Studies on the ecology of medical care: a comparative analysis in historical perspective, 1928-2018. / Estudios de ecología de la atención médica: análisis comparado en dimensión histórica, 1928-2018.

In the definition of health policies and decision-making on the part of health officials, there is often a prevailing separation between clinical practice, epidemiology, and public health. Although this division is naturalized from the viewpoint of hospitals and public agencies, it is artificial in the context of concrete territories and communities, where problems are not structured according to the fragmentation of knowledge, but rather express the complexities of the problems faced by individuals and population groups. In this context, this article compiles and analyzes studies on the ecology of medical care carried out between 1928 and 2018 that have revisited the pioneering study "The ecology of medical care" by White, Williams and Greenberg. The discussion is structured around three central issues: 1) recurrent themes in studies on the ecology of medical care; 2) health information systems and health surveys; and 3) the institutional hegemony of hospitals in the health field.

En la definición de las políticas de salud y en la toma de decisiones por parte de la gestión suele primar una separación entre clínica, epidemiología y salud pública, situación naturalizada desde la mirada de los hospitales y ministerios, pero artificial en los territorios, donde los problemas no se estructuran siguiendo la fragmentación de saberes, sino que se expresan en la complejidad de los problemas de las personas y los conjuntos poblacionales. Desde esa concepción, este trabajo recopila y analiza los estudios de ecología de la atención médica, realizados entre 1928 y 2018, que retoman el estudio precursor "The ecology of medical care", de White, Williams y Greenberg, para centrar la discusión en tres ejes: 1) las regularidades presentes en los estudios de ecología de la atención médica, independientemente del año y el país; 2) los sistemas de información en salud y las encuestas de salud; y 3) la hegemonía institucional del hospital en el campo de la salud.

Social inequalities and COVID-19 mortality between neighborhoods of Bariloche city, Argentina.

BACKGROUND: The COVID-19 pandemic has shown how intraurban inequalities are likely to reinforce health and social inequalities. Studies at small area level help to visualize social inequialities hidden in large areas as cities or regions. AIM: To describe the spatial patterning of COVID-19 death rates in neighborhoods of the medium-sized city of Bariloche, Argentina, and to explore its relationship with the socioeconomic characteristics of neighborhoods. METHODS: We conducted an ecological study in Bariloche, Argentina. The outcome was counts of COVID-19 deaths between June 2020 and May 2022 obtained from the surveillance system and georeferenced to neighborhoods. We estimated crude- and age-adjusted death rates by neighborhood using a Bayesian approach through a Poisson regression that accounts for spatial-autocorrelation via Conditional Autoregressive (CAR) structure. We also analyzed associations of age-adjusted death rates with area-level socioeconomic indicators. RESULTS: Median COVID-19 death rate across neighborhoods was 17.9 (10th/90th percentile of 6.3/35.2) per 10,000 inhabitants. We found lower age-adjusted rates in the city core and western part of the city. The age-adjusted death rate in the most deprived areas was almost double than in the least deprived areas, with an education-related relative index of inequality (RII) of 2.14 (95% CI 1.55 to 2.96). CONCLUSION: We found spatial heterogeneity and intraurban variability in age-adjusted COVID-19 death rates, with a clear social gradient, and a higher burden in already deprived areas. This highlights the importance of studying inequalities in health outcomes across small areas to inform placed-based interventions.

Assessing cohesion and diversity in the collaboration network of the SALURBAL project.

The SALURBAL (Urban Health in Latin America) Project is an interdisciplinary multinational network aimed at generating and disseminating actionable evidence on the drivers of health in cities of Latin America. We conducted a temporal multilayer network analysis where we measured cohesion over time using network structural properties and assessed diversity within and between different project activities according to participant attributes. Between 2017 and 2020 the SALURBAL network comprised 395 participants across 26 countries, 23 disciplines, and 181 institutions. While the cohesion of the SALURBAL network fluctuated over time, overall, an increase was observed from the first to the last time point of our analysis (clustering coefficient increased [0.83-0.91] and shortest path decreased [1.70-1.68]). SALURBAL also exhibited balanced overall diversity within project activities (0.5-0.6) by designing activities for different purposes such as capacity building, team-building, research, and dissemination. The network's growth was facilitated by the creation of new diverse collaborations across a range of activities over time, while maintaining the diversity of existing collaborations (0.69-0.75 between activity diversity depending on the attribute). The SALURBAL experience can serve as an example for multinational research projects aiming to build cohesive networks while leveraging heterogeneity in countries, disciplines, career stage, and across sectors.

Spatial Inequities in Life Expectancy in Small Areas of Buenos Aires, Argentina 2015-2017.

Studies of life expectancy (LE) in small areas of cities are relatively common in high-income countries but rare in Latin American countries. Small-area estimation methods can help to describe and quantify inequities in LE between neighborhoods and their predictors. Our objective was to analyze the distribution and spatial patterning of LE across small areas of Ciudad Autónoma de Buenos Aires (CABA), Argentina, and its association with socioeconomic characteristics. As part of the SALURBAL project, we used georeferenced death certificates in 2015-2017 for CABA, Argentina. We used a spatial Bayesian Poisson model using the TOPALS method to estimate age- and sex-specific mortality rates. We used life tables to estimate LE at birth. We obtained data on neighborhood socioeconomic characteristics from the 2010 census and analyzed their associations. LE at birth was higher for women (median of across neighborhoods = 81.1 years) compared to men (76.7 years). We found a gap in LE of 9.3 (women) and 14.9 years (men) between areas with the highest and the lowest LE. Better socioeconomic characteristics were associated with higher LE. For example, mean differences in LE at birth in areas with highest versus lowest values of composite SES index were 2.79 years (95% CI: 2.30 to 3.28) in women and 5.61 years (95% CI: 4.98 to 6.24) in men. We found large spatial inequities in LE across neighborhoods of a large city in Latin America, highlighting the importance of place-based policies to address this gap.

Variation in youth and young adult homicide rates and their association with city characteristics in Latin America: the SALURBAL study.

Background: Latin America and the Caribbean (LAC) is one of the most urbanized and violent regions worldwide. Homicides in youth (15-24 years old, yo) and young adults (25-39yo) are an especially pressing public health problem. Yet there is little research on how city characteristics relate to homicide rates in youth and young adults. We aimed to describe homicide rates among youth and young adults, as well as their association with socioeconomic and built environment factors across 315 cities in eight LAC countries. Methods: This is an ecological study. We estimated homicide rates in youth and young adults for the period 2010-2016. We investigated associations of homicide rates with sub-city education and GDP, Gini, density, landscape isolation, population and population growth using sex-stratified negative binomial models with city and sub-city level random intercepts, and country-level fixed effects. Findings: The mean sub-city homicide rate per 100,000 in persons aged 15-24 was 76.9 (SD = 95.9) in male and 6.7 (SD = 8.5) in female, and in persons aged 25-39 was 69.4 (SD = 68.9) in male and 6.0 (SD = 6.7) in female. Rates were higher in Brazil, Colombia, Mexico and El Salvador than in Argentina, Chile, Panama and Peru. There was significant variation in rates across cities and sub-cities, even after accounting for the country. In fully adjusted models, higher sub-city education scores and higher city GDP were associated with a lower homicide rate among male and female (rate ratios (RR) per SD higher value in male and female, respectively, 0.87 (CI 0.84-0.90) and 0.90 (CI 0.86-0.93) for education and 0.87 (CI 0.81-0.92) and 0.92 (CI 0.87-0.97) for GDP). A higher city Gini index was associated with higher homicide rates (RR 1.28 (CI 1.10-1.48) and 1.21 (CI 1.07-1.36) in male and female, respectively). Greater isolation da was also associated with higher homicide rates (RR 1.13 (CI 1.07-1.21) and 1.07 (CI 1.02-1.12) in male and female, respectively). Interpretation: City and sub-city factors are associated with homicide rates. Improvements to education, social conditions and inequality and physical integration of cities may contribute to the reduction of homicides in the region. Funding: The Wellcome Trust [205177/Z/16/Z].

Estudios de ecología de la atención médica: análisis comparado en dimensión histórica, 1928-2018 / Studies on the ecology of medical care: a comparative analysis in historical perspective, 1928-2018

RESUMEN En la definición de las políticas de salud y en la toma de decisiones por parte de la gestión suele primar una separación entre clínica, epidemiología y salud pública, situación naturalizada desde la mirada de los hospitales y ministerios, pero artificial en los territorios, donde los problemas no se estructuran siguiendo la fragmentación de saberes, sino que se expresan en la complejidad de los problemas de las personas y los conjuntos poblacionales. Desde esa concepción, este trabajo recopila y analiza los estudios de ecología de la atención médica, realizados entre 1928 y 2018, que retoman el estudio precursor "The ecology of medical care", de White, Williams y Greenberg, para centrar la discusión en tres ejes: 1) las regularidades presentes en los estudios de ecología de la atención médica, independientemente del año y el país; 2) los sistemas de información en salud y las encuestas de salud; y 3) la hegemonía institucional del hospital en el campo de la salud.

ABSTRACT In the definition of health policies and decision-making on the part of health officials, there is often a prevailing separation between clinical practice, epidemiology, and public health. Although this division is naturalized from the viewpoint of hospitals and public agencies, it is artificial in the context of concrete territories and communities, where problems are not structured according to the fragmentation of knowledge, but rather express the complexities of the problems faced by individuals and population groups. In this context, this article compiles and analyzes studies on the ecology of medical care carried out between 1928 and 2018 that have revisited the pioneering study "The ecology of medical care" by White, Williams and Greenberg. The discussion is structured around three central issues: 1) recurrent themes in studies on the ecology of medical care; 2) health information systems and health surveys; and 3) the institutional hegemony of hospitals in the health field.

Cesarean sections and social inequalities in 305 cities of Latin America.

Background: Cesarean section (CS) is a surgical procedure that, when medically justified, can help reduce maternal and infant morbidity and mortality. Worldwide CS rates (CSR) have been increasing; Latin America has rates that are among the highest in the world. Aim: Describe the variability of CSR across cities in Brazil, Colombia, Guatemala, Mexico, and Peru and examine the relationship of individual-level, sub-city, and city-level socioeconomic status (SES) with CSR. Methods: We used individual level data from vital statistics over the period 2014-2016 (delivery method, mother's age and education), census data to characterize sub-city SES and city GDP per capita from other sources compiled by the SALURBAL project. We fitted multilevel negative binomial regression models to estimate associations of SES with CSR. Results: 11,549,028 live births from 1,101 sub-city units in 305 cities of five countries were included. Overall, the CSR was 52%, with a wide range across sub-cities (13-91%). Of the total variability in sub-city CSRs, 67% was within countries. In fully adjusted model higher CSR was associated with higher maternal education [(PRR (CI95%) 0.81 (0.80-0.82) for lower educational level, 1.32 (1.31-1.33) for higher level (ref. medium category)], with higher maternal age [PRR (CI95%) 1.23 (1.22-1.24) for ages 20-34 years, and 1.48 (1.47-1.49) for ages ≥ 35 years (ref. ≤19 years], higher sub-city SES [(PRR (CI95%) 1.02 (1.01-1.03) per 1SD)], and higher city GDP per capita [(PRR (CI95%): 1.03 (1.00-1.07) for GDP between 10,500-18,000, and 1.09 (1.06-1.13) for GDP 18,000 or more (ref. <10,500)]. Conclusion: We found large variability in CSR across cities highlighting the potential role of local policies on CSR levels. Variability was associated in part with maternal and area education and GDP. Further research is needed to understand the reasons for this pattern and any policy implications it may have.

Enfoques predominantes en los estudios sobre calidad de vida relacionada a la salud de jóvenes sobrevivientes de cáncer en la infancia o adolescencia. Revisión integradora de la literatura científica / Predominant approaches in studies on health-related quality of life of young survivors of childhood or adolescent cancer: an integrative literature review

Resumen Los sobrevivientes de cáncer pediátrico constituyen una población creciente. La enfermedad padecida, su tratamiento o la ocurrencia de complicaciones tardías pueden afectar su calidad de vida relacionada a la salud (CVRS). Comprender la CVRS, es un desafío por su complejidad conceptual y la modalidad de su estudio. Objetivo: identificar las líneas de investigación predominantes en el estudio de CVRS en esta población. Métodos: revisión bibliográfica integrativa. Búsqueda sistematizada de artículos primarios indizados. Bases Scopus y PubMed. Resultados: 48 publicaciones seleccionadas, se identificaron cuatro líneas principales de investigación: CVRS en sobrevivientes en general; en sobrevivientes de largo plazo; estudio de determinantes de la CVRS; y estudio de aspectos metodológicos sobre medición de CVRS. Predomina el abordaje cuantitativo con instrumentos genéricos de medición, y el modelo conceptual de CVRS basado en la función, enfatiza la importancia de la funcionalidad física, psíquica y social y el impacto sobre ella de la enfermedad y el tratamiento. Conclusiones: incorporar un abordaje cualitativo, basado en el significado, para la comprensión de experiencias vividas desde una perspectiva subjetiva y holística, sería indispensable.

Abstract Survivors of childhood cancer constitute a growing population. The disease experienced, its treatment or the occurrence of late complications may affect survivors' health-related quality of life (HRQOL). Understanding HRQOL is a challenge due to its conceptual complexity and the mode in which it is studied. Objective: To identify the predominant lines of research in the study of HRQOL in this population. Methods: An integrative literature review was carried out, involving a systematic search of primary articles indexed in the Scopus and PubMed databases. Results: In the 48 publications selected, four main lines of research were identified: HRQOL in survivors in general; HRQOL in long-term survivors; the study of determinants of HRQOL; and the study of methodological aspects of HRQOL measurement. A quantitative approach using generic measurement instruments predominates, and the conceptual model of HRQOL based on function emphasizes the importance of physical, psychological, and social functionality and the impact of the disease and treatment on these aspects. Conclusions: incorporating a qualitative, meaning-based approach to the understanding of lived experiences from a subjective and holistic perspective is indispensable.

Predominant approaches in studies on health-related quality of life of young survivors of childhood or adolescent cancer: an integrative literature review. / Enfoques predominantes en los estudios sobre calidad de vida relacionada a la salud de jóvenes sobrevivientes de cáncer en la infancia o adolescencia. Revisión integradora de la literatura científica.

Survivors of childhood cancer constitute a growing population. The disease experienced, its treatment or the occurrence of late complications may affect survivors' health-related quality of life (HRQOL). Understanding HRQOL is a challenge due to its conceptual complexity and the mode in which it is studied. OBJECTIVE: To identify the predominant lines of research in the study of HRQOL in this population. METHODS: An integrative literature review was carried out, involving a systematic search of primary articles indexed in the Scopus and PubMed databases. RESULTS: In the 48 publications selected, four main lines of research were identified: HRQOL in survivors in general; HRQOL in long-term survivors; the study of determinants of HRQOL; and the study of methodological aspects of HRQOL measurement. A quantitative approach using generic measurement instruments predominates, and the conceptual model of HRQOL based on function emphasizes the importance of physical, psychological, and social functionality and the impact of the disease and treatment on these aspects. CONCLUSIONS: incorporating a qualitative, meaning-based approach to the understanding of lived experiences from a subjective and holistic perspective is indispensable.

Los sobrevivientes de cáncer pediátrico constituyen una población creciente. La enfermedad padecida, su tratamiento o la ocurrencia de complicaciones tardías pueden afectar su calidad de vida relacionada a la salud (CVRS). Comprender la CVRS, es un desafío por su complejidad conceptual y la modalidad de su estudio. OBJETIVO: identificar las líneas de investigación predominantes en el estudio de CVRS en esta población. Métodos: revisión bibliográfica integrativa. Búsqueda sistematizada de artículos primarios indizados. Bases Scopus y PubMed. RESULTADOS: 48 publicaciones seleccionadas, se identificaron cuatro líneas principales de investigación: CVRS en sobrevivientes en general; en sobrevivientes de largo plazo; estudio de determinantes de la CVRS; y estudio de aspectos metodológicos sobre medición de CVRS. Predomina el abordaje cuantitativo con instrumentos genéricos de medición, y el modelo conceptual de CVRS basado en la función, enfatiza la importancia de la funcionalidad física, psíquica y social y el impacto sobre ella de la enfermedad y el tratamiento. CONCLUSIONES: incorporar un abordaje cualitativo, basado en el significado, para la comprensión de experiencias vividas desde una perspectiva subjetiva y holística, sería indispensable.

Social inequalities between neighborhoods and cardiovascular disease: a multilevel analysis in a Latin American city.

Studies analyzing relations between cardiovascular diseases (CVDs) and environmental aspects in Latin American cities are relatively recent and limited, since most of them are conducted in high-income countries, analyzing mortality outcomes, and comprising large areas. This research focuses on adults with diabetes and/or hypertension under clinical follow-up who live in deprived areas. At the individual level we evaluated sociodemographic and cardiovascular risk factors from patient's records, and at the neighborhood level, socioeconomic conditions from census data. A multilevel analysis was carried out to study CVD. More women than men were under clinical follow-up, but men had higher frequency, higher odds, and shorter time to CVD diagnosis. Multilevel analysis showed that residing in neighborhoods with worst socioeconomic conditions leads to higher odds of CVDs, even after controlling for individual variables: OR (CI95%) of CVD in quartile 2 (Q2) 3.9 (1.2-12.1); Q3 4.0 (1.3-12.3); Q4 2.3 (0.7-8.0) (vs. highest socioeconomic level quartile). Among individuals living in unequal contexts, we found differences in CVD, which makes visible inequalities within inequalities. Differences between women and men should be considered through a gender perspective.

Social inequalities between neighborhoods and cardiovascular disease: a multilevel analysis in a Latin American city / Desigualdades sociais entre vizinhanças e doenças cardiovasculares: análise multinível em uma cidade latino-americana

Abstract Studies analyzing relations between cardiovascular diseases (CVDs) and environmental aspects in Latin American cities are relatively recent and limited, since most of them are conducted in high-income countries, analyzing mortality outcomes, and comprising large areas. This research focuses on adults with diabetes and/or hypertension under clinical follow-up who live in deprived areas. At the individual level we evaluated sociodemographic and cardiovascular risk factors from patient's records, and at the neighborhood level, socioeconomic conditions from census data. A multilevel analysis was carried out to study CVD. More women than men were under clinical follow-up, but men had higher frequency, higher odds, and shorter time to CVD diagnosis. Multilevel analysis showed that residing in neighborhoods with worst socioeconomic conditions leads to higher odds of CVDs, even after controlling for individual variables: OR (CI95%) of CVD in quartile 2 (Q2) 3.9 (1.2-12.1); Q3 4.0 (1.3-12.3); Q4 2.3 (0.7-8.0) (vs. highest socioeconomic level quartile). Among individuals living in unequal contexts, we found differences in CVD, which makes visible inequalities within inequalities. Differences between women and men should be considered through a gender perspective.

Resumo Os estudos que analisam as relações entre doenças cardiovasculares (DCVs) e aspectos ambientais em cidades latino-americanas são relativamente recentes e limitados. A maioria é realizada em países de alta renda analisando a mortalidade em grandes áreas. Esta investigação foca a população de adultos em acompanhamento clínico por diabetes e/ou hipertensão residentes em áreas carentes. No nível individual foram avaliados fatores sociodemográficos e de risco cardiovascular a partir dos prontuários médicos; e a partir de dados censitários, as condições socioeconômicas no nível da vizinhança. Mais mulheres do que homens estavam sob acompanhamento clínico, mas os homens apresentaram maior frequência, maior chance e menor tempo para diagnóstico de DCV. A análise multinível mostrou que residir em bairros com piores condições socioeconômicas leva a maiores chances de DCV, mesmo após o controle de variáveis ​​individuais. As OR (IC95%) de DCV foram: Q2 OR 3,9 (1,2-12,1); Q3 OR 4,0 (1,3-12,3); Q4 OR 2,3 (0,7-8,0) (referência: quartil de maior nível socioeconômico). Entre os indivíduos que vivem em contextos desiguais, encontramos diferenças nas DCV, mostrando desigualdades dentro das desigualdades. Diferenças entre homens e mulheres devem ser abordadas com uma perspectiva de gênero.

Are Wealthier Times Healthier in Cities? Economic Fluctuations and Mortality in Urban Areas of Latin America.

Objective: To analyze the relationship between economic conditions and mortality in cities of Latin America. Methods: We analyzed data from 340 urban areas in ten countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Guatemala, Mexico, Panama, Peru, and El Salvador. We used panel models adjusted for space-invariant and time-invariant factors to examine whether changes in area gross domestic product (GDP) per capita were associated with changes in mortality. Results: We find procyclical oscillations in mortality (i.e., higher mortality with higher GDP per capita) for total mortality, female population, populations of 0-9 and 45+ years, mortality due to cardiovascular diseases, malignant neoplasms, diabetes mellitus, respiratory infections and road traffic injuries. Homicides appear countercyclical, with higher levels at lower GDP per capita. Conclusions: Our results reveal large heterogeneity, but in our sample of cities, for specific population groups and causes of death, mortality oscillates procyclically, increasing when GDP per capita increases. In contrast we find few instances of countercyclical mortality.

[Intra-urban differentials of suicide: the role of social fragmentation in Argentina]. / Diferenciales intra-urbanos del suicidio: el rol de la fragmentación social en Argentina.

El suicidio constituye una de las principales causas de muerte por lesiones en Argentina y existen pocos estudios que analicen las variaciones geográficas intra-urbanas en países en desarrollo. El objetivo de este estudio fue analizar la relación entre el suicidio y el nivel socioeconómico y la fragmentación social en áreas pequeñas de la Ciudad Autónoma de Buenos Aires (CABA) durante el período 2011-2015. Se realizó un estudio ecológico utilizando datos sobre registros de suicidio en población residente de la CABA disponibles en el Ministerio de Seguridad de la Nación. Se llevó a cabo una regresión múltiple espacial para poner a prueba la relación entre el suicidio e indicadores de nivel socioeconómico y de fragmentación social por área. El riesgo de suicidio estuvo asociado positivamente a mayores índices de fragmentación social, mientras no mostró relación con el índice de pobreza. Los resultados de este estudio apoyan la hipótesis de fragmentación social como un factor asociado positivamente al aumento del suicidio a nivel intra-urbano en ciudades de países en desarrollo.

Suicide is one of the leading causes of death from injury in Argentina, and there are few studies analyzing intra-urban geographic variations in developing countries. The scope of this study was to analyze the relationship between suicide and socioeconomic status and social fragmentation in small areas of the Autonomous City of Buenos Aires (CABA) during the 2011-2015 period. An ecological study was conducted using data on suicide records in the resident population of the CABA available at the National Ministry of Security. A multiple spatial regression was carried out to test the relationship between suicide and indicators of socioeconomic status and social fragmentation by area. The risk of suicide was positively associated with higher indices of social fragmentation, whereas it was not related to the indices of poverty. The results of this study support the hypothesis of social fragmentation as a factor positively associated with the increase of intra-urban suicide in cities of developing countries.

Diferenciales intra-urbanos del suicidio: el rol de la fragmentación social en Argentina / Intra-urban differentials of suicide: the role of social fragmentation in Argentina

Abstract Suicide is one of the leading causes of death from injury in Argentina, and there are few studies analyzing intra-urban geographic variations in developing countries. The scope of this study was to analyze the relationship between suicide and socioeconomic status and social fragmentation in small areas of the Autonomous City of Buenos Aires (CABA) during the 2011-2015 period. An ecological study was conducted using data on suicide records in the resident population of the CABA available at the National Ministry of Security. A multiple spatial regression was carried out to test the relationship between suicide and indicators of socioeconomic status and social fragmentation by area. The risk of suicide was positively associated with higher indices of social fragmentation, whereas it was not related to the indices of poverty. The results of this study support the hypothesis of social fragmentation as a factor positively associated with the increase of intra-urban suicide in cities of developing countries.

Resumen El suicidio constituye una de las principales causas de muerte por lesiones en Argentina y existen pocos estudios que analicen las variaciones geográficas intra-urbanas en países en desarrollo. El objetivo de este estudio fue analizar la relación entre el suicidio y el nivel socioeconómico y la fragmentación social en áreas pequeñas de la Ciudad Autónoma de Buenos Aires (CABA) durante el período 2011-2015. Se realizó un estudio ecológico utilizando datos sobre registros de suicidio en población residente de la CABA disponibles en el Ministerio de Seguridad de la Nación. Se llevó a cabo una regresión múltiple espacial para poner a prueba la relación entre el suicidio e indicadores de nivel socioeconómico y de fragmentación social por área. El riesgo de suicidio estuvo asociado positivamente a mayores índices de fragmentación social, mientras no mostró relación con el índice de pobreza. Los resultados de este estudio apoyan la hipótesis de fragmentación social como un factor asociado positivamente al aumento del suicidio a nivel intra-urbano en ciudades de países en desarrollo.

Life expectancy and mortality in 363 cities of Latin America.

The concept of a so-called urban advantage in health ignores the possibility of heterogeneity in health outcomes across cities. Using a harmonized dataset from the SALURBAL project, we describe variability and predictors of life expectancy and proportionate mortality in 363 cities across nine Latin American countries. Life expectancy differed substantially across cities within the same country. Cause-specific mortality also varied across cities, with some causes of death (unintentional and violent injuries and deaths) showing large variation within countries, whereas other causes of death (communicable, maternal, neonatal and nutritional, cancer, cardiovascular disease and other noncommunicable diseases) varied substantially between countries. In multivariable mixed models, higher levels of education, water access and sanitation and less overcrowding were associated with longer life expectancy, a relatively lower proportion of communicable, maternal, neonatal and nutritional deaths and a higher proportion of deaths from cancer, cardiovascular disease and other noncommunicable diseases. These results highlight considerable heterogeneity in life expectancy and causes of death across cities of Latin America, revealing modifiable factors that could be amenable to urban policies aimed toward improving urban health in Latin America and more generally in other urban environments.

Characterising variability and predictors of infant mortality in urban settings: findings from 286 Latin American cities.

BACKGROUND: Urbanisation in Latin America (LA) is heterogeneous and could have varying implications for infant mortality (IM). Identifying city factors related to IM can help design policies that promote infant health in cities. METHODS: We quantified variability in infant mortality rates (IMR) across cities and examined associations between urban characteristics and IMR in a cross-sectional design. We estimated IMR for the period 2014-2016 using vital registration for 286 cities above 100 000 people in eight countries. Using national censuses, we calculated population size, growth and three socioeconomic scores reflecting living conditions, service provision and population educational attainment. We included mass transit availability of bus rapid transit and subway. Using Poisson multilevel regression, we estimated the per cent difference in IMR for a one SD (1SD) difference in city-level predictors. RESULTS: Of the 286 cities, 130 had <250 000 inhabitants and 5 had >5 million. Overall IMR was 11.2 deaths/1000 live births. 57% of the total IMR variability across cities was within countries. Higher population growth, better living conditions, better service provision and mass transit availability were associated with 6.0% (95% CI -8.3 to 3.7%), 14.1% (95% CI -18.6 to -9.2), 11.4% (95% CI -16.1 to -6.4) and 6.6% (95% CI -9.2 to -3.9) lower IMR, respectively. Greater population size was associated with higher IMR. No association was observed for population-level educational attainment in the overall sample. CONCLUSION: Improving living conditions, service provision and public transportation in cities may have a positive impact on reducing IMR in LA cities.

Bariloche: contrastes ocultos en un paraíso alpino: desigualdades socio-sanitarias en el espacio urbano / Bariloche: hidden contrasts in an alpine paradise: socio-sanitary inequalities in the urban space

INTRODUCCIÓN. La mayor parte de las desigualdades en salud observadas están relacionadas con desigualdades de otros planos de la vida social. Estudios de pequeñas áreas nos permiten visibilizar estos gradientes al descender el análisis a escalas más pequeñas. El objetivo de este estudio es relacionar la distribución espacial de enfermedad cardiovascular según condiciones de vida y lugar de atención. MATERIALES Y MÉTODOS. Se caracterizó la ciudad de Bariloche en base a las condiciones de vida de sus vecindarios seleccionando indicadores mediante un análisis factorial. Se ubicó espacialmente a la población atendida por diabetes e hipertensión arterial en los centros de salud. Se relevaron los registros médicos de esta población para analizar sus problemas de salud. Se analizó la distribución de cada dimensión y se calcularon las proporciones de las personas atendidas según condiciones de vida y lugar de atención. RESULTADOS. Casi la mitad (47,6%) de la población vive en vecindarios con condiciones de vida deficitarias y críticas. El 63,2% de las personas atendidas en centros de salud viven en vecindarios con peores condiciones de vida. Y la identificación de un gradiente positivo: ante peores condiciones de vida, mayor es la proporción de enfermedad cardiovascular. DISCUSIÓN. En el espacio urbano se entrelazan condiciones de vida con problemas de salud, configurándose distintas posibilidades de desarrollarlos. Al interior de una ciudad, pertenecer a determinada área implica la posibilidad/imposibilidad de acceder a niveles relativos de satisfacción de necesidades y presentar determinados problemas de salud. Permite identificar grupos y zonas críticas podría ser un insumo para el diseño de políticas públicas.

INTRODUCTION. Most of the observed health inequalities are related to inequalities in other contexts of social life. Local studies allow us to visualize these variations on a smaller scale. AIM. To examine spatial distribution of cardiovascular disease based on the living conditions and geographical location of health-care attention. Materials and Methods. Bariloche was characterized according to the living conditions of its neighborhoods by the selection of indicators through a factor analysis. The population treated for diabetes or hypertension in health-care centers was spatially distributed. Health problems were obtained from medical records. The distribution of each dimension was analyzed and the proportions of treated individuals according to living conditions and location of health-care attention were obtained. RESULTS. Almost half (47.6%) of the population lived in neighborhoods with deficient and cri-tical living conditions. Of those individuals treated for diabetes and/or hypertension, 63.2% lived in the neighborhoods with the worst living conditions. A positive gradient was identified: We identified a clear correlation between the overall quality of life and cardiovascular disease. DISCUSSION. In urban space, living conditions are closely related to health problems, establi-shing different possibilities to address the latter . In a city, residency in specific neighborhoods informs the possibilities / impossibilities to access to relative levels of needs satisfaction, and to develop certain outcomes. Identification of groups and critical zones could contribute to the development of specific public policies

["We see them from Monday to Friday:" Births by day of the week in the Autonomous City of Buenos Aires, 2004-2013]. / "Las atendemos de lunes a viernes": nacimientos según días de la semana en la Ciudad Autónoma de Buenos Aires, 2004-2013.

The objective of this article is to describe births according to their distribution by day of the week in order to characterize the scheduled or non-scheduled aspect of the labor and delivery process. A descriptive epidemiological study of the temporal distribution of the days of the week on which births occurred in the Autonomous City of Buenos Aires was carried out for the period 2004-2013, based on the Statistical Reports of Live Births database of the Directorate of Statistics and Health Information at the National Ministry of Health. The following variables were analyzed using descriptive statistics: establishment (public or private sector), gestational age, maternal age, and mother's level of education. The analysis reveals that births decrease significantly on Saturdays and Sundays in both public and private establishments, with a greater decrease being observed in private establishments. Births at week 37 are more frequent in private establishments and decrease on non-working days. For mothers with higher levels education, fewer births occurred on weekends. Analyzing the day of the week on which births occur reveals the medicalization of the delivery process and could indicate that the scheduling and induction of births occur in private establishments to a greater extent than in public establishments.

El objetivo de este trabajo es describir los nacimientos según su distribución en días de la semana a fin de caracterizar el aspecto programado o no del proceso de parto y nacimiento. Se realizó un estudio epidemiológico descriptivo de la distribución temporal de los días de la semana en que ocurrieron los nacimientos en la Ciudad Autónoma de Buenos Aires, para el período 2004-2013, a partir de la base de datos del Informe Estadístico de Nacido Vivo de la Dirección de Estadísticas e Información de Salud del Ministerio de Salud de la Nación. Se analizaron las siguientes variables: establecimiento (público o privado), edad gestacional, edad y nivel de instrucción de la madre. El análisis muestra que los nacimientos disminuyen significativamente los sábados y domingos en los establecimientos públicos y privados, siendo mayor la disminución en los establecimientos privados; que los nacimientos en la semana 37 son más frecuentes en los establecimientos privados y disminuyen en los días no laborables; y que a mayor nivel de instrucción materna son menores los nacimientos durante los fines de semana. Analizar el día de la semana en el que ocurren los nacimientos transparenta la medicalización del proceso de parto e indicaría que la programación e inducción de los nacimientos ocurre en los establecimientos privados en mayor medida que en los establecimientos públicos.

Geografías del suicidio en Argentina: un estudio ecológico espacial durante los períodos 1999-2003 y 2008-2012 / Geographies of suicide in Argentina: a spatial ecological study during 1999-2003 and 2008-2012 periods

RESUMEN Objetivo Describir la distribución geográfica y el rol de factores sociodemográficos sobre la mortalidad por suicidios, de acuerdo con sexo y grupos de edad en Argentina durante los períodos 1999-2003 y 2008-2012. Método El rol de factores sociodemográficos sobre la mortalidad por suicidios y su distribución geográfica fueron analizados mediante regresiones múltiples espaciales. Se incluyeron tres variables independientes: un índice de fragmentación social, un índice de pobreza y la densidad poblacional como indicador del nivel de ruralidad. Resultados La fragmentación social y el suicidio estuvieron directamente relacionados en hombres de 10-59 años y mujeres de 10-29 años durante 1999-2003. Durante 2008-2012 el riesgo de suicidio fue mayor en áreas de baja densidad poblacional, salvo en mujeres de 10-29 años. Conclusiones Los resultados obtenidos en este estudio apoyan la hipótesis de fragmentación social como fenómeno asociado al riesgo de suicidio en departamentos de la Argentina, pero también dan apoyo a la hipótesis de un mayor riesgo de suicidio en áreas rurales. Las medidas de prevención del suicidio podrían enfocarse en políticas que promuevan la integración social, especialmente en población joven, así como también una mayor integración de las áreas rurales con el resto del territorio.(AU)

ABSTRACT Objective The aim of this study was to describe the geographical distribution and the role of sociodemographic factors on mortality by suicides, according to sex and age groups, in Argentina during the periods 1999-2003 and 2008-2012. Methods The role of sociodemographic factors on mortality by suicides and their geographical distribution were analyzed by means of multiple spatial regressions. Three independent variables were included: an index of social fragmentation, a poverty index and population density, as an indicator of the level of rurality. Results Social fragmentation and suicide were directly related in men 10-59 years old and women 10-29 years old during 1999-2003. During 2008-2012, the risk of suicide was higher in areas of low population density, except for women aged 10-29 years. Conclusions The results obtained in this study support the hypothesis of social fragmentation as a phenomenon associated with the risk of suicide in departments of Argentina, but also support the hypothesis of an increased risk of suicide in rural areas. Suicide prevention measures could focus on policies that promote social integration, especially in the young population, as well as greater cohesion of rural areas.(AU)