Situational diagnosis of policies in Latin American and Caribbean countries for the use of fluoride and reduction of sugar consumption

Abstract Policy evaluation and guidance on fluoride use and sugar consumption in Latin American and Caribbean countries (LACC) may provide a scientific evidence basis for policymakers, dental professionals, civil society organizations and individuals committed to improving public oral health. A cross-sectional study was conducted to evaluate the extent of implementation of policies/guidelines on fluoride use, and sugar consumption in LACC. The study had two stages. First a questionnaire covering four major areas was developed: fluoridation of public water supplies; salt fluoridation; fluoride dentifrices, and sugar consumption. Then, the questionnaire was applied to collect data among representative participants in public oral health from LACC. Ninety-six participants from 18 LACC answered the questionnaire. One-hundred seventy documents were attached, and 285 links of websites were provided by the respondents. Implementation of policies and guidelines on water and table salt fluoridation and processed and ultra-processed food consumption were found in most countries, with some issues in the consensus and coverage. Thus, differences were identified in the extent of implementation of public oral health strategies on sugar consumption and fluoridation among the countries. There is no consensus on the policies in LACC to reduce sugar consumption and for the use of fluoride. A few policies and guidelines were applied in isolated countries, with a variety of strategies and standards. For future actions, it will be important to encourage the development of strategies and public policies within countries, and to evaluate the effectiveness of existing policies in reducing dental caries and in improving oral health in LACC.

Plan de seguro de salud: factor que más contribuye a las desigualdades en la mortalidad por COVID-19 en Colombia / Health insurance scheme: main contributor to inequalities in COVID-19 mortality in Colombia / Tipo de cobertura de assistência à saúde: o principal fator contribuinte para as desigualdades em mortalidade por COVID-19 na Colômbia

RESUMEN Objetivo. Cuantificar las desigualdades socioeconómicas en la mortalidad por COVID-19 en Colombia y evaluar en qué medida el tipo de seguro de salud, la carga de enfermedades concomitantes, la zona de residencia y el origen étnico explican estas desigualdades. Métodos. Se analizaron los datos de una cohorte retrospectiva de casos de COVID-19. Se estimó el índice relativo de desigualdad (IRD) y el índice de desigualdad basado en la pendiente (IDP) utilizando modelos de supervivencia con todos los participantes, y estratificándolos por edad y sexo. El porcentaje de reducción del IRD y el IDP se calculó después de ajustar con respecto a factores que podrían ser relevantes. Resultados. Se pusieron en evidencia desigualdades notables en toda la cohorte y en los subgrupos (edad y sexo). Las desigualdades fueron mayores en los adultos más jóvenes y disminuyeron de manera gradual con la edad, pasando de un IRD de 5,65 (intervalo de confianza de 95% [IC 95%] = 3,25-9,82) en los participantes menores de 25 años a un IRD de 1,49 (IC 95% = 1,41-1,58) en los mayores de 65 años. El tipo de seguro de salud fue el factor más importante, al cual se atribuyó 20% de las desigualdades relativas y 59% de las absolutas. Conclusiones. La mortalidad por COVID-19 en Colombia presenta importantes desigualdades socioeconómicas. El seguro de salud aparece como el factor que más contribuye a estas desigualdades, lo cual plantea retos al diseño de las estrategias de salud pública.

ABSTRACT Objectives. To quantify socioeconomic inequalities in COVID-19 mortality in Colombia and to assess the extent to which type of health insurance, comorbidity burden, area of residence, and ethnicity account for such inequalities. Methods. We analyzed data from a retrospective cohort of COVID-19 cases. We estimated the relative and slope indices of inequality (RII and SII) using survival models for all participants and stratified them by age and gender. We calculated the percentage reduction in RII and SII after adjustment for potentially relevant factors. Results. We identified significant inequalities for the whole cohort and by subgroups (age and gender). Inequalities were higher among younger adults and gradually decreased with age, going from RII of 5.65 (95% confidence interval [CI] = 3.25, 9.82) in participants younger than 25 years to RII of 1.49 (95% CI = 1.41, 1.58) in those aged 65 years and older. Type of health insurance was the most important factor, accounting for 20% and 59% of the relative and absolute inequalities, respectively. Conclusions. Significant socioeconomic inequalities exist in COVID-19 mortality in Colombia. Health insurance appears to be the main contributor to those inequalities, posing challenges for the design of public health strategies.

RESUMO Objetivos. Quantificar as desigualdades socioeconômicas na mortalidade por COVID-19 na Colômbia e avaliar até que ponto o tipo de cobertura de assistência à saúde, a carga de comorbidades, o local de residência e a etnia contribuíram para tais desigualdades. Métodos. Analisamos dados de uma coorte retrospectiva de casos de COVID-19. Calculamos os índices relativo e angular de desigualdade (RII e SII, respectivamente) utilizando modelos de sobrevivência em todos os participantes, estratificando-os por idade e gênero. Calculamos o percentual de redução no RII e no SII após ajuste para fatores possivelmente relevantes. Resultados. Identificamos desigualdades significativas na coorte como um todo e por subgrupos (idade e gênero). As desigualdades foram maiores para adultos mais jovens e decaíram gradualmente com a idade, indo de um RII de 5,65 (intervalo de confiança [IC] de 95% = 3,25; 9,82] nos participantes com idade inferior a 25 anos a um RII de 1,49 [IC 95% = 1,41; 1,58] nas pessoas com 65 anos ou mais. O tipo de cobertura de assistência à saúde foi o fator mais importante, representando 20% e 59% das desigualdades relativa e absoluta, respectivamente. Conclusões. Desigualdades socioeconômicas significativas afetaram a mortalidade por COVID-19 na Colômbia. O tipo de cobertura de saúde parece ser o principal fator contribuinte para essas desigualdades, impondo desafios à elaboração de estratégias de saúde pública.

Inequidad en los años de vida potencial perdida, por departamentos en Colombia 1985-2005 / Inequity in lost life years by departments in Colombia 1985-2005

Objetivo Describir las diferencias en los años de vida perdidos en la expectativa de vida al nacer por Departamentos en Colombia, durante el periodo de estudio. Métodos Los datos sobre expectativa de vida al nacer por género, fueron tomados del Departamento Administrativo Nacional de Estadística (DAÑE) para los periodos: 1985-1990, 1995-2000 y 2000-2005. Los datos sobre el país con la mejor expectativa de vida en el mundo fue tomado de los reportes de la Organización Mundial de la Salud. Los años de vida perdidos en expectativa de vida (AVPP) fueron estimados a partir de las diferencias relativas entre valores regionales y los mejores valores del mundo para los periodos de estudio. Resultados El número de AVPP tuvo una tendencia a disminuir en ambos géneros durante el periodo de estudio. Sin embargo hubo Departamentos en los cuales los AVPP fueron mayores para mujeres que para hombres en los tres periodos. Adicionalmente, el peor quintil de AVPP tuvo un valor medio de 18,98 ±2,36 AVPP para hombres y 18,45+/-2,43 AVPP para mujeres en 1985-1990; 16,99+/-1,7 AVPP para hombres y 16,01+/1,46 para mujeres en 1995-2000; y 15,99+/-1,34 AVPP para hombres y 14,51 +/-0,96 AVPP para mujeres en 2000-2005. Los valores para el mejor quintil de AVPP fueron respectivamente para hombres y mujeres: 7,41+/-0,65; 8,34+/-0,65 en 1985-1990; 7,22+/-0,62 y 8,59+/-0,31 en 1995-2000; y 7,72+/ 0,58 y 8,89+/-0,67 en 2000-2005. Conclusiones Hubo diferencias en la expectativa de vida al nacer entre Departamentos y géneros en los tres periodos estudiados. Hubo disparidad en el numero de AVPP, comparando con el mejor país en el mundo, por Departamentos, durante los periodos de estudio.

Objectives Describing differences in years of life lost (LLY) regarding life expectancy at birth in Colombia amongst Departments during the study period. Methods Data about life expectancy at birth by gender were taken from the Colombian Statistics Administration Department (DAÑE) databases for 1985-1990, 1995-2000 and 2000-2005. Data about the country having the best world health expectancy value was taken from World Health Organisation Reports. LLY regarding life expectancy at birth (LEB) were estimated with relative differences between regional values and the best world value for the study periods. Results LLY tended to become reduced for both genders throughout the whole study period; however, LLY was higher for women than men in some departments during the three periods. The worst LLY quintile for 1985-1990 was 18.98+/-2.36 mean LLY value for men and 18.45+/-2.43 for women. Mean LLY value for men was 16.99+/-1.7 and 16.01+71.46 for women for 1995-2000 and mean 15.99+/-1.34 LLY for men and 14.51+/-0.96 LLY for women for 2000-2005. LLY values for the best quintile for men and women were 7.41+/-0.65; 8.34+/-0.65 in 1985-1990, 7.22+/-0.62 and 8.59+/-0.31 in 1995-2000 and 7.72+/0.58 and 8.89+/-0.67 in 2000-2005, respectively. Conclusions There were differences in life expectancy at birth between departments and gender during the three periods studied. There was disparity regarding LLY compared to the best country in the world by department and gender in Colombia during the study periods.

Equidad de género en el acceso a los servicios de salud en Colombia / Gender-related equity/inequity in gaining access to health services

Objetivo Identificar inequidades de género en el acceso a los servicios de salud en el sistema de seguridad social en salud. Métodos Se realizó una evaluación de dos etapas de la Encuesta Nacional de Hogares, antes y después de implementada la reforma al sistema de salud colombiano. Se identificaron variables socioeconómicas, de necesidad, acceso a los servicios y financiación. Se realizó un análisis descriptivo de las variables, se realizó la recodificación y creación de nuevas variables. Se hicieron análisis bivariados, comparando algunas variables por medio de Chi². Resultados La necesidad en salud sentida fue mayor en las mujeres en las dos encuestas. Las diferencias entre hombres y mujeres en la consulta por problema de salud no fueron significativas en 1994; en el 2000, consultaron el 73 por ciento de los hombres y el 81 por ciento de las mujeres (p<0.0001). Respecto al antecedente de hospitalización, la proporción de hombres y mujeres que utilizaron este servicio disminuyó en el 2000. En el 2000, las mujeres emplearon en mayor proporción los recursos propios como fuente de financiación. Por niveles de ingreso, las personas pertenecientes a los quintiles uno y dos emplearon los recursos propios como fuente de financiación de los servicios. Conclusiones Al comparar los dos períodos, se incrementó el total de consultas, más rápidamente en las mujeres. En el año 2000 las mujeres tuvieron más acceso al servicio de consulta. Las inequidades en el financiamiento de los servicios de salud por sexo han persistido aún después de implementada la reforma.

Objective Identifying gender-related inequities in gaining access to health services in the Colombian social health security system. Methods A two-stage evaluation of the National Household Survey was made, before and after the Colombian health system reform was implemented. Socioeconomic,needs, access to health services and financing variables were identified. A descriptive analysis of the variables was made, they were re-codified and new variables created. Bivariate analysis was done, comparing some variables by means of Chi². Results Needs in health were felt more by women in both surveys. Differences between males and females in consultation for health problems were not significant in 1994; 73 percent of the males and 81 percent of the females were consulted in 2000 (p<0.0001). Regarding antecedents of having been hospitalised, the percentage of males and females using this service became reduced during 2000. Females used their own resources more as the source of financing services in 2000. People belonging to the 1st and 2nd quintiles used their own resources as financing source in terms of income levels. Conclusions Comparing both periods, total consultations became increased (more rapidly in females). Females had greater access to consultation services in 2000. Gender-related inequities in financing health services have still persisted, even after the reform was implemented.