Trends in socioeconomic inequalities in stunting prevalence in Latin America and the Caribbean countries: differences between quintiles and deciles.

BACKGROUND: With the adoption of the Sustainable Development Goals (SDGs), there is a renewed commitment of tackling the varied challenges of undernutrition, particularly stunting (SDG 2.2). Health equity is also a priority in the SDG agenda and there is an urgent need for disaggregated analyses to identify disadvantaged subgroups. We compared time trends in socioeconomic inequalities obtained through stratification by wealth quintiles and deciles for stunting prevalence. METHODS: We used 37 representative Demographic and Health Surveys and Multiple Indicator Cluster surveys from nine Latin American and Caribbean (LAC) countries conducted between 1996 and 2016. Stunting in children under-5 years was assessed according to the 2006 WHO Child Growth Standards and stratified by wealth quintiles and deciles. Within-country socioeconomic inequalities were measured through concentration index (CIX) and slope index of inequality (SII). We used variance-weighted least squares regression to estimate annual changes. RESULTS: Eight out of nine countries showed a statistical evidence of reduction in stunting prevalence over time. Differences between extreme deciles were larger than between quintiles in most of countries and at every point in time. However, when using summary measures of inequality, there were no differences in the estimates of SII with the use of deciles and quintiles. In absolute terms, there was a reduction in socioeconomic inequalities in Peru, Honduras, Dominican Republic, Belize, Suriname and Colombia. In relative terms, there was an increase in socioeconomic inequalities in Peru, Bolivia, Haiti, Honduras and Guatemala. CONCLUSIONS: LAC countries have made substantial progress in terms of reducing stunting,. Nevertheless, renewed actions are needed to improve equity. Particularly in those countries were absolute and relative inequalities did not change over time such Bolivia and Guatemala. Finer breakdowns in wealth distribution are expected to elucidate more differences between subgroups; however, this approach is relevant to cast light on those subgroups that are still lagging behind within populations and inform equity-oriented health programs and practices.

Summary indices for monitoring universal coverage in maternal and child health care.

OBJECTIVE: To compare two summary indicators for monitoring universal coverage of reproductive, maternal, newborn and child health care. METHODS: Using our experience of the Countdown to 2015 initiative, we describe the characteristics of the composite coverage index (a weighted average of eight preventive and curative interventions along the continuum of care) and co-coverage index (a cumulative count of eight preventive interventions that should be received by all mothers and children). For in-depth analysis and comparisons, we extracted data from 49 demographic and health surveys. We calculated percentage coverage for the two summary indices, and correlated these with each other and with outcome indicators of mortality and undernutrition. We also stratified the summary indicators by wealth quintiles for a subset of nine countries. FINDINGS: Data on the component indicators in the required age range were less often available for co-coverage than for the composite coverage index. The composite coverage index and co-coverage with 6+ indicators were strongly correlated (Pearson r  = 0.73, P < 0.001). The composite coverage index was more strongly correlated with under-five mortality, neonatal mortality and prevalence of stunting (r =  -0.57, -0.68 and -0.46 respectively) than was co-coverage (r = -0.49, -0.43 and -0.33 respectively). Both summary indices provided useful summaries of the degrees of inequality in the countries' coverage. Adding more indicators did not substantially affect the composite coverage index. CONCLUSION: The composite coverage index, based on the average value of separate coverage indicators, is easy to calculate and could be useful for monitoring progress and inequalities in universal health coverage.

Inequalities in full immunization coverage: trends in low- and middle-income countries.

OBJECTIVE: To investigate disparities in full immunization coverage across and within 86 low- and middle-income countries. METHODS: In May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage - i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine - in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries. FINDINGS: In each of the World Health Organization's regions, it appeared that about 56-69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations. CONCLUSION: Most low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.

Coverage and equity in reproductive and maternal health interventions in Brazil: impressive progress following the implementation of the Unified Health System.

BACKGROUND: The Brazilian SUS (Unified Health System) was created in 1988 within the new constitution, based on the premises of being universal, comprehensive, and equitable. The SUS offers free health care, independent of contribution or affiliation. Since then, great efforts and increasing investments have been made for the system to achieve its goals. We assessed how coverage and equity in selected reproductive and maternal interventions progressed in Brazil from 1986 to 2013. METHODS: We reanalysed data from four national health surveys carried out in Brazil in 1986, 1996, 2006 and 2013. We estimated coverage for six interventions [use of modern contraceptives; antenatal care (ANC) 1+ visits by any provider; ANC 4+ visits by any provider; first ANC visit during the first trimester of pregnancy; institutional delivery; and Caesarean sections] using standard international definitions, and stratified results by wealth quintile, urban or rural residence and country regions. We also calculated two inequality indicators: the slope index of inequality (SII) and the concentration index (CIX). RESULTS: All indicators showed steady increases in coverage over time. ANC 1+ and 4+ and institutional delivery reached coverage above 90 % in 2013. Prevalence of use of modern contraceptives was 83 % in 2013, indicating nearly universal satisfaction of need for contraception. On a less positive note, the proportion of C-sections has also grown continuously, reaching 55 % in 2013. There were marked reductions in wealth inequalities for all preventive interventions. Inequalities were significantly reduced for all indicators except for the C-section rate (p = 0.06), particularly in absolute terms (SII). CONCLUSIONS: Despite the difficulties faced in the implementation of SUS, coverage of essential interventions increased and equity has improved dramatically, due in most cases to marked increase in coverage among the poorest 40 %. An increase in unnecessary Caesarean sections was also observed during the period. Further evaluation on the quality of healthcare provided is needed.

Remaining missed opportunities of child survival in Peru: modelling mortality impact of universal and equitable coverage of proven interventions.

BACKGROUND: Peru has made great improvements in reducing stunting and child mortality in the past decade, and has reached the Millennium Development Goals 1 and 4. The remaining challenges or missed opportunities for child survival needs to be identified and quantified, in order to guide the next steps to further improve child survival in Peru. METHODS: We used the Lives Saved Tool (LiST) to project the mortality impact of proven interventions reaching every women and child in need, and the mortality impact of eliminating inequalities in coverage distribution between wealth quintiles and urban-rural residence. RESULTS: Our analyses quantified the remaining missed opportunities in Peru, where prioritizing scale-up of facility-based case management for all small and sick babies will be most effective in mortality reduction, compared to other evidenced-based interventions that prevent maternal and child deaths. Eliminating coverage disparities between the poorest quintiles and the richest will reduce under-five and neonatal mortality by 22.0 and 40.6 %, while eliminating coverage disparities between those living in rural and urban areas will reduce under-five and neonatal mortality by 29.3 and 45.2 %. This projected neonatal mortality reduction achieved by eliminating coverage disparities is almost comparable to that already achieved by Peru over the past decade. CONCLUSIONS: Although Peru has made great strides in improving child survival, further improvement in child health, especially in newborn health can be achieved if there is universal and equitable coverage of proven, quality health facility-based interventions. The magnitude of reduction in mortality will be similar to what has been achieved in the past decade. Strengthening health system to identify, understand, and direct resources to the poor and rural areas will ensure that Peru achieve the Sustainable Development Goals by 2030.

Examining national and district-level trends in neonatal health in Peru through an equity lens: a success story driven by political will and societal advocacy.

BACKGROUND: Peru has impressively reduced its neonatal mortality rate (NMR). We aimed, for the period 2000-2013, to: (a) describe national and district NMR variations over time; (b) assess NMR trends by wealth quintile and place of residence; (c) describe evolution of mortality causes; (d) assess completeness of registered mortality; (e) assess coverage and equity of NMR-related interventions; and (f) explore underlying driving factors. METHODS: We compared national NMR time trends from different sources. To describe NMR trends by wealth quintiles, place of residence and districts, we pooled data on births and deaths by calendar year for neonates born to women interviewed in multiple surveys. We disaggregated coverage of NMR-related interventions by wealth quintiles and place of residence. To identify success factors, we ran regression analyses and combined desk reviews with qualitative interviews and group discussions. RESULTS: NMR fell by 51 % from 2000 to 2013, second only to Brazil in Latin America. Reduction was higher in rural and poorest segments (52 and 58 %). District NMR change varied by source. Regarding cause-specific NMRs, prematurity decreased from 7.0 to 3.2 per 1,000 live births, intra-partum related events from 2.9 to 1.2, congenital abnormalities from 2.4 to 1.8, sepsis from 1.9 to 0.8, pneumonia from 0.9 to 0.4, and other conditions from 1.2 to 0.7. Under-registration of neonatal deaths decreased recently, more in districts with higher development index and lower rural population. Coverage of family planning, antenatal care and skilled birth attendance increased more in rural areas and in the poorest quintile. Regressions did not show consistent associations between mortality and predictors. During the study period social determinants improved substantially, and dramatic out-of-health-sector and health-sector changes occurred. Rural areas and the poorest quintile experienced greater NMR reduction. This progress was driven, within a context of economic growth and poverty reduction, by a combination of strong societal advocacy and political will, which translated into pro-poor implementation of evidence-based interventions with a rights-based approach. CONCLUSIONS: Although progress in Peru for reducing NMR has been remarkable, future challenges include closing remaining gaps for urban and rural populations and improving newborn health with qualified staff and intermediate- and intensive-level health facilities.

The association of maternal age with birthweight and gestational age: a cross-cohort comparison.

BACKGROUND: We examined the associations of maternal age with low birthweight (LBW) and preterm birth in four cohorts from a middle- and a high-income country, where the patterning of maternal age by socio-economic position (SEP) is likely to differ. METHODS: Population-based birth cohort studies were carried out in the city of Pelotas, Brazil in 1982, 1993, and 2004, and in Avon, UK in 1991 [Avon Longitudinal Study of Parents and Children (ALSPAC)]. Adjustment for multiple indicators of SEP were applied. RESULTS: Low SEP was associated with younger age at childbearing in all cohorts, but the magnitudes of these associations were stronger in ALSPAC. Inverse associations of SEP with LBW and preterm birth were observed in all cohorts. U-shaped associations were observed between maternal age and odds of LBW in all cohorts. After adjustment for SEP, increased odds of LBW for young mothers (<20 years) attenuated to the null but remained or increased for older mothers (≥ 35 years). Very young (<16 years) maternal age was also associated with both outcomes even after full SEP adjustment. SEP adjusted odds ratio of having a LBW infant in women <16 years and ≥ 35 years, compared with 25-29 years, were 1.48 [95% confidence interval (CI) 1.00, 2.20] and 1.66 [95% CI 1.36, 2.02], respectively. The corresponding results for preterm birth were 1.80 [95% CI 1.23, 2.64)] and 1.38 [95% CI 1.15, 1.67], respectively. CONCLUSION: Confounding by SEP explains much of the excess risk of LBW and preterm among babies born to teenage mothers as a whole, but not for mothers aged <16 or ≥ 35 years. Given that the proportion of women becoming pregnant at <16 years is smaller than for those ≥ 35 years, the population burden is greater for older age.

Time trends in socio-economic inequalities in stunting prevalence: analyses of repeated national surveys.

OBJECTIVE: Much is known about national trends in child undernutrition, but there is little information on how socio-economic inequalities are evolving over time. We aimed to assess socio-economic inequalities in stunting prevalence over time. DESIGN: We selected nationally representative surveys carried out since the mid-1990s for which information was available on asset indices and on child anthropometry. We identified twenty-five countries that had at least two surveys over an interval of 10 years or more, totalling eighty-seven surveys. Stunting prevalence was calculated according to wealth quintiles. Absolute and relative inequalities were calculated and time trends were obtained by regression. Setting Nationally representative household surveys from twenty-five low- and middle-income countries. SUBJECTS: Children <5 years of age. RESULTS: National prevalence declined significantly in twenty-two of the twenty-five countries. In eighteen out of twenty-five countries, relative reductions were higher among the rich than among the poor. Overall, there was no indication that inequalities improved. Striking examples are Nepal, with a 17·0 percentage points decline in stunting per decade, but where inequalities increased sharply; and Brazil, where stunting fell by 6·7 percentage points and inequalities were all but eliminated. CONCLUSIONS: Global progress in reducing stunting has not been accompanied by improved equity, but countries varied markedly in how successful they were in reducing prevalence among the poorest children. It is important to document how some countries were able to reduce inequalities, so that these lessons can be used to foster global progress, particularly in light of the increased importance of within-country inequalities in the post-2015 agenda.

Progress in reducing inequalities in reproductive, maternal, newborn,' and child health in Latin America and the Caribbean: an unfinished agenda.

OBJECTIVE: To expand the "Countdown to 2015" analyses of health inequalities beyond the 75 countries being monitored worldwide to include all countries in Latin America and the Caribbean (LAC) that have adequate data available. METHODS: Demographic and Health Surveys and Multiple Indicator Cluster Surveys were used to monitor progress in health intervention coverage and inequalities in 13 LAC countries, five of which are included in the Countdown (Bolivia, Brazil, Guatemala, Haiti, and Peru) and eight that are not (Belize, Colombia, Costa Rica, Dominican Republic, Guyana, Honduras, Nicaragua, and Suriname). The outcomes included neonatal and under-5 year mortality rates, child stunting prevalence, and the composite coverage index-a weighted average of eight indicators of coverage in reproductive, maternal, newborn, and child health. The slope index of inequality and concentration index were used to assess absolute and relative inequalities. RESULTS: The composite coverage index showed monotonic patterns over wealth quintiles, with lowest levels in the poorest quintile. Under-5 and neonatal mortality as well as stunting prevalence were highest among the poor. In most countries, intervention coverage increased, while under-5 mortality and stunting prevalence fell most rapidly among the poor, so that inequalities were reduced over time. However, Bolivia, Guatemala, Haiti, Nicaragua, and Peru still show marked inequalities. Brazil has practically eliminated inequalities in stunting. CONCLUSIONS: LAC countries presented substantial progress in terms of reducing inequalities in reproductive, maternal, newborn, and child health interventions, child mortality, and nutrition. However, the poorest 20% of the population in most countries is still lagging behind, and renewed actions are needed to improve equity.

Real-World Evidence to Support EU Regulatory Decision Making-Results From a Pilot of Regulatory Use Cases.

Studies using real-world data (RWD) can complement evidence from clinical trials and fill evidence gaps during different stages of a medicine's lifecycle. This review presents the experience resulting from the European Medicines Agency (EMA) pilot to generate RWE to support evaluations by EU regulators and down-stream decision makers from September 2021 to February 2023. A total of 61 research topics were identified for RWE generation during this period, covering a wide range of research questions, primarily generating evidence on medicines safety (22, 36%), followed by questions on the design and feasibility of clinical trials (11, 18%), drug utilization (10, 16%), clinical management (10, 16%), and disease epidemiology. A significant number of questions were related to the pediatric population and/or rare diseases. A total of 27 regulatory-led RWD studies have been conducted. Most studies were descriptive and aimed at estimating incidence and prevalence rates of clinical outcomes including adverse events or to evaluate medicines utilization. The review highlights key learnings to guide further efforts to enable the use and establish the value of real-world evidence (RWE) for regulatory decisions. For instance, there is a need to access additional fit-for-purpose and representative data, and to explore further means to provide timely evidence that meets regulatory timelines. The need for early interactions and close collaboration with study requesters, e.g., from the Agency's scientific Committees, to better understand the research question is equally important. Finally, the review provides our perspective on the way forward to maximize the potential of regulatory-led RWE generation.

Scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues.

BACKGROUND: Maternal nutrition interventions are efficacious in improving birth outcomes. It is important to demonstrate that if delivered in field conditions they produce improvements in health and nutrition. OBJECTIVE: Analyses of scaling-up of five program implemented in several countries. These include micronutrient supplementation, food fortification, food supplements, nutrition education and counseling, and conditional cash transfers (as a platform for delivering interventions). Evidence on impact and cost-effectiveness is assessed, especially on achieving high, equitable, and sustained coverage, and reasons for success or failure METHODS: Systematic review of articles on large-scale programs in several databases. Two separate reviewers carried out independent searches. A separate review of the gray literature was carried out including websites of the most important organizations leading with these programs. With Google Scholar a detailed review of the 100 most frequently cited references on each of the five above topics was conducted. RESULTS: Food fortification programs: iron and folic acid fortification were less successful than salt iodization initiatives, as the latter attracted more advocacy. Micronutrient supplementation programs: Nicaragua and Nepal achieved good coverage. Key elements of success are antenatal care coverage, ensuring availability of tablets, and improving compliance. Integrated nutrition programs in India, Bangladesh, and Madagascar with food supplementation and/or behavioral change interventions report improved coverage and behaviors, but achievements are below targets. The Mexican conditional cash transfer program provides a good example of use of this platform to deliver maternal nutritional interventions. CONCLUSIONS: Programs differ in complexity, and key elements for success vary with the type of program and the context in which they operate. Special attention must be given to equity, as even with improved overall coverage and impact inequalities may even be increased. Finally, much greater investments are needed in independent monitoring and evaluation.

The role of individual, household, and area of residence factors on self-rated health in Colombian adults: A multilevel study. / Efecto de las condiciones individuales, del hogar y del área de residencia en la autopercepción de su salud en adultos colombianos: un estudio multinivel

INTRODUCTION: Self-rated health is strongly associated with morbidity and mortality. It is largely influenced by individual factors but also by individuals' social surroundings and environment. OBJECTIVE: To investigate individual, household, and locality factors associated with self-rated ealth in Colombian adults. MATERIALS AND METHODS: We conducted a cross-sectional multilevel study using data from national databases on 19 urban localities and 37,352 individuals nested within 15,788 households using a population-based survey. Given the natural hierarchical structure of the data, the estimates of self-rated health related to individual, household, and locality characteristics were obtained by fitting a three-level logistic regression. RESULTS: The adjusted multilevel logistic models showed that at individual level, higher odds of poor self-rated health were found among older adults, persons from low socio-economic status, those living without a partner, with no regular physical activity, and reporting morbidities. At the household level, poor self-rated health was associated with households of low socioeconomic status located near noise sources and factories and in polluted and insecure areas. At the locality level, only poverty was associated with poor self-rated health after adjusting for individual and household variables. CONCLUSIONS: These results highlight the need for a more integrated framework when designing and implementing strategies and programs that aim to improve health conditions in urban populations in Latin America.

Introducción. La autopercepción de la salud se asocia con la morbilidad y la mortalidad debido principalmente al efecto de las condiciones individuales y las características sociales y del ambiente en el que viven las personas. Objetivo. Investigar los factores individuales, del hogar y de la localidad asociados con la autopercepción de la salud en adultos colombianos. Materiales y métodos. Se llevó a cabo un estudio transversal. La información sobre las 19 localidades urbanas consideradas se obtuvo de bases de datos nacionales, en tanto que los datos sobre los 37.352 individuos anidados en 15.788 hogares provinieron de una encuesta de base poblacional. Dada la estructura jerárquica de los datos, las estimaciones del efecto de las variables individuales, del hogar y de la localidad sobre la autopercepción de la salud se hicieron utilizando un modelo de regresión logística de tres niveles. Resultados. Los modelos multinivel ajustados evidenciaron que a nivel individual había una mayor probabilidad de tener una peor percepción de la salud entre adultos mayores, personas de bajo nivel socioeconómico, sin compañero, físicamente inactivos y con enfermedades. A nivel de hogar, la peor percepción de la salud se asoció con la pertenencia a familias de bajo nivel socioeconómico, residentes cerca de fábricas, áreas contaminadas, inseguras y de alto ruido. Por último, a nivel de localidad y después del ajuste por variables individuales y del hogar, la residencia en localidades pobres aumentó la probabilidad de tener una peor percepción de la propia salud. Conclusiones. Los resultados evidencian la necesidad de considerar un marco conceptual más amplio en el momento de diseñar e implementar estrategias y programas que apunten al mejoramiento de las condiciones de salud de las poblaciones urbanas en Latinoamérica.

Sistema de Monitoreo a la equidad territorial y avances en los Objetivos de Desarrollo Sostenible en Colombia

Aunque el cumplimiento de los Objetivos de Desarrollo del Milenio tuvo un balance positivo, con promedios nacionales que en general mejoraron, las desigualdades dentro de los países aumentaron. La agenda de los Objetivos de Desarrollo Sostenible (ODS) busca promover avances en términos de equidad territorial, por esto la incorporación del espacio geográfico en su monitoreo a escalas subnacionales ofrece ventajas importantes. Este artículo tuvo como objetivo describir el Sistema de Monitoreo Territorial a los ODS3 (MOT-ODS3), una herramienta digital diseñada para incrementar la disponibilidad de información a nivel municipal sobre las desigualdades e inequidades territoriales relacionadas con la salud y el bienestar en Colombia. Para demostrar su funcionalidad se describen los componentes del Sistema, indicadores, mapas, gráficos y métricas de desigualdad utilizados, así como también los perfiles de país y departamento, diseñados para reportar los resultados del monitoreo. Como ejemplo práctico de la utilización del Sistema se analizan los indicadores de Colombia entre 2015 y 2017. Según el monitoreo, Colombia mostró mejoras en la salud y el bienestar de la población; sin embargo, se apreciaron diferencias notables intermunicipales en casi todos los indicadores y brechas territoriales en la mortalidad entre municipios ricos y pobres y entre la zona rural y la urbana. Puede decirse que el MOT-ODS3 incrementó la disponibilidad de información para estimular y apoyar el avance del país hacia el logro de los Objetivos de Desarrollo Sostenible.

Although compliance with the Millennium Development Goals had a positive balance, with national averages that generally improved, inequalities within countries increased. The Sustainable Development Goals (SDGs) agenda seeks to promote progress in terms of territorial equity, which is why the incorporation of geographic space in its monitoring at subnational scales offers important advantages. This article aimed to describe the Territorial Monitoring System for the SDGs3 (MOT-ODS3), a digital tool designed to increase the availability of information at the municipal level on territorial inequalities and inequities related to health and well-being in Colombia. To demonstrate its functionality, the components of the System, indicators, maps, graphs and inequality metrics used are described, as well as the country and departmental profiles designed to report monitoring results. As a practical example of the use of the System, the indicators for Colombia between 2015 and 2017 are analyzed. According to the monitoring, Colombia showed improvements in the health and well-being of the population; however, notable inter-municipal differences were seen in almost all indicators and territorial gaps in mortality between rich and poor municipalities and between rural and urban areas. It can be said that the MOT-ODS3 increased the availability of information to stimulate and support the country's progress towards the achievement of the Sustainable Development Goals.

Measurement of social inequalities in health: concepts and methodological approaches in the Brazilian context. / Mensuração de desigualdades sociais em saúde: conceitos e abordagens metodológicas no contexto brasileiro.

This study aims to describe methodological approaches to measure and monitor health inequalities and to illustrate their applicability. The measures most frequently used in the literature were reviewed. Data on coverage and quality of pre-natal care in Brazil, from the Demographic and Maternal and Child Health Survey (PNDS-2006) and the National Health Survey (PNS-2013) were used to illustrate their applicability. Absolute and relative measures of inequalities were presented, highlighting their complementary character. Despite the progress achieved in the national indicators of pre-natal care, important inequalities were still identified between population subgroups, with no change in the magnitude of the differences throughout the studied period. Brazil has important social inequalities, whose consequences still lead to health inequalities. Their description and monitoring are highly relevant to support polices focused on those vulnerable population groups who have been left behind.

O objetivo deste artigo é apresentar os principais métodos de mensuração e monitoramento das desigualdades sociais em saúde e ilustrar suas aplicações. Foram revisadas as medidas mais frequentemente empregadas na literatura. Dados de cobertura e qualidade do cuidado pré-natal no Brasil, provenientes da Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS-2006) e da Pesquisa Nacional de Saúde (PNS-2013), foram utilizados para exemplificar as aplicações. Medidas de desigualdade absoluta e relativa foram apresentadas, destacando-se sua complementaridade. Apesar dos avanços evidenciados nos indicadores nacionais de pré-natal, importantes desigualdades foram identificadas entre subgrupos da população, sem que houvesse redução da magnitude dessas diferenças no período estudado. O Brasil apresenta importantes desigualdades sociais, que ainda se refletem em persistentes desigualdades em saúde. A descrição e monitoramento dessas desigualdades são fundamentais para o direcionamento de políticas de saúde, com foco em grupos mais vulneráveis que vêm sendo deixados para trás.

El objetivo de este artículo es presentar los principales métodos de medición y monitoreo de las desigualdades sociales en salud, y demostrar sus aplicaciones prácticas. Se realizó una revisión de los métodos más frecuentemente utilizados en la literatura. Datos sobre cobertura y calidad de la atención prenatal en Brasil, provenientes de la Encuesta Nacional de Demografía y Salud del Niño y la Mujer (PNDS-2006) y de la Encuesta Nacional de Salud (PNS-2013) fueran usados como ejemplo. Fueron presentadas medidas de desigualdad absoluta y relativa, destacando su complementariedad. A pesar de los avances evidenciados en los indicadores de atención prenatal en Brasil, fueron identificadas desigualdades importantes, sin que hubiese una reducción de la magnitud de esas diferencias en el periodo estudiado. Brasil presenta desigualdades sociales importantes, que aún se ven reflejadas en las persistentes desigualdades en salud. Su descripción y seguimiento son fundamentales para el direccionamiento de políticas en salud, focalizadas en grupos más vulnerables que han sido relegados.

Growth across life course and cardiovascular risk markers in 18-year-old adolescents: the 1993 Pelotas birth cohort.

OBJECTIVE: To evaluate the association between growth trajectories from birth to adolescence and cardiovascular risk marker levels at age 18 years in a population-based cohort. In order to disentangle the effect of weight gain from that of height gain, growth was analysed using conditional weight relative to linear growth (CWh) and conditional length/height (CH). DESIGN: Prospective study. SETTING: 1993 Pelotas birth cohort, Southern Brazil. PARTICIPANTS: Individuals who have been followed up from birth to adolescence (at birth, 1, 4, 11, 15 and 18 years). PRIMARY OUTCOME MEASURES: C-reactive protein (CRP), total cholesterol (TC), LDL cholesterol (LDL-C), HDL-cholesterol (HDL-C), triglycerides (TGL), systolic and diastolic blood pressure (SBP and DBP), body mass index (BMI) and waist circumference (WC). RESULTS: In both sexes, greater CWh at 1 year was positively associated with BMI and WC, whereas greater CWh at most age periods in childhood and adolescence predicted higher CRP, TC, LDL-C, TGL, SBP, DBP, BMI and WC levels, as well as lower HDL-C level. Higher CH during infancy and childhood was positively related with SBP in boys and girls, and with BMI and WC only in boys. CONCLUSION: Our study shows that rapid weight gain from 1 year onwards is positively associated with several markers of cardiovascular risk at 18 years. Overall, our results for the first year of life add evidence to the 'first 1000 days initiative' suggesting that prevention of excessive weight gain in childhood might be important in reducing subsequent cardiovascular risk.

Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries.

BACKGROUND: Latin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions. METHODS: We analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15-49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12-23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), woman's education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression. FINDINGS: Ethnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66-0·92), antenatal care (0·86, 0·75-0·94), and skilled birth attendants (0·75, 0·68-0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries. INTERPRETATION: The lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level-such as vaccines-show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes. FUNDING: The Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.

Prevalence of erectile dysfunction oral drugs use in a city of southern Brazil.

The last decade has seen a breakthrough in the treatment of erectile dysfunction (ED) with the advent of phosphodiesterase-5 inhibitors. There are few population-based observational studies on the prevalence of use of these drugs. We conducted a cross-sectional population-based study in the city of Pelotas (Brazil). Our sample comprised 1,082 men aged 20 years or older who answered a confidential and self-administered questionnaire. Prevalence of EDD use was 5% (IC95% = 4%;7%). ED and advanced age were strongly associated with a higher prevalence of EDD use. ED prevalence in men who used EDD was 68%, which was much higher than the one found in the entire sample (27%). The use of EDD was more frequently reported among separated men, respondents with higher level of education and those without ED. A high proportion of respondents (68%) did not seek medical advice on the use of EDD. Sildenafil was the most commonly used drug (38%) but non-regulated and non-evidence-based drugs were also frequently used (14%). Prevalence of EDD use is higher among individuals with ED, opposing to the notion of recreational use of EDD.

Socioeconomic inequalities in skilled birth attendance and child stunting in selected low and middle income countries: Wealth quintiles or deciles?

BACKGROUND: Wealth quintiles derived from household asset indices are routinely used for measuring socioeconomic inequalities in the health of women and children in low and middle-income countries. We explore whether the use of wealth deciles rather than quintiles may be advantageous. METHODS: We selected 46 countries with available national surveys carried out between 2003 and 2013 and with a sample size of at least 3000 children. The outcomes were prevalence of under-five stunting and delivery by a skilled birth attendant (SBA). Differences and ratios between extreme groups for deciles (D1 and D10) and quintiles (Q1 and Q5) were calculated, as well as two summary measures: the slope index of inequality (SII) and concentration index (CIX). RESULTS: In virtually all countries, stunting prevalence was highest among the poor, and there were larger differences between D1 and D10 than between Q1 and Q5. SBA coverage showed pro-rich patterns in all countries; in four countries the gap was greater than 80 pct points. With one exception, differences between extreme deciles were larger than between quintiles. Similar patterns emerged when using ratios instead of differences. The two summary measures provide very similar results for quintiles and deciles. Patterns of top or bottom inequality varied with national coverage levels. CONCLUSION: Researchers and policymakers should consider breakdowns by wealth deciles, when sample sizes allow. Use of deciles may contribute to advocacy efforts, monitoring inequalities over time, and targeting health interventions. Summary indices of inequalities were unaffected by the use of quintiles or deciles in their calculation.