Social inequalities and their impact on children's health: a current and global perspective

Abstract Objective: To describe the consequences of social inequalities on children's health as a global and persistent problem, demonstrating its historical and structural roots in different societies. Data sources: Relevant articles in the PubMed/MEDLINE database, in addition to those found in a manual search and in the bibliographic references of selected studies and consultation to the websites of international organizations to obtain relevant data and documents. Data synthesis: To understand how inequities affect health, it is necessary to know the unequal distribution of their social determinants among population groups. In the case of children, the parental pathway of determinants is central. The non-equitable way in which many families or social groups live, determined by social and economic inequalities, produces unequal health outcomes, particularly for children. This is observed between and within countries. Children from the most vulnerable population groups consistently have worse health conditions. Interventions aimed at children's health must go beyond care and act in an integrated manner on poverty and on social and economic inequalities, aiming to end systematic and unfair differences. Conclusions: Despite the considerable advances observed in children's health in recent decades at a global level, the inequalities measured by different indicators show that they persist. This scenario deserves attention from researchers and decision-makers, especially in the context of the global health crisis caused by the COVID-19 pandemic, which has further intensified the situation of vulnerability and social inequalities in health around the world.

Ausência de raça e gênero no enfrentamento da pandemia no Brasil / Absence of race and gender in the fight against the pandemic in Brazil / Falta de raza y género en el enfrentamiento a la pandemia en Brasil

Esta nota discute a ausência dos quesitos cor/raça e gênero nos boletins epidemiológicos da Covid-19 e como essa omissão está articulada ao modo como se operacionaliza o racismo no Brasil. Coloca-se em evidência a apropriação da identidade racial e de gênero por alguns estados brasileiros que ganharam visibilidade midiática, como sendo solidários, ao iniciarem a campanha de vacinação com mulheres negras, grupo social mais vulnerável. É o jogo da dissimulação, em que se evidencia a raça/gênero na aparência, embora essas variáveis não sejam consideradas no enfrentamento da pandemia.

This note discusses the non-inclusion of information about color/race and gender in Covid-19 epidemiological reports and how this omission is related to the way that the racism is operated in Brazil. It highlights the racial and gender identity appropriation by some Brazilian states, which have gained media visibility as sympathetic governments to Black women, by starting the vaccination campaign with them, an extremely vulnerable social group. It is like a confidence trick, in which race and gender are in the spotlight, although these features are not considered in the fight against the pandemic.

Esta nota discute la ausencia de las informaciones sobre cor/raza y género en los boletines epidemiológicos de la Covid-19 y como esa omisión se encuentra articulada al modo en que se opera el racismo en Brasil. Destaca la apropiación de la identidad racial y de género por parte de algunos estados brasileños que han ganado visibilidad mediática, vistos como solidarios, puesto que han iniciado la campaña de vacunación con algunas mujeres negras, el grupo social más vulnerable. Es el juego del disimulo, por lo cual es evidenciada la raza/género en la apariencia, sin embargo esas variables no sean tenidas en cuenta en el enfrentamiento a la pandemia.

Bases teórico-conceptuales para el análisis de inequidades sociales en salud: una discusión / Theoretical Implications for the Analysis of Social Health Inequalities: A Discussion

RESUMEN Las Inequidades Sociales en Salud (ISS) continúan representando un gran reto para la salud pública en los diferentes países del mundo. Por su parte, el estudio, análisis y generación de conocimiento en esta materia ha sido reconocida como prioritaria para la Organización Mundial de la Salud desde 1991. La investigación de las ISS debe basarse en fundamentos teóricos y conceptuales sólidos, pues son estos las que guiarán las decisiones metodológicas en términos de diseño de investigaciones, formulación de intervenciones y políticas públicas en salud. En Latinoamérica, los estudios realizados se han basado primordialmente en experiencias que se han llevado a cabo en países industrializados. Esto ha fomentado que el análisis de las ISS reproduzca posturas teóricas y metodologías, sin necesariamente presentar una perspectiva crítica de los posibles estratificadores sociales que aproximan de la mejor forma los determinantes sociales de la salud en los contextos particulares. Por esta razón, se expone que las aproximaciones teórico-metodológicas deben ajustarse a los contextos específicos de los países; que la estratificación social de la salud debe ser evaluada de forma prioritaria; que los determinantes de la salud individuales y estructurales deben ser considerados dentro de las mediciones; y que la justificación teórica de las decisiones metodológicas realizadas en los estudios y las medidas seleccionadas deben ser explícitas y responder a hipótesis concretas. Esto con el fin de proveer un análisis crítico y herramientas útiles tanto para la investigación como para la toma de decisiones en salud. Este estudio inicia con una síntesis de los principales antecedentes históricos que han permitido la evolución del concepto de ISS. Seguidamente, se presentan los principales conceptos subyacentes relativos a la definición de ISS (determinantes sociales, equidad, justicia, estratificación y gradiente social en salud) y cómo estos deben guiar las decisiones prácticas y metodológicas. Finalmente, se concluye con algunas recomendaciones para la generación de esta evidencia científica para Latinoamérica.

ABSTRACT Social health inequalities (or inequities) continue to represent a great challenge for public health research worldwide. Since 1991, the World Health Organization established that the study and analysis of health inequalities represented a priority for all countries. To better guide methodological and practical implications of health inequalities, research on this topic should present a solid theoretical model, able to impact future public health policies. Previous studies of health inequalities in Latin America are often inspired from abroad experiences, encouraging the reproduction of mainly European theoretical positions and methodologies. However, especially when it comes to this topic, it is known the important role of the social context and culture, playing an important role in promoting differences in health outcomes. From this perspective, to operationalize the different social determinants in health, a critical perspective and thoughtful analysis of the context is mandatory. In order to provide a critical analysis and useful tools for both research and health decision making, we recommend that the theoretical and methodological approaches used in social health inequalities research must be well adapted to the specific contexts; that health social stratification must be assessed as a priority; that individual and the wider health determinants must be well characterized; and that the theoretical justification of the methodological decisions made in the studies and the selected measures must be explicit and should answer specific hypotheses. This research provides a brief historical background, to share the basis for the conceptual evolution of social health inequalities; the main underlying concepts related to the definition of health inequalities (social determinants, equity, justice, stratification and social gradient in health); and some recommendations for the future perspectives of health inequalities research in Latin America.

Contradicciones y desafios de políticas públicas de salud en un contexto intraurbano brasileño: mapeando inequidades sociales y actividad física / Contradictions and challenges of public health policies in a brazilian intra-urban context: mapping social inequities and physical activity

El tema de las inequidades socio-económicas sigue siendo vital para la constitución de los movimientos críticos de la promoción de la salud en América Latina. Al hacer referencia a tales premisas, el presente texto busca articularlas sobre una cuestión emergente en el campo sanitario: la institucionalización pública de prácticas de actividad física (AF) y el modo como han sido desvinculadas de las acciones y políticas de combate contra las inequidades georeferenciadas en territorios urbanos brasileños. En ese sentido, toma como escenario de análisis a la ciudad de Vitória, localizada en la región sudeste del país, para examinar contextualmente una iniciativa pública allí existente, que fomenta prácticas de AF. Para el estudio se utilizaron informaciones secundarias relativas a las condiciones de vida de algunos barrios de Vitória y las características de ese programa de AF, obtenidas a partir de un banco de datos en el municipio. Los resultados revelaron un cuadro intraurbano de inequidades sociales, sanitarias y económicas persistentes, que han sido descuidados sistemáticamente por la gestión pública durante el proceso de implantación y expansión de la AF como política de salud. (AU)

Understanding social and economic inequities continues to be essential to establi-shing critical health promotion movements in Latin America. This article aims to arti-culate this context with an up-and-coming issue in healthcare: the public institutio-nal of physical activity (PA) and the way in which they have been decoupled from interventions and policies that seeks to combat georeferenced inequities in Brazilian urban territories. This manuscript focuses its analysis on the city of Vitória, located in southeastern Brasil, to examine a local public initiative that promotes PA, though the exploration of secondary information about the living conditions in some neighbor-hoods of Vitória and the characteristics of the PA program that was obtained through a municipal database. The findings revealed an intra-urban context of persistent so-cial, sanitary and economical inequities that have been systematically neglected by public authorities during the process of implementation and expansion of PA as a health policy in Vitória. (AU)

Determinantes sociales de la mortalidad infantil por causas reducibles en la Argentina, 2009-2011

bjetivo: identificar los determinantes sociales de la mortalidad infantil, según el criterio de reducibilidad, en tres niveles de determinación (individual, familiar y poblacional).Métodos: se realizó un estudio transversal para el análisis de las características de la mortalidad infantil en partidos y departamentos de la República Argentina, y de los determinantes sociales de la mortalidad infantil, en tres niveles de análisis. Para el primero y el segundo nivel, se utilizaron variables relacionadas con los fallecidos que están disponibles en los informes estadísticos de defunción. Para el tercer nivel se utilizaron los datos poblacionales provenientes del Censo Nacional de Población y Viviendas del 2010.Resultados: de los determinantes sociales de la salud considerados, las variables que presentaron asociación estadísticamente significativa con la mortalidad infantil por causas reducibles fueron: edad del fallecido al momento de la muerte, la edad gestacional, lugar de ocurrencia de la muerte, haber tenido atención o no, el nivel de instrucción de la madre, la situación laboral, primaria incompleta y hacinamiento.Conclusión: existe una influencia de factores tanto del nivel individual, como del nivel familiar y poblacional sobre la mortalidad infantil y en mayor proporción sobre las muertes por causas reducibles.

he objective of this project is to identify the social determinants of infant mortality according to the criteria of reducibility and to investigate the association between the infant mortality and its determinants on multiple levels.Methods: A cross-sectional study analyzed the characteristics of infant mortality in parties and departments of Argentina and the social determinants of infant mortality in three levels of analysis.Results: The variables that showed a statistically significant association with infant mortality due to avoidable causes were: age of the deceased at the time of death, gestational age, place of occurrence of death, having attention or not, the level of instruction of the mother, employment status, overcrowding, and incomplete primary care.Conclusions: The factors that influence infant mortality exists as much at an individual level as they do at the family and population levels, and a large proportion of deaths are from preventable causes.

Pré-natal em mulheres usuárias do Sistema Único de Saúde em duas maternidades no Estado do Rio de Janeiro, Brasil: a cor importa? / Prenatal care in women using the Brazilian National Health System (SUS) in two maternity hospitals in the State of Rio de Janeiro, Brazil: does color matter?

Identificar fatores associados ao pré-natal inadequado, com destaque para cor da pele, em usuárias do SUS do Estado do Rio de Janeiro (RJ), no último trimestre de 2011. Métodos: estudo de corte seccional em duas maternidades públicas no RJ. Foram entrevistadas 1790 parturientes, arroladas sequencialmente. Número de consultas e início do acompanhamento foram coletados dos cartões de pré-natal. O desfecho foi adequação do pré-natal, classificada pelo Índice de Adequação de Utilização do Pré-natal. A exposição principal foi cor da pele, além de covariáveis sociodemográficas e reprodutivas. A regressão logística multivariada usou níveis hierárquicos: variáveis predisponentes e capacitantes da utilização do pré-natal no primeiro e segundo nível, respectivamente. Resultados: a cor da pele preta manteve-se associada ao pré-natal inadequado, mesmo após ajuste para covariáveis (OR=1,37; IC95 por cento:1,02-1,83). Gravidez adolescente (OR=1,85; IC95 por cento:1,43-2,41); ausência de companheiro (OR=1,75; IC95 por cento:1,38- 2,20) e multiparidade (OR=2,40; IC95 por cento:1,49-3,85) também se associaram positivamente ao desfecho. O atendimento ao pré-natal em serviços públicos (OR=0,67; IC95 por cento: 0,49-0,91) e primiparidade (OR=0,41; IC95 por cento: 0,32 e 0,52) tiveram efeito protetor. Conclusões: gestantes de cor preta tiveram maior chance de realizar pré-natal inadequado no RJ. São necessárias políticas para reduzir iniquidades de raça/cor na assistência pré-natal desta população...

To identify factors associated with inadequate prenatal care, with a special focus on skin color, among female users of the SUS in the State of Rio de Janeiro (RJ), in the final trimester of 2011. Methods: a cross-sectional cohort study was carried out at two public maternity hospitals in RJ. Interviews were conducted with 1790 women bearing children, in order of sequence. The number of consults and the date on which accompaniment of the women commenced were gathered from prenatal cards. The outcome was adequate prenatal care, classified according to the Adequate Use of Prenatal Care Index. The main factor associated with exposure was skin color, along with other socio-demographic and reproductive co-variables. Multivariate logistic regression used hierarchical levels: the variables predisposing women to the use of prenatal care were on the first and second levels, respectively. Results: dark skin color remained associated with inadequate prenatal care, even after adjustment for co-variables (OR=1.37; CI95 percent:1.02-1.83). Teenage pregnancy (OR=1.85; CI95 percent:1.43-2.41); absence of a partner (OR=1.75; CI95 percent:1.38-2.20) and multiparity (OR=2.40; CI95 percent:1.49-3.85) were also positively associated with the outcome. Prenatal care in public services (OR=0.67; CI95 percent: 0.49-0.91) and primiparity (OR=0.41; CI95 percent: 0.32 and 0.52) were protective factors. Conclusions: pregnant women who were black stood a greater chance of receiving inadequate prenatal care in RJ. Policies are needed to reduce inequalities relating to color/race in the prenatal care of this population...

Inequidades en el diagnóstico de anomalías congénitas mayores en recién nacidos en Cali, Colombia / Inequities in the diagnosis of major congenital anomalies in newborns in Cali, Colombia

Antecedentes: Las anomalías congénitas mayores (ACM) están presentes en el 2-3 por ciento de los nacidos vivos. La mayoría de ellas diagnosticables mediante ecografía prenatal (EcoPN). Los países en desarrollo presentan inequidades en el acceso al procedimiento. Objetivos: Determinar las inequidades existentes en la realización de EcoPN en las madres de recién nacidos (RN) con ACM hospitalizados en dos unidades de cuidado intensivo neonatal (UCIN) e identificar las inequidades en el diagnóstico de ACM en las madres a quienes les fue realizada al menos una EcoPN. Métodos: Estudio transversal en RN con ACM diagnosticables por EcoPN, hospitalizados en dos UCIN de Cali, Colombia, entre 2005 y 2009. Se determinó el índice de concordancia (kappa) entre variables sociodemográficas y el diagnóstico de ACM prenatal y definitivo. Se determinaron las asociaciones entre ausencia de EcoPN y del diagnóstico de ACM con factores sociodemográficos y aseguramiento en salud. Resultados: Se incluyeron 404 casos que presentaron 573 anomalías congénitas. El 51,7 por ciento (IC95 por ciento 46,7 por ciento -56,7 por ciento) tuvieron al menos una EcoPN; de éstos el 31,1 por ciento (IC95 por ciento 24,9 por ciento -37,9 por ciento) no tuvo diagnóstico de ACM. La ausencia de EcoPN estuvo asociada a la afiliación al régimen de salud subsidiado, la no afiliación al sistema de salud, a las madres procedentes de municipios diferentes a la capital de la provincia, de otras provincias y del área rural. Hubo asociaciones similares para la ausencia de diagnóstico de alguna ACM en la EcoPN. Conclusiones: Se detectaron inequidades en la realización EcoPN y en el diagnóstico de ACM en las madres de mayor vulnerabilidad social y demográfica. Se debe mejorar el acceso a los servicios de EcoPN en Colombia para cerrar estas disparidades sociales.

Background: Major Congenital Anomalies (MCA) are present in 2-3 percent of live births. Most of these are diagnosable by prenatal ultrasound (PNUS). Developing countries have inequities in access to this screening test. Objectives: To determine existing inequities access to PNUS in mothers of newborns (NB) with MCA hospitalized in two neonatal intensive care units (NICU) and to identify inequities in the diagnosis of MCA among mothers to whom it was made at least one PNUS. Methods: Cross-sectional study in NB with MCA diagnosable by PNUS hospitalized in two NICUs of Cali, Colombia, between 2005 and 2009. The index of agreement (kappa) between prenatal diagnosis and definitive MCA was calculated. It was established associations between absence of PNUS and diagnosis of MCA with socio-demographic factors and health insurance schemes. Results: 404 cases with 573 MCA were included. 51.7 percent (95 percent CI: 46.7 percent -56.7 percent) had at least one PNUS; of these 31.1 percent (95 percent CI: 24.9 percent -37.9 percent) had no diagnosis of MCA. The absence of PNUS was associated with affiliation to the subsidized health scheme, no-affiliation to the health system, mothers from municipalities different to the capital of the province, from other provinces and from rural areas. There were similar associations for the absence of a diagnosis of MCA in PNUS. Conclusions: It was detected inequities in access to the PNUS and in diagnosis of MCA for mothers of greater social and demographic vulnerability. The access to services of PNUS in Colombia should been improved, in order to reduce these social disparities.

Desigualdades sociales en Salud: Su expresión en niños y adolescentes con cáncer ingresados en el Servicio de Oncohematologia del Hospital de Especialidades Pediátricas de Maracaibo. Estado Zulia

Objetivo: Determinar las desigualdades sociales en la salud de los niños y adolescentes con cáncer, ingresados en el Servicio de oncohematologia del Hospital de Especialidades Pediátricas de Maracaibo Estado Zulia. Venezuela Metodología: Estudio descriptivo, transversal sobre una muestra no probabilística intencional constituida por 46 madres y padres de los niños y adolescentes del servicio. Para determinar las desigualdades sociales en la salud, se aplicó un cuestionario mediante la técnica de encuesta el cual contenía indicadores de condición socioeconómica, procedencia, accesibilidad geográfica al hospital, a los medicamentos quimioterapeúticos y a la tecnología médica. Resultados: 46.9% de los padres mostró bajos niveles de educación formal. 56.5% tenían ingresos iguales al salario mínimo mensual y el 65,8 % era obrero no calificado. 92.3% de los pacientes eran trasladados al hospital en transporte público (promedio 2.9 horas de viaje). El 91% del tratamiento quimioterapéutico era dotado por la ONG Fundación Amigos del Niño con Cáncer gratuita y oportunamente y el 8% por el Estado Venezolano. Conclusiones: Persisten las inequidades en salud expresadas en un marcado deterioro de las condiciones materiales de vida de las familias de los niños de este estudio y en el incumplimiento del papel del Estado Venezolano como garante del derecho a la salud y calidad de vida. La reducción de estas desigualdades constituye uno de los mayores desafíos de nuestra sociedad.

Objective: To determine the inequities in health in children and adolescents with illness neoplásica, entered in the Service of hematooncologic of the Hospital of pediatric Specialties of Maracaibo. Zulia. Methodology: The sample was conformed by 46 mother and father. The sample was integrated by 246 patients. The Social inequalities were determined by socioeconomic status (measured by education, income, and employment), origin, geographical accessibility of the users to the Hospital, and accessibility to the chemotherapeutic treatment and medical technology. Interviews were made structured the parents of the children, to the Manager of pharmacy of the Hospital and representatives of the Foundation friends of children with cancer. Results: 46.9% the mother and father showed low levels of formal education. 56.5% had revenue similar to the monthly minimum wage, and 65,8% were labor unqualified. 92.3% of the patients were transferred to the Hospital in public transportation (average 2.96 hours of trip). 91% of the chemotherapeutic treatment is endowed by the Organization non government boy's foundation friends with gratuitous cancer, and appropriately and 8% for the Venezuelan State. Conclusion: The inequities persist in health expressed in a marked deterioration of the material conditions of life of the families of the children of this study and in the nonfulfillment of the paper of the Venezuelan state as guarantor of the right to the health and quality of life. The reduction of these inequities constitutes one of the biggest challenges in our society.