The role of gender inequality and health expenditure on the coverage of demand for family planning satisfied by modern contraceptives: a multilevel analysis of cross-sectional studies in 14 LAC countries.

Background: Despite international efforts to improve reproductive health indicators, little attention is paid to the contributions of contextual factors to modern contraceptive coverage, especially in the Latin America and the Caribbean (LAC) region. This study aimed to identify the association between country-level Gender Inequality and Health Expenditure with demand for family planning satisfied by modern contraceptive methods (DFPSm) in Latin American sexually active women. Methods: Our analyses included data from the most recent (post-2010) Demographic and Health Survey or Multiple Indicator Cluster Survey from 14 LAC countries. Descriptive analyses and multilevel logistic regressions were performed. Six individual-level factors were included. The effect of the country-level factors Gender Inequality Index (GII) and Current Health Expenditure on DFPSm was investigated. Findings: DFPSm ranged from 41.8% (95% CI: 40.2-43.5) in Haiti to 85.6% (95% CI: 84.9-86.3) in Colombia, with an overall median coverage of 77.8%. A direct association between the odds of DFPSm and woman's education, wealth index, and the number of children was identified. Women from countries in the highest GII tertile were less likely (OR: 0.32, 95% CI: 0.13-0.76) to have DFPSm than those living in countries in the lowest tertile. Interpretation: Understanding the contribution of country-level factors to modern contraception may allow macro-level actions focused on the population's reproductive needs. In this sense, country-level gender inequalities play an important role, as well as individual factors such as wealth and education. Funding: Bill and Melinda Gates Foundation and Associação Brasileira de Saúde Coletiva (ABRASCO).

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

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

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

[Economic, social, and health determinants that influence exclusive breastfeeding in Colombia]. / Determinantes económicos, sociales y de salud que inciden en la lactancia materna exclusiva en Colombia.

Exclusive breastfeeding (EBF) is an important practice that offers many benefits, such as nutritional support, prevention of infectious and chronic diseases, and assistance in psychosocial and cognitive development. This study aims to identify the determinants associated with EBF abandonment in 1,527 children under six months of age, based on information collected by the Colombian National Survey of Nutritional Status and the Colombian National Demographic and Health Survey, 2010. This is an observational cross-sectional cohort study, in which a hierarchical Poisson regression model with robust variance was applied; considering in the first level the factors associated with the mother and child and, in the second level, the information of 32 departments and Bogotá. We noticed a high rate abandonment of EBF (57.6%) and its variation between departments. The factors associated with a longer time of EBF were higher maternal schooling level, having a partner, knowledge in breastfeeding, belonging to a lower level of income, living in the eastern region, having delivery assisted by qualified team, and low birth weight. According to the variance partition coefficient (VPC), 3.2% of the probability of abandonment of EBF may be related to factors within the departmental scope. The median odds ratio (MOR) indicates that the individual risk of abandoning EBF of a child would increase by 47% if the child moved from a department with a low prevalence of abandonment to a department with high prevalence. This study allows a better understanding of the abandonment of EBF from its determinants, providing evidence to implement more effective interventions for child nutrition.

La lactancia materna exclusiva (LME) es fundamental. Algunos beneficios son su aporte nutricional, prevención de enfermedades infecciosas y crónicas, el desarrollo psicosocial y cognitivo. El objetivo del estudio fue establecer los determinantes asociados al abandono de la LME en 1.527 menores de seis meses, a partir de la información recolectada en la Encuesta Nacional de Situación Nutricional en Colombia y en la Encuesta Nacional de Demografía y Salud, 2010. Es un estudio observacional de corte transversal en el que se aplicó un modelo jerárquico de regresión de Poisson con varianza robusta, tomando como primer nivel factores asociados a la madre y al niño, y como segundo nivel, la información de 32 departamentos y Bogotá. Se resalta el elevado abandono de la LME (57,6%) y su variación entre departamentos. La mayor escolaridad de la madre, tener un compañero, educación en lactancia, pertenecer al quintil de riqueza más pobre, residir en la región oriental, contar con un parto atendido por personal calificado y el bajo peso al nacer favorecen el tiempo de LME. Según el coeficiente de partición de varianza (CPV), un 3,2% de la probabilidad de abandono de la LME podría deberse a factores del nivel departamental. La mediana del odds ratio (MOR) indicó que el riesgo individual de abandono de LME para un niño se incrementa en 47% si este cambiara de residencia de un departamento de baja prevalencia de abandono a uno de alta. Este estudio contribuye a una mayor comprensión del abandono de la LME desde los determinantes, aportando evidencia para el diseño de intervenciones más costo-efectivas en alimentación infantil.

O aleitamento materno exclusivo (AME) é importante. Essa prática oferece muitos benefícios, como aporte nutricional, prevenção de doenças infecciosas e crônicas, e auxílio no desenvolvimento psicossocial e cognitivo. Este estudo teve como objetivo identificar os determinantes associados ao abandono do AME em 1.527 crianças menores de seis meses, com base nas informações coletadas na Pesquisa Colombiana de Situação Alimentar e Nutricional e na Pesquisa Nacional de Demografia e Saúde da Colômbia, 2010. Trata-se de um estudo observacional, de coorte transversal, no qual foi aplicado um modelo hierárquico de regressão de Poisson com variância robusta, considerando no primeiro nível os fatores associados à mãe e à criança e no segundo nível as informações de 32 departamentos e de Bogotá. Destaca-se o elevado abandono do AME (57,6%) e sua variação entre os departamentos. Estiveram associados ao maior tempo de AME maior escolaridade da mãe, ter companheiro, conhecimento em amamentação, pertencer ao baixo nível de renda, morar na região oriental, ter parto assistido por equipe qualificada e baixo peso ao nascer. De acordo com o coeficiente de partição de variância (CPV), 3,2% da probabilidade de abandono do AME pode estar relacionada a fatores no âmbito departamental. A mediana do odds ratio (MOR) aponta que o risco individual de abandono do AME para uma criança aumentaria em 47% se a criança mudasse de um departamento com baixa prevalência de abandono para um departamento com alta prevalência. Este estudo possibilita uma melhor compreensão do abandono do AME a partir de seus determinantes, fornecendo evidências para implementar intervenções mais efetivas para a alimentação infantil.

Trends in undernutrition mortality among children under five years of age and adults over 60. / Tendencias en la mortalidad por desnutrición en menores de 5 años y mayores de 60 años

INTRODUCTION: Children under five years of age living in poor areas and with low availability of healthy food have a higher risk of undernutrition-related mortality. However, this relationship has not been well established among older adults. OBJECTIVE: To analyse socioeconomic inequality trends related to undernutrition mortality in children under five years of age and adults over 60 in Colombian municipalities during 2003-2009 and 2010-2016. MATERIALS AND METHODS: We conducted an ecological study of trends between 2003 and 2016. The study population consisted of children under five years of age and adults over 60 residing in the Colombian municipalities during the study period. We estimated smoothed and standardized mortality rates by fitting a hierarchical Bayesian model and explored their relationship with five socioeconomic area-level variables. RESULTS: In most of the municipalities, undernutrition-related mortality was three times higher in older adults compared to children. Moreover, the difference in the risk of undernutrition-related mortality between municipalities showed a marked reduction. Finally, the poor and less developed municipalities had higher rates of undernutrition-related mortality in children; conversely, wealthier territories had higher rates in older adults. CONCLUSIONS: Although in most of the municipalities the mortality rates due to undernutrition in children under five and older adults have decreased, their socioeconomic conditions influence in different ways the risk of mortality for these two populations so there is the need to develop age-specific strategies to close social gaps considering the structural conditions of the areas.

Introducción. Los niños menores de cinco años que viven en zonas pobres y con poca disponibilidad de alimentos saludables, tienen mayor riesgo de mortalidad relacionada con la desnutrición, relación que no se ha determinado claramente entre los adultos mayores. Objetivo. Analizar las tendencias de la desigualdad socioeconómica relacionada con la mortalidad por desnutrición en niños menores de cinco años y adultos mayores de 60 en los municipios colombianos durante 2003-2009 y 2010-2016. Materiales y métodos. Se hizo un estudio ecológico de tendencias entre 2003 y 2016. La población de estudio incluyó a niños menores de cinco años y adultos mayores de 60 residentes en los municipios colombianos durante el período de estudio. Se estimaron las tasas de mortalidad suavizadas y estandarizadas ajustadas mediante un modelo bayesiano jerárquico y se exploró su relación con cinco variables socioeconómicas a nivel de área. Resultados. En la mayoría de los municipios, la mortalidad relacionada con la desnutrición fue tres veces mayor en los adultos mayores que en los niños. Además, la diferencia en el riesgo de mortalidad por desnutrición entre municipios mostró una marcada reducción. Por último, los municipios pobres y menos desarrollados registraron tasas más altas de mortalidad infantil relacionada con la desnutrición, en tanto que, en los territorios más ricos, las tasas más altas se registraron en adultos mayores. Conclusiones. Si bien en la mayoría de los municipios las tasas de mortalidad por desnutrición en niños menores de cinco años y adultos mayores han disminuido, sus condiciones socioeconómicas influyen de diferente manera en el riesgo de mortalidad de estas dos poblaciones, por lo que surge la necesidad de desarrollar estrategias específicas por edades para cerrar las brechas sociales con base en las condiciones estructurales de las zonas.

Trends in undernutrition mortality among children under five years of age and adults over 60 / Tendencias en la mortalidad por desnutrición en menores de 5 años y mayores de 60 años

Introduction: Children under five years of age living in poor areas and with low availability of healthy food have a higher risk of undernutrition-related mortality. However, this relationship has not been well established among older adults. Objective: To analyse socioeconomic inequality trends related to undernutrition mortality in children under five years of age and adults over 60 in Colombian municipalities during 2003-2009 and 2010-2016. Materials and methods: We conducted an ecological study of trends between 2003 and 2016. The study population consisted of children under five years of age and adults over 60 residing in the Colombian municipalities during the study period. We estimated smoothed and standardized mortality rates by fitting a hierarchical Bayesian model and explored their relationship with five socioeconomic area-level variables. Results: In most of the municipalities, undernutrition-related mortality was three times higher in older adults compared to children. Moreover, the difference in the risk of undernutrition-related mortality between municipalities showed a marked reduction. Finally, the poor and less developed municipalities had higher rates of undernutrition-related mortality in children; conversely, wealthier territories had higher rates in older adults. Conclusions: Although in most of the municipalities the mortality rates due to undernutrition in children under five and older adults have decreased, their socioeconomic conditions influence in different ways the risk of mortality for these two populations so there is the need to develop age-specific strategies to close social gaps considering the structural conditions of the areas.

Introducción. Los niños menores de cinco años que viven en zonas pobres y con poca disponibilidad de alimentos saludables, tienen mayor riesgo de mortalidad relacionada con la desnutrición, relación que no se ha determinado claramente entre los adultos mayores. Objetivo. Analizar las tendencias de la desigualdad socioeconómica relacionada con la mortalidad por desnutrición en niños menores de cinco años y adultos mayores de 60 en los municipios colombianos durante 2003-2009 y 2010-2016. Materiales y métodos. Se hizo un estudio ecológico de tendencias entre 2003 y 2016. La población de estudio incluyó a niños menores de cinco años y adultos mayores de 60 residentes en los municipios colombianos durante el período de estudio. Se estimaron las tasas de mortalidad suavizadas y estandarizadas ajustadas mediante un modelo bayesiano jerárquico y se exploró su relación con cinco variables socioeconómicas a nivel de área. Resultados. En la mayoría de los municipios, la mortalidad relacionada con la desnutrición fue tres veces mayor en los adultos mayores que en los niños. Además, la diferencia en el riesgo de mortalidad por desnutrición entre municipios mostró una marcada reducción. Por último, los municipios pobres y menos desarrollados registraron tasas más altas de mortalidad infantil relacionada con la desnutrición, en tanto que, en los territorios más ricos, las tasas más altas se registraron en adultos mayores. Conclusiones. Si bien en la mayoría de los municipios las tasas de mortalidad por desnutrición en niños menores de cinco años y adultos mayores han disminuido, sus condiciones socioeconómicas influyen de diferente manera en el riesgo de mortalidad de estas dos poblaciones, por lo que surge la necesidad de desarrollar estrategias específicas por edades para cerrar las brechas sociales con base en las condiciones estructurales de las zonas.

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

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

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

Exploratory spatial analysis of diabetes mortality and its relationship with the socioeconomic conditions of Colombian municipalities.

Type 2 diabetes mellitus prevalence has increased worldwide, especially in low- and middle-income countries. This study aimed to evaluate in the Colombian context whether the geographic variations of mortality due to type 2 diabetes mellitus are random or statistically significant and to measure the effect of the socioeconomic conditions of municipalities on these variations. An ecological study of trends for regions and subregions was undertaken considering two periods (2003-2009 and 2010-2016). The study population consisted of adults of 20 to 79 years old residing in each of Colombia's municipalities during the period 2003-2016. Smoothed and standardized mortality rates were obtained by fitting a hierarchical Bayesian model, which considers the spatial structure of the data. Four socioeconomic variables related to municipal deprivation and development were included into the model to obtain their relative risk (RR) and 95% credible intervals. Mortality due to type 2 diabetes mellitus decrease between 2003 and 2016 in Colombia, both nationally and regionally. In addition, there was a clear positive association between mortality due to diabetes mellitus and the level of municipal development; the wealthiest and most developed municipalities had higher mortality risks.

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

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

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

Tendencia del bajo peso al nacer en recién nacidos a término y su relación con la pobreza y el desarrollo municipal en Colombia. 2000-2014 / Tendency of low birth weight in full-term newborns and its relationship with poverty and municipal development in Colombia. 2000-2014

El objetivo del estudio fue describir las prevalencias de bajo peso al nacer a término y las desigualdades socio-geográficas entre los municipios y regiones de Colombia. Se realizó un estudio ecológico longitudinal a partir de los registros de estadísticas vitales del Departamento Administrativo Nacional de Estadística (DANE) de 1096 municipios de Colombia entre los años 2000 y 2014. La población de estudio fueron 7.514.492 nacidos vivos a término, de partos de único feto de madres entre 15 a 45 años. Se ajustó un modelo jerárquico bayesiano para la estimación de riesgos relativos suavizados y sus intervalos de credibilidad (95%). Como resultados se encontró que la prevalencia de bajo peso al nacer en Colombia fue de 2,28 (2,26-2,29), con una tendencia a la reducción pasando de 2,80 en el 2000 a 1.79 en el 2014. Se observaron desigualdades territoriales, en donde los municipios más pobres y menos desarrollados mostraron mayores riesgos de bajo peso al nacer a término, tendencia que se mantuvo a lo largo del periodo analizado. En conclusión, existe una tendencia a la disminución de bajo peso al nacer a término en Colombia, para cada una de sus regiones y un gradiente social negativo.

The objective of the study was to describe the prevalence of term low birth weight and the relationship with sociogeographical inequalities between the municipalities and regions of Colombia. A longitudinal ecological study was carried out based on the vital statistics records of the National Administrative Department of Statistics (DANE) of 1096 Colombian municipalities between 2000 and 2014. The study population was 7,514,492 live births at term, from deliveries to mothers between 15 and 45 years old. A Bayesian hierarchical model was adjusted for the estimation of smoothed relative risks and their credibility intervals (95%). The prevalence of term low birth weight in Colombia was 2.28 (2.26-2.29), with a tendency to decrease from 2.80 in 2000 to 1.79 in 2014. Territorial inequalities were observed, where poorer and less developed municipalities showed greater risks of term low birth weight, a trend that was maintained throughout the period analyzed. In conclusion, term low birth weight is decreasing in Colombia overall and in each of its regions, with a negative social gradient.

Exploratory spatial analysis of diabetes mortality and its relationship with the socioeconomic conditions of Colombian municipalities / Análisis espacial exploratorio de la mortalidad por diabetes y la relación con condiciones socioeconómicas en los municipios colombianos / Análise espacial exploratória da mortalidade por diabetes e a relação com condições socioeconômicas nos municípios colombianos

Type 2 diabetes mellitus prevalence has increased worldwide, especially in low- and middle-income countries. This study aimed to evaluate in the Colombian context whether the geographic variations of mortality due to type 2 diabetes mellitus are random or statistically significant and to measure the effect of the socioeconomic conditions of municipalities on these variations. An ecological study of trends for regions and subregions was undertaken considering two periods (2003-2009 and 2010-2016). The study population consisted of adults of 20 to 79 years old residing in each of Colombia's municipalities during the period 2003-2016. Smoothed and standardized mortality rates were obtained by fitting a hierarchical Bayesian model, which considers the spatial structure of the data. Four socioeconomic variables related to municipal deprivation and development were included into the model to obtain their relative risk (RR) and 95% credible intervals. Mortality due to type 2 diabetes mellitus decrease between 2003 and 2016 in Colombia, both nationally and regionally. In addition, there was a clear positive association between mortality due to diabetes mellitus and the level of municipal development; the wealthiest and most developed municipalities had higher mortality risks.

La prevalencia de la diabetes mellitus tipo 2 ha aumentado a nivel global, principalmente en los países de renta media y baja. El estudio tuvo como objetivo evaluar si en Colombia las variaciones geográficas de la mortalidad por diabetes mellitus tipo 2 son aleatorias o estadísticamente significativas, además de medir el efecto de las condiciones socioeconómicas de los municipios sobre esas variaciones. Se realizó un estudio ecológico de las tendencias en las regiones y sub-regiones, considerando dos períodos (2003-2009 y 2010-2016). La población del estudio incluía adultos entre 20 y 79 años de edad, residentes en cada municipio de Colombia, durante el período de 2003-2016. Las tasas de mortalidad suavizadas y estandarizadas se obtuvieron mediante un ajuste de un modelo bayesiano jerárquico, teniendo en cuenta la estructura espacial de los datos. Cuatro variables socioeconómicas relacionadas con la privación y el desarrollo municipal se incluyeron en el modelo para obtener el riesgo relativo (RR) e intervalos de credibilidad de 95%. La mortalidad por diabetes mellitus tipo 2 disminuyó entre 2003 y 2016 en Colombia, en los niveles tanto nacional, como regional. Asimismo, hubo una asociación positiva entre mortalidad por diabetes mellitus y nivel de desarrollo municipal; los municipios más ricos y más desarrollados presentaron un mayor riesgo de mortalidad.

A prevalência do diabetes mellitus tipo 2 tem aumentado em nível global, principalmente nos países de renda média e baixa. O estudo teve como objetivo avaliar se na Colômbia, as variações geográficas da mortalidade por diabetes mellitus tipo 2 são aleatórias ou estatisticamente significativas, além de medir o efeito das condições socioeconômicas dos municípios sobre essas variações. Foi realizado um estudo ecológico das tendências nas regiões e sub-regiões, considerando dois períodos (2003-2009 e 2010-2016). A população do estudo incluía adultos entre 20 e 79 anos de idade, residentes em cada município da Colômbia no período de 2003-2016. As taxas de mortalidade suavizadas e padronizadas foram obtidas pelo ajuste de um modelo bayesiano hierárquico, levando em conta a estrutura espacial dos dados. Quatro variáveis socioeconômicas relacionadas à privação e ao desenvolvimento municipal foram incluídas no modelo para obter o risco relativo (RR) e intervalos de credibilidade de 95%. A mortalidade por diabetes mellitus tipo 2 diminuiu entre 2003 e 2016 na Colômbia, nos níveis tanto nacional quanto regional. Além disso, houve uma associação positiva entre mortalidade por diabetes mellitus e nível de desenvolvimento municipal; os municípios mais ricos e mais desenvolvidos apresentaram o maior risco de mortalidade.

[Full-term low birth weight and its relationship with the socioeconomic conditions of municipalities in Antioquia: Spatio-temporal analysis].

INTRODUCTION: Low birth weight is one of the main health predictors for childhood and adulthood. It is highly prevalent in developing countries and in children from poorer social classes. OBJECTIVE: To analyze the geographical distribution and the trends of full-term low birth weight in the 125 municipalities of the department of Antioquia and their association with the socioeconomic conditions of the municipalities between 2000 and 2014. MATERIALS AND METHODS: We conducted a longitudinal ecological study. The dependent variable was the prevalence of full-term low birth weight in 125 municipalities. The socioeconomic conditions of the municipalities were evaluated using the Human Development Index and the unsatisfied basic needs index. RESULTS: Between 2000 and 2014, the prevalence of full-term low birth weight in Antioquia was 2.7 per 100 live births; this prevalence decreased steadily over time. This trend was also observed between regions, with the exception of the Occidente and Urabá regions, which showed increases of approximately 20.0%. The results also showed a reduction in geographical differences between the 125 municipalities, with the coefficient of variation decreasing from 20.6% to 13.72% over the 14-yearperiod. Finally, we found a positive social gradient between the full-term low birth weight prevalence and the level of development in the municipalities. CONCLUSION: Full-term low birth weight prevalence decreased between 2000 and 2014, with some regions showing greater reductions than others. Paradoxically, less developed and poorer areas had a lower prevalence, which may be a result of underreporting of birth weight information in these municipalities.

Full-term low birth weight and its relationship with the socioeconomic conditions of municipalities in Antioquia: Spatio-temporal analysis / Bajo peso al nacer en niños nacidos a término en Antioquia y su relación con las condiciones socioeconómicas de los municipios, un análisis espacio-temporal

Abstract Introduction: Low birth weight is one of the main health predictors for childhood and adulthood. It is highly prevalent in developing countries and in children from poorer social classes. Objective: To analyze the geographical distribution and the trends of full-term low birth weight in the 125 municipalities of the department of Antioquia and their association with the socioeconomic conditions of the municipalities between 2000 and 2014. Materials and methods: We conducted a longitudinal ecological study. The dependent variable was the prevalence of full-term low birth weight in 125 municipalities. The socioeconomic conditions of the municipalities were evaluated using the Human Development Index and the unsatisfied basic needs index. Results: Between 2000 and 2014, the prevalence of full-term low birth weight in Antioquia was 2.7 per 100 live births; this prevalence decreased steadily over time. This trend was also observed between regions, with the exception of the Occidente and Urabá regions, which showed increases of approximately 20.0%. The results also showed a reduction in geographical differences between the 125 municipalities, with the coefficient of variation decreasing from 20.6% to 13.72% over the 14-year period. Finally, we found a positive social gradient between the full-term low birth weight prevalence and the level of development in the municipalities. Conclusion: Full-term low birth weight prevalence decreased between 2000 and 2014, with some regions showing greater reductions than others. Paradoxically, less developed and poorer areas had a lower prevalence, which may be a result of underreporting of birth weight information in these municipalities.

Resumen Introducción. El bajo peso al nacer es uno de los principales indicadores predictores de la salud en la infancia y la adultez, y su prevalencia es elevada en los países en desarrollo y en niños de clases sociales pobres. Objetivo. Analizar la distribución geográfica y la tendencia del bajo peso al nacer de niños nacidos a término en los 125 municipios de Antioquia, y su asociación con las condiciones socioeconómicas de los municipios entre el 2000 y el 2014. Materiales y métodos. Se hizo un estudio ecológico longitudinal. La variable dependiente fue el bajo peso al nacer a término en los 125 municipios; las condiciones socioeconómicas de los municipios se evaluaron según sus índices de desarrollo humano y de necesidades básicas insatisfechas. Resultados. La prevalencia de bajo peso al nacer a término en Antioquia fue de 2,7 por 100 nacidos vivos entre 2000 y 2014, con una reducción constante. Esta tendencia se observó en todas las subregiones, excepto en las de Occidente y Urabá, en las cuales el incremento fue de 20 %. Los resultados evidenciaron una reducción de las brechas geográficas entre los 125 municipios. Además, en todos los trienios se evidenció un gradiente social positivo en la asociación entre el bajo peso al nacer a término y las condiciones socioeconómicas de los municipios. Conclusión. Se observó una mayor tendencia decreciente del bajo peso al nacer a término en unas subregiones. Paradójicamente, se registró una menor prevalencia de bajo peso al nacer a término en las regiones menos desarrolladas y más pobres, lo que posiblemente se explica por el subregistro del peso al nacer.

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

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

Índice de vulnerabilidad al VIH en población habitante de calle / HIV vulnerability index in homeless persons

Objetivo. Se reconoce que las vulnerabilidades sociales tienden a ocurrir con el VIH, pero pocos estudios han tratado de medir la vulnerabilidad al VIH y no se logra identificar en la literatura la unificación frente al concepto y la manera de operativizarlo. El objetivo de esta investigación fue determinar un índice de vulnerabilidad, y su relación con la infección por VIH en población habitante de calle de la ciudad de Medellín. Material y método. Se realizó un estudio descriptivo transversal con 338 habitantes de calle de Medellín utilizando el muestreo de tiempo y lugar. En la construcción del índice se realizó un análisis factorial de tipo exploratorio y un análisis factorial confirmatorio. Resultados. Se identificaron cuatro factores que explicaron el 50,49% de la varianza. Se encontró que la población con alta vulnerabilidad al VIH tenía cinco veces el riesgo de tener VIH, esta asociación fue ajustada por variables sociodemográficas de edad, sexo, estado civil y nivel de escolaridad. Conclusiones. Se propone un índice de vulnerabilidad al VIH, el cual se definió como la reducción de la capacidad de anticiparse (conocimientos y creencias erróneas), resistirse (prácticas sexuales y consumo de drogas) y recuperarse (apoyo social y rechazo). Lo cual limita la capacidad para acceder a servicios de prevención, atención, y apoyo al VIH (AU)

Purpose: While there is evidence that social vulnerabilities tend to co-occur with HIV, few studies have measured HIV vulnerability. To date, there is no consensus in the literature regarding how to measure or operationalize HIV vulnerability. Therefore, the purpose of this study was to determine an HIV vulnerability index in homeless persons in the city of Medellín, Colombia. Material and methods: This cross-sectional study included 338 homeless persons in the city of Medellín, Colombia, and time-location sampling was used. During the construction of the index, an exploratory factor analysis, and a confirmatory factor analysis (CFA) were performed. Results: Four factors accounting for 50,49% of the variance were identified. The population with high HIV vulnerability had a five-fold greater risk of being infected with HIV. This association was adjusted for socio-demographic variables including age, gender, civil status, and education level. Conclusions. We propose an HIV vulnerability index that is defined as the reduced ability to anticipate (knowledge and erroneous beliefs), resist (sexual practices and drug use), and recover (social support and rejection), which limits the ability to access HIV prevention, attention, and support services (AU)

Accesibilidad geográfica al cuidado obstétrico y neonatal y su efecto en la mortalidad neonatal temprana en Colombia 2012-2014 / Geographical Accessibility to Obstetric and Neonatal Care and its Effect on Early Neonatal Mortality in Colombia, 2012-2014

Introduction: The distribution of health resources influences early neonatal mortality, granting access to obstetric care which is a major public health problem. However, the geographical dimension of this influence has not been studied in Colombia. Objective: To describe the geographical accessibility to obstetric and neonatal care beds and its association with early neonatal mortality in Colombia and its municipalities. Method: An ecological study at municipal level was carried out. Ordinary least squares (OLS) regression and a geographically weighted regression (GWR) were used to explore statistical and spatial associations. Results: The municipalities in Colombia with Higher mortality tend to have lower geographical accessibility to obstetric and neonatal beds after controlling the fertility and economic characteristics of these municipalities. This association is significant only in municipalities of the west coast. The strength of this association decreases in inner municipalities. Discussion: The centralization of obstetric and neonatal beds in major municipalities around the central region leaves municipalities with high risk of mortality underserved. The decentralization of obstetric and neonatal healthcare resources is a mandatory issue in order to reduce geographical disparities in mortality and to improve neonatal survival, and a healthy beginning of life...(AU)

Introducción: La distribución de los recursos de salud influencia la mortalidad neonatal temprana, garantizar el acceso atención obstétrica es un problema de salud pública. Sin embargo, la dimensión geográfica de esta influencia no ha sido estudiada en Colombia. Objetivo: Describir la accesibilidad geográfica a camas obstétricas y neonatales y su asociación con la mortalidad neonatal temprana en Colombia por municipios. Método: Se realizó un estudio ecológico a nivel municipal. Se recurrió a regresión por mínimos cuadrados y a regresión geográficamente ponderada para explorar las asociaciones estadísticas y espaciales. Resultados: Municipios con mayores tasas de mortalidad tienden a mostrar menor accesibilidad geográfica a camas obstétricas y neonatales, después de controlar las características municipales, económicas y de fecundidad. Esta asociación solo es significativa en municipios de la costa oeste. La fuerza de la asociación disminuye en municipios del interior. Discusión: Centralizar las camas obstétricas y neonatales en ciudades principales de la región central deja desatendidos a los municipios con mayor mortalidad. La descentralización de recursos de cuidado obstétrico y neonatal es un asunto obligatorio para reducir desigualdades geográficas en mortalidad, aumentar la supervivencia neonatal y lograr un inicio de vida saludable...(AU)

Introdução: A distribuição dos recursos da saúde tem influência na mortalidade precoce do neonatal, garantir o acesso aos cuidados obstétricos é um problema da saúde pública. A pesar de que, a dimensão geográfica desta influência não foi estudada na Colômbia. Objetivo: Descrever a acessibilidade geográfica aos leitos obstétricos e neonatos e, a sua associação com a mortalidade neonatal precoce na Colômbia, nos municípios. Método: O estudo ecológico foi realizado nos municípios. A regressão de mínimos quadrados e a regressão geograficamente ponderada foram utilizadas para explorar as associações estatísticas e espaciais. Resultados: Os municípios com taxas de mortalidade mais elevadas tendem a mostrar menor acessibilidade geográfica aos leitos obstétricos e neonatos após o controle das características municipais, econômicas e da fertilidade. Esta associação é apenas significativa nos municípios do litoral oeste. A força da associação diminui nos municípios do interior. Discussão: A centralização de camas obstétricas e neonatas nas principais cidades da região central, deixa os municípios não atendidos com a maior taxa de mortalidade. A descentralização dos recursos dos cuidados obstétricos e neonatos é uma questão obrigatória para reduzir as desigualdades geográficas na mortalidade, aumentar a sobrevivência neonatal e alcançar um bom início de vida saudável...(AU)

Evolución de las inequidades en mortalidad por causas externas entre los municipios de Antioquia (Colombia) / Trend in inequalities in mortality due to external causes among the municipalities of Antioquia (Colombia)

Objetivo: analizar la evolución de las inequidades en la mortalidad por causas externas en los municipios de Antioquia, departamento de Colombia, entre los años 2000 y 2010, y la asociación con sus condiciones socioeconómicas. Las causas externas incluyen, entre otras, las muertes violentas como los homicidios, los suicidios y los accidentes de tránsito. Método: diseño ecológico de tendencias de mortalidad con los 125 municipios del departamento de Antioquia como unidad de análisis. Para cada uno de los municipios se estimó la razón de mortalidad estandarizada y suavizada (RMEs) ajustada por la edad utilizando un modelo bayesiano empírico. Las diferencias en los riesgos de mortalidad entre los municipios más pobres y menos pobres se analizaron mediante un modelo jerárquico de dos niveles (nivel 1: año; nivel 2: municipio). Resultados: la mortalidad por causas externas presenta una tendencia decreciente en el departamento en el periodo analizado, pero la situación no es similar en todos los municipios. Los resultados muestran que municipios pobres y con bajo desarrollo incrementan significativamente el riesgo de morir por causas externas. Conclusiones: es necesaria una intervención con políticas que tengan en cuenta las diferencias municipales en la mortalidad por causas externas

Objective: to analyse the trend in inequalities in mortality due to external causes among municipalities in Antioquia, department of Colombia, from 2000 to 2010, and its association with socioeconomic conditions. External causes included violent deaths, such as homicides, suicides and traffic accidents, among others. Methods: ecological design of mortality trends, with the 125 municipalities of Antioquia as the unit of analysis. The age-adjusted smoothed standardized mortality ratio (SMR) was estimated for each of the municipalities by using an empirical Bayesian model. Differences in the SMR between the poorest and least poor municipalities were estimated by using a two-level hierarchical model (level-1: year, level-2: municipality). Results: mortality due to external causes showed a downward trend in the department in the period under review, although the situation was not similar in all municipalities. The findings showed that the risk of death from external causes significantly increased in poor and underdeveloped municipalities. Conclusions: intervention is required through policies that take into account local differences in mortality due to external causes

[Trend in inequalities in mortality due to external causes among the municipalities of Antioquia (Colombia)]. / Evolución de las inequidades en mortalidad por causas externas entre los municipios de Antioquia (Colombia).

OBJECTIVE: To analyse the trend in inequalities in mortality due to external causes among municipalities in Antioquia, department of Colombia, from 2000 to 2010, and its association with socioeconomic conditions. External causes included violent deaths, such as homicides, suicides and traffic accidents, among others. METHODS: Ecological design of mortality trends, with the 125 municipalities of Antioquia as the unit of analysis. The age-adjusted smoothed standardized mortality ratio (SMR) was estimated for each of the municipalities by using an empirical Bayesian model. Differences in the SMR between the poorest and least poor municipalities were estimated by using a two-level hierarchical model (level-1: year, level-2: municipality). RESULTS: Mortality due to external causes showed a downward trend in the department in the period under review, although the situation was not similar in all municipalities. The findings showed that the risk of death from external causes significantly increased in poor and underdeveloped municipalities. CONCLUSIONS: Intervention is required through policies that take into account local differences in mortality due to external causes.

Causas de mortalidad en jóvenes y su contribución al cambio en la esperanza de vida: Bogotá. 1989-1999 / Causes of mortality in young people and their contribution to the change in life expectancy: Bogotá. 1989-1999

Antecedentes La situación de salud de los jóvenes es un aspecto a tener en cuenta en las estrategias sanitarias. Los cambios en las condiciones socioeconómicas y culturales exigen mayor atención a este grupo. Objetivo Estimar la mortalidad juvenil en la ciudad de Bogotá entre 1989 y 1999 y la contribución de las causas de muerte al cambio en la esperanza de vida. Métodos La información fue proporcionada por el Departamento Administrativo Nacional de Estadística (Dane). Se analizó mediante los programas Excel y SPSS v. 11.0. Las causas de mortalidad se agruparon según la lista 6/67 de la Organización Panamericana de la Salud (OPS). Para la construcción de tablas de vida se estimaron tasas de mortalidad por edad, sexo y causa. Mediante la aplicación del Método de Pollard se establecieron las causas de muerte que generaron pérdida o ganancia en la esperanza de vida juvenil. Resultados Hubo predominio de causas externas, tumores y enfermedades transmisibles, en la mortalidad juvenil. Se observó una ganancia total en la esperanza de vida de 4, 6 años. Se presentó una pérdida en la esperanza de vida juvenil debida al grupo de enfermedades del sistema circulatorio y al grupo de enfermedades transmisibles, 0,07 y 0,001 años respectivamente. Los grupos de causas externas y tumores se asociaron a una ganancia en la esperanza de vida juvenil de 0,46 y 0,02 años, respectivamente. Conclusión Se sugiere implementar políticas de prevención de la violencia, promoción de estilos de vida sanos y estímulos que mejoren las condiciones de vida de la población joven.

Background The health situation of young people is an aspect to be taken into account in health strategies. Changes in socioeconomic and cultural conditions demand greater attention to this group. Objective To estimate youth mortality in the city of Bogotá between 1989 and 1999 and the contribution of causes of death to the change in life expectancy. Methods The information was provided by the National Administrative Department of Statistics (Dane). It was analyzed using Excel and SPSS v. 11.0 programs. The causes of mortality were grouped according to the Pan American Health Organization (PAHO) list 6/67. For the construction of life tables, mortality rates were estimated by age, sex and cause. The causes of death that generated loss or gain in juvenile life expectancy were established by applying Pollard's method. Results There was a predominance of external causes, tumors and communicable diseases in juvenile mortality. A total gain in life expectancy of 4, 6 years was observed. There was a loss in juvenile life expectancy due to the circulatory system diseases group and the communicable diseases group, 0.07 and 0.001 years respectively. The external causes and tumors groups were associated with a gain in juvenile life expectancy of 0.46 and 0.02 years, respectively. Conclusion It is suggested to implement policies for the prevention of violence, promotion of healthy lifestyles and stimuli that improve the living conditions of the young population.