Educational inequalities and premature mortality: the Cuba Prospective Study.

BACKGROUND: Although socioeconomic status is a major determinant of premature mortality in many populations, the impact of social inequalities on premature mortality in Cuba, a country with universal education and health care, remains unclear. We aimed to assess the association between educational level and premature adult mortality in Cuba. METHODS: The Cuba Prospective Study (a cohort study) enrolled 146 556 adults aged 30 years and older from the general population in five provinces from Jan 1, 1996, to Nov 24, 2002. Participants were followed up until Jan 1, 2017, for cause-specific mortality. Deaths were identified through linkage to the Cuban Public Health Ministry's national mortality records. Cox regression models yielded rate ratios (RRs) for the effect of educational level (a commonly used measure for social status) on mortality at ages 35-74 years, with assessment for the mediating effects of smoking, alcohol consumption, and BMI. FINDINGS: A total of 127 273 participants aged 35-74 years were included in the analyses. There was a strong inverse association between educational level and premature mortality. Compared with a university education, men who did not complete primary education had an approximately 60% higher risk of premature mortality (RR 1·55, 95% CI 1·40-1·72), while the risk was approximately doubled in women (1·96, 1·81-2·13). Overall, 28% of premature deaths could be attributed to lower education levels. Excess mortality in women was primarily due to vascular disease, while vascular disease and cancer were equally important in men. 31% of the association with education in men and 18% in women could be explained by common modifiable risk factors, with smoking having the largest effect. INTERPRETATION: This study highlights the value of understanding the determinants of health inequalities in different populations. Although many major determinants lie outside the health system in Cuba, this study has identified the diseases and risk factors that require targeted public health interventions, particularly smoking. FUNDING: UK Medical Research Council, British Heart Foundation, Cancer Research UK, CDC Foundation (with support from Amgen).

Alcohol consumption and cause-specific mortality in Cuba: prospective study of 120 623 adults.

BACKGROUND: The associations of cause-specific mortality with alcohol consumption have been studied mainly in higher-income countries. We relate alcohol consumption to mortality in Cuba. METHODS: In 1996-2002, 146 556 adults were recruited into a prospective study from the general population in five areas of Cuba. Participants were interviewed, measured and followed up by electronic linkage to national death registries until January 1, 2017. After excluding all with missing data or chronic disease at recruitment, Cox regression (adjusted for age, sex, province, education, and smoking) was used to relate mortality rate ratios (RRs) at ages 35-79 years to alcohol consumption. RRs were corrected for long-term variability in alcohol consumption using repeat measures among 20 593 participants resurveyed in 2006-08. FINDINGS: After exclusions, there were 120 623 participants aged 35-79 years (mean age 52 [SD 12]; 67 694 [56%] women). At recruitment, 22 670 (43%) men and 9490 (14%) women were current alcohol drinkers, with 15 433 (29%) men and 3054 (5%) women drinking at least weekly; most alcohol consumption was from rum. All-cause mortality was positively and continuously associated with weekly alcohol consumption: each additional 35cl bottle of rum per week (110g of pure alcohol) was associated with ∼10% higher risk of all-cause mortality (RR 1.08 [95%CI 1.05-1.11]). The major causes of excess mortality in weekly drinkers were cancer, vascular disease, and external causes. Non-drinkers had ∼10% higher risk (RR 1.11 [1.09-1.14]) of all-cause mortality than those in the lowest category of weekly alcohol consumption (<1 bottle/week), but this association was almost completely attenuated on exclusion of early follow-up. INTERPRETATION: In this large prospective study in Cuba, weekly alcohol consumption was continuously related to premature mortality. Reverse causality is likely to account for much of the apparent excess risk among non-drinkers. The findings support limits to alcohol consumption that are lower than present recommendations in Cuba. FUNDING: Medical Research Council, British Heart Foundation, Cancer Research UK, CDC Foundation (with support from Amgen).

Burden of hypertension and associated risks for cardiovascular mortality in Cuba: a prospective cohort study.

BACKGROUND: In Cuba, hypertension control in primary care has been prioritised as a cost-effective means of addressing premature death from cardiovascular disease. However, there is little evidence from large-scale studies on the prevalence and management of hypertension in Cuba, and no direct evidence of the expected benefit of such efforts on cardiovascular mortality. METHODS: In a prospective cohort study, adults in the general population identified via local family medical practices were interviewed between Jan 1, 1996, and Nov 24, 2002, in five areas of Cuba, and a subset of participants were resurveyed between July 14, 2006, and Oct 19, 2008, in one area. During household visits, blood pressure was measured and information obtained on diagnosis and treatment of hypertension. We calculated the prevalence of hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, or receiving treatment for hypertension) and the proportion of people with hypertension in whom it was diagnosed, treated, and controlled (systolic blood pressure <140 mm Hg, diastolic blood pressure <90 mm Hg). Deaths were identified through linkage by national identification numbers to the Cuban Public Health Ministry records, to Dec 31, 2016. We used Cox regression analysis to compare cardiovascular mortality between participants with versus without uncontrolled hypertension. Rate ratios (RRs) were used to estimate the fraction of cardiovascular deaths attributable to hypertension. FINDINGS: 146 556 participants were interviewed in the baseline survey in 1996-2002 and 24 345 were interviewed in the resurvey in 2006-08. After exclusion for incomplete data and age outside the range of interest, 136 111 respondents aged 35-79 years (mean age 54 [SD 12] years; 75 947 [56%] women, 60 164 [44%] men) were eligible for inclusion in the analyses. 34% of participants had hypertension. Among these, 67% had a diagnosis of hypertension. 76% of participants with diagnosed hypertension were receiving treatment and blood pressure was controlled in 36% of those people. During 1·7 million person-years of follow-up there were 5707 cardiovascular deaths. In the age groups 35-59, 60-69, and 70-79 years, uncontrolled hypertension at baseline was associated with RRs of 2·15 (95% CI 1·88-2·46), 1·86 (1·69-2·05), and 1·41 (1·32-1·52), respectively, and accounted for around 20% of premature cardiovascular deaths. INTERPRETATION: In this Cuban population, a third of people had hypertension. Although levels of hypertension diagnosis and treatment were commensurate with those in some high-income countries, the proportion of participants whose blood pressure was controlled was low. As well as reducing hypertension prevalence, improvement in blood pressure control among people with diagnosed hypertension is required to prevent premature cardiovascular deaths in Cuba. FUNDING: Medical Research Council, British Heart Foundation, Cancer Research UK.

Calidad de las estadísticas de mortalidad materna en Cuba, 2013

[RESUMEN]. Objetivos. Evaluar el grado de integridad del registro estadístico cubano de muertes maternas y la calidad de la clasificación de las causas de muerte recogidas en ese registro. Métodos. Se analizó la información de todas las cubanas fallecidas en edad fértil en el año 2013 según el registro continuo de mortalidad de la Dirección de Registros Médicos y Estadísticas de Salud del Ministerio de Salud Pública de Cuba (MINSAP), independientemente de la causa básica de muerte consignada. Cuatro grupos de investigación (nacional, de expertos, provincial y de unidades de salud), con funciones definidas, aplicaron cuatro formularios para determinar si hubo embarazo en el año previo a la defunción, reevaluar si los casos correspondían a una muerte materna y, en ese caso, revisar la clasificación. Resultados. Se investigaron las 2 731 mujeres fallecidas en edad reproductiva notificadas en Cuba en el 2013; de ellas las causas de muerte de 2 711 (99,3%) resultaron concluyentes y, de estas, 97 (3,6%) habían tenido un embarazo en el año previo a la defunción. Se encontraron 50 muertes maternas (una más que en el registro continuo) para 2% de error y un factor de ajuste de 1,02. De las 97 muertes estudiadas, solo se reclasificaron 4 casos: 2 muertes maternas y 1 muerte relacionada con el embarazo, el parto y el puerperio, según el registro continuo, que se reclasificaron como muertes directas, y 1 muerte considerada no materna por el registro continuo que se reclasificó como muerte materna tardía, para una concordancia de 95,9%. Conclusiones. La información sobre las muertes maternas recogida en el registro continuo de mortalidad del MINSAP tiene un alto nivel de integridad. La calidad de la clasificación de las muertes maternas en ese registro es elevada, al existir muy pocos cambios en la reclasificación de las causas de muerte.

[ABSTRACT]. Objective. Evaluate the degree of integrity of the Cuban statistical registry of maternal deaths and the quality of the classification of the causes of death included in that registry. Methods. We analyzed the information of all Cuban women who died in fertile age in 2013 according to the continuous mortality registry of the Directorate of Medical Records and Health Statistics of the Ministry of Public Health of Cuba (MINSAP), regardless of the main cause of death informed. Four research groups (national, expert, provincial and health units), each with defined functions, applied four forms to establish if the women had been pregnant in the year prior to death, to reassess whether the cases corresponded to a maternal death and, in that case, to review the classification. Results. Deaths of 2 731 women of reproductive age notified in Cuba in 2013 were assessed. Of them, the cause of death of 2 711 (99.3%) was conclusive and, of these, 97 (3.6%) had had a pregnancy in the year prior to death. We found 50 maternal deaths (one more than in the continuous registry) for a 2% error and an adjustment factor of 1.02. Of the 97 deaths studied, only 4 cases were reclassified: 2 maternal deaths and 1 death related to pregnancy, delivery and puerperium, according to the continuous registry, which were reclassified as direct deaths; and 1 death considered non-maternal by the continuous registry that was reclassified as late maternal death, for a 95.9% concordance. Conclusions. The information on maternal deaths included in the MINSAP’s continuous mortality registry has a high level of integrity. The quality of the classification of maternal deaths in this registry is high; reclassification of causes of death is uncommon.

[RESUMO]. Objetivos. Avaliar o grau de integridade do registro estatístico cubano de óbitos maternos e a qualidade da classificação das causas de óbito incluídas nesse registro. Métodos. Analisamos a informação de todas as mulheres cubanas que morreram em idade fértil em 2013 de acordo com o histórico de mortalidade contínua da Diretoria de Registros Médicos e Estatísticas de Saúde do Ministério da Saúde Pública de Cuba (MINSAP), independentemente da causa básica da morte consignada. Quatro grupos de pesquisa (nacional, especialistas, provincial e unidades de saúde), com funções definidas, aplicaram quatro formas para determinar se houve gravidez no ano anterior à morte, reavaliam se os casos corresponderam a uma morte materna e, em nesse caso, rever a classificação. Resultados. Foram investigadas as 2 731 mulheres falecidas de idade reprodutiva notificadas em Cuba em 2013, das quais as causas de morte de 2 711 (99,3%) foram conclusivas e, destas, 97 (3,6%) tiveram gravidez no ano anterior à morte. Encontramos 50 mortes maternas (uma mais do que no registro contínuo) por erro de 2% e um fator de ajuste de 1,02. Das 97 mortes estudadas, apenas 4 casos foram reclassificados: 2 mortes maternas e 1 morte relacionada à gravidez, parto e puerpério, de acordo com o registro contínuo, que foram reclassificadas como mortes diretas, e 1 morte considerada não materna pelo registro contínuo que foi reclassificada como morte materna tardia, para uma concordância de 95,9%. Conclusões. A informação sobre mortes maternas incluída no registro de mortalidade contínua do MINSAP tem alto nível de integridade. A qualidade da classificação das mortes maternas neste registro é alta; a reclassificação das causas de morte é pouco frequente.

Consideraciones socioéticas sobre el ingreso domiciliario en el sistema de salud cubano durante el 2007 / Social and ethical considerations on the home care in the Cuban health system during the 2007

Se realizó un estudio descriptivo, longitudinal y retrospectivo sobre el ingreso domiciliario en la provincia de Santiago de Cuba durante el 2007 para emitir algunas consideraciones sobre el procedimiento médico-asistencial en el período 1998-2006 y ofrecer elementos cuantitativos y cualitativos del 2007. Se concluyó que en el sistema de atención primaria de salud se han logrado impactos socioéticos, culturales y económicos positivos, tales como: servicio gratuito, oferta y control de los recursos, así como cercanía del equipo de trabajo al paciente, la familia y la comunidad, entre otros grandes beneficios. Se recomienda perfeccionar el proceso para el ingreso domiciliario, sobre la base de la enseñanza y aplicación de principios bioéticos desde las universidades médicas en su etapa de pregrado.

A descriptive, longitudinal and retrospective study on the home care was carried out in Santiago de Cuba city during 2007 to give some considerations on the medical care procedure in the period 1998-2006 and to offer quantitative and qualitative elements of 2007. It was concluded that in the health primary care system positive social, ethical, cultural and economic impacts have been achieved, such as: free service, supply and control of resources, as well as proximity of the work team to the patient, the family and the community, among other great benefits. It is recommended to improve the process for the home care, on the basis of teaching and applying bioethical principles from the medical universities in their pre-degree stage.

Consideraciones socioéticas sobre el ingreso domiciliario en el sistema de salud cubano durante el 2007 / Social and ethical considerations on the home care in the Cuban health system during the 2007

Se realizó un estudio descriptivo, longitudinal y retrospectivo sobre el ingreso domiciliario en la provincia de Santiago de Cuba durante el 2007 para emitir algunas consideraciones sobre el procedimiento médico-asistencial en el período 1998-2006 y ofrecer elementos cuantitativos y cualitativos del 2007. Se concluyó que en el sistema de atención primaria de salud se han logrado impactos socioéticos, culturales y económicos positivos, tales como: servicio gratuito, oferta y control de los recursos, así como cercanía del equipo de trabajo al paciente, la familia y la comunidad, entre otros grandes beneficios. Se recomienda perfeccionar el proceso para el ingreso domiciliario, sobre la base de la enseñanza y aplicación de principios bioéticos desde las universidades médicas en su etapa de pregrado(AU)

A descriptive, longitudinal and retrospective study on the home care was carried out in Santiago de Cuba city during 2007 to give some considerations on the medical care procedure in the period 1998-2006 and to offer quantitative and qualitative elements of 2007. It was concluded that in the health primary care system positive social, ethical, cultural and economic impacts have been achieved, such as: free service, supply and control of resources, as well as proximity of the work team to the patient, the family and the community, among other great benefits. It is recommended to improve the process for the home care, on the basis of teaching and applying bioethical principles from the medical universities in their pre-degree stage(AU)

Influencia del medio familiar en un grupo de 5 a 19 años con riesgo suicida / Influence of the family environment on a group of persons between 5 and 19 years old with suicide risk

Se realizó un estudio descriptivo, prospectivo y transversal, en el que se comparó el medio familiar de pacientes dispensarizados como riesgo suicida, con el de otro grupo de similares características no controlados por esta causa, pertenecientes al área de salud del Policlínico "Carlos J. Finlay" de Santiago de Cuba, que abarcó los meses de junio a diciembre de 1997. En los 44 pacientes de riesgo encuestados se comprobó predominio del sexo femenino y de las edades entre 15 y 19 años; el mayor número había sido dispensarizado como de riesgo por antecedente de intento suicida, embarazo precoz y anuncio del suicidio. Entre los antecedentes patológicos personales en la esfera psiquiátrica prevalecieron los trastornos distímicos y las alteraciones incipientes de la personalidad de tipo desinhibido; en tanto que los antecedentes patológicos familiares de riesgo e intento suicida resultaron ser más frecuentes en el grupo de estudio que en el control. La disfuncionalidad familiar y la ausencia de ambos padres fueron factores asociados al riesgo suicida. Prevalecieron las ideas suicidas, la impulsividad y los trastornos afectivos como manifestaciones psicopatológicas (AU)