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1.
Int J Equity Health ; 19(1): 53, 2020 Apr 09.
Artículo en Inglés | MEDLINE | ID: mdl-32272935

RESUMEN

BACKGROUND: Although the prevalence of child stunting is falling in Latin America, socioeconomic inequalities persist. However, there is limited evidence on ethnic disparities. We aimed to describe ethnic inequalities of stunting and feeding practices in thirteen Latin American countries using recent nationally representative surveys. METHODS: We analyzed national surveys carried out since 2006. Based on self-reported ethnicity, skin color or language, children were classified into three categories: indigenous/ afrodescendant/reference group (European or mixed ancestry). Stunting was defined as height (length)-for-age < - 2 standard deviations relative to WHO standards. Family wealth was assessed through household asset indices. We compared mean length/height-for-age and prevalence of stunting among the three ethnic groups. RESULTS: Thirteen surveys had information on indigenous and seven on afrodescendants. In all countries, the average length/height-for-age was significantly lower for indigenous, and in eleven countries there were significant differences in the prevalence of stunting: the pooled crude stunting prevalence ratio between indigenous and the reference group was 1.97 (95% CI 1.89; 2.05); after adjustment for wealth and place of residence, prevalence remained higher among indigenous (PR = 1.34, 95% CI 1.28; 1.39) in eight countries. Indigenous aged 6-23 months were more likely to be breastfed, but with poor complementary feeding, particularly in terms of dietary diversity. Afrodescendants showed few differences in height, and in two countries tended to be taller compared to the reference group. CONCLUSIONS: In all Latin American countries studied, indigenous tended to be shorter and afrodescendants presented few differences with relation to the reference group. In order to reach the SDG's challenge of leaving no one behind, indigenous need to be prioritized.

2.
Reprod Health ; 17(1): 55, 2020 Apr 19.
Artículo en Inglés | MEDLINE | ID: mdl-32306969

RESUMEN

BACKGROUND: The Sustainable Development Goals (SDGs) include specific targets for family planning (SDG 3.7) and birth attendance (SDG 3.1.2), and require analyses disaggregated by age and other dimensions of inequality (SDG 17.18). We aimed to describe coverage with demand for family planning satisfied with modern methods (DFPSm) and institutional delivery in low- and middle-income countries across the reproductive age spectrum. We attempted to identify a typology of patterns of coverage by age and compare their distribution according to geographic regions, World Bank income groups and intervention coverage levels. METHODS: We used Demographic and Health Survey and Multiple Indicator Cluster Surveys. For DFPSm, we considered the woman's age at the time of the survey, whereas for institutional delivery we considered the woman's age at birth of the child. Both age variables were categorized into seven groups of 5 year-intervals, 15-19 up to 45-49. Five distinct patterns were identified: (a) increasing coverage with age; (b) similar coverage in all age groups; (c) U-shaped; (d) inverse U-shaped; and (e) declining coverage with age. The frequency of the five patterns was examined according to UNICEF regions, World Bank income groups, and coverage at national level of the given indicator. RESULTS: We analyzed 91 countries. For DFPSm, the most frequent age patterns were inverse U-shaped (53%, 47 countries) and increasing coverage with age (41%, 36 countries). Inverse-U shaped patterns for DFPSm was the commonest pattern among lower-middle income countries, while low- and upper middle-income countries showed a more balanced distribution between increasing with age and U-shaped patterns. In the first and second tertiles of national coverage of DFPSm, inverse U-shaped was observed in more than half of countries. For institutional delivery, declining coverage with age was the prevailing pattern (44%, 39 countries), followed by similar coverage across age groups (39%, 35 countries). Most (79%) upper-middle income countries showed no variation by age group while most low-income countries showed declining coverage with age (71%). CONCLUSION: Large inequalities in DFPSm and institutional delivery were identified by age, varying from one intervention to the other. Policy and programmatic approaches must be tailored to national patterns, and in most cases older women and adolescents will require special attention due to lower coverage and because they are at higher risk for maternal mortality and other poor obstetrical outcomes.

3.
Am J Clin Nutr ; 2020 Apr 02.
Artículo en Inglés | MEDLINE | ID: mdl-32239193

RESUMEN

BACKGROUND: Growth faltering in the first 1000 d is associated with lower human capital among adults. The existence of a second window of opportunity for nutritional interventions during adolescence has been postulated. OBJECTIVES: We aimed to verify the associations between growth from birth to 18 y and intelligence and schooling in a cohort. METHODS: A total of 5249 hospital-born infants in Pelotas, Brazil, were enrolled during 1993. Follow-up visits to random subsamples took place at 6, 12, and 48 mo and to the full cohort at 11, 15, and 18 y. Weight and length/height were collected in all visits. The Wechsler Adult Intelligence Scale was applied at age 18 y, and primary school completion was recorded. Conditional length/height and conditional BMI were calculated and expressed as z scores according to the WHO Growth Standards. These express the difference between observed and expected size at a given age based on a regression that includes earlier anthropometric measures. Analyses were adjusted for income, parental education, maternal skin color and smoking, and breastfeeding duration. RESULTS: In the adjusted analyses, participants with conditional length ≥1 z score at 1 y had mean intelligence quotient (IQ) scores at 18 y 4.50 points (95% CI: 1.08, 7.92) higher than those with conditional length ≤-1 at 1 y. For height-for-age at 4 y, this difference was equal to 3.70 (95% CI: 0.49, 6.90) IQ points. There were no associations between conditional height at 11, 15, or 18 y and IQ. For the same previously mentioned comparison, the prevalence ratio for less than primary schooling was 1.42 (95% CI: 1.12, 1.80) for conditional height at 1 y. There were no consistent associations with conditional BMI. CONCLUSIONS: Our findings show that adolescent growth is not associated with intelligence and schooling, and are consistent with the literature on the associations between intelligence and schooling and early linear growth.

4.
PLoS One ; 15(4): e0232350, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32348356

RESUMEN

BACKGROUND: Monitoring universal health coverage in reproductive, maternal and child health requires appropriate indicators for assessing coverage and equity. In 2008, the composite coverage index (CCI)-a weighted average of eight indicators reflecting family planning, antenatal and delivery care, immunizations and management of childhood illnesses-was proposed. In 2017, the CCI formula was revised to update the family planning and diarrhea management indicators. We explored the implications of adding new indicators to the CCI. METHODS: We analysed nationally representative surveys to investigate how addition of early breastfeeding initiation (EIBF), tetanus toxoid during pregnancy and post-natal care for babies affected CCI levels and the magnitude of wealth-related inequalities. We used Pearson's correlation coefficient to compare different formulations, and the slope index of inequalities [SII] and concentration index [CIX] to assess absolute and relative inequalities, respectively. RESULTS: 47 national surveys since 2010 had data on the eight variables needed for the original and revised formulations, and on EIBF, tetanus vaccine and postnatal care, related to newborn care. The original CCI showed the highest average value (65.5%), which fell to 56.9% when all 11 indicators were included. Correlation coefficients between pairs of all formulations ranged from 0.93 to 0.99. When analysed separately, 10 indicators showed higher coverage with increasing wealth; the exception was EIBF (SII = -2.1; CIX = -0.5). Inequalities decreased when other indicators were added, especially EIBF-the SII fell from 24.8 pp. to 19.2 pp.; CIX from 7.6 to 6.1. The number of countries with data from two or more surveys since 2010 was 30 for the original and revised formulations and 15 when all the 11 indicators were included. CONCLUSIONS: Given the growing importance of newborn mortality, it would be desirable to include relevant coverage indicators in the CCI, but this would lead a reduction in data availability, and an underestimation of coverage inequalities. We propose that the 2017 version of the revised CCI should continue to be used.

5.
BMJ Glob Health ; 5(1): e002229, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32133180

RESUMEN

Introduction: Wealth-related inequalities in reproductive, maternal, neonatal and child health have been widely studied by dividing the population into quintiles. We present a comprehensive analysis of wealth inequalities for the composite coverage index (CCI) using national health surveys carried out since 2010, using wealth deciles and absolute income estimates as stratification variables, and show how these new approaches expand on traditional equity analyses. Methods: 83 low-income and middle-income countries were studied. The CCI is a combined measure of coverage with eight key reproductive, maternal, newborn and child health interventions. It was disaggregated by wealth deciles for visual inspection of inequalities, and the slope index of inequality (SII) was estimated. The correlation between coverage in the extreme deciles and SII was assessed. Finally, we used multilevel models to examine how the CCI varies according to the estimated absolute income for each wealth quintile in the surveys. Results: The analyses of coverage by wealth deciles and by absolute income show that inequality is mostly driven by coverage among the poor, which is much more variable than coverage among the rich across countries. Regardless of national coverage, in 61 of the countries, the wealthiest decile achieved 70% or higher CCI coverage. Well-performing countries were particularly effective in achieving high coverage among the poor. In contrast, underperforming countries failed to reach the poorest, despite reaching the better-off. Conclusion: There are huge inequalities between the richest and the poorest women and children in most countries. These inequalities are strongly driven by low coverage among the poorest given the wealthiest groups achieve high coverage irrespective of where they live, overcoming any barriers that are an impediment to others. Countries that 'punched above their weight' in coverage, given their level of absolute wealth, were those that best managed to reach their poorest women and children.

6.
Lancet Glob Health ; 8(3): e352-e361, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32087172

RESUMEN

BACKGROUND: The UN Sustainable Development Goals (SDGs) call for stratification of social indicators by ethnic groups; however, no recent multicountry analyses on ethnicity and child survival have been done in low-income and middle-income countries (LMICs). METHODS: We used data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys collected between 2010 and 2016, from LMICs that provided birth histories and information on ethnicity or a proxy variable. We calculated neonatal (age 0-27 days), post-neonatal (age 28-364 days), child (age 1-4 years), and under-5 mortality rates (U5MRs) for each ethnic group within each country. We assessed differences in mortality between ethnic groups using a likelihood ratio test, Theil's index, and between-group variance. We used multivariable analyses of U5MR by ethnicity to adjust for household wealth, maternal education, and urban-rural residence. FINDINGS: We included data from 36 LMICs, which included 2 812 381 livebirths among 415 ethnic groups. In 25 countries, significant differences in U5MR by ethnic group were identified (all p<0·05 likelihood ratio test). In these countries, the median mortality ratio between the ethnic groups with the highest and lowest U5MRs was 3·3 (IQR 2·1-5·2; range 1·5-8·5), whereas among the remaining 11 countries, the median U5MR ratio was 1·9 (IQR 1·7-2·5; range 1·4-10·0). Ethnic gaps were wider for child mortality than for neonatal or post-neonatal mortality. In nearly all countries, adjustment for wealth, education, and place of residence did not affect ethnic gaps in mortality, with the exception of Guatemala, India, Laos, and Nigeria. The largest ethnic group did not have the lowest U5MR in any of the countries studied. INTERPRETATION: Significant ethnic disparities in child survival were identified in more than two-thirds of the countries studied. Regular analyses of ethnic disparities are essential for monitoring trends, targeting, and assessing the impact of health interventions. Such analyses will contribute to the effort towards leaving no one behind, which is at the centre of the SDGs. FUNDING: Bill & Melinda Gates Foundation, UNICEF, Wellcome Trust, Associação Brasileira de Saúde Coletiva.

9.
Vaccine ; 38(3): 482-488, 2020 Jan 16.
Artículo en Inglés | MEDLINE | ID: mdl-31718899

RESUMEN

Vaccine hesitancy has been increasingly reported in Brazil. We describe secular trends and socioeconomic disparities from 1982 to 2015, using data from four population-based birth cohorts carried out in the city of Pelotas. Full immunization coverage (FIC) was defined as having received four basic vaccines (one dose of BCG and measles, and three doses of polio and DTP) scheduled for the first year of life. Information on income was collected through standardized questionnaires, and the slope index of inequality (SII) was calculated to express the difference in percent points between the rich and poor extremes of the income distribution. Full immunization coverage was 80.9% (95% CI 79.8%; 82.0%) in 1982, 97.2% (96.1%; 98.0%) in 1993, 87.8% (86.7%; 88.8%) in 2004 and 77.2% (75.8%; 78.4%) in 2015. In 1982 there was a strong social gradient with higher coverage among children from wealthy families (SII = 25.0, P < 0.001); by 2015, the pattern was inverted with higher coverage among poor children (SII = -6.0; P = 0.01). Vertical immunization programs in the 1980s and creation of the National Health Services in 1980 eliminated the social gradient that had been present up to the 1980s, to reach near universal coverage. The recent decline in coverage is likely associated with the growing complexity of the vaccination schedule and underfunding of the health sector. In addition, the faster decline observed among children from wealthy families is probably due to vaccine hesitancy.

10.
Vaccine ; 38(5): 1160-1169, 2020 Jan 29.
Artículo en Inglés | MEDLINE | ID: mdl-31791811

RESUMEN

BACKGROUND: Although religious affiliation has been identified as a potential barrier to immunization in some African countries, there are no systematic multi-country analyses, including within-country variability, on this issue. We investigated whether immunization varied according to religious affiliation and sex of the child in sub-Saharan African (SSA) countries. METHODS: We used data from 15 nationally representative surveys from 2010 to 2016. The major religious groups were described by country in terms of wealth, residence, and education. Proportions of fully immunized and unvaccinated children were stratified by country, maternal religion, and sex of the child. Poisson regression with robust variance was used to assess whether the outcomes varied according to religion, with and without adjustment for the above cited sociodemographic confounders. Interactions between child sex and religion were investigated. RESULTS: Fifteen countries had >10% of families affiliated with Christianity and >10% affiliated with Islam, and four also had >10% practicing folk religions. In general, Christians were wealthier, more educated and more urban. Nine countries had significantly lower full immunization coverage among Muslims than Christians (pooled prevalence ratio = 0.81; 95%CI: 0.79-0.83), of which seven remained significant after adjustment for confounders (pooled ratio = 0.90; 0.87-0.92). Four countries had higher coverage among Muslims, of which two remained significant after adjustment. Regarding unvaccinated children, six countries showed higher proportions among Muslims, all of which remained significant after adjustment [crude pooled ratio = 1.83 (1.59-2.07); adjusted = 1.31 (1.14-1.48)]. Children from families practicing folk religions did not show any consistent patterns in immunization. Child sex was not consistently associated with vaccination. CONCLUSION: Muslim religion was associated with lower vaccine coverage in several SSA countries, both for boys and girls. The involvement of religious leaders is essential for increasing immunization coverage and supporting the leave no one behind agenda of the Sustainable Development Goals.

11.
J Adolesc Health ; 66(1S): S51-S57, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31866038

RESUMEN

PURPOSE: Brazilian society is characterized by deep socioeconomic inequalities. Using data from a population-based birth cohort, we explored how the intersectionality of family income and gender may affect adolescent health and behavioral outcomes. METHODS: Children born in 1993 in the Brazilian city of Pelotas have been followed up prospectively at the age of 15 years when the follow-up rate was 85.7% of the original cohort. Participants answered standardized questionnaires, and anthropometric measures were obtained. Outcomes in five domains were studied: overweight (body mass index above +1 SD of the World Health Organization standard for age and sex), cigarette smoking (in the previous month), violence (fight in which someone was injured, in the past year), self-reported unhappiness (based on a face scale), and psychological symptoms (Strengths and Difficulties Questionnaire). Monthly family income was recoded in quintiles. RESULTS: Results were available for more than 4,101-4,334 adolescents, depending on the outcome. Overweight was more common among boys than girls (29.7% and 25.6%; p = .004) and was directly related to family income among boys (p < .001), but not among girls (p = .681). Smoking was less common among boys than girls (12.3% and 21.0%, p < .001) and showed strong inverse association with income among girls (p < .001), but not among boys (p = .099). Reported violence was twice as common among boys than girls (16.4% vs. 8.0%; p < .001); an inverse association with income was present among girls (p < .001), but not for boys (p = .925). Boys and girls were similarly likely to report being unhappy (18.4% and 20.1%; p = .176), with an inverse association with family income in girls. Psychological symptoms were slightly less common among boys than girls (25.3% and 28.3%; p = .014), with strong inverse associations with income in both sexes (p < .001). Adolescent girls from poor families were the group with the highest prevalence for three of the five outcomes: smoking, unhappiness, and psychological problems. CONCLUSIONS: Gender norms influence adolescent health and behavioral outcomes, but the direction and strength of the associations are modified by socioeconomic position. Preventive strategies must take into account the intersectionality of gender and wealth.

12.
J Adolesc Health ; 66(1S): S9-S16, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31866039

RESUMEN

PURPOSE: Body image-related norms can be imposed by parents and can shape adolescents' body satisfaction in consequential ways, yet evidence on long-term effects is scarce. Longitudinal data from a country with strong body image focus provided a unique opportunity to investigate long-term influences of normative parent-related perceptions. METHODS: Multinomial logistic regression was used on data from a 1993 birth cohort in Brazil to investigate the association of normal-body mass index (BMI) adolescents' perception of their parent's opinion of their weight at age 11 years with their weight control attempts at 18 years, testing a mediating role for body dissatisfaction at age 15 years. All models controlled for body dissatisfaction at age 11 years and BMI change between ages 11 and 15 years. RESULTS: A total of 1150 boys and 1336 girls were included. Girls were more likely than boys to diet without nutritionist advice to lose weight (51.5% vs. 34.3% among boys) and use medication to gain weight (12.7% vs. 4.2%). Normal-BMI adolescents who reported at age 11 years that their parents thought they were thin had higher odds of feeling thinner than ideal at age 15 years (odds ratio 2.8, 95% confidence interval 1.8-3.2; and odds ratio 2.0, 95% confidence interval 1.5-2.7) among boys and girls, respectively). Feeling thinner than ideal at age 15 years was associated among girls with higher odds of weight gain attempts at age 18 years. Similar patterns appeared among girls reporting that their parents thought they were fat at age 11 years, feeling fatter than ideal at age 15 years and having higher odds of weight loss attempts at age 18 years. Body dissatisfaction was a statistically significant mediator among girls but not boys. CONCLUSIONS: A long-term influence of parent-related perceptions via a likely trajectory of body dissatisfaction is evident among girls.

13.
Int J Obes (Lond) ; 44(3): 609-616, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31852998

RESUMEN

OBJECTIVE: To analyze socioeconomic inequalities in the prevalence of underweight and overweight or obesity in women from low and middle-income countries (LMICs). METHODS: Using the last available Demographic Health Survey between 2010 and 2016 from 49 LMICs, we estimated the prevalence of underweight (BMI < 18.5 kg/m2) and overweight or obesity combined (BMI ≥ 25 kg/m2) for women aged 20-49 years. We used linear regression to explore the associations between the two outcomes and gross national income (GNI). We assess within-country socioeconomic inequalities using wealth deciles. The slope index of inequality (SII) and the inequality pattern index (IPI) were calculated for each outcome. Negative values of the latter express bottom inequality (when inequality is driven by the poorest deciles) while positive values express top inequality (driven by the richest deciles). RESULTS: In total, 931,145 women were studied. The median prevalence of underweight, overweight or obesity combined, and obesity were 7.3% (range 0.2-20.5%), 31.5% (8.8-85.3%), and 10.2% (1.9-48.8%), respectively. Pearson correlation coefficients with log GNI were -0.33 (p = 0.006) for underweight, 0.72 (p < 0.001) for overweight or obesity, and 0.66 (p < 0.001) for obesity. For underweight, the SII was significantly negative in 38 of the 49 countries indicating a higher burden among poor women. There was no evidence of top or bottom inequality. Overweight or obesity increased significantly with wealth in 44 of the 49 countries. Top inequality was observed in low-prevalence countries, and bottom inequality in high-prevalence countries. CONCLUSION: Underweight remains a problem among the poorest women in poor countries, but overweight and obesity are the prevailing problem as national income increases. In low-prevalence countries, overweight or obesity levels are driven by the higher prevalence among the richest women; as national prevalence increases, only the poorest women are relatively preserved from the epidemic.

14.
J Nutr ; 150(4): 910-917, 2020 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-31875480

RESUMEN

BACKGROUND: In contrast with the ample literature on within- and between-country inequalities in breastfeeding practices, there are no multi-country analyses of socioeconomic disparities in breastmilk substitute (BMS) consumption in low- and middle-income countries (LMICs). OBJECTIVE: This study aimed to investigate between- and within-country socioeconomic inequalities in breastfeeding and BMS consumption in LMICs. METHODS: We examined data from the Demographic Health Surveys and Multiple Indicator Cluster Surveys conducted in 90 LMICs since 2010 to calculate Pearson correlation coefficients between infant feeding indicators and per capita gross domestic product (GDP). Within-country inequalities in exclusive breastfeeding, intake of formula or other types of nonhuman milk (cow/goat) were studied for infants aged 0-5 mo, and for continued breastfeeding at ages 12-15 mo through graphical presentation of coverage wealth quintiles. RESULTS: Between-country analyses showed that log GDP was inversely correlated with exclusive (r = -0.37, P < 0.001) and continued breastfeeding (r = -0.74, P < 0.0001), and was positively correlated with formula intake (r = 0.70, P < 0.0001). Continued breastfeeding was inversely correlated with formula (r = -0.79, P < 0.0001), and was less strongly correlated with the intake of other types of nonhuman milk (r = -0.40, P < 0.001). Within-country analyses showed that 69 out of 89 did not have significant disparities in exclusive breastfeeding. Continued breastfeeding was significantly higher in children belonging to the poorest 20% of households compared with the wealthiest 20% in 40 countries (by ∼30 percentage points on average), whereas formula feeding was more common in the wealthiest group in 59 countries. CONCLUSIONS: BMS intake is positively associated with GDP and negatively associated with continued breastfeeding in LMICs. In most countries, BMS intake is positively associated with family wealth, and will likely become more widespread as countries develop. Urgent action is needed to protect, promote, and support breastfeeding in all income groups and to reduce the intake of BMS, in light of the hazards associated with their use.

15.
Lancet Glob Health ; 7(12): e1589-e1590, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31708129
16.
BMJ Glob Health ; 4(4): e001495, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31543985

RESUMEN

Introduction: The private sector accounts for an important share of health services available in South Asia. It is not known to what extent socioeconomic and urban-rural inequalities in maternal, newborn and child health (MNCH) interventions are being affected by the presence of private providers. Methods: Nationally representative surveys carried out from 2009 to 2015 were analysed for seven of the eight countries in South Asia, as data for Sri Lanka were not available. The outcomes studied included antenatal care (four or more visits), institutional delivery, early initiation of breast feeding, postnatal care for babies, and careseeking for diarrhoea and pneumonia. Results were stratified according to quintiles of household wealth and urban-rural residence. Results: At regional level, the public sector played a larger role than the private sector in providing antenatal (24.8% vs 15.6% coverage), delivery (51.9% vs 26.8%) and postnatal care (15.7% vs 8.2%), as well as in the early initiation of breast feeding (26.1% vs 11.1%). The reverse was observed in careseeking for diarrhoea (15.0% and 46.2%) and pneumonia (18.2% and 50.5%). In 28 out of 37 possible analyses of coverage by country, socioeconomic inequalities were significantly wider in the private than in the public sector, and in only four cases the reverse pattern was observed. In 20 of the 37 analyses, the public sector was also more likely to be used by the wealthiest women and children. Conclusion: The private sector plays a substantial role in delivering MNCH interventions in South Asia but is more inequitable than the public sector.

17.
Lancet ; 393(10189): 2455-2468, 2019 06 15.
Artículo en Inglés | MEDLINE | ID: mdl-31155273

RESUMEN

Despite global commitments to achieving gender equality and improving health and wellbeing for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and subnational data provide some key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies showed that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes. Limitations of survey-based data are described that resulted in missed opportunities for investigating certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.


Asunto(s)
Prestación de Atención de Salud , Identidad de Género , Normas Sociales , Femenino , Humanos , Masculino
18.
Int J Epidemiol ; 48(Suppl 1): i54-i62, 2019 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-30883653

RESUMEN

BACKGROUND: Infant-mortality rates have been declining in many low- and middle-income countries, including Brazil. Information on causes of death and on socio-economic inequalities is scarce. METHODS: Four birth cohorts were carried out in the city of Pelotas in 1982, 1993, 2004 and 2015, each including all hospital births in the calendar year. Surveillance in hospitals and vital registries, accompanied by interviews with doctors and families, detected fetal and infant deaths and ascertained their causes. Late-fetal (stillbirth)-, neonatal- and post-neonatal-death rates were calculated. RESULTS: All-cause and cause-specific death rates were reduced. During the study period, stillbirths fell by 47.8% (from 16.1 to 8.4 per 1000), neonatal mortality by 57.0% (from 20.1 to 8.7) and infant mortality by 62.0% (from 36.4 to 13.8). Perinatal causes were the leading causes of death in the four cohorts; deaths due to infectious diseases showed the largest reductions, with diarrhoea causing 25 deaths in 1982 and none in 2015. Late-fetal-, neonatal- and infant-mortality rates were higher for children born to Brown or Black women and to low-income women. Absolute socio-economic inequalities based on income-expressed in deaths per 1000 births-were reduced over time but relative inequalities-expressed as ratios of mortality rates-tended to remain stable. CONCLUSION: The observed improvements are likely due to progress in social determinants of health and expansion of health care. In spite of progress, current levels remain substantially greater than those observed in high-income countries, and social and ethnic inequalities persist.


Asunto(s)
Causas de Muerte , Mortalidad Infantil/tendencias , Mortinato/epidemiología , Brasil/epidemiología , Enfermedades Transmisibles/mortalidad , Femenino , Edad Gestacional , Humanos , Lactante , Recién Nacido , Masculino , Distribución de Poisson , Embarazo , Factores Socioeconómicos
19.
Int J Epidemiol ; 48(Suppl 1): i4-i15, 2019 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-30883654

RESUMEN

BACKGROUND: Few low-middle-income countries have data from comparable birth cohort studies spanning over time. We report on the methods used by the Pelotas cohorts (1982, 1993, 2004 and 2015) and describe time trends in sociodemographic characteristics of the participant families. METHODS: During the four study years, all maternity hospitals in the city were visited daily, and all urban women giving birth were enrolled. Data on socioeconomic and demographic characteristics were collected using standardized questionnaires, including data on maternal and paternal skin colour, age and schooling, maternal marital status, family income and household characteristics. The analyses included comparisons of time trends and of socioeconomic and ethnic group inequalities. RESULTS: Despite a near 50% increase in the city's population between 1982 and 2015, the total number of births declined from 6011 to 4387. The proportion of mothers aged ≥35 years increased from 9.9% to 14.8%, and average maternal schooling from 6.5 [standard deviation (SD) 4.2] to 10.1 (SD 4.0) years. Treated water was available in 95.3% of households in 1982 and 99.3% in 2015. Three-quarters of the families had a refrigerator in 1982, compared with 98.3% in 2015. Absolute income-related inequalities in maternal schooling, household crowding, household appliances and access to treated water were markedly reduced between 1982 and 2015. Maternal skin colour was associated with inequalities in age at childbearing and schooling, as well as with household characteristics. CONCLUSIONS: During the 33-year period, there were positive changes in social and environmental determinants of health, including income, education, fertility and characteristics of the home environment. Socioeconomic inequality was also reduced.


Asunto(s)
Salud del Niño/tendencias , Disparidades en el Estado de Salud , Salud Materna/tendencias , Adolescente , Adulto , Brasil , Niño , Estudios de Cohortes , Escolaridad , Composición Familiar , Femenino , Fertilidad , Encuestas Epidemiológicas , Humanos , Masculino , Edad Materna , Embarazo , Factores Socioeconómicos , Adulto Joven
20.
Int J Epidemiol ; 48(Suppl 1): i16-i25, 2019 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-30883655

RESUMEN

BACKGROUND: Brazil experienced important progress in maternal and child health in recent decades. We aimed at describing secular trends as well as socioeconomic and ethnic inequalities in reproductive history indicators (birth spacing, previous adverse perinatal outcome, parity and multiple births) over a 33-year span. METHODS: Four population-based birth cohort studies included all hospital births in 1982, 1993, 2004 and 2015 in Pelotas, Southern Brazil. Information on reproductive history was collected through interviews. Indicators were stratified by family income quintiles and skin colour. Absolute and relative measures of inequality were calculated. RESULTS: From 1982 to 2015, the proportion of primiparae increased from 39.2% to 49.6%, and median birth interval increased by 23.2 months. Poor women were more likely to report short intervals and higher parity, although reductions were observed in all income and ethnic groups. History of previous low birthweight was inversely related to income and increased by 7.7% points (pp) over time-more rapidly in the richest (12.1 pp) than in the poorest quintile (0.4 pp). Multiple births increased from 1.7% to 2.7%, with the highest increase observed among the richest quintile and for white women (220% and 70% increase, respectively). Absolute and relative income and ethnic-related inequalities for short birth intervals increased, whereas inequalities for previous low birthweight decreased over time. CONCLUSIONS: In this 33-year period there were increases in birth intervals, multiple births and reports of previous low-birthweight infants. These trends may be explained by increased family planning coverage, assisted reproduction and a rise in preterm births, respectively. Our results show that socioeconomic and ethnic inequalities in health are dynamic and vary over time, within the same location.


Asunto(s)
Intervalo entre Nacimientos/estadística & datos numéricos , Progenie de Nacimiento Múltiple/estadística & datos numéricos , Trabajo de Parto Prematuro/epidemiología , Resultado del Embarazo/epidemiología , Salud Reproductiva/tendencias , Brasil/epidemiología , Femenino , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Recien Nacido Prematuro , Modelos Logísticos , Paridad , Vigilancia de la Población , Embarazo , Factores Socioeconómicos
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