the case of As Pontes. The results show that the narratives propagated by different stakeholders have a great impact on the acceptance of the decarbonization policies and measures adopted by the central government and the pace of the energy transition in different parts of Spain, including the region of As Pontes.

How Has the Aspergillosis Case Fatality Rate Changed over the Last Two Decades in Spain?

(1) Background: Aspergillus produces high morbidity and mortality, especially in at-risk populations. In Spain, the evolution of mortality in recent years due to this fungus is not well established. The aim of this study was to estimate the case fatality rate of aspergillosis in inpatients from 1997 to 2017 in Spain. (2) Methodology: A retrospective descriptive study was conducted with records of inpatients admitted to the National Health System with a diagnosis of aspergillosis. (3) Principal findings: Of 32,960 aspergillosis inpatients, 24.5% of deaths were registered, and 71% of the patients who died were men. The percentage of deaths increased progressively with age. The case fatality rate progressively decreased over the period, from 25.4 and 27.8% in 1997–1998 to values of 20.6 and 20.8% in 2016 and 2017. Influenza and pneumonia occurrence/association significantly increased case fatality rates in all cases. (4) Conclusions: Our study shows that lethality significantly decreased in the last two decades despite the increase in cases. This highlights the fact that patients with solid and/or hematological cancer do not have a much higher mortality rate than the group of patients with pneumonia or influenza alone, these two factors being the ones that cause the highest CFRs. We also need studies that analyze the causes of mortality to decrease it and studies that evaluate the impact of COVID-19.

Theoretical approaches to the engagement with patients in case-management programmes and assertive outreach teams: A systematic review of the literature.

WHAT IS KNOWN ON THE SUBJECT?: It is generally accepted that all interventions carried out by mental health nurses involve engagement with the patient; this engagement is a process that is gradually constructed and is not immediate. In Spain during last decade, nurses working in assertive outreach teams have gradually replaced the traditional institutional setting in favour of environments that are more familiar to the patient. In contrast, when patients and nurses interact outside institutional settings, a new approach and skillset is required in order to adapt to the new environment. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We have systematically identified and assessed the available evidence on how nurses work in assertive outreach team programmes. The therapeutic link is not just assistance; it is actually a construct, which is established between nurse and patient, with the aim of favouring, fostering and strengthening the therapeutic relationship. Only a few studies have discussed the nurse-patient therapeutic link in assertive outreach services. However, it seems important that nurses use a standardized language, that is, a language promoted as a model of correct use and used for functions of greater prestige, especially in public administration and teaching, to integrate it into the theoretical framework. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: With the synthesis that we present, we hope that it promote a more consistent use of the engagement concept in research on this topic. In turn, this will enhance staff support and training and will foster evidence-based practice. The conceptualization of nursing language and its use by professionals helps to improve practice and the lack of a theoretical framework with a nurse perspective. It is necessary to establish a consensus between mental health nurses around the engagement' meaning in the programmes of assertive outreach teams. ABSTRACT: Introduction During last decade in Spain, nurses working in assertive outreach programmes have replaced the traditional institutional setting in favour of the patient's own environment. Engagement with patients requires a different skillset when the axis of the nurse-patient interaction is the patient's own environment. The engagement alone could be associated with the innate concept of patient's care and the helping relationship. However, in the individualized care models, the engagement seems to be an instrument with its own characteristics for the purpose of providing mental health care. Aim/Question To systematically identify and assess the empirical evidence on the relationships and engagement between patients with mental illness (schizophrenia, psychotic disorders, schizoaffective disorders, mood disorders and disorders of adult personality) and nursing mental health nurses. Method Systematic literature review based on PRISMA guidance. Results We identified and reviewed seven primary research studies. Following the analytic processes, three themes emerged: existence of different engagement levels, training needs and skills in the creation and consolidation of the engagement, and engagement as process. Discussion The engagement of nurse and patient is understood as a process that incorporates different stages. Whilst it is established, the engagement is subject to positive and negative influences. For the creation of the engagement and its maintenance specialized skills, knowledge and personal attributes (resilience, psychosocial skills, compressive knowledge of mental health illnesses, capacity to build effective relationships, adaptability and problem-solving) are necessary, but the main focus is on context where it develops, selected by the patient himself, for example, his home. Implications for Practice Administrators may have questions about appropriate hiring practices for assertive outreach teams since certain skills are necessary to obtain un engagement process, and staff training should be considered a key issue to provide specific skills for enhancing engagement and the therapeutic relationship. Conclusion The engagement must be understood as a long-term process. For the creation of the engagement and its maintenance, specialized skills, knowledge and personal attributes are necessary.

Gobernanza y políticas públicas contra la despoblación rural a través del caso de La Rioja (España)

Rural depopulation has become one of the central issues on the public agenda in the last decade in Spain. However, despite this visibility and the measures that are being developed, the process is still present. Within the policies against depopulation and rural development, the role of participation and empowerment of the affected populations has become particularly important. The objective is based on the fact that, through a more horizontal governance, they are the protagonists of the actions and measures that affect them, and that this governance becomes a means to avoid the depopulation of rural areas. The European Union's LEADER approach and the Local Action Groups have become the paradigm of this rural governance that favours their development and tackles depopulation. This article analyses the situation of rural governance in the case of a Spanish region such as La Rioja, which is affected by the depopulation of a large part of its rural areas. It starts with a theoretical framework that addresses the concept itself and how it is being articulated with issues such as social capital, territorial capital and participation, as well as the strengths and weaknesses of the scenarios that are being generated, based on the differences between territories. Next, the frameworks of depopulation in Spain are presented, which are marking the very public policies on the issue. Finally, the situation in La Rioja is addressed, focusing on the role of the regional government's plans and strategies to tackle depopulation and the role of the Local Action Groups.

The moderating effect of the public finances on transport infrastructures in Spain

In recent decades, Spain has witnessed a considerable increase in railway and road transport infrastructure. The driver of this change has been investment from the central government, which has generated speculation regarding the possible distribution of new infrastructure according to partisan political interests. This paper aims to determine whether this political influence impacts the efficiency of the transport infrastructure. This study proposes an empirical model to assess the impact of the central government's investment in roads and railways in the country's 15 mainland autonomous communities. The empirical results reveal that the political factor, as a proxy of public finances, moderates the accessibility process. The empirical model analyses the impact of new infrastructure on structuring and territorial cohesion during 1995–2007, considered the golden decade in Spain. Based on the econometric results, we conclude that state investment in rail, moderated by the consideration of political factors, improves the accessibility of rail transport infrastructure. Finally, this study presents relevant policy implications, suggesting a new line of regulations to increase local transport infrastructure projects' quality regarding “network efficiency.”

Future Projections of Heat Mortality Risk for Major European Cities

AbstractOver the last few decades heat waves have intensified and have led to excess mortality. While the probability of being affected by heat stress has significantly increased, the risk of heat mortality is rarely quantified. This quantification of heat mortality risk is necessary for systematic adaptation measures. Furthermore, heat mortality records are sparse and short, which presents a challenge for assessing heat mortality risk for future climate projections. It is therefore crucial to derive indicators for a systematic heat mortality risk assessment. Here, risk indicators based on temperature and mortality data are developed and applied to major cities in Germany, France and Spain, using regional climate model simulations. Bias-corrected daily maximum, minimum and wet-bulb temperatures show increasing trends in future climate projections for most considered cities. Additionally, we derive a relationship between daily maximum temperatures and mortality for producing future projections of heat mortality risk due to extreme temperatures based on low (Representative Concentration Pathway; RCP2.6) and high (RCP8.5) emission scenario future climate projections. Our results illustrate that heat mortality increases by about 0.9%/decade in Germany, 1.7%/decade in France and 7.9%/decade in Spain for RCP8.5 by 2050. The future climate projections also show that wet-bulb temperatures above 30°Cwill be reached regularly with maxima above 40°Clikely by 2050. Our results suggest a significant increase of heat mortality in the future, especially in Spain. On average, our results indicate that the mortality risk trend is almost twice as high in all three countries for the RCP8.5 scenario compared to RCP2.6.