Racial inequalities in the development of multimorbidity of chronic conditions: results from a Brazilian prospective cohort.

BACKGROUND: The occurrence of multimorbidity and its impacts have differentially affected population subgroups. Evidence on its incidence has mainly come from high-income regions, with limited exploration of racial disparities. This study investigated the association between racial groups and the development of multimorbidity and chronic conditions in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). METHODS: Data from self-reported white, brown (pardos or mixed-race), and black participants at baseline of ELSA-Brasil (2008-2010) who were at risk for multimorbidity were analysed. The development of chronic conditions was assessed through in-person visits and self-reported diagnosis via telephone until the third follow-up visit (2017-2019). Multimorbidity was defined when, at the follow-up visit, the participant had two or more morbidities. Cumulative incidences, incidence rates, and adjusted incidence rate ratios (IRRs) were estimated using Poisson models. RESULTS: Over an 8.3-year follow-up, compared to white participants: browns had a 27% greater incidence of hypertension and obesity; and blacks had a 62% and 45% greater incidence, respectively. Blacks also had 58% more diabetes. The cancer incidence was greater among whites. Multimorbidity affected 41% of the participants, with a crude incidence rate of 57.5 cases per 1000 person-years (ranging from 56.3 for whites to 63.9 for blacks). Adjusted estimates showed a 20% higher incidence of multimorbidity in black participants compared to white participants (IRR: 1.20; 95% CI: 1.05-1.38). CONCLUSIONS: Significant racial disparities in the risk of chronic conditions and multimorbidity were observed. Many associations revealed a gradient increase in illness risk according to darker skin tones. Addressing fundamental causes such as racism and racial discrimination, alongside considering social determinants of health, is vital for comprehensive multimorbidity care. Intersectoral, equitable policies are essential for ensuring health rights for historically marginalized groups.

Long-term inequalities in health among older Mexican adults: An outcome-wide analysis.

The relationship between socioeconomic level and health outcomes in older people has been widely studied, but less information about health inequalities associated with gender and place of residence exists. Also, there is scarce evidence of longitudinal inequalities, particularly in countries from the global south. This study aimed to describe the longitudinal patterns of health inequalities associated with wealth, gender, and residence area among older Mexican adults. We used data from two longitudinal studies in Mexico: The Study on Global AGEing and Adult Health (SAGE) and the Mexican Health and Aging Study (MHAS). Three domains to characterize health inequities were used: wealth, gender, and rurality. We conducted an outcome-wide analysis with nine health indicators assessing older adults' physical and cognitive function. The Slope Index of Inequality and the Relative Index of Inequality were used as inequality measurements. Our results indicate that the greatest inequalities are observed in relation to wealth and gender. Older adults with lower socioeconomic status demonstrated higher rates of depression, sarcopenia, falls, and limitations in both basic and instrumental activities of daily living compared to their wealthier counterparts, with increasing trends in physical functionality over time. Furthermore, women experienced higher rates of depression, sarcopenia, frailty, and physical limitations compared to men. The only significant difference related to rurality was a lower rate of frailty among rural older adults. Longitudinal trajectories revealed an increase in the gap of inequality for various health indicators, especially in terms of wealth and gender. Health inequalities in old age are one of the greatest challenges facing health systems globally. Actions like universal coverage of health services for older people and the empowerment of individuals and their communities to have control over their lives and circumstances must be guaranteed.

COVID-19 mitigation measures increase preterm birth and low birth weight in the public healthcare system in Uruguay.

OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on preterm birth (PB) and low birth weight (LBW), comparing public and private healthcare systems of the National Integrated Health System in Uruguay, where the mitigation measures for the COVID-19 pandemic generated an immediate socioeconomic and psychological crisis, which caused a sharp widening of existing socioeconomic inequalities. METHODS: A national observational study was conducted comparing perinatal outcomes in the first 6 months of 2020 (period of the pandemic without pregnancy infections), which was the beginning of the pandemic, with the same period of the previous year 2019 (pre-pandemic period with no mitigation measures) among pregnant women from the public and private health systems. Data were retrieved from the national database (Informatic Perinatal System) and analyzed by healthcare system category. RESULTS: A total of 36 559 deliveries were assessed: 18 563 in the 2019 study period and 17 996 in the 2020 study period. In the public system, there was a significant increase in the risk of LBW (adjusted relative risk [aRR] 1.12, 95% confidence interval [CI] 1.05-1.36) and of the composite outcome (PB or LBW) (aRR 1.15, 95% CI 1.04-1.26). In the private system, by contrast, there was a non-statistically significant decrease of LBW and there were no changes in the incidence of PB and the composite outcome in 2020. CONCLUSION: The different evolution of birth outcomes in the public and private systems suggests an unequal impact of mitigation measures on populations of different socioeconomic levels. Given that no COVID-19 infections were identified in pregnant women during the study period, this research offers an opportunity to differentiate the biologic effects of the virus from the psychological and social impacts derived from containment measures. GOV IDENTIFIER: NCT05087160.

A covid-19 como uma crise multifacetada e suas implicações sobre o tráfico de pessoas ou outras formas de exploração humana / Covid-19 as a multifaceted crisis and its implications on human trafficking or other forms of human exploitation

Resumo Este ensaio se propõe a analisar em que medida a pandemia de covid-19 e a abordagem a ela conferida afetam a dinâmica do tráfico de pessoas, da exploração sexual, dos abusos laborais, e o atendimento recebido pelas vítimas. O tráfico de pessoas é contextualizado em um cenário de fragilidade global, estabelecendo riscos adicionais relacionados à realidade migrante, à classe social, ao gênero e à idade, e adquirindo agravantes próprios em decorrência da covid-19, considerando-se a redução da investigação e da oferta de assistência aos afetados. As medidas de isolamento repercutem gravemente sobre tais indivíduos, na medida em que deixam de gerar lucros para seus algozes e permanecem em ambientes precários, em um cenário propício à exploração laboral e outras formas de violência. A exploração sexual passa a ser ainda mais clandestina, expondo a vítima a novas formas de pressão e à contaminação. A informação em saúde e a possibilidade de prevenção e tratamento é modesta ou inexistente para as pessoas traficadas, comumente apartadas das estratégias referentes à emergência sanitária, sem acesso aos protocolos de proteção, em meio à ausência de autonomia. Realça-se a necessidade de um modelo sociossanitário inclusivo, em constante observação às demandas relacionadas aos grupos marginalizados.

Abstract This essay aims to analyze to what extent the covid-19 pandemic and the approach given to it affect the dynamics of human trafficking, sexual exploitation, labor abuse, and the care received by victims. Human trafficking is contextualized in a scenario of global fragility, establishing additional risks related to the migrant reality, social class, gender and age, and acquiring its own aggravating factors as a result of covid-19, considering the reduction in investigating and offering assistance to those affected. Isolation measures have a serious impact on these individuals, as they fail to generate profits for their tormentors and remain in precarious environments, in a scenario conducive to labor exploitation and other forms of violence. Sexual exploitation becomes even more clandestine, exposing the victim to new forms of pressure and contamination. Health information and the possibility of prevention and treatment are modest or non-existent for trafficked people, who are commonly cut off from strategies related to health emergencies, without access to protection protocols, amid a lack of autonomy. The need for an inclusive socio-sanitary model, constantly observing the demands related to marginalized groups, is highlighted.

Area-level inequalities in Covid-19 outcomes in Brazil in 2020 and 2021: An analysis of 1,894,165 severe Covid-19 cases.

The study aims to analyze inequalities in Covid-19 outcomes in Brazil in 2020/2021 according to the per capita Gross Domestic Product (pcGDP) of municipalities. All cases of Severe Acute Respiratory Syndrome (SARS) who were hospitalized or died, regardless of hospitalization, registered in Brazil in 2020 and 2021 were analyzed (n = 2,902,742), including those with a confirmed diagnosis of Covid-19 (n = 1,894,165). We calculated lethality due to Covid-19, the performance of diagnostic tests among patients with SARS, and the hospital care received by those with Covid-19 according to the pcGDP of the patients' municipalities of residence. Data were analyzed for each epidemiological week and the risk of each outcome was estimated using Poisson regression. Municipalities in the lowest pcGDP decile had (i) 30% (95%CI 28%-32%) higher lethality from Covid-19, (ii) three times higher proportion of patients with SARS without the collection of biological material for the diagnosis of Covid-19, (iii) 16% (95%CI 15%-16%) higher proportion of SARS patients testing in a period longer than two days from the onset of symptoms, (iv) 140% (95%CI 134%-145%) higher absence of CT scan use. There is deep socioeconomic inequality among Brazilian municipalities regarding the occurrence of Covid-19 negative outcomes.

Racial inequalities in multimorbidity: baseline of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

BACKGROUND: Evidence of multimorbidity has come mainly from high-income regions, while disparities among racial groups have been less explored. This study examined racial differences in multimorbidity in the multiracial cohort of the Longitudinal Study of Adult Health (Estudo Longitudinal de Saúde do Adulto), ELSA-Brasil. METHODS: The study examined baseline (2008-2010) data for 14 099 ELSA-Brasil participants who self-reported being white, mixed-race, or black. A list of 16 morbidities was used to evaluate multimorbidity, operationalised by simple count into ≥ 2, ≥ 3, ≥ 4, ≥ 5 and ≥ 6 morbidities, in addition to evaluating the number of coexisting conditions. Prevalence ratios (PR) were estimated from logistic models and a quantile model was used to examine racial differences graphically in the distribution quantiles for the number of morbidities. RESULTS: Overall prevalence of multimorbidity (≥ 2 morbidities) was 70% and, after controlling for age and sex, was greater among mixed-race and black participants - by 6% (PR: 1.06; 95% CI: 1.03-1.08) and 9% (PR: 1.09; 95% CI: 1.06-1.12), respectively - than among white participants. As the cutoff value for defining multimorbidity was raised, so the strength of the association increased, especially among blacks: if set at ≥ 6 morbidities, the prevalence was 27% greater for those of mixed-race (PR: 1.27; 95% CI: 1.07-1.50) and 47% greater for blacks (PR: 1.47; 95% CI: 1.22-1.76) than for whites. The disparities were smaller in the lower morbidity distribution quantiles and larger in the upper quantiles, indicating a heavier burden of disease, particularly on blacks. CONCLUSIONS: Multimorbidity was common among adults and older adults in a Brazilian cohort, but important racial inequalities were found. Raising the cutoff point for defining multimorbidity revealed stronger associations between race/skin colour and multimorbidity, indicating a higher prevalence of multimorbidity among mixed-race and black individuals than among whites and that the former groups coexisted more often with more complex health situations (with more coexisting morbidities). Interventions to prevent and manage the condition of multimorbidity that consider the social determinants of health and historically discriminated populations in low- and middle-income regions are necessary.

Inequidades en la detección temprana del cáncer de cérvix: una realidad en la población costarricense / Inequalities in the early detection of cervical cancer: a reality in the Costa Rica

Resumen Introducción: el cáncer de cérvix es una de las enfermedades neoplásicas más frecuentes que afecta la salud de las mujeres en el mundo. Objetivo: determinar si existen diferencias entre regiones de Costa Rica en el uso del papanicoláu, con el fin de visualizar las inequidades relacionadas con la detección temprana del cáncer cérvico-uterino. Metodología: este estudio se realizó a partir de la Encuesta Nacional de Hogares de 2014, la cual es representativa en el ámbito nacional. Se utilizó R-Studio para estimar dos modelos de regresión multinomial que explican el tiempo transcurrido desde el último papanicoláu y las razones por las que las mujeres nunca se habían realizado uno. Se recurrió a datos del Registro Nacional de Tumores del Ministerio de Salud para evaluar la razón in-situ/invasor. Resultados: en comparación con las residentes de la región Central, las mujeres de las regiones Chorotega, Pacífico Central y Huetar Caribe son respectivamente un 80 % (OR=1,80; p<0,01), un 52 % (OR=1,52; p=0,031) y un 58 % (OR=1,58; p<0,01) más propensas a haberse realizado la citología vaginal por última vez hace 5 años o más que hace 1 o 2 años. Discusión: de acuerdo con los resultados de la presente investigación, la Región Chorotega presenta las condiciones más desventajosas en cuanto a la práctica de PAP, esto implica un mayor riesgo de desarrollar lesiones y cáncer de cérvix. Conclusiones: en busca de reducir las brechas y mejorar las condiciones de acceso, es necesario coordinar y articular esfuerzos institucionales tanto gubernamentales como no gubernamentales, incluyendo la participación y el protagonismo de las mujeres.

Abstract Introduction. Cervical cancer is one of the most common cancer types that affects the health of women worldwide. Objective: To determine if there are differences in the use of Pap smears at the regional level in Costa Rica, in order to visualize the inequalities related to the early detection of cervical-uterine cancer. Methodology. This study was conducted based on information from the 2014 National Household Survey. This survey is representative at the national level. R-Studio was used to estimate two multinomial regression models. The first one was used to explain the time that has elapsed since the last time women had a Pap smear. The second one was used to explain the reasons why women had never had a Pap smear. Data on the incidence of cervical cancer, from the National Tumor Registry of the Ministry of Health, were used in order to estimate the in-situ/invasive ratio. Results: Women who participate less regularly in screening are those residing in the Chorotega, Central Pacific and Huetar Caribbean regions. Compared to women in the Central region, women in these three regions are 80% (OR=1.80; p<0.01), 52% (OR=1.52; p=0.031) and 58% (OR=1.58; p<0.01) respectively more likely to have had a Pap screening 5 or more years ago, as compared to 1 to 2 years ago. Discussion: According to the results of this research, the Chorotega Region presents the most disadvantageous conditions in terms of the use of PAP, which represents a higher risk for women to develop lesions and cervical cancer. Conclusions: In order to reduce gaps and improve conditions of access to prevention, it is necessary to coordinate institutional efforts, both governmental and non-governmental, as well as the participation and protagonism of women.

Racial discrimination is associated with greater arterial stiffness and carotid intima-media thickness: the ELSA-Brasil study.

PURPOSE: The association between racial discrimination and subclinical cardiovascular markers remains under-examined. We aimed to investigate the association of race/skin color and racial discrimination with pulse wave velocity (PWV) and carotid intima-media thickness (c-IMT) in the Brazilian context. METHODS: We used data from 13,284 participants from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline with information of PWV and 9850 for c-IMT. Self-reported race/skin color and perceived racial discrimination were the exposures. PWV and c-IMT were used continuously and categorizing according to cutoff that indicates increased cardiovascular risk. Linear and logistic regression models were used. RESULTS: Experience of racial discrimination was reported by 7% of total participants, but this prevalence was much higher among Blacks than Browns (PWV sample: 31,9% vs. 6,1%; c-IMT sample: 33,7% vs. 6,8%). After adjustments for age, sex, and research center, Blacks and Browns presented higher means of PWV and c-IMT and had greater chances of PWV>10 m/s and c-IMT≥75th percentile than Whites. The magnitude of all these associations were higher among Blacks and Browns with racial discrimination. In final models adjusted for education this pattern of association remained the same, although an attenuation in the magnitude of the association has been observed. CONCLUSIONS: Blacks and Browns presented worse profiles of subclinical cardiovascular markers compared to Whites and those exposed to racial discrimination seem to have an additional cardiovascular risk.

Mudanças no acesso gratuito a medicamentos prescritos no sistema público de saúde no Brasil / Changes in the free access to prescribed medicines in the public health system in Brazil

Resumo Introdução Os medicamentos são a intervenção terapêutica mais utilizada e a mais custo efetiva para o tratamento de diversas patologias. A falta de acesso a medicamentos entre grupos com menores condições socioeconômicas representa uma iniquidade nos cuidados com a saúde. Nesse sentido, o fornecimento gratuito de medicamentos pelo setor público é essencial para a promoção da equidade. Objetivo Avaliar a mudança, no tempo, da prevalência de acesso gratuito, pela população adulta brasileira, a medicamentos prescritos no Sistema Único de Saúde (SUS) ao longo de 10 anos. Método Análise dos dados, por regressão logística, das Pesquisas Nacionais por Amostra de Domicílios (PNAD) realizadas no Brasil em 1998, 2003 e 2008. A variável de interesse foi o acesso gratuito a medicamentos prescritos. Resultados O acesso gratuito a medicamentos pelo Sistema Único de Saúde aumentou ao longo do tempo. Indivíduos com renda socioeconômica mais baixa tiveram maior chance de acesso a medicamentos e esse cenário se manteve constante ao longo dos anos avaliados. Conclusão Os achados revelam a importância do SUS como ferramenta efetiva para a promoção do acesso a medicamentos, especialmente para os indivíduos mais pobres. Entretanto, a redução da desigualdade no acesso a medicamentos permanece como desafio.

Abstract Background The medicines are the most used and most effective therapeutic intervention for the treatment of various pathologies. The lack of access to medicines among groups with lower socioeconomic conditions represents an inequity in health care. In this sense, the public supply of medicines is free of charge by the public sector to promote equity. Objective To evaluate the change, in time and prevalence of free access, by the Brazilian adult population, to medicines prescribed in the Unified Health System (SUS) over 10 years. Method Data came from the National Household Sample Surveys (PNAD) conducted in Brazil in 1998, 2003 and 2008. The dependent variable was free access to prescribed medicines. Results Free access to medicines in the SUS increased over time. Individuals with lower socioeconomic income had higher chance to access the medicines and this scenario remained constant over the years evaluated. Conclusion The findings reveal the importance of SUS as an effective tool for promoting access to medicines, especially for the poorest individuals. However, reducing inequality in access to medicines remains a challenge.

Socioeconomic inequalities in low birth weight risk before and during the COVID-19 pandemic in Argentina: A cross-sectional study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic may have exacerbated existing socioeconomic inequalities in health. In Argentina, public hospitals serve the poorest uninsured segment of the population, while private hospitals serve patients with health insurance. This study aimed to assess whether socioeconomic inequalities in low birth weight (LBW) risk changed during the first wave of the COVID-19 pandemic. METHODS: This multicenter cross-sectional study included 15929 infants. A difference-in-difference (DID) analysis of socioeconomic inequalities between public and private hospitals in LBW risk in a pandemic cohort (March 20 to July 19, 2020) was compared with a prepandemic cohort (March 20 to July 19, 2019) by using medical records obtained from ten hospitals. Infants were categorized by weight as LBW < 2500 g, very low birth weight (VLBW) < 1500 g and extremely low birth weight (ELBW) < 1000 g. Log binomial regression was performed to estimate risk differences with an interaction term representing the DID estimator. Covariate-adjusted models included potential perinatal confounders. FINDINGS: Of the 8437 infants in the prepandemic cohort, 4887 (57•9%) were born in public hospitals. The pandemic cohort comprised 7492 infants, 4402 (58•7%) of whom were born in public hospitals. The DID estimators indicated no differences between public versus private hospitals for LBW risk (-1•8% [95% CI -3•6, 0•0]) and for ELBW risk (-0•1% [95% CI -0•6, 0•3]). Significant differences were found between public versus private hospitals in the DID estimators (-1•2% [95% CI, -2•1, -0•3]) for VLBW risk. The results were comparable in covariate-adjusted models. INTERPRETATION: In this study, we found evidence of decreased disparities between public and private hospitals in VLBW risk. Our findings suggest that measures that prioritize social spending to protect the most vulnerable pregnant women during the pandemic contributed to better birth outcomes. FUNDING: No funding was secured for this study.

Prevalence and risk factors for micronutrient deficiencies during pregnancy in Cayenne, French Guiana.

BACKGROUND: Involved in physical and brain development, immunity and metabolism, micronutrients have profound health effects. The nutritional status of pregnant women is a major determinant of foetal health. French Guiana has a rapid population growth. Social inequalities, cultural practices and gastrointestinal nematode infections in French Guiana could affect the prevalence of these deficiencies. The main objective of the present study was to estimate the prevalence of micronutrient deficiency among pregnant women in French Guiana. The secondary objective was to identify socio-demographic, dietary, obstetrical and neonatal risk factors associated with deficiencies. METHODS: Pregnant women over 22 weeks of pregnancy hospitalized for delivery at the Obstetrical Emergency Department of the Hospital Center in Cayenne from May 2018 to March 2019 were included. A socio-demographic and food questionnaire was administered. Medical data were collected from the medical records. Blood and urine samples were taken. The descriptive analysis used Student and chi-squared tests. RESULTS: A total of 341 women were included. The majority were born in Haiti (39%) and French Guiana (34%). At least one micronutrient deficiency was observed in 81% of women. Precarious women had a significantly greater risk of micronutrient deficiency during pregnancy compared to those with both normal and complementary health insurance. CONCLUSIONS: Micronutrient deficiencies in pregnant women in French Guiana are a public health problem, a fact that was previously overlooked in the context of rising obesity. With over half the women overweight or obese, and 81% with at least 1 micronutrient deficiency, balanced nutrition should be a major focus.

Intra-urban differentials of congenital and acquired syphilis and syphilis in pregnant women in an urban area in northeastern Brazil.

BACKGROUND: Currently syphilis is considered an epidemic disease worldwide. The objective of this study was to identify intra-urban differentials in the occurrence of congenital and acquired syphilis and syphilis in pregnant women in the city of Natal, in northeast Brazil. METHODS: Cases of syphilis recorded by the municipal surveillance system from 1 January 2011 to 30 December 2018 were analysed. Spatial statistical analyses were performed using the kernel density estimator of the quadratic smoothing function (weighted). SaTScan software was applied for the calculation of risk based on a discrete Poisson model. RESULTS: There were 2163 cases of acquired syphilis, 738 cases of syphilis in pregnant women and 1279 cases of congenital syphilis. Kernel density maps showed that the occurrence of cases is more prevalent in peripheral areas and in areas with more precarious urban infrastructure. In 2011-2014 and 2015-2018, seven statistically significant clusters of acquired syphilis were identified. From 2011 to 2014, the most likely cluster had a relative risk of 3.54 (log likelihood ratio [LLR] 38 895; p<0.001) and from 2015 to 2018 the relative risk was 0.54 (LLR 69 955; p<0.001). CONCLUSIONS: In the municipality of Natal, there was a clustered pattern of spatial distribution of syphilis, with some areas presenting greater risk for the occurrence of new cases.

Relationship between social capital and the experience of dental carie: systematic review and meta-analysis / Relação entre o capital social e a experiência da cárie dentária: revisão sistemática e meta-análise

ABSTRACT Objective Understanding the individual and collective behavior of individuals about their oral health conditions is important to prevent and control of dental caries. This study aimed to seek evidence of the relationship between social capital and caries experience. Methods Using a systematic review with meta-analysis, we searched articles in PubMed, ISI Web of Knowledge, LILACS, IBECS, BBO, SCIELO, The Cochrane Library and MEDLINE databases. Studies with humans, of all ages and languages, published until July 2019, which related social capital to the caries experience, were included in this review. Results We identified 1163 articles evaluated considering inclusion and exclusion criteria, leaving 5 articles selected to compose the study sample, and only 3 included in the meta-analysis. In the final analysis p value was significant (p <0.001), showing that both social cohesion and neighborhood empowerment are associated with the caries experience. In the random model, the individual has 2.39 chances of not having the caries disease. The results reinforce the importance of community social capital in the caries experience of individuals. Conclusions The high level of community social capital is directly related to lower caries experience rates.

RESUMO Objetivo A compreensão do o padrão de comportamento dos indivíduos no nível individual e coletivo frente às suas condições de saúde bucal é de importância inequívoca para prevenção e controle da cárie dentária. Nesta perspectiva o objetivo deste estudo foi buscar evidências da relação entre o capital social e a experiência de cárie. Métodos Utilizando como método revisão sistemática com meta-análise, foram pesquisados artigos nas bases de dados PubMed, ISI Web of Knowledge, LILACS, IBECS, BBO, SciELO, The Cochrane Library e MEDLINE. Estudos com humanos, de todas as idades e línguas, publicados até julho de 2019, que relacionaram o capital social com a experiência de cárie, foram incluídos nesta revisão. Resultados Foram identificados 1163 artigos, que passaram por avaliação sob critérios de inclusão e exclusão, restando 5 artigos selecionados para compor a amostra do estudo, sendo apenas 3 incluídos na meta-análise. Na análise final o p-valor foi significativo (<0,001), mostrando que tanto a coesão social como o empoderamento de vizinhança estão associados com a experiência de cárie. No modelo randômico foi constatado que o indivíduo tem 2,39 chances de não ter a doença cárie. Os resultados do estudo reforçam a importância do capital social comunitário na experiência de cárie dos indivíduos. Conclusão O alto nível de capital social comunitário tem relação direta com menores índices de experiência de cárie nos indivíduos.

Globalización, inequidades sociales y financierización de la salud, debate a partir del caso Colombia / Globalization, social inequalities and financialization of health: debate on the Colombian case

Este artículo tiene el objetivo de exponer la esencia, las fuerzas y el motor capitalista de la globalización como fenómeno histórico, mostrando las esferas de su intervención y sus efectos sobre la vida humana en general. Luego, se adentra en la relación globalización-mercados financieros y se enlazan sus impactos con las inequidades sociales y su expresión en el caso del sector de la salud en Colombia. Se cuestiona el rol de las Empresas Promotoras de Salud en este país y se ilustra cómo se han convertido en grupos empresariales como palanca financiera de negocios impensables del orden nacional y trasnacional. Uno a uno se fueron configurando entramados irreconocibles y difíciles de auditar que, junto a la falta de voluntad política por una reforma estructural al sistema de salud y seguridad social en Colombia mantiene al país en un escenario complejo, aun cuando luego de muchas disputas sociales, se declarara en el año 2015 que la salud es un derecho humano fundamental(AU)

This article has the aim of presenting the essence and capitalist forces of globalization as a historical phenomenon by showing the scopes of its intervention and its effects on human life in general terms. The article deepens in the globalization- financial markets relation and how its impacts link with social inequalities and its expression in the case of the health sector in Colombia. It is questionned the role of Health Promotion companies in that country and it is showed how they have become bussiness groups with financial leverage of inconceivable bussinesses in the national and transnational fields. There was step by step a configuration of unrecognizable structures and hard to audit which along together to the lack of political will for an structural reformation fo the health and the social wellfare systems in Colombia make the country to remain in a complex scenario; even after many social disputes it was declared in 2015 that health care is a fundamental human right(AU)

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.

Municipal expenditures using own-source revenues and resilience of territorial inequalities in health / Despesa municipal com receitas próprias e resiliência das desigualdades territoriais em saúde

Abstract The objective of this study is to assess the importance of municipal expenses executed with own-source revenues for the maintenance of the territorial inequalities between resources allocated by Brazilian municipalities in the health sector, in spite of the redistributive effects attributed to the vertical transfers of the Brazilian National Health System. The formation of municipal own-source revenues is strongly impacted by regional economic inequalities, corresponding to almost 60% of the resources allocated by municipalities to health in recent years. Based on the Tree Edge Removal method, the total expenditures and those executed with own-source revenues by the municipalities were spatially distributed, thereby enabling identification of clusters from 2005 to 2015 in both cases. Central and dispersion measures were calculated for the two types of expenditure in this interval for the clusters. In the end, we found municipal expenditures with own-source revenues show levels of inequality which are significantly higher than those of the total municipal health expenditure, and even more significant is that these inequalities increase in time with higher intensity in the case of the former. Since municipalities are the main implementers of public health policy, results suggest higher levels of territorial equity will necessarily require adjustments in fiscal federalism in this sector.

Resumo O objetivo deste estudo é dimensionar a importância das despesas municipais executadas com receitas próprias para a manutenção das desigualdades territoriais entre recursos alocados pelos municípios brasileiros no setor da saúde a despeito dos efeitos redistributivos atribuídos às transferências verticais do Sistema Único de Saúde. Correspondendo a quase 60% dos recursos alocados à saúde pelos municípios nos últimos anos, a formação das receitas próprias municipais é fortemente impactada pelas desigualdades econômicas regionais. Com base no método da Árvore Geradora Mínima, as despesas totais e as executadas com receitas próprias pelos municípios foram distribuídas espacialmente, permitindo identificar a formação de clusters para o período compreendido entre 2005 e 2015 em ambos os casos. Para os clusters foram calculadas medidas centrais e de dispersão para os dois tipos de despesa neste intervalo. Ao final, constatamos que as despesas municipais com receitas próprias apresentam níveis de desigualdade significativamente superiores aos da despesa municipal total em saúde e, mais que isto, que estas desigualdades aumentam no tempo com intensidade superior no caso da primeira. Em sendo os municípios os principais implementadores da política pública de saúde, os resultados sugerem que maiores níveis de equidade territorial irão requerer, necessariamente, ajustes no federalismo fiscal neste setor.

¿Cómo medir la posición socioeconómica en el marco de las inequidades sociales de salud?: El caso de Costa Rica / Measuring Socioeconomic Position From The Social Inequalities In Health Perspective?: The Case of Costa Rica

RESUMEN Introducción: La medición de la posición socioeconómica (PSE) es central para el análisis de las inequidades sociales en salud (ISS) y requiere de instrumentos actualizados, adaptados a un marco conceptual de referencia, al contexto local y a las características de las poblaciones. El objetivo de este estudio es presentar y discutir, a la luz de la literatura internacional, las ventajas y desventajas de las diferentes formas de medición de la posición socioeconómica para el análisis de las ISS que existen en Costa Rica. Materiales y métodos: Se realizó una revisión sistemática de los instrumentos y métodos existentes en Costa Rica para la medición de las ISS. Resultados: Se encontró que en Costa Rica existe una gran diversidad de instrumentos a nivel individual o geográfico que permiten medir la posición socioeconómica en el marco de las ISS. Cada proxy de la PSE se desarrolla en función de un marco conceptual de referencia, y se debe adaptar al diseño del estudio, a las características de la población de estudio (e.g. edad) y de la factibilidad de la recolección de los datos. Sin embargo, debido a la gran diversidad de variables y marcos conceptuales existentes sobre la PSE, no es posible establecer la existencia de un patrón de oro para la medición de las ISS aplicable a todos los estudios. Conclusión: Esta revisión de la literatura costarricense a la luz de la literatura internacional, podría contribuir a un mejor uso de las herramientas existentes. Permitirá a los investigadores escoger los instrumentos más adaptados al contexto local que han sido validados previamente, los marcos teóricos respectivos que existen detrás de cada medición, y sus eventuales limitaciones.

ABSTRACT Introduction: Measuring socioeconomic position (SEP) is central in the analysis of social inequalities in health (SIH). It requires the use of updated instruments, adapted to a particular conceptual framework, taking into account the local context and the population characteristics. This study aims to present and discuss the advantages and disadvantages of different measurement of SEP used in Costa Rica for the analysis of health inequalities. Materials and methods: A systematic review of the existing instruments and methods used to characterize SEP in Costa Rica was carried out. Results: There is a great diversity of instruments used as proxies of SEP in Costa Rica, both at the individual, and at geographical level. These measures allow to capture specific dimensions of SEP potentially associated with different health outcomes. Being a latent concept, variables approaching SEP should refer to their specific conceptual framework, be adapted to the study design, and population's characteristics (e.g. age), and should consider the study feasibility of data collection. Due to the variety and different conceptual frameworks behind each SEP variable, it is not possible to establish the existence of a gold standard. Conclusion: This review of the Costa Rican health inequalities literature regarding SEP instruments, can contribute to a better use of the existing tools. It will allow researchers to better evaluate the instruments that have been previously validated, their respective theoretical frameworks and limitations, to choose the most suitable proxy of SEP for the local context analyzed.

Risco gestacional e desigualdades sociais: uma relação possível? / Gestational risk and social inequalities: a possible relationship?

Resumo O objetivo do estudo é analisar a associação entre as desigualdades sociais e o risco gestacional em regiões administrativas do estado do Espírito Santo. Estudo transversal, com base em duas regiões administrativas do estado do Espírito Santo. A amostra foi composta por 1.777 mulheres que realizaram o pré-natal nos municípios da Região Metropolitana da Grande Vitória (RMGV-ES) e Microrregião de São Mateus internadas nos estabelecimentos da rede pública de saúde, por ocasião do parto, entre 2010 e 2012/2013. Realizou-se Regressão Logística Multivariada para testar a associação entre variáveis sociais e risco gestacional. As variáveis que apresentaram nível de significância menor que 20% no teste Qui-quadrado foram utilizadas para o modelo final, permanecendo aquelas com significância menor que 5%. Encontrou-se associação entre alto risco gestacional e o local de moradia da mulher na RMGV-ES (OR = 1,74; IC 95% 1,32-2,28), a chefia da mulher na família (OR = 3,03; IC 95% 1,64-5,61), a escolaridade da chefia familiar menor que cinco anos (OR = 1,58; IC 95% 1,14-2,20) e o recebimento do benefício social "Bolsa Família" (OR = 1,46; IC 95% 1,04-2,03). Apesar de algumas variáveis sociais comporem a classificação do risco gestacional, outros fatores sociais revelaram-se como produtores do risco gestacional.

Abstract This study aims to analyze the association between social inequalities and gestational risk in administrative regions of the state of Espírito Santo. This is a cross-sectional study based on two administrative regions of the state of Espírito Santo. The sample consisted of 1,777 women who underwent prenatal care in the municipalities of the Greater Vitória Metropolitan Region (RMGV-ES) and São Mateus Microregion (MRSM) and were admitted to the public health facilities at the time of delivery between 2010 and 2012/2013. The multivariate logistic regression was performed to test the association between social and gestational risk variables. Variables with a significance level < 0.20 in the Chi-square test were adopted for the final model, and only those variables with a p-value < 0.05 remained. An association was found between high gestational risk and women's dwelling place in the RMGV-ES (OR = 1.74; CI95% 1.32-2.28), women as head of households (OR = 3.03; CI95% 1.64-5.61), head of household with less than five years of schooling (OR = 1.58; CI95% 1.14-2.20) and receipt of social benefit "Bolsa Família" (Family Grant) (OR = 1.46; CI95% 1.04-2.03). While some social variables underpin the classification of gestational risk, other social factors have been shown to produce this risk.

Six-year trends in dental pain and maternal education inequalities among Brazilian adolescents.

OBJECTIVE: To analyse trends in dental pain prevalence among Brazilian adolescent students over 6 years, focusing on inequalities by maternal education. METHODS: Data from the National Adolescent School-Based Health Survey (PeNSE) carried out in 2009 (n = 45 239), 2012 (n = 46 482) and 2015 (n = 35 592) were analysed, including ninth grade students from the 27 state capitals in Brazil who were of ages 11-17 years or older. Variables analysed were dental pain within the last 6 months (yes/no) and the following sociodemographic factors: age, sex, race, type of school and maternal schooling (years of study: ≤8; 9-11; ≥12). The prevalence of dental pain in the 3 years was compared using the Rao-Scott test. Relative and absolute measures of socioeconomic (maternal education) inequalities in dental pain were applied using the slope index of inequality (SII) and the relative concentration index (RCI). RESULTS: The prevalence of dental pain increased from 17.5% (95% CI = 16.9-18.2) in 2009 to 20.4% (95% CI = 19.7-21.1) in 2012, then to 21.8% (95% CI = 21.1-22.5) in 2015. All sociodemographic factors investigated were associated with dental pain in all survey years. There was an increasing proportion of the outcome in all categories of maternal education over the years studied. Absolute (SII) and relative (RCI) inequalities regarding of maternal education were found; these indicate higher levels of dental pain in the lower socioeconomic group in each study year. However, no significant changes in inequalities were found from 2009 to 2015. CONCLUSIONS: The prevalence of dental pain increased in the 2009-2012 and 2012-2015 periods, and social inequalities were found. Higher levels of dental pain persisted in the lower maternal education group. Inequalities remained stable over time. Broader actions to reduce the existing inequalities are needed and should be a priority for public policies.

Socioeconomic inequalities in survival of children with acute lymphoblastic leukemia insured by social security in Mexico: a study of the 2007-2009 cohorts.

BACKGROUND: Although acute lymphoblastic leukemia (ALL) 5 years survival in minors has reached 90%, socioeconomic differences have been reported among and within countries. Within countries, the difference has been related to the socioeconomic status of the parents, even in the context of public health services with universal coverage. In Mexico, differences in the mortality of children with cancer have been reported among sociodemographic zones. The Instituto Mexicano del Seguro Social (IMSS), the country's main social security institution, has reported socioeconomic differences in life expectancy within its affiliated population. Here, the socioeconomic inequalities in the survival of children (< 15 years old) enrolled in the IMSS were analyzed. METHODS: Five-year survival data were analyzed in cohorts of patients diagnosed with ALL during the period 2007-2009 in the two IMSS networks of medical services that serve 7 states of the central region of Mexico. A Cox proportional risk model was developed and adjusted for the socioeconomic characteristics of family, community of residence and for the clinical characteristics of the children. The slope of socioeconomic inequality of the probability of dying within five years after the diagnosis of ALL was estimated. RESULTS: For the 294 patients studied, the 5 years survival rate was 53.7%; the median survival was 4.06 years (4.9 years for standard-risk diagnosis; 2.5 years for high-risk diagnosis). The attrition rate was 12%. The Cox model showed that children who had been IMSS-insured for less than half their lives had more than double the risk of dying than those who had been insured for their entire lives. CONCLUSIONS: We did not find evidence of socioeconomic inequalities in the survival of children with ALL associated with family income, educational and occupational level of parents. However, we found a relevant gradient related social security protection: the longer children's life insured by social security, the higher their probability of surviving ALL was. These results add evidence of the effectiveness of social security, as a mechanism of wealth redistribution and a promoter of social mobility. Extending these social security benefits to the entire Mexican population could promote better health outcomes.