Health Insurance Scheme: Main Contributor to Inequalities in COVID-19 Mortality in Colombia.

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. (Am J Public Health. 2022;112(S6):S586-S590. https://doi.org/10.2105/AJPH.2021.306637).

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

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.

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.

Plan de seguro de salud: factor que más contribuye a las desigualdades en la mortalidad por COVID-19 en Colombia

[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 participan- tes 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 socioeconó- micas. 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 insu- rance 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 ava- liar 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.

Do alcohol and cannabis substitute or complement each other? Analysis from behavioral economics for formulating public policy on substance use in Colombia.

After alcohol and tobacco, cannabis is the third most used substance among young Colombian adults, and many consume alcohol and cannabis concomitantly. However, academics have debated whether these substances substitute or complement each other among consumers. Understanding the relationship between the price and demand for psychoactive substances can clarify consumption patterns and help to develop strategies to reduce harmful consumption. This paper summarizes worldwide evidence of both complementary and substitution relationships and discusses the most probable relationship types in Colombia based on its substance use patterns and current regulations. Like other countries, Colombia is considering legalizing recreational cannabis use. However, there is a growing concern that legalization would increase the negative impacts of cannabis and increase alcohol use among the young adult population. The lack of Colombian empirical studies about the impacts of legal changes on the cannabis market makes it difficult to predict how such changes would affect demand and price elasticities.

Global control of COVID-19: good vaccines may not suffice

[ABSTRACT]. The COVID-19 pandemic has unveiled health and socioeconomic inequities around the globe. Effective epidemic control requires the achievement of herd immunity, where susceptible individuals are conferred indirect protection by being surrounded by immunized individuals. The proportion of people that need to be vaccinated to obtain herd immunity is determined through the herd immunity threshold. However, the number of susceptible individuals and the opportunities for contact between infectious and susceptible individuals influence the progress of an epidemic. Thus, in addition to vaccination, control of a pandemic may be difficult or impossible to achieve without other public health measures, including wearing face masks and social distancing. This article discusses the factors that may contribute to herd immunity and control of COVID-19 through the availability of effective vaccines and describes how vaccine effectiveness in the community may be lower than that expected. It also discusses how pandemic control in some countries and populations may face vaccine accessibility barriers if market forces strongly regulate the new technologies available, according to the inverse care law.

[RESUMEN]. La pandemia de COVID-19 ha puesto al descubierto inequidades socioeconómicas y de salud en todo el mundo. Un control epidémico eficaz requiere el logro de la inmunidad colectiva, mediante la cual se confiere a las personas vulnerables una protección indirecta al estar rodeadas de personas inmunizadas. El umbral de inmunidad colectiva determina la proporción de personas que deben vacunarse para llegar a la inmunidad colectiva. Sin embargo, el número de personas vulnerables y las oportunidades de contacto entre las personas infecciosas y las personas vulnerables influyen en el progreso de una epidemia. Por lo tanto, además de la vacunación, el control de una pandemia puede ser difícil o imposible de lograr sin otras medidas de salud pública, como las mascarillas y el distanciamiento social. Este artículo trata sobre los factores que pueden contribuir al logro de la inmunidad colectiva y el control de la COVID-19 mediante la disponibilidad de vacunas efectivas y describe cómo la efectividad de las vacunas en la comunidad puede ser inferior a la prevista. También aborda cómo el control pandémico en algunos países y grupos poblacionales puede enfrentarse a obstáculos que dificultan la accesibilidad de las vacunas si las fuerzas del mercado son el principal factor que regula las nuevas tecnologías disponibles, como se indica en la ley de atención inversa.

[RESUMO]. A pandemia de COVID-19 revelou iniquidades socioeconômicas e de saúde no mundo todo. Um controle epidêmico eficaz requer a obtenção da imunidade coletiva, em que indivíduos suscetíveis recebem proteção indireta por estarem rodeados de indivíduos imunizados. A proporção de pessoas que precisam ser vacinadas para se alcançar a imunidade coletiva é definida pelo limiar da imunidade coletiva. Porém, o número de indivíduos suscetíveis e as oportunidades de contato entre indivíduos infecciosos e suscetíveis influenciam o progresso de uma epidemia. Portanto, além da vacinação, o controle de uma pandemia pode ser difícil ou impossível de ser alcançado sem outras medidas de saúde pública, incluindo o uso de máscaras e o distanciamento social. Este artigo discute os fatores que podem contribuir para a imunidade coletiva e para o controle da COVID-19 por meio da disponibilidade de vacinas eficazes, e descreve como a eficácia das vacinas na comunidade pode ser menor do que o esperado. Também discute como o controle da pandemia em alguns países e populações pode enfrentar barreiras de acessibilidade às vacinas se as forças de mercado regularem fortemente as novas tecnologias disponíveis, conforme a lei dos cuidados inversos.

Preferences based interventions to address the use of antibiotics without prescription: A discrete choice experiment.

BACKGROUND: In many countries, concerns have arisen over the population using antibiotics without consulting a physician. This practice can place patients at risk and increase antibiotic resistance in the community. OBJECTIVE: To evaluate individuals' preferences regarding the use of antibiotics. The study also assessed the likely effectiveness of interventions aimed at reducing inappropriate use of antibiotics. METHODS: A discrete choice experiment (DCE) was conducted in Bogotá, Colombia. The attributes were determined by a systematic literature review and four focus group sessions. The DCE included nine factors - cost, time to get attention, level of symptoms, efficacy, safety, among others- and one label -using or not antibiotics. Data analysis was carried out using a generalized multinomial logit (GMNL) model. Marginal probabilities of different sets of attributes' levels were compared to estimate the likely effectiveness of interventions. RESULTS: The survey was administered to 222 participants from diverse socioeconomic backgrounds. The results suggest that participants preferred not taking antibiotics and having a physician as an advisor, but the probability of inappropriate antibiotic use increased as the waiting time or the cost of receiving advice rose. The pharmacy was the preferred source of antibiotics, and participants chose the pharmacy worker (nonprofessional) as an advisor over the nurse on the phone. In the absence of any interventions aimed at reducing the use of antibiotics, approximately 47.3% of people would misuse antibiotics. This reduces to 26.5% when people perceive the efficacy of the antibiotics as low and the potential risks of self-medicating as high. An alternative model using a nursing service would likely lower inappropriate use of antibiotics. CONCLUSIONS: Even though people prefer not using antibiotics or visiting a physician in case of disease rather than self-medicating, current access conditions might discourage them from appropriately use antibiotics. The results suggest that interventions that informing people about the risks of self-medication and the low efficacy might significantly reduce inappropriate use of antibiotics. Our results also suggest that programs that empower other health professionals to provide access to antibiotics would likely further lower inappropriate use.

Desigualdades en la incidencia de sífilis congénita relacionada con las condiciones de vida, Bogotá Colombia 2013-2014 / Inequalities in the incidence of congenital syphilis related to living conditions, Bogotá Colombia 2013-2014

Resumen Introducción Las desigualdades en salud están vinculadas a la organización social y reflejan la inequidad presente en una sociedad. La sífilis congénita es un problema de salud pública en países menos desarrollados, su incidencia se relaciona con la pobreza. Objetivo Analizar las desigualdades en la incidencia de sífilis congénita relacionada con las condiciones de vida en las localidades de la ciudad de Bogotá, Colombia, en los años 2013 y 2014. Método Se realizó un estudio ecológico de grupos múltiples. La información se tomó de fuentes oficiales (SIVIGILA y RUAF) de la ciudad. La información del índice de condiciones de vida (ICV) se tomó de la Encuesta Multipropósito (Bogotá, 2011). Se utilizó la fracción atribuible como medida relativa de desigualdad y el coeficiente de Spearman (rho) como medida de correlación. Resultados La ISC acumulada en el periodo 2013-2014 fue de 2.08 por 1000 nacidos vivos, aumentó en localidades observadas como Mártires y Santafé, el exceso de riesgo de nacer con sífilis congénita fue de 94%, en ciudad Bolívar y Usme fue de 90% y 80% respectivamente. Conclusión las desigualdades evidenciadas en la ISC entre las localidades de Bogotá, se relacionó con las desigualdades encontradas en el Índice de Condiciones de Vida.

Abstract Background Health inequalities are linked to social organization and reflect the degree of inequality in a society. Congenital syphilis is a non-tolerable outcome that has persisted in developing countries and is related to poverty. Objective To analyze the inequalities in the incidence of congenital syphilis related to Social Conditions in the localities of Bogotá, Colombia 2013-2014 Method An ecological study of multiple groups was carried out. The information was taken from official sources (SIVIGILA and RUAF) of the city. The information on the Social Conditions Index (SCI) was taken from the Multipurpose Survey (Bogotá, 2011). Attributable fractions were used as a relative measure of inequality and correlation analysis used the Spearman coefficient. Results A cumulative SCI of 2.08 per 1000 live births was observed between 2013-2014, this incidence increased in districts such as Mártires and Santafé, there was a 94% additional risk of being born with congenital syphilis, and in Ciudad Bolívar and Usme the risk excess was 90% and 80% respectively. Conclusion the inequalities evidenced in the CSI among the localities of Bogotá was correlated with the inequalities found in Index Social Conditions

An overview of reviews on strategies to reduce health inequalities.

BACKGROUND: Governments are incentivized to develop and implement health action programs focused on equity to ensure progress with effective strategies or interventions. OBJECTIVE: Identify and synthesize strategies or interventions that facilitate the reduction of health inequalities. METHODS: A systematic search strategy was carried out up until August 2019 in MEDLINE (Ovid), Embase (Elsevier), Cochrane Database of Systematic Reviews, LILACS, Scopus, Scielo and Epistemonikos. In addition, a snowball strategy was used. Literature reviews (LRs) of experimental and quasi-experimental studies were included. The identified interventions and outcomes were categorized based on the recommendation by the Cochrane group in "Effective Practice and Organization of Care". The quality of the included LRs was evaluated using the AMSTAR 2 tool. RESULTS: Four thousand ninety-five articles were identified, of which 97 were included in the synthesis of evidence. Most of the studies included focused on the general population, vulnerable populations and minority populations. The subjects of general health and healthy lifestyles were the most commonly addressed. According to the classification of the type of intervention, the domain covered most was the delivery arrangements, followed by the domain of implementation strategies. The most frequent group of outcomes was the reported outcome in (clinical) patients, followed by social outcomes. CONCLUSION: The strategies that facilitate the reduction of health inequalities must be intersectoral and multidisciplinary in nature, including all sectors of the health system. It is essential to continue generating interventions focused on strengthening health systems in order to achieve adequate universal health coverage, with a process of comprehensive and quality care.

Prognostic Factors Associated with Clinical and Economic Outcomes of Appendectomies in Children: A Multilevel Analysis in a National Retrospective Cohort Study.

BACKGROUND: Acute appendicitis is the most common acute surgical abdominal pathology in children, and it has a large impact on morbidity and the costs incurred by health care systems. In low- and median-income countries, national information on the clinical and economic outcomes associated with this surgery does not exist. This study aimed to identify and describe the clinical and economic outcomes for children undergoing appendectomy in Colombia's contributory system and to determine the prognostic factors associated with these outcomes. METHODS: A retrospective cohort study was conducted using administrative data from patients under 18 years of age who underwent an appendectomy between July 1, 2013, and September 30, 2015, in Colombia's contributory health system. Thirty-day mortality rates, intensive care unit (ICU) admission rates, length of stay (LOS), readmission rates and median costs were estimated for the entire country by geographic region and insurer. The prognostic factors associated with these outcomes were identified using generalized multilevel mixed models. RESULTS: A total of 21,674 children were included. The 30-day postoperative mortality rate was 0.06% [95% CI 0.02-0.9], the ICU admission rate was 8.00% [95% CI 7.63-8.36], the mean LOS was 2.48 days (SD 5.24), the readmission rate was 1.5% [95% CI 1.33-1.66] and the median cost for Colombia was 394 USD [p25-p75: 256-555]. The prognostic factors that were associated with the 30-day ICU admission rate, LOS and readmission rate were the insurer, geographic region, age, occurrence of an appendectomy with peritoneal drainage, and certain comorbidities, such as cancer and neurological, respiratory and gastrointestinal illnesses. The prognostic factors associated with costs were those previously mentioned as well as the occurrence of a laparoscopic appendectomy. CONCLUSIONS: In Colombia's contributory health system, large differences in clinical outcomes and the costs incurred by the system exist, and these differences are associated with the geographic region, the insurer, and some of the clinical characteristics of the children undergoing appendectomy.

Effectiveness assessment of maternal and neonatal health video clips in knowledge transfer using neuromarketing tools: A randomized crossover trial.

Audiovisual educational material has been used effectively as a knowledge translation strategy in patient education. Given the need to impact maternal mortality rates, 12 video clips related to maternal and neonatal health information were designed based on the results of a previous systematic review (SR). The content was formulated based on clinical practice guideline recommendations and validated following a formal consensus methodology. This study evaluated the effectiveness of knowledge transfer from the 12 video clips in terms of attention, emotional response, and recall by using neuroscience tools. In a randomized cross-over trial, 155 subjects (pregnant women, non-pregnant women, and men) received random sequences of 13 video clips, including a control video clip. Participants' attention levels were evaluated through eye tracking, their emotional reactions were monitored by electrodermal activity and pupillary diameter, and their recall was tested via a questionnaire. An analysis was performed to evaluate differences in the groups and between the video clips and the control clip using variance analysis models that considered period, sequence, and carry-over effects. Results revealed that fixation length was greater in women than in men, while the greatest emotional effects occurred in men. All three groups had good recall results, without any significant differences between them. Although the sequencing did influence attentional processes, no carry-over effect was demonstrated. However, a differential effect was noted among video clips in all three outcomes, that is, when adjusted for group, level of education, and having had children. The control clip generated less attention, emotional reaction, and recall than the experimental video clips. The video clips about maternal and neonatal health were shown to be effective in the transference and comprehension of information. Therefore, cognitive neuroscience techniques are useful in evaluating knowledge translation strategies through audiovisual formats.

Clinical Outcomes and Healthcare Costs Associated with Laparoscopic Appendectomy in a Middle-Income Country with Universal Health Coverage.

BACKGROUND: Although many studies have compared outcomes of laparoscopic appendectomy (LA) and open appendectomy (OA), some clinical and economic outcomes continue to be controversial, particularly in low-medium-income countries. We aimed at determining clinical and economic outcomes associated with LA versus OA in adult patients in Colombia. METHODS: Retrospective, cohort study based on administrative healthcare records included all patients who underwent LA or OA in Colombia's contributory regime between July 1, 2013, and September 30, 2015. Outcomes were 30-day mortality rates, ICU admissions rates, length of stay (LOS), and hospital costs provided until discharge. Propensity score matching techniques were used to balance the baseline characteristics of patients (age, sex, comorbidities based on the Charlson index, insurer, and geographic location) and to estimate the average treatment effect (ATE) of LA as compared to OA over outcomes. RESULTS: A total of 65,625 subjects were included, 92.9% underwent OA and 7.1% LA. For the entire population, 30-day mortality was 0.74 per 100 appendectomies (95% CI 0.67-0.81), the mean and median LOS were 3.83 days and 1 day, respectively, and the ICU admissions rate during the first 30 days was 7.92% (95% CI 7.71-8.12). The ATE shows an absolute difference in the mortality rate after 30 days of -0.35 per 100 appendectomies (p = 0.023), in favor of LA. No effects on ICU admissions or LOS were identified. LA was found to increase costs by 514.13 USD on average, with total costs of 772.78 USD for OA and 1286.91 USD for LA (p < 0.001). CONCLUSIONS: In Colombia's contributory regime, LA is associated with lower 30-day mortality rate and higher hospital costs as compared to OA. No differences are found in ICU admissions or LOS.

Incorporación de equidad en salud en la investigación sobre implementación: revisión de los modelos conceptuales

[RESUMEN]. Objetivo. Buscar y elaborar una síntesis sistemática de los marcos o modelos conceptuales que incorporan aspectos de equidad en salud en implementación de la investigación. Métodos. Búsqueda sistemática en Medline-Pubmed, Embase y Lilacs (1965-2016) y Scopus (1998-2016). Además, se utilizó una estrategia en bola de nieve y búsqueda de la literatura gris. Se evaluó el tipo de artículo y los elementos que se incluyeron sobre investigación de la implementación (IR, por sus siglas en inglés), la ciencia de la implementación y equidad en salud. Resultados. Se encontraron 701 artículos, de los cuales 100 se incluyeron para revisión de relevancia. De estos, quedaron 19 artículos relacionados con marcos conceptuales: 12 fueron generales, cinco sobre disparidades étnicas o raciales y dos relacionados con salud infantil. Las categorías más frecuentes fueron: financiación, infraestructura, abogacía, calidad, barreras internas y cobertura. Las menos frecuentes fueron: otros sectores, las necesidades de los pacientes externos, el estado de salud y la evaluación del impacto sobre la equidad. Conclusiones. Para disminuir las brechas en salud y con ellas las inequidades en salud, se hace necesario contar con un marco consolidado de IR en el que se incluyan los aspectos de equidad en salud. Este marco facilitaría mejorar los procesos de implementación de las intervenciones, los servicios y los programas de salud.

[ABSTRACT]. Objective. Search for conceptual frameworks or models that incorporate aspects of health equity into implementation research and prepare a systematic synthesis of them. Methods. A systematic search was done of MEDLINE-PubMed, Embase, and LILACS (1965–2016), and Scopus (1998–2016) databases, employing, in addition, a snowball strategy and gray literature search. Article type was assessed, along with elements that were included on implementation research, the science of implementation, and health equity. Results. A total of 701 articles were found, of which 100 were included for review of relevance. Of these, 19 articles related to conceptual frameworks: 12 were general, five were on ethnic or racial disparities, and two related to child health. The most frequent categories were financing, infrastructure, advocacy, quality, internal barriers, and coverage. The least frequent were other sectors, outpatient needs, health status, and equity impact assessment. Conclusions. In order to reduce health gaps and with them health inequities, it becomes necessary to have a consolidated implementation research framework that includes aspects of health equity. This framework would facilitate improving implementation processes for interventions, services, and health programs.

[RESUMO]. Objetivo. Fazer uma busca e revisão sistemática dos marcos ou modelos conceituais que abrangem aspectos de igualdade em saúde em pesquisa de implementação. Métodos. Busca sistemática nas bases de dados MEDLINE-PubMed, Embase e LILACS (1965–2016) e Scopus (1998–2016) com o uso de estratégia de amostragem em bola de neve e busca da literatura cinzenta. Foram avaliados o tipo de artigo e os elementos contidos sobre pesquisa de implementação (implementation research, IR), ciência de implementação e igualdade em saúde. Resultados. Foram identificados 701 artigos, dos quais 100 foram incluídos na revisão. Destes, 19 artigos estavam relacionados aos marcos conceituais: 12 gerais, cinco sobre disparidades étnicas ou raciais e dois relacionados com saúde infantil. As categorias mais frequentes dos marcos conceituais foram: financiamento, infraestrutura, defesa da causa, qualidade, barreiras internas e cobertura. As menos frequentes foram: outros setores, necessidades dos pacientes ambulatoriais, estado de saúde e avaliação do impacto na equidade. Conclusões. Para reduzir as lacunas em saúde e as desigualdades em saúde, faz-se necessário dispor de um modelo consolidado de pesquisa de implementação no qual sejam incluídos os aspectos de igualdade em saúde. Este modelo contribuiria para melhorar os processos de implementação das intervenções, serviços e programas de saúde.

Considering health equity when moving from evidence-based guideline recommendations to implementation: a case study from an upper-middle income country on the GRADE approach.

The availability of evidence-based guidelines does not ensure their implementation and use in clinical practice or policy making. Inequities in health have been defined as those inequalities within or between populations that are avoidable, unnecessary and also unjust and unfair. Evidence-based clinical practice and public health guidelines ('guidelines') can be used to target health inequities experienced by disadvantaged populations, although guidelines may unintentionally increase health inequities. For this reason, there is a need for evidence-based clinical practice and public health guidelines to intentionally target health inequities experienced by disadvantaged populations. Current guideline development processes do not include steps for planned implementation of equity-focused guidelines. This article describes nine steps that provide guidance for consideration of equity during guideline implementation. A critical appraisal of the literature followed by a process to build expert consensus was undertaken to define how to include consideration of equity issues during the specific GRADE guideline development process. Using a case study from Colombia we describe nine steps that were used to implement equity-focused GRADE recommendations: (1) identification of disadvantaged groups, (2) quantification of current health inequities, (3) development of equity-sensitive recommendations, (4) identification of key actors for implementation of equity-focused recommendations, (5) identification of barriers and facilitators to the implementation of equity-focused recommendations, (6) development of an equity strategy to be included in the implementation plan, (7) assessment of resources and incentives, (8) development of a communication strategy to support an equity focus and (9) development of monitoring and evaluation strategies. This case study can be used as model for implementing clinical practice guidelines, taking into account equity issues during guideline development and implementation.

GRADE equity guidelines 4: considering health equity in GRADE guideline development: evidence to decision process.

OBJECTIVES: The aim of this paper is to provide detailed guidance on how to incorporate health equity within the GRADE (Grading Recommendations Assessment and Development Evidence) evidence to decision process. STUDY DESIGN AND SETTING: We developed this guidance based on the GRADE evidence to decision framework, iteratively reviewing and modifying draft documents, in person discussion of project group members and input from other GRADE members. RESULTS: Considering the impact on health equity may be required, both in general guidelines and guidelines that focus on disadvantaged populations. We suggest two approaches to incorporate equity considerations: (1) assessing the potential impact of interventions on equity and (2) incorporating equity considerations when judging or weighing each of the evidence to decision criteria. We provide guidance and include illustrative examples. CONCLUSION: Guideline panels should consider the impact of recommendations on health equity with attention to remote and underserviced settings and disadvantaged populations. Guideline panels may wish to incorporate equity judgments across the evidence to decision framework. This is the fourth and final paper in a series about considering equity in the GRADE guideline development process. This series is coming from the GRADE equity subgroup.

A province-wide survey on self-reported language proficiency and its influence in global health education / Encuesta autoreportada sobre dominio del idioma y su influencia en la educación sanitaria global

ABSTRACT Objective Literature has reported that language is the most common barrier in a health care setting and a risk factor associated with negative outcomes. The present study reports the differences between nursing students who speak one language and nursing students who speak two or more languages (self-reported language proficiency) and their skills and learning needs in global health. Method An observational cross-sectional study was performed among nursing students from five Ontario universities. A survey was designed to measure knowledge, skills and learning needs in global health. Results Students who speak more than two languages are more likely to have more interest in learning global health issues, such as health risks and their association with travel and migration (p=0.44), and social determinants of health (p=0.042). Conclusion Language training is needed for nursing students to be able to face language barriers in health care settings and improve global health, locally and internationally.(AU)

RESUMEN Objetivo De acuerdo con la literatura, el idioma es el obstáculo más común en el contexto de la atención médica y un factor de riesgo asociado con resultados negativos. El objetivo de este estudio es presentar las diferencias percibidas entre los estudiantes de enfermería que hablan un idioma y aquellos que hablan dos o más (competencia lingüística reportada por ellos mismos) y sus habilidades y necesidades de aprendizaje en salud global. Método Estudio observacional de corte transversal entre estudiantes de enfermería de cinco universidades de Ontario. Se diseñó una encuesta para medir el conocimiento, las habilidades y las necesidades de aprendizaje en salud global. Resultados Se observó que los estudiantes que hablan más de dos idiomas tienen mayor probabilidad de interesarse más en aprender sobre problemas de salud global, los riesgos para la salud y su asociación con los viajes y la migración (p=0,44), así como sobre los determinantes sociales de la salud (p=0,042). Conclusión Es necesario que se brinde capacitación en aprendizaje de otros idiomas a los estudiantes de enfermería para que puedan afrontar las barreras impuestas por el lenguaje en los contextos de atención médica y mejorar la salud global, de manera local e internacional.(AU)

GRADE equity guidelines 2: considering health equity in GRADE guideline development: equity extension of the guideline development checklist.

OBJECTIVE: To provide guidance for guideline developers on how to consider health equity at key stages of the guideline development process. STUDY DESIGN AND SETTING: Literature review followed by group discussions and consensus building. RESULTS: The key stages at which guideline developers could consider equity include setting priorities, guideline group membership, identifying the target audience(s), generating the guideline questions, considering the importance of outcomes and interventions, deciding what evidence to include and searching for evidence, summarizing the evidence and considering additional information, wording of recommendations, and evaluation and use. We provide examples of how guidelines have actually considered equity at each of these stages. CONCLUSION: Guideline projects should consider the aforementioned suggestions for recommendations that are equity sensitive.