Trends in stunting and overweight in Peruvian pre-schoolers from 1991 to 2011: findings from the Demographic and Health Surveys.

OBJECTIVE: To examine trends in stunting and overweight in Peruvian children, using 2006 WHO Multicentre Growth Reference Study criteria. DESIGN: Trend analyses using nationally representative cross-sectional surveys from Demographic and Health Surveys (1991-2011). We performed logistic regression analyses of stunting and overweight trends in sociodemographic groups (sex, age, urban-rural residence, region, maternal education and household wealth), adjusted for sampling design effects (strata, clusters and sampling weights). SETTING: Peru. SUBJECTS: Children aged 0-59 months surveyed in 1991-92 (n 7999), 1996 (n 14 877), 2000 (n 11 754), 2007-08 (n 8232) and 2011 (n 8186). RESULTS: Child stunting declined (F(1, 5149) = 174·8, P ≤ 0·00) and child overweight was stable in the period 1991-2011 (F(1, 5147) = 0·4, P ≤ 0·54). Over the study period, levels of stunting were highest in rural compared with urban areas, the Andean and Amazon regions compared with the Coast, among children of low-educated mothers and among children living in households in the poorest wealth quintile. The trend in overweight rose among males in coastal areas (F(1, 2250) = 4·779, P ≤ 0·029) and among males in the richest wealth quintile (F(1, 1730) = 5·458, P ≤ 0·020). CONCLUSIONS: The 2011 levels of stunting and overweight were eight times and three and a half times higher, respectively, than the expected levels from the 2006 WHO growth standards. The trend over the study period in stunting declined in most sociodemographic subgroups. The trend in overweight was stable in most sociodemographic subgroups.

Equity in health and health care in Peru, 2004-2008.

OBJECTIVE: This study evaluates whether recent positive economic trends and pro-poor health policies have resulted in more health equity and explores key factors that explain such change. METHODS: This study focuses on the evolution of measures of health status (self-reported morbidity) and use of health care services obtained from the 2004 and 2008 rounds of the Peruvian National Household Survey (Encuesta Nacional de Hogares). It concentrates on health inequalities associated with socioeconomic status and uses interquintile differences (gradient), concentration indices with and without needs-based adjustments, and decomposition analysis. RESULTS: Findings show a low level of inequality in measures of health status, with a slightly pro-poor inequality in self-reported health problems and a slightly pro-rich inequality in self-reported chronic illness. Inequity in the use of curative services declined significantly between 2004 and 2008, while inequity in the use of preventive services increased slightly. Use of hospital and dental services remained unchanged during the same period. CONCLUSIONS: Limitations of self-reported morbidity measures probably underestimate the results of health inequalities across socioeconomic groups. Improved equity in the use of curative health services can be explained by a number of positive factors that occurred concurrently during the analysis-namely, increased mean household income, reduced economic inequality, the Juntos conditional cash transfer program, and gradual expansion of public health insurance, Seguro Integral de Salud (SIS). Given that SIS expansion is the main public policy for promoting health equity in Peru, it is crucial that future steps in expansion come with a strategy to isolate its contribution to health equity improvements from that of other positive socioeconomic trends.

[Ultrasound-guided puncture of the jugular vein using a posterior approach]. / Punción ecodirigida de la vena yugular interna por abordaje posterior.

BACKGROUND: Ultrasound-guided central venous catheterization provides a direct view of anatomical structures, making it easier to determine the exact puncture site, thereby reducing the associated mechanical complications. PATIENTS AND METHODS: This study included patients scheduled for central venous catheterization. An ultrasound examination was performed on the necks of all patients before the right internal jugular vein was catheterized by a single operator using ultrasound monitoring. RESULTS: We studied 21 men and 14 women; the mean (SD) age of the patients was 53 (17) years. Forty percent were kidney transplant recipients and 57% had had the right internal jugular vein catheterized on other occasions. The carotid artery had accidentally been punctured using the standard catheterization technique in 4 of the patients; the internal jugular vein was then catheterized successfully using ultrasound-guidance, which clearly showed the hematoma caused by the carotid puncture. The right internal jugular vein was successfully catheterized in 34 patients; it was necessary to catheterize the left jugular vein in 1 patient as the ultrasound examination revealed thrombosis of the right vein. A single puncture was performed in all cases and none of the complications associated with venous puncture were observed. CONCLUSION: Ultrasound images allowed us to effectively examine the jugular vein prior to puncture for central venous catheterization. Ultrasound-guided puncture of the vein was satisfactory and free from complications in all cases.

Assessing Latin America's Progress Toward Achieving Universal Health Coverage.

Two commonly used metrics for assessing progress toward universal health coverage involve assessing citizens' rights to health care and counting the number of people who are in a financial protection scheme that safeguards them from high health care payments. On these metrics most countries in Latin America have already "reached" universal health coverage. Neither metric indicates, however, whether a country has achieved universal health coverage in the now commonly accepted sense of the term: that everyone--irrespective of their ability to pay--gets the health services they need without suffering undue financial hardship. We operationalized a framework proposed by the World Bank and the World Health Organization to monitor progress under this definition and then constructed an overall index of universal health coverage achievement. We applied the approach using data from 112 household surveys from 1990 to 2013 for all twenty Latin American countries. No country has achieved a perfect universal health coverage score, but some countries (including those with more integrated health systems) fare better than others. All countries except one improved in overall universal health coverage over the time period analyzed.

Poverty, health infrastructure and the nutrition of Peruvian children.

This paper offers empirical evidence on the impact of the expansion in health infrastructure of the 1990s upon child nutrition in Peru, as measured by the height for age z-score. Using a pooled sample of three rounds of the Peruvian DHS, I have controlled for biases in the allocation of public investments by using a district fixed effects model. The econometric analysis shows a positive effect of the expansion of the last decade in urban areas, but not in rural areas. Furthermore, the effect for urban children is highly non-linear and has a pro-poor bias, in the sense that the estimated effect is larger for children of less educated mothers. These findings support the idea that reducing distance and waiting time barriers is necessary to improve child health and nutrition in developing countries, but that we need more explicitly inclusive policies to improve the health of the rural poor, especially indigenous groups, that are caught in this type of poverty trap.

Equity in health and health care in Peru, 2004 - 2008 / Equidad en la salud y la atención sanitaria en Perú, 2004 - 2008

OBJECTIVE: This study evaluates whether recent positive economic trends and pro-poor health policies have resulted in more health equity and explores key factors that explain such change. METHODS: This study focuses on the evolution of measures of health status (self-reported morbidity) and use of health care services obtained from the 2004 and 2008 rounds of the Peruvian National Household Survey (Encuesta Nacional de Hogares). It concentrates on health inequalities associated with socioeconomic status and uses interquintile differences (gradient), concentration indices with and without needs-based adjustments, and decomposition analysis. RESULTS: Findings show a low level of inequality in measures of health status, with a slightly pro-poor inequality in self-reported health problems and a slightly pro-rich inequality in self-reported chronic illness. Inequity in the use of curative services declined significantly between 2004 and 2008, while inequity in the use of preventive services increased slightly. Use of hospital and dental services remained unchanged during the same period. CONCLUSIONS: Limitations of self-reported morbidity measures probably underestimate the results of health inequalities across socioeconomic groups. Improved equity in the use of curative health services can be explained by a number of positive factors that occurred concurrently during the analysis-namely, increased mean household income, reduced economic inequality, the Juntos conditional cash transfer program, and gradual expansion of public health insurance, Seguro Integral de Salud (SIS). Given that SIS expansion is the main public policy for promoting health equity in Peru, it is crucial that future steps in expansion come with a strategy to isolate its contribution to health equity improvements from that of other positive socioeconomic trends.

OBJETIVO. Evaluar la evolución del nivel de equidad en la salud en Perú e identificar los factores clave que explican los cambios. MÉTODOS. Se evaluó la evolución del estado de salud (morbilidad autoinformada) y la utilización de los servicios de atención sanitaria según los datos recogidos en la Encuesta Nacional de Hogares de 2004 y de 2008. Se analizaron las desigualdades en salud con respecto a la situación socioeconómica y se calcularon las diferencias entre los quintiles (gradientes) y los índices de concentración (con y sin ajustes) basados en las necesidades de servicios, y se aplicó el análisis de descomposición. RESULTADOS. Se observó un nivel bajo de desigualdad en el estado de salud, con una leve desigualdad a favor de las personas de menos ingresos en los problemas de salud y a favor de las personas de mayores ingresos en las enfermedades crónicas, según los autoinformes. La inequidad en la utilización de los servicios curativos descendió significativamente entre el 2004 y el 2008, mientras la inequidad en la utilización de los servicios preventivos aumentó ligeramente. No se observaron cambios en el uso de servicios hospitalarios y odontológicos durante el mismo período. CONCLUSIONES. Las limitaciones de las medidas de morbilidad autoinformadas probablemente ocasionan una subestimación de las desigualdades en salud en todos los grupos socioeconómicos. La mejor equidad en la utilización de los servicios de salud curativos puede deberse a varios factores positivos que tuvieron lugar en el período analizado, como el aumento del ingreso promedio por hogar, la menor desigualdad económica, el programa Juntos de transferencia de dinero condicionada a la asistencia escolar y la atención sanitaria maternoinfantil, y la ampliación gradual del Seguro Integral de Salud (SIS). Puesto que la ampliación del SIS es la política pública dirigida a promover la equidad en la salud en Perú, es crucial que sus próximas etapas incluyan estrategias para aislar su contribución a las mejoras en la equidad sanitaria de las generadas por otras tendencias socioeconómicas positivas.

Household catastrophic health expenditures: a comparative analysis of twelve Latin American and Caribbean Countries / Gastos catastróficos en salud de los hogares: un análisis comparativo de doce países en América Latina y el Caribe

OBJETIVO: Comparar los patrones de gastos catastróficos en salud en 12 países de América Latina y el Caribe. MATERIAL Y MÉTODOS: Se estimó la prevalencia de gastos catastróficos de manera uniforme para doce países usando encuestas de hogares. Se emplearon dos tipos de indicadores para medir la prevalencia basados en el gasto de bolsillo en salud: a) en relación con una línea de pobreza internacional; y b) en relación con la capacidad de pago del hogar en términos de su propia canasta alimentaria. Se estimaron razones para comparar el nivel de gastos catastróficos entre subgrupos poblacionales definidos por variables económicas y sociales. RESULTADOS: El porcentaje de hogares con gastos catastróficos variaron de 1 a 25 por ciento en los 12 países. En general, la residencia rural, el bajo nivel de ingresos, la presencia de adultos mayores, y la carencia de aseguramiento en salud de los hogares se asocian con mayor propensión a sufrir gastos catastróficos en salud. Sin embargo, existe una marcada heterogeneidad por país. CONCLUSIONES: Los estudios comparativos entre países pueden servir para examinar cómo los sistemas de salud contribuyen a la protección social de los hogares en América Latina.

OBJECTIVE: Compare patterns of catastrophic health expenditures in 12 countries in Latin America and the Caribbean. MATERIAL AND METHODS: Prevalence of catastrophic expenses was estimated uniformly at the household level using household surveys. Two types of prevalence indicators were used based on out-of-pocket health expense: a) relative to an international poverty line, and b) relative to the household's ability to pay net of their food basket. Ratios of catastrophic expenditures were estimated across subgroups defined by economic and social variables. RESULTS: The percent of households with catastrophic health expenditures ranged from 1 to 25 percent in the twelve countries. In general, rural residence, lowest quintile of income, presence of older adults, and lack of health insurance in the household are associated with higher propensity of catastrophic health expenditures. However, there is vast heterogeneity by country. CONCLUSIONS: Cross national studies may serve to examine how health systems contribute to the social protection of Latin American households.

Levels of endothelial and platelet microparticles and their interactions with leukocytes negatively correlate with organ dysfunction and predict mortality in severe sepsis.

OBJECTIVE: Mortality in sepsis is believed to be associated with exaggerated inflammatory responses, but recent evidence suggests that poor outcome is associated with reduced inflammation. To test this hypothesis, we measured several inflammatory markers to determine whether any of them or any combinations are associated with mortality or organ dysfunction. DESIGN: Clinical study. SETTING: School of medicine. PATIENTS: Thirty-five patients with severe sepsis. INTERVENTIONS: Markers of endothelial, platelet, and leukocyte activation were measured on days 1, 2, and 3 after enrollment. The markers were a) endothelial microparticles (EMPs) and their conjugates with monocytes (EMP/MONO); b) platelet microparticles (PMPs) and platelet activation marker CD62P; c) platelet-leukocyte conjugates (PLT/LEU) and leukocyte activation marker CD11b; and d) intracellular nitric oxide in leukocytes. MEASUREMENTS AND MAIN RESULTS: The 28-day mortality rate was 51% (18 of 35). Significant differences between survivors and nonsurvivors on day 1 were found in PLT/LEU (p = .001), CD11b (p = 0.02), and EMP/MONO (p = .02) groups. Using logistic regression to assess if these markers predict mortality on day 1, we found that PLT/LEU had the best predictive value among the markers used (area under receiver operating characteristics curve = 0.82). All markers of cell activation and inflammation were significantly higher among survivors on days 2 and 3, except nitric oxide, which was lower. This marker showed significant negative correlation with the Sequential Organ Failure Assessment score throughout the study. CONCLUSIONS: Our data support the hypothesis that early increased, not decreased, inflammatory response as measured by our markers is associated with improved survival rate. A high negative correlation was found between some of these markers and Sequential Organ Failure Assessment score.

Public health infrastructure and equity in the utilization of outpatient health care services in Peru.

This article analyzes the magnitude and nature of socioeconomic differences in the utilization of outpatient health care services in Peru. In particular, it explores the potential equity-enhancing effect of the expansion and improvements in the network of health centres during the 1990s. The Peruvian health reform made relatively little progress in terms of the reform agenda promoted internationally during the 1990s. Nevertheless, the expansion of the public network of health centres and the improvements in their equipment has been noteworthy during the same period. Using the 1997 survey of the Peruvian Living Standards Measurement Study (PLSMS), we find large differences in the utilization of outpatient health care services. The richest to poorest quintile ratio is 1.9, and even larger in rural areas. Estimating a probit model with random effects at the district level to control for the systematic geographic bias associated with the optimal public allocation of such infrastructure, we find the income effect to be very large, even after controlling for other socioeconomic characteristics. Finally, we also find that the expansion of the public network of health centres has indeed an equity-enhancing effect, but this is rather small. These results indicate that although the expansion of the public network of health facilities may be necessary, it is not sufficient to promote equity in the utilization of health care services by Peruvian adults, especially in rural areas. It is important to look deeper into the costs of consultations and drugs as economic barriers to the utilization of health services by the poor. In particular, the expansion of health insurance mechanisms for the poor should be carefully monitored and evaluated.

Inequalities in health in Latin America and the Caribbean: descriptive and exploratory results for self-reported health problems and health care in twelve countries.

OBJECTIVE: To explore and describe inequalities in health and use of health care as revealed by self-report in 12 countries of Latin America and the Caribbean. METHODS: A descriptive and exploratory study was performed based on the responses to questions on health and health care utilization that were included in general purpose household surveys. Inequalities are described by quintile of household expenditures (or income) per capita, sex, age group (children, adults, and older adults), and place of residence (urban vs. rural area). For those who sought health care, median polishing was performed by economic status and sex, for the three age groups. RESULTS: Although the study is exploratory and descriptive, its findings show large economic gradients in health care utilization in these countries, with generally small differences between males and females and higher percentages of women seeking health care than men, although there were some exceptions among the lower economic strata in urban areas. CONCLUSIONS: Inequalities in self-reported health problems among the different economic strata were small, and such problems were usually more common among women than men. The presence of small inequalities may be due to cultural and social differences in the perception of health. However, in most countries included in the study, large inequalities were found in the use of health care for the self-reported health problems. It is important to develop regional projects aimed at improving the questions on self reported health in household interview surveys so that the determinants of the inequalities in health can be studied in depth. The authors conclude that due to the different patterns of economic gradients among different age groups and among males and females, the practice of standardization used in constructing concentration curves and in computing concentration indices should be avoided. At the end is a set of recommendations on how to improve these sources of data. Despite their shortcomings, household interview surveys are very useful in understanding the dimensions of health inequalities in these countries.

Inequalities in health in Latin America and the Caribbean: descriptive and exploratory results for self-reported health problems and health care in twelve countries / Desigualdades de salud en América Latina y el Caribe: resultados descriptivos y exploratorios basados en la autonotificación de problemas de salud y atención de salud en doce países

Objective. To explore and describe inequalities in health and use of health care as revealed by self-report in 12 countries of Latin America and the Caribbean. Methods. A descriptive and exploratory study was performed based on the responses to questions on health and health care utilization that were included in general purpose household surveys. Inequalities are described by quintile of household expenditures (or income) per capita, sex, age group (children, adults, and older adults), and place of residence (urban vs. rural area). For those who sought health care, median polishing was performed by economic status and sex, for the three age groups. Results. Although the study is exploratory and descriptive, its findings show large economic gradients in health care utilization in these countries, with generally small differences between males and females and higher percentages of women seeking health care than men, although there were some exceptions among the lower economic strata in urban areas. Conclusions. Inequalities in self-reported health problems among the different economic strata were small, and such problems were usually more common among women than men. The presence of small inequalities may be due to cultural and social differences in the perception of health. However, in most countries included in the study, large inequalities were found in the use of health care for the self-reported health problems. It is important to develop regional projects aimed at improving the questions on selfreported health in household interview surveys so that the determinants of the inequalities in health can be studied in depth. The authors conclude that due to the different patterns of economic gradients among different age groups and among males and females, the practice of standardization used in constructing concentration curves and in computing concentration indices should be avoided. At the end is a set of recommendations on how to improve these sources of data. Despite their shortcomings, household interview surveys are very useful in understanding the dimensions of health inequalities in these countries

Objetivo. Explorar y describir las desigualdades detectadas a partir de la autonotificación de problemas de salud y de la búsqueda de atención sanitaria en 12 países de América Latina y el Caribe. Métodos. Se analizan las preguntas sobre los problemas de salud y la búsqueda de atención en encuestas de hogares de tipo general y se describen las desigualdades correspondientes de acuerdo con quintiles de gasto (o ingreso) doméstico per cápita, sexo, grupo de edad (niños, adultos y adultos mayores) y área urbana o rural. En el caso de las personas que buscaron atención de salud, se aplica la técnica de pulimiento de medianas por nivel económico y sexo para los tres grupos de edad. Resultados. Aun cuando el trabajo es exploratorio y descriptivo, los resultados muestran en los países estudiados la existencia de importantes gradientes en la utilización de servicios de salud según nivel económico, y la presencia de diferencias generalmente pequeñas entre hombres y mujeres, con algunas excepciones en los estratos económicos más bajos en áreas urbanas. Conclusiones. Las desigualdades detectadas a partir de la autonotificación de problemas de salud son muy pequeñas entre personas de diferente nivel económico y los problemas suelen ser más frecuentes entre las mujeres que entre los hombres. Esto se debe posiblemente a diferencias culturales y sociales en la percepción de la salud. Las desigualdades en la búsqueda de atención son grandes en la mayoría de los países estudiados. Es muy importante que se desarrollen proyectos regionales encaminados a mejorar las preguntas para la autonotificación de problemas de salud con el fin de poder estudiar a fondo los factores que determinan las desigualdades en el ámbito sanitario. Los autores concluyen que debido a que los gradientes económicos muestran patrones diferentes en los distintos grupos de edad y en hombres y mujeres, los datos no deben estandarizarse a la hora de derivar curvas de concentración y calcular los índices de concentración. Al final hay una lista de recomendaciones sobre cómo mejorar estas fuentes de datos. Pese a sus deficiencias, las encuestas de hogares nos ayudan a entender las complejidades de las desigualdades de salud en estos países.

Acerca de la magnitud de la inequidad en salud en el Perú / About the magnitude of inequity in health in Peru

El análisis presentado muestra que la magnitud de las inequidades en salud y en la utilización de servicios de salud en el Perú es muy grande, aun para un país con el nivel de desarrollo del Perú