'It's a delicate topic': Stigma, capabilities and young people's mental health in post-conflict Colombia.

Young people in Colombia present high rates of mental health problems, to which the country's history of armed internal conflict contributes in complex ways. Mental health services in Colombia are fragmented, inadequate, and difficult to access for many. Young people's help-seeking is often hindered by mental health stigma and/or poor experiences with services. This paper presents a thematic analysis of qualitative data from a mixed-methods study aimed at developing and testing a mental health intervention for Colombian youths. We draw upon theoretical lenses from scholarly work on stigma and Sen's 'capabilities approach' to inform our analysis of interviews and group discussions with staff and young people involved in the state-funded human capital building programme 'Jovenes en Acción' (JeA). By illustrating how study participants talked about stigma, vulnerability, mental health services organisation, and the challenges of discussing mental health topics in a learning environment, we illuminate aspects of mental health support and anti-stigma interventions that might need enhancing. In particular, we suggest that more emphasis on 'community competencies' as complementary to and interrelated with individual competencies would strengthen young people's individual and collective resources for mental wellbeing while being in line with the sociocritical principles of existing human capital-enhancing programmes.

Current and Projected Mortality and Hospitalization Rates Associated With Conditional Cash Transfer, Social Pension, and Primary Health Care Programs in Brazil, 2000-2030.

Importance: The health outcomes of increased poverty and inequalities in low- and middle-income countries (LMICs) have been substantially amplified as a consequence of converging multiple crises. Brazil has some of the world's largest conditional cash transfer (Programa Bolsa Família [PBF]), social pension (Beneficio de Prestacão Continuada [BPC]), and primary health care (Estratégia de Saúde da Família [ESF]) programs that could act as mitigating interventions during the current polycrisis era of increasing poverty, slow or contracting economic growth, and conflicts. Objective: To evaluate the combined association of the Brazilian conditional cash transfer, social pension, and primary health care programs with the reduction of morbidity and mortality over the last 2 decades and forecast their potential mitigation of the current global polycrisis and beyond. Design, Setting, and Participants: This cohort study used a longitudinal ecological design with multivariable negative binomial regression models (adjusted for relevant socioeconomic, demographic, and health care variables) integrating the retrospective analysis from 2000 to 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. Participants included a cohort of 2548 Brazilian municipalities from 2004 to 2019, projected from 2020 to 2030. Data analysis was performed from September 2022 to February 2023. Exposure: PBF coverage of the target population (those who were poorest) was categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%). ESF coverage was categorized as null (0), low (0.1%-29.9%), intermediate (30.0%-69.9%), and consolidated (70.0%-100%). BPC coverage was categorized by terciles. Main outcomes and measures: Age-standardized, all-cause mortality and hospitalization rates calculated for the entire population and by age group (<5 years, 5-29 years, 30-69 years, and ≥70 years). Results: Among the 2548 Brazilian municipalities studied from 2004 to 2019, the mean (SD) age-standardized mortality rate decreased by 16.64% (from 6.73 [1.14] to 5.61 [0.94] deaths per 1000 population). Consolidated coverages of social welfare programs studied were all associated with reductions in overall mortality rates (PBF: rate ratio [RR], 0.95 [95% CI, 0.94-0.96]; ESF: RR, 0.93 [95% CI, 0.93-0.94]; BPC: RR, 0.91 [95% CI, 0.91-0.92]), having all together prevented an estimated 1 462 626 (95% CI, 1 332 128-1 596 924) deaths over the period 2004 to 2019. The results were higher on mortality for the group younger than age 5 years (PBF: RR, 0.87 [95% CI, 0.85-0.90]; ESF: RR, 0.89 [95% CI, 0.87-0.93]; BPC: RR, 0.84 [95% CI, 0.82-0.86]), on mortality for the group aged 70 years and older, and on hospitalizations. Considering a shorter scenario of economic crisis, a mitigation strategy that will increase the coverage of PBF, BPC, and ESF to proportionally cover the newly poor and at-risk individuals was projected to avert 1 305 359 (95% CI, 1 163 659-1 449 256) deaths and 6 593 224 (95% CI, 5 534 591-7 651 327) hospitalizations up to 2030, compared with fiscal austerity scenarios that would reduce the coverage of these interventions. Conclusions and relevance: This cohort study's results suggest that combined expansion of conditional cash transfers, social pensions, and primary health care should be considered a viable strategy to mitigate the adverse health outcomes of the current global polycrisis in LMICs, whereas the implementation of fiscal austerity measures could result in large numbers of preventable deaths.

Strengthening self-regulation and reducing poverty to prevent adolescent depression and anxiety: Rationale, approach and methods of the ALIVE interdisciplinary research collaboration in Colombia, Nepal and South Africa.

AIMS: Depression and anxiety are the leading contributors to the global burden of disease among young people, accounting for over a third (34.8%) of years lived with disability. Yet there is limited evidence for interventions that prevent adolescent depression and anxiety in low- and middle-income countries (LMICs), where 90% of adolescents live. This article introduces the 'Improving Adolescent mentaL health by reducing the Impact of poVErty (ALIVE)' study, its conceptual framework, objectives, methods and expected outcomes. The aim of the ALIVE study is to develop and pilot-test an intervention that combines poverty reduction with strengthening self-regulation to prevent depression and anxiety among adolescents living in urban poverty in Colombia, Nepal and South Africa. METHODS: This aim will be achieved by addressing four objectives: (1) develop a conceptual framework that identifies the causal mechanisms linking poverty, self-regulation and depression and anxiety; (2) develop a multi-component selective prevention intervention targeting self-regulation and poverty among adolescents at high risk of developing depression or anxiety; (3) adapt and validate instruments to measure incidence of depression and anxiety, mediators and implementation parameters of the prevention intervention; and (4) undertake a four-arm pilot cluster randomised controlled trial to assess the feasibility, acceptability and cost of the selective prevention intervention in the three study sites. RESULTS: The contributions of this study include the active engagement and participation of adolescents in the research process; a focus on the causal mechanisms of the intervention; building an evidence base for prevention interventions in LMICs; and the use of an interdisciplinary approach. CONCLUSIONS: By developing and evaluating an intervention that addresses multidimensional poverty and self-regulation, ALIVE can make contributions to evidence on the integration of mental health into broader development policy and practice.

Piloting a mental health intervention for young adults in poverty enrolled in post-secondary education in post-conflict regions in Colombia: a study protocol.

Background: Colombia has endured more than five decades of internal armed conflict, which led to substantial costs for human capital and mental health. There is currently little evidence about the impact of incorporating a mental health intervention within an existing public cash transfer program to address poverty, and this project aims to develop and pilot a mental health support intervention embedded within the human capital program to achieve better outcomes among beneficiaries, especially those displaced by conflict and the most socioeconomically vulnerable. Methods: The study will consist of three phases: semi-structured one-to-one interviews, co-design and adaptations of the proposed intervention with participants and pilot of the digital intervention based on cognitive behavioral therapy and transdiagnostic techniques to determine its feasibility, acceptability, efficacy, and usefulness in 'real settings'. Results will inform if the intervention improves clinical, educational and employment prospects among those who use it. Results: Knowledge will be generated on whether the mental health intervention could potentially improve young people's mental health and human capital in conflict-affected areas? We will evaluate of the impact of potential mental health improvements on human capital outcomes, including educational and employment outcomes. Conclusion: Findings will help to make conclusions about the feasibility and acceptability of the intervention, and it will assess its effectiveness to improve the mental health and human capital outcomes of beneficiaries. This will enable the identification of strategies to address mental health problems among socioeconomically vulnerable young people that can be adapted to different contexts in in low and middle-income countries.

Evaluation and Forecasting Analysis of the Association of Conditional Cash Transfer With Child Mortality in Latin America, 2000-2030.

Importance: Latin America has implemented the world's largest and most consolidated conditional cash transfer (CCT) programs during the last 2 decades. As a consequence of the COVID-19 pandemic, poverty rates have markedly increased, and a large number of newly low-income individuals, especially children, have been left unprotected. Objective: To evaluate the association of CCT programs with child health in Latin American countries during the last 2 decades and forecast child mortality trends up to 2030 according to CCT alternative implementation options. Design, Setting, and Participants: This cohort study used a multicountry, longitudinal, ecological design with multivariable negative binomial regression models, which were adjusted for all relevant demographic, socioeconomic, and health care variables, integrating the retrospective impact evaluations from January 1, 2000, to December 31, 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. The study cohort included 4882 municipalities from Brazil, Ecuador, and Mexico with adequate quality of civil registration and vital statistics according to a validated multidimensional criterion. Data analysis was performed from September 2022 to February 2023. Exposure: Conditional cash transfer coverage of the target (lowest-income) population categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%). Main Outcomes and Measures: The main outcomes were mortality rates for those younger than 5 years and hospitalization rates (per 1000 live births), overall and by poverty-related causes (diarrheal, malnutrition, tuberculosis, malaria, lower respiratory tract infections, and HIV/AIDS), and the mortality rates for those younger than 5 years by age groups, namely, neonatal (0-28 days), postneonatal (28 days to 1 year), infant (<1 year), and toddler (1-4 years). Results: The retrospective analysis included 4882 municipalities. During the study period of January 1, 2000, to December 31, 2019, mortality in Brazil, Ecuador, and Mexico decreased by 7.8% in children and 6.5% in infants, and an increase in coverage of CCT programs of 76.8% was observed in these Latin American countries. Conditional cash transfer programs were associated with significant reductions of mortality rates in those younger than 5 years (rate ratio [RR], 0.76; 95% CI, 0.75-0.76), having prevented 738 919 (95% CI, 695 641-782 104) child deaths during this period. The association of highest coverage of CCT programs was stronger with poverty-related diseases, such as malnutrition (RR, 0.33; 95% CI, 0.31-0.35), diarrhea (RR, 0.41; 95% CI, 0.40-0.43), lower respiratory tract infections (RR, 0.66, 95% CI, 0.65-0.68), malaria (RR, 0.76; 95% CI, 0.63-0.93), tuberculosis (RR, 0.62; 95% CI, 0.48-0.79), and HIV/AIDS (RR, 0.32; 95% CI, 0.28-0.37). Several sensitivity and triangulation analyses confirmed the robustness of the results. Considering a scenario of moderate economic crisis, a mitigation strategy that will increase the coverage of CCTs to protect those newly in poverty could reduce the mortality rate for those younger than 5 years by up to 17% (RR, 0.83; 95% CI, 0.80-0.85) and prevent 153 601 (95% CI, 127 441-180 600) child deaths by 2030 in Brazil, Ecuador, and Mexico. Conclusions and Relevance: The results of this cohort study suggest that the expansion of CCT programs could strongly reduce childhood hospitalization and mortality in Latin America and should be considered an effective strategy to mitigate the health impact of the current global economic crisis in low- and middle-income countries.

Combining cash transfers and cognitive behavioral therapy to reduce antisocial behavior in young men: A mediation analysis of a randomized controlled trial in Liberia.

BACKGROUND: Interventions that combine cognitive behavioral therapy (CBT) with unconditional cash transfers (UCT) reduce the risk of antisocial behavior (ASB), but the underlying mechanisms are unclear. In this paper, we test the role of psychological and cognitive mechanisms in explaining this effect. We assessed the mediating role of executive function, self-control, and time preferences. METHODS: We used data from the Sustainable Transformation of Youth in Liberia, a community-based randomized controlled trial of criminally engaged men. The men were randomized into: Group-1: control (n = 237); and Group-2: CBT+UCT (n = 207). ASB was measured 12-13 months after the interventions were completed, and the following mediators were assessed 2-5 weeks later: (i) self-control, (ii) time preferences and (iii) executive functions. We estimated the natural direct effect (NDE) and the natural indirect effect (NIE) of the intervention over ASB. RESULTS: Self-control, time preferences and a weighted index of all three mediators were associated with ASB scores, but the intervention influenced time preferences only [B = 0.09 95%CI (0.03; 0.15)]. There was no evidence that the effect of the intervention on ASB was mediated by self-control [BNIE = 0.007 95%CI (-0.01; 0.02)], time preferences [BNIE = -0.02 95%CI (-0.05; 0.01)], executive functions [BNIE = 0.002 95%CI (-0.002; 0.006)] or the weighted index of the mediators [BNIE = -0.0005 95%CI (-0.03; 0.02)]. CONCLUSIONS: UCT and CBT lead to improvements in ASB, even in the absence of mediation via psychological and cognitive functions. Findings suggest that the causal mechanisms may involve non-psychological pathways.

The burden of mild cognitive impairment attributable to physical inactivity in Colombia.

BACKGROUND: Mild cognitive impairment often precedes dementia. The purpose of this analysis was to estimate the population attributable fraction for physical activity in Colombia, which is the reduction in cases that would occur if all participants were physically active. METHODS: The sample included 20,174 men and women aged 70.04 ± 7.68 years (mean ± SD) from the National Survey of Health, Wellbeing and Ageing. Trained interviewers administered a shorter version of the mini-mental state examination and mild cognitive impairment was defined as a score of 12 or less out of 19. Logistic regression models were fitted and population attributable fractions for physical activity were calculated. All analyses were adjusted for age, sex, height, education, income, civil status, smoking, and alcohol drinking. RESULTS: The prevalence of physical activity was approximately 50% when defined as walking between 9 and 20 blocks at least three times per week. Theoretically, 19% of cases of mild cognitive impairment would be eliminated if all adults were to walk (95% confidence interval: 16%, 22%). The prevalence was approximately 20% when defined as taking part in vigorous sport or exercise at least three times per week. Theoretically, 23% of cases of mild cognitive impairment would be eliminated if all adults were to take part in vigorous sport or exercise (16%, 30%). Similar results were observed after removing those who reported mental health problems. CONCLUSION: Physical activity, whether walking or vigorous sport and exercise, has the potential to substantially reduce the burden of mild cognitive impairment in Colombia.

Associations of body mass index and sarcopenia with screen-detected mild cognitive impairment in older adults in Colombia.

Background and objective: More research is required to understand associations of body mass index (BMI) and sarcopenia with cognition, especially in Latin America. The objective of this study was to investigate associations of BMI and sarcopenia with mild cognitive impairment in Colombia. Design setting and participants: Data were from the National Survey of Health, Wellbeing and Aging in Colombia (SABE Colombia, in Spanish). Community-dwelling adults aged 60 years or older were invited to participate. Methods: Trained interviewers administered a shorter version of the mini-mental state examination and mild cognitive impairment was defined as a score of 12 or less out of 19. Body mass index was defined using standard cut-offs. Sarcopenia was defined as low grip strength or slow chair stands. Logistic regression models were adjusted for age, sex, height, education, income, civil status, smoking, and alcohol drinking. Results: The prevalence of mild cognitive impairment was 20% in 23,694 participants in SABE Colombia and 17% in 5,760 participants in the sub-sample in which sarcopenia was assessed. Overweight and obesity were associated with decreased risk of mild cognitive impairment and sarcopenia was associated with increased risk. Sarcopenia was a risk factor for mild cognitive impairment in those with normal BMI (adjusted model included 4,911 men and women). Compared with those with normal BMI and without sarcopenia, the odds ratio for mild cognitive impairment was 1.84 in those with normal BMI and sarcopenia (95% confidence interval: 1.25, 2.71). Sarcopenia was also a risk factor in those with obesity but did not present a greater risk than sarcopenia alone. Compared with those with normal BMI and without sarcopenia, the odds ratio was 1.62 in those with obesity and sarcopenia (95% confidence interval: 1.07, 2.48). Sarcopenia was not a risk factor for mild cognitive impairment in those with overweight. Similar results were observed when reference values from Colombia were used to set cut-offs for grip strength. Similar results were also observed in cross-validation models, which suggests the results are robust. Conclusion: This is the first study of the combined associations of sarcopenia and obesity with cognition in Colombia. The results suggest that sarcopenia is the major predictor of screen-detected mild cognitive impairment in older adults, not overweight or obesity.

Wealth and inequality gradients for the detection and control of hypertension in older individuals in middle-income economies around 2007-2015.

Socioeconomic inequalities in the detection and treatment of non-communicable diseases represent a challenge for healthcare systems in middle-income countries (MICs) in the context of population ageing. This challenge is particularly pressing regarding hypertension due to its increasing prevalence among older individuals in MICs, especially among those with lower socioeconomic status (SES). Using comparative data for China, Colombia, Ghana, India, Mexico, Russia and South Africa, we systematically assess the association between SES, measured in the form of a wealth index, and hypertension detection and control around the years 2007-15. Furthermore, we determine what observable factors, such as socio-demographic and health characteristics, explain existing SES-related inequalities in hypertension detection and control using a Blinder-Oaxaca decomposition. Results show that the prevalence of undetected hypertension is significantly associated with lower SES. For uncontrolled hypertension, there is evidence of a significant gradient in three of the six countries at the time the data were collected. Differences between rural and urban areas as well as lower and higher educated individuals account for the largest proportion of SES-inequalities in hypertension detection and control at the time. Improved access to primary healthcare in MICs since then may have contributed to a reduction in health inequalities in detection and treatment of hypertension. However, whether this indeed has been the case remains to be investigated.

Urban landscape and street-design factors associated with road-traffic mortality in Latin America between 2010 and 2016 (SALURBAL): an ecological study.

BACKGROUND: Road-traffic injuries are a key cause of death and disability in low-income and middle-income countries, but the effect of city characteristics on road-traffic mortality is unknown in these countries. The aim of this study was to determine associations between city-level built environment factors and road-traffic mortality in large Latin American cities. METHODS: We selected cities from Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico, Panama, and Peru; cities included in the analysis had a population of at least 100 000 people. We extracted data for road-traffic deaths that occurred between 2010 and 2016 from country vital registries. Deaths were grouped by 5-year age groups and sex. Road-traffic deaths were identified using ICD-10 codes, with adjustments for ill-defined codes and incomplete registration. City-level measures included population, urban development, street design, public transportation, and social environment. Associations were estimated using multilevel negative binomial models with robust variances. FINDINGS: 366 cities were included in the analysis. There were 328 408 road-traffic deaths in nearly 3·5 billion person-years across all countries, with an average crude rate of 17·1 deaths per 100 000 person-years. Nearly half of the people who died were younger than 35 years. In multivariable models, road-traffic mortality was higher in cities where urban development was more isolated (rate ratio [RR] 1·05 per 1 SD increase, 95% CI 1·02-1·09), but lower in cities with higher population density (0·94, 0·90-0·98), higher gross domestic product per capita (0·96, 0·94-0·98), and higher intersection density (0·92, 0·89-0·95). Cities with mass transit had lower road mortality rates than did those without (0·92, 0·86-0·99). INTERPRETATION: Urban development policies that reduce isolated and disconnected urban development and that promote walkable street networks and public transport could be important strategies to reduce road-traffic deaths in Latin America and elsewhere. FUNDING: Wellcome Trust.

The relationship between multidimensional poverty, income poverty and youth depressive symptoms: cross-sectional evidence from Mexico, South Africa and Colombia.

Whereas monetary poverty is associated with increased risk of depressive symptoms in young people, poverty is increasingly understood as a multidimensional problem. However, it is yet to be understood how the associations between different dimensions of poverty and youth mental health differ across countries. We examine the relationship between multidimensional, as well as income poverty, and depressive symptoms in young people (age 11-25 years) across three middle-income countries. Based on harmonised data from surveys in Colombia, Mexico and South Africa (N=16 173) we constructed a multidimensional poverty index that comprised five deprivations We used Poisson regression to examine relationships between different forms of poverty with depressive symptoms across the countries. Multidimensional poverty was associated with higher rates of depressive symptoms in the harmonised dataset (IRR (incidence rate ratio)=1.25, 95% CI 1.10 to 1.42), in Mexico (IRR=1.34, 95% CI 1.11 to 1.64) and Colombia (IRR=2.01, 95% CI 1.30 to 3.10) but not in South Africa, a finding driven by a lack of associations between child labour and health insurance coverage with depressive symptoms. There was only an association with income poverty and depressive symptoms in South Africa, not in Colombia or Mexico. Depressive symptoms were associated with individual deprivations such as school lag, child labour and lack of access to health services in the harmonised dataset, but not with household deprivations, such as parental unemployment and housing conditions, though the opposite pattern was observed in South Africa. Our findings suggest that the importance of specific dimensions of poverty for mental health varies across countries, and a multidimensional approach is needed to gain insights into the relationship between youth depression and poverty.

Conditional cash transfers and adolescent mental health in Brazil: Evidence from the 2004 Pelotas Birth Cohort.

BACKGROUND: Young people living in poverty are at higher risk of mental disorders, but whether interventions aimed to reduce poverty have lasting effects on mental health has not been well established. We examined whether exposure to Brazil's conditional cash transfers programme (CCT), Bolsa Família (BFP), during childhood reduces the risk of mental health problems in early adolescence. METHODS: We used data from 2063 participants in the 2004 Pelotas Birth Cohort study. Propensity score matching (PSM) estimated the association between BFP participation at age 6 and externalising problems (Strengths and Difficulties Questionnaire - SDQ and violent behaviour) and socio-emotional competencies (Development and Well-Being Assessment questionnaire, and the Nowick-Strickland Internal-External Scale) at age 11. RESULTS: PSM results suggest that programme participation at age of six was not significantly associated with externalising problems (P = 0.433), prosocial behaviour (P = 0.654), violent behaviour (P = 0.342), social aptitudes (P = 0.281), positive attributes (P = 0.439), or locus of control (P = 0.148) at the age of 11 years. CONCLUSIONS: Participation in BFP during childhood was not associated with improved or worsened mental health in early adolescence. While we cannot fully discard that findings may be due to adverse selection, results suggest that CCTs alone may not be sufficient to improve mental health outcomes and would be prudent to assess whether mental health interventions as an addition to CCTs may be helpful.

Educational inequalities in obesity: a multilevel analysis of survey data from cities in Latin America.

OBJECTIVE: Using newly harmonised individual-level data on health and socio-economic environments in Latin American cities (from the Salud Urbana en América Latina (SALURBAL) study), we assessed the association between obesity and education levels and explored potential effect modification of this association by city-level socio-economic development. DESIGN: This cross-sectional study used survey data collected between 2002 and 2017. Absolute and relative educational inequalities in obesity (BMI ≥ 30 kg/m2, derived from measured weight and height) were calculated first. Then, a two-level mixed-effects logistic regression was run to test for effect modification of the education-obesity association by city-level socio-economic development. All analyses were stratified by sex. SETTING: One hundred seventy-six Latin American cities within eight countries (Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico and Peru). PARTICIPANTS: 53 186 adults aged >18 years old. RESULTS: Among women, 25 % were living with obesity and obesity was negatively associated with educational level (higher education-lower obesity) and this pattern was consistent across city-level socio-economic development. Among men, 18 % were living with obesity and there was a positive association between education and obesity (higher education-higher obesity) for men living in cities with lower levels of development, whereas for those living in cities with higher levels of development, the pattern was inverted and university education was protective of obesity. CONCLUSIONS: Among women, education was protective of obesity regardless, whereas among men, it was only protective in cities with higher levels of development. These divergent results suggest the need for sex- and city-specific interventions to reduce obesity prevalence and inequalities.

Association Between Social Pensions With Depression, Social, and Health Behaviors Among Poor Older Individuals in Colombia.

OBJECTIVES: Many low- and middle-income countries have introduced social pensions to alleviate extreme poverty and improve the well-being of older individuals. However, evidence remains inconclusive about the potential effects of such programs on mental health, social, and health behaviors. METHODS: Data for individuals aged 60 or older came from the nationally representative Encuesta Nacional de Salud, Bienestar y Envejeciamiento survey in Colombia 2015 (N = 9,456). We used propensity score matching to estimate the association between the country's social pension program (Colombia Mayor) with depression, self-rated health, food insecurity, alcohol consumption, social participation, and labor force participation. RESULTS: Results show that receiving the program does not significantly affect the likelihood of suffering from depression or self-rated health among either men or women. However, receiving the program is associated with significant reductions in the likelihood of experiencing food insecurity and significant increases in the likelihood of participating socially. Among women, receiving the program is associated with significant reduction in the likelihood of participating in the labor force. DISCUSSION: The absence of a measurable effect on depression and self-rated health may be explained, at least partly, by the program's comparatively small cash benefit and the sharing of resources with other family members. Policymakers should assess possibilities to maximize the health and social benefits of social pensions.

Education in early life markedly reduces the probability of cognitive impairment in later life in Colombia.

The objective of this study was to investigate associations between education in early life and cognitive impairment in later life in Colombia. Participants were community-dwelling adults aged 60 years or older from the National Study of Health, Wellbeing and Ageing. Trained interviewers administered a shorter version of the mini-mental state examination. Cognitive impairment was defined as the lowest tertile in the main analysis and as a score of 12 or less out of 19 in the sensitivity analysis. Logistic regression models were adjusted for education, other early life characteristics, and later life characteristics. The prevalence of cognitive impairment was 17.93% in the main analysis (n = 16,505). Compared with participants with no education, the fully adjusted odds ratio for cognitive impairment was 0.57 (95% confidence interval: 0.52, 0.63) in those with some primary education and 0.29 (95% confidence interval: 0.25, 0.34) in those with some secondary education or more. The population attributable fraction for education suggests that at least 10% of cases of cognitive impairment would be eliminated if all children received an education. Similar results were observed in the sensitivity analysis (n = 20,174). This study suggests that education in early life markedly reduces the probability of cognitive impairment in late life in Colombia.

Increases In Women's Political Representation Associated With Reductions In Child Mortality In Brazil.

We assessed the effects of female political representation on mortality among children younger than age five in Brazil and the extent to which this effect operates through coverage with conditional cash transfers and primary care services. We combined data on under-five mortality rates with data on women elected as mayors or representatives in state and federal legislatures for 3,167 municipalities during 2000-15. Results from fixed-effects regression models suggest that the election of a female mayor and increases in the shares of women elected to state legislatures and to the federal Chamber of Deputies to 20 percent or more were significantly associated with declines in under-five mortality. Increasing the political representation of women was likely associated with beneficial effects on child mortality through pathways that expanded access to primary health care and conditional cash transfer programs.

Socio-economic inequalities in high blood pressure and additional risk factors for cardiovascular disease among older individuals in Colombia: Results from a nationally representative study.

BACKGROUND: Studies in high-income countries have documented a consistent gradient between socio-economic status (SES) and high blood pressure (HBP), a key risk factor for cardiovascular disease (CVD). However, evidence from Latin American countries (LA) remains comparatively scarce and inconclusive. DATA: Data for 3,984 individuals came from a nationally representative survey of individuals aged 60 years or above in Colombia (Encuesta de Salud, Bienestar y Envejecimiento) (SABE) conducted in 2015. SES was measured by educational achievement and household assets. CVD risk factors included objectively measured HBP and body mass index (BMI), as well as behaviors (smoking, alcohol consumption, fruit and vegetables intake, and physical activity). METHODS: Bivariate methods and multivariate regression models were used to assess associations between SES with HBP as well as additional risk factors for CVD. RESULTS: Individuals with lower SES have significantly higher risk of suffering from HBP. Compared to those with no formal education, individuals with secondary or post-secondary education have a 37% lower risk of HBP (odds ratio [OR] = 0.63, P-value<0.001). Being in the highest asset quartile (most affluent) is associated with a 44% lower risk (OR = 56, P-value = 0.001) of HBP compared to those in the lowest asset quartile (most deprived). Individuals with lower SES are more likely to smoke, not engage in regular physical activity and not regularly consume fruits or vegetables. In contrast, individuals with higher SES are more likely to consume alcohol and, those with more assets, more likely to be obese. CONCLUSIONS: Among older Colombians there exists a marked SES gradient in HBP as well as several additional risk factors for CVD. The results highlight the importance of a public health approach towards HBP and additional CVD risk factors that takes into account the specific conditions of older individuals, especially among disadvantaged groups.

Urban Transformations and Health: Methods for TrUST-a Natural Experiment Evaluating the Impacts of a Mass Transit Cable Car in Bogotá, Colombia.

Background: Cable cars provide urban mobility benefits for vulnerable populations. However, no evaluation has assessed cable cars' impact from a health perspective. TransMiCable in Bogotá, Colombia, provides a unique opportunity to (1) assess the effects of its implementation on the environmental and social determinants of health (microenvironment pollution, transport accessibility, physical environment, employment, social capital, and leisure time), physical activity, and health outcomes (health-related quality of life, respiratory diseases, and homicides); and (2) use citizen science methods to identify, prioritize, and communicate the most salient negative and positive features impacting health and quality of life in TransMiCable's area, as well as facilitate a consensus and advocacy-building change process among community members, policymakers, and academic researchers. Methods: TrUST (In Spanish: Transformaciones Urbanas y Salud: el caso de TransMiCable en Bogotá) is a quasi-experimental study using a mixed-methods approach. The intervention group includes adults from Ciudad Bolívar, the area of influence of TransMiCable. The control group includes adults from San Cristóbal, an area of future expansion for TransMiCable. A conceptual framework was developed through group-model building. Outcomes related to environmental and social determinants of health as well as health outcomes are assessed using questionnaires (health outcomes, physical activity, and perceptions), secondary data (crime and respiratory outcomes) use of portable devices (air pollution exposure and accelerometry), mobility tracking apps (for transport trajectories), and direct observation (parks). The Stanford Healthy Neighborhood Discovery Tool is being used to capture residents' perceptions of their physical and social environments as part of the citizen science component of the investigation. Discussion: TrUST is innovative in its use of a mixed-methods, and interdisciplinary research approach, and in its systematic engagement of citizens and policymakers throughout the design and evaluation process. This study will help to understand better how to maximize health benefits and minimize unintended negative consequences of TransMiCable.

Educational inequalities in disability linked to social security coverage among older individuals in five Latin American countries.

Although Latin American populations are ageing rapidly, many countries have important shortcomings in terms of access to social security coverage. Despite significant improvements regarding access to healthcare, the coverage gap in terms of pensions represents a major challenge for public health and equity in the region. The principal aim of this study was to systematically assess the association between social security coverage and disability among older individuals in five Latin American countries, as well as the extent of existing inequalities and its determinants. To do so we use cross-sectional and comparative data for individuals aged 60 and older in Chile, Colombia, El Salvador, Paraguay and Uruguay from the Longitudinal Social Protection Survey (ELPS). We used multivariate regression to assess the association between disability and healthcare as well as pension coverage. Concentration indices (CI) and an Oaxaca-Blinder decomposition approach were used to assess overall inequalities in disability according to education as well as their components. With the exception of El Salvador, we find significant inequalities in disability disfavoring lower educated individuals. With regards to healthcare, we find no significant association of healthcare coverage with disability in any of the five countries, nor does it explain educational inequalities in disability. However, pension access was associated with lower risks of disability in Chile, Colombia, Paraguay and Uruguay, and explains a substantial share of educational inequality in Chile, Colombia and Paraguay. Whereas significant changes have already been made regarding universal healthcare coverage, the results suggest that expanding access to pensions may not only lead to improvements in health among older individuals in the region, but also substantially reduce socio-economic inequalities in health and successful ageing.