Education and wealth inequalities in healthy ageing in eight harmonised cohorts in the ATHLOS consortium: a population-based study.

BACKGROUND: The rapid growth of the size of the older population is having a substantial effect on health and social care services in many societies across the world. Maintaining health and functioning in older age is a key public health issue but few studies have examined factors associated with inequalities in trajectories of health and functioning across countries. The aim of this study was to investigate trajectories of healthy ageing in older men and women (aged ≥45 years) and the effect of education and wealth on these trajectories. METHODS: This population-based study is based on eight longitudinal cohorts from Australia, the USA, Japan, South Korea, Mexico, and Europe harmonised by the EU Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) consortium. We selected these studies from the repository of 17 ageing studies in the ATHLOS consortium because they reported at least three waves of collected data. We used multilevel modelling to investigate the effect of education and wealth on trajectories of healthy ageing scores, which incorporated 41 items of physical and cognitive functioning with a range between 0 (poor) and 100 (good), after adjustment for age, sex, and cohort study. FINDINGS: We used data from 141 214 participants, with a mean age of 62·9 years (SD 10·1) and an age range of 45-106 years, of whom 76 484 (54·2%) were women. The earliest year of baseline data was 1992 and the most recent last follow-up year was 2015. Education and wealth affected baseline scores of healthy ageing but had little effect on the rate of decrease in healthy ageing score thereafter. Compared with those with primary education or less, participants with tertiary education had higher baseline scores (adjusted difference in score of 10·54 points, 95% CI 10·31-10·77). The adjusted difference in healthy ageing score between lowest and highest quintiles of wealth was 8·98 points (95% CI 8·74-9·22). Among the eight cohorts, the strongest inequality gradient for both education and wealth was found in the Health Retirement Study from the USA. INTERPRETATION: The apparent difference in baseline healthy ageing scores between those with high versus low education levels and wealth suggests that cumulative disadvantage due to low education and wealth might have largely deteriorated health conditions in early life stages, leading to persistent differences throughout older age, but no further increase in ageing disparity after age 70 years. Future research should adopt a lifecourse approach to investigate mechanisms of health inequalities across education and wealth in different societies. FUNDING: European Union Horizon 2020 Research and Innovation Programme.

Development of a healthy ageing index in Latin American countries - a 10/66 dementia research group population-based study.

BACKGROUND: Our population is ageing and in 2050 more than one out of five people will be 60 years or older; 80% of whom will be living in a low-and-middle income country. Living longer does not entail living healthier; however, there is not a widely accepted measure of healthy ageing hampering policy and research. The World Health Organization defines healthy ageing as the process of developing and maintaining functional ability that will enable well-being in older age. We aimed to create a healthy ageing index (HAI) in a subset of six low-and-middle income countries, part of the 10/66 study, by using items of functional ability and intrinsic capacity. METHODS: The study sample included residents 65-years old and over (n = 12,865) from catchment area sites in Cuba, Dominican Republic, Peru, Venezuela, Mexico and Puerto Rico. Items were collected by interviewing participants or key informants between 2003 and 2010. Two-stage factor analysis was employed and we compared one-factor, second-order and bifactor models. The psychometric properties of the index, including reliability, replicability, unidimensionality and concurrent convergent validity as well as measurement invariance per ethnic group and gender were further examined in the best fit model. RESULTS: The bifactor model displayed superior model fit statistics supporting that a general factor underlies the various items but other subdomain factors are also needed. The HAI indicated excellent reliability (ω = 0.96, ωΗ = 0.84), replicability (H = 0.96), some support for unidimensionality (Explained Common Variance = 0.65) and some concurrent convergent validity with self-rated health. Scalar measurement invariance per ethnic group and gender was supported. CONCLUSIONS: A HAI with excellent psychometric properties was created by using items of functional ability and intrinsic capacity in a subset of six low-and-middle income countries. Further research is needed to explore sub-population differences and to validate this index to other cultural settings.

Healthy ageing trajectories and lifestyle behaviour: the Mexican Health and Aging Study.

Projections show that the number of people above 60 years old will triple by 2050 in Mexico. Nevertheless, ageing is characterised by great variability in the health status. In this study, we aimed to identify trajectories of health and their associations with lifestyle factors in a national representative cohort study of older Mexicans. We used secondary data of 14,143 adults from the Mexican Health and Aging Study (MHAS). A metric of health, based on the conceptual framework of functional ability, was mapped onto four waves (2001, 2003, 2012, 2015) and created by applying Bayesian multilevel Item Response Theory (IRT). Conditional Growth Mixture Modelling (GMM) was used to identify latent classes of individuals with similar trajectories and examine the impact of physical activity, smoking and alcohol on those. Conditional on sociodemographic and lifestyle behaviour four latent classes were suggested: high-stable, moderate-stable, low-stable and decliners. Participants who did not engage in physical activity, were current or previous smokers and did not consume alcohol at baseline were more likely to be in the trajectory with the highest deterioration (i.e. decliners). This study confirms ageing heterogeneity and the positive influence of a healthy lifestyle. These results provide the ground for new policies.

The role of unhealthy lifestyles in the incidence and persistence of depression: a longitudinal general population study in four emerging countries.

BACKGROUND: Unhealthy lifestyles and depression are highly interrelated: depression might elicit and exacerbate unhealthy lifestyles and people with unhealthy lifestyles are more likely to become depressed over time. However, few longitudinal evidence of these relationships has been collected in emerging countries. The present study aims i) to analyse whether people with unhealthy lifestyles are more likely to develop depression, and ii) to examine whether depressed people with unhealthy lifestyles are more likely to remain depressed. A total of 7908 participants from Ghana, India, Mexico and Russia were firstly evaluated in the World Health Organization's Study on Global AGEing and Adult Health (SAGE) Wave 0 (2002-2004) and re-evaluated in 2007-2010 (Wave 1). Data on tobacco use, alcohol drinking and physical activity, were collected. Logistic regressions models were employed to assess whether baseline unhealthy lifestyles were related to depression in Wave 1, among people without 12-month depression in Wave 0 and any previous lifetime diagnosis of depression, and to 12-month depression at both study waves (persistent depression). RESULTS: Baseline daily and non-daily smoking was associated with depression in Wave 1. Low physical activity and heavy alcohol drinking were associated with persistent depression. CONCLUSIONS: Unhealthy lifestyles and depression are also positively related in emerging countries. Smoking on a daily and non-daily basis was longitudinally related to depression. Depressed people with low physical activity and with heavy drinking patterns were more likely to become depressed over time. Several interpretations of these results are given. Further studies should check whether a reduction of these unhealthy lifestyles leads to lower depression rates and/or to a better clinical prognosis of depressed people.

Multi-country evaluation of affective experience: validation of an abbreviated version of the day reconstruction method in seven countries.

BACKGROUND: The Day Reconstruction Method (DRM) was developed to assess affective states as measures of experienced well-being. The present study aimed to validate an abbreviated version of the DRM in a representative sample of the population in seven countries (China, Ghana, India, Mexico, Russia, South Africa, and Spain), and to examine whether there are country differences in affect and in the relationships among the activities based on the similarity of the affect associated with each of them. METHODS: Interviews were conducted with 47,222 non-institutionalized adults from seven countries, using an abbreviated version of the DRM. A cluster analysis was carried out to classify activities on the basis of the similarity of the associated affect. In each country, the factorial structure of the affect adjectives was tested through Confirmatory Factor Analysis. Internal consistency and construct validity were also assessed. Moreover, the differences in affect across countries and the diurnal cycles of affect were evaluated. RESULTS: The DRM showed adequate psychometric properties regarding reliability and construct validity in all countries. Respondents from Ghana and South Africa reported more positive net affect whereas Indian respondents reported less positive net affect. Most of the countries showed a similar diurnal variation of affect, which tended to improve throughout the day. CONCLUSIONS: The results show that this abbreviated version of the DRM is a useful tool for multi-country evaluation of experienced well-being.

Hacia la cobertura universal en salud: protección social para todos en México

México alcanzará la cobertura universal en salud en 2012. El seguro nacional de salud denominado Seguro Popular, introducido en 2003, garantiza el acceso a un paquete de servicios de salud integrales con protección financiera a más de 50 millones de mexicanos previamente excluidos de la seguridad social. La cobertura universal en México es sinónimo de protección social en salud. Este informe analiza el camino hacia la cobertura universal en sus tres dimensiones de protección: a) contra riesgos para la salud, b) de los pacientes a través de la garantía de calidad de la atención a la salud y c) contra las consecuencias financieras de la enfermedad y las lesiones. Se presenta una discusión conceptual sobre la transición de una seguridad social basada en la condición laboral a la protección social en salud, que implica el acceso a una atención integral de la salud como derecho universal basado en la ciudadanía, plataforma ética de la reforma mexicana. Se describen asimismo las condiciones que llevaron a la reforma, así como su diseño y puesta en marcha, y se discute el proceso de implantación a nueve años de iniciado y las evidencias que dieron origen a actualizaciones y mejoras del programa original. El núcleo del informe se centra en los efectos e impactos de la reforma que se desprenden de la literatura sobre el tema, que incluye artículos científicos y otras publicaciones disponibles. La evidencia indica que el Seguro Popular está mejorando el acceso a los servicios de salud y reduciendo la prevalencia de los gastos en salud catastróficos y empobrecedores, especialmente entre los pobres. Estudios recientes muestran asimismo una mejora en la cobertura efectiva. También se discuten los desafíos prevalentes, incluyendo la necesidad de traducir los recursos financieros en servicios de salud más efectivos, equitativos y sensibles a las expectativas de los usuarios. Se requiere una nueva generación de reformas que incluya medidas sistémicas para consolidar la reorganización del sistema de salud por funciones. El artículo concluye con una discusión sobre las implicaciones de la búsqueda de la cobertura universal de salud en México y su importancia para otros países de ingresos bajos y medios.

Lessons learned from the first evaluation of the Medical Insurance for a New Generation: bridging research and policy.

The first evaluation of the Medical Insurance for a New Generation program (SMNG) was conducted in 2009. A mixed-method approach was used to obtain a comprehensive picture of SMNG members and the program itself. The evaluation comprised: 1) Program design; 2) Social and health conditions of its members; 3); Evaluation of SMNG's performance by measuring coverage, productivity and efficiency; 4) Families health expenditures. The lessons learned for the program are that SMNG is focused on a vulnerable segment of the population with pervasive unmet health needs; prevalence of malnutrition, anemia and other conditions remains high. Further efforts are necessary to deploy the program where it is most needed, particularly in rural areas; most of its members are urban dwellers. However, more needs to be done to educate members about the importance of preventive care and to build the capability of health providers to provide high quality care. Families are still experiencing hardship to provide medical care to their children, so additional efforts are needed to decrease out-of-pocket and catastrophic expenditures. The lessons learned for the evaluation allow concluding that this first evaluation set the groundwork for better-targeted subsequent interventions and evaluations aimed at showing the impact of SMNG to bridge existing gaps in equity, access, coverage, and health status of Mexican children.

The quest for universal health coverage: achieving social protection for all in Mexico.

Mexico is reaching universal health coverage in 2012. A national health insurance programme called Seguro Popular, introduced in 2003, is providing access to a package of comprehensive health services with financial protection for more than 50 million Mexicans previously excluded from insurance. Universal coverage in Mexico is synonymous with social protection of health. This report analyses the road to universal coverage along three dimensions of protection: against health risks, for patients through quality assurance of health care, and against the financial consequences of disease and injury. We present a conceptual discussion of the transition from labour-based social security to social protection of health, which implies access to effective health care as a universal right based on citizenship, the ethical basis of the Mexican reform. We discuss the conditions that prompted the reform, as well as its design and inception, and we describe the 9-year, evidence-driven implementation process, including updates and improvements to the original programme. The core of the report concentrates on the effects and impacts of the reform, based on analysis of all published and publically available scientific literature and new data. Evidence indicates that Seguro Popular is improving access to health services and reducing the prevalence of catastrophic and impoverishing health expenditures, especially for the poor. Recent studies also show improvement in effective coverage. This research then addresses persistent challenges, including the need to translate financial resources into more effective, equitable and responsive health services. A next generation of reforms will be required and these include systemic measures to complete the reorganisation of the health system by functions. The paper concludes with a discussion of the implications of the Mexican quest to achieve universal health coverage and its relevance for other low-income and middle-income countries.

Lessons learned from the first evaluation of the Medical Insurance for a New Generation: bridging research and policy / Lecciones aprendidas de la primera evaluación del Seguro Médico para una Nueva Generación

The first evaluation of the Medical Insurance for a New Generation program (SMNG) was conducted in 2009. A mixed-method approach was used to obtain a comprehensive picture of SMNG members and the program itself. The evaluation comprised: 1) Program design; 2) Social and health conditions of its members; 3); Evaluation of SMNG's performance by measuring coverage, productivity and efficiency; 4) Families health expenditures. The lessons learned for the program are that SMNG is focused on a vulnerable segment of the population with pervasive unmet health needs; prevalence of malnutrition, anemia and other conditions remains high. Further efforts are necessary to deploy the program where it is most needed, particularly in rural areas; most of its members are urban dwellers. However, more needs to be done to educate members about the importance of preventive care and to build the capability of health providers to provide high quality care. Families are still experiencing hardship to provide medical care to their children, so additional efforts are needed to decrease out-of-pocket and catastrophic expenditures. The lessons learned for the evaluation allow concluding that this first evaluation set the groundwork for better-targeted subsequent interventions and evaluations aimed at showing the impact of SMNG to bridge existing gaps in equity, access, coverage, and health status of Mexican children.

La primera evaluación del Seguro Médico para una Nueva Generación (SMNG) se llevó a cabo en 2009. La evaluación utilizó métodos mixtos para obtener una imagen completa de los miembros del SMNG y del programa. La evaluación comprendió: 1) el diseño del programa, 2) las condiciones sociales y de salud de los miembros, 3) acceso y uso de los servicios de salud, 4) la calidad de los servicios de atención ambulatoria y hospitalaria y 5) el efecto en los gastos de salud de las familias. El SMNG está enfocado a la población vulnerable con necesidades de salud no satisfechas, donde persiste la prevalencia de la desnutrición, anemia y otras enfermedades. Son necesarios esfuerzos adicionales para aumentar la cobertura del programa en zonas rurales donde la necesidad es mayor; pues la mayoría de sus miembros habitan en áreas urbanas, también es indispensable fortalecer la atención preventiva y fortalecer la capacidad de los proveedores de salud para proporcionar atención de alta calidad. Las familias todavía están experimentando dificultades para prestar atención a sus hijos, son necesarios esfuerzos adicionales para disminuir los gastos de bolsillo y catastrófico. Esta primera evaluación establece las bases para intervenciones y evaluaciones posteriores sustentadas en objetivos mejor definidos y enfocados a demostrar que SMNG está disminuyendo las brechas existentes en equidad, acceso, cobertura y estado de salud de la niñez mexicana.

Anomalías físicas menores y esquizofrenia

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Summary: The neurodevelopment hypothesis in schizophrenia is a theoretic construction that tries to explain, at least partially, the etiopatho-geny of this disease. Since Kraepelin's early descriptions it has been suggested that schizophrenia is a disease linked to the Central Nervous System structure, and vast efforts have been made to prove the existence of the biological markers of schizophrenia that include clinically distinguishable features (like dermatoglyphs and neuropsychological tests), electrophysiological, endocrine, immunologic and genetic tests, and neuroimaging studies. The Minor Physical Anomalies (MPAs) are slight anatomical deviations of an individual's external physical features, which imply neither a serious medical consequence nor an aesthetic problem. MPAs could be considered a valid biological marker in the evaluation of schizophrenia if we interpret this disease as a disorder originating in the early months of intrauterine life during the first stages of neurodevelopment. Like dermatoglyphs, the MPAs may be seen as "fossil" signs that reflect the intrauterine environment. They could be useful as an indirect measurement of an alteration of structures related to the Central Nervous System in its embryologic origin, or in nervous structures and non-neuronal epidermic and other superficial tissues derived from ectoderm, especially in skin, eyes and ears, or else with those that belong to embrionary developmental fields adjacent to brain structures, that may induce cranial-facial alterations. This developmental fields theory explains the existence of a relationship between tissues or structures that do not have a common embryologic origin. After embryogenesis, they determine topographic zones of development, and the presence of a defect could affect a single structure (monotopic defect), but those that appear earlier would promote several areas in the body (polytopic field defects). Due to these complex interactions, it is not easy to correlate the intensity of the damage with the moment in which this occurred. A minor malformation could even have been generated in blastogenesis and could therefore be related to associated defects. It is not always a 'benign' abnormality. This observation is important if we consider that several genetic syndromes exist that present specific malformations. These are strongly associated with a high risk to develop schizophrenia (around 25 fold), such as the 22qll.2 deletion (velocardiofacial syndrome, DiGeorge syndrome and other variations). There has been speculation around a so-called "congenital" schizophrenia subtype on the basis of an association with several clinical features such as gender, age of onset, positive or negative symptoms, brain abnormalities that show up in MRI scans, additional cognitive impairment and a worse evolution and prognosis in which the neurodevelopmental disturbances factor would have a widespread significance in the etiopathogeny of the disease. The Waldrop's Scale for Minor Physical Anomalies has been the most used tool to measure these abnormalities and has been subject to numerous modifications. Even though it is considered a reliable instrument, with a good internal consistence, numerous limitations in results interpretation have been noted, most of them derived of limited inter-evaluator reliability, lack of consensus about the relative importance of each item and the extensive interracial variability in the presentation of MPAs. In the 1980's, the neurodevelopmental theory emerged as an explanation of the origin of schizophrenia and a number of investigations have been carried out, to measure MPAs and other biologic markers of neurodevelopment (like dermatoglyphs). Most studies have shown a greater prevalence of MPAs in schizophrenic patients compared to control groups, as it has been observed in other disorders like mental retardation, autism, attention-deficit disorder and violent behavior in adolescence. Nevertheless, there are only a few consistent data sets that correlate with an increased number of MPAs, and amongst them we can point out a positive correlation with male gender, neuroimaging brain alterations, genetic charge for schizophrenia, more frequent obstetric complications and a more perceptible cognitive impairment. Additionally, other investigations draw attention to a positive correlation with a lower premorbid adjustment, an earlier beginning of the disease, a predominance of negative symptoms and a larger tendency to develop late dyskinesia, although these data show contradictory results. Even though the diverse ethnic groups' phenotypic variants tend to limit the interpretation of each minor physical anomaly, most investigations have found a prevalence of these abnormalities in the cranial-facial area, most of them in ears and mouth, although the peripheral zones are not unaffected. When we consider those studies, we notice that the diversity of data is predominant. We can explain this if we bear in mind that some of the MPAs can be normal phenotypic features in some ethnic groups, or frequent enough to be a normal variant without discriminative meaning. We must also take into account that different scales have been used for the measurements. For this specific problem it has been suggested to use anthropometric scales, similar to those used by cranial-facial surgeons. The variability of the presentation of MPAs and the phenotypic variations compel us to conduct local investigations focused on determining which variants are outstanding or not in any ethnic group in relation to neurodevelopment deviations. We can conclude than MPAs might be a biological marker that can help us to characterize at least a subgroup of clinically recognizable schizophrenic patients, or those that have predisposition to present some clinical features, but it is necessary to develop an objective evaluation tool that ideally would incorporate anthropometric measurements in order to compare these MPAs with the phenotypic variants in each ethnic group. It is necessary to design and carry out genetic studies (first among first and second-degree relatives and afterwards in bigger populations and also comparative studies with the general population) with the aim to distinguish between genetically-determined variants and those resulting from environmental factors, as well as establishing the interaction of both types of variants. The existence of a clinically recognizable subtype of schizophrenia on which we can rely on as an etiopathogeny hypothesis is an appreciable area that is still under discussion and which deserves further investigation efforts. This could have implications on our approach to nosologic, diagnostic and even prognostic features of this heterogeneous disorder. Such investigation could help us to reformulate the schizophrenia notion itself.