Trends in traffic accident mortality and social inequalities in Ecuador from 2011 to 2022

BACKGROUND

Traffic accidents (TA) remain a significant global public health concern, impacting low-and middle-income countries. This study aimed to describe the trend in TA mortality and inequalities in Ecuador for 2011-2022, distributed by year, gender, age group, geographical location, type of accident, and social inequalities.

METHODS

An ecological study was conducted using INEC national-level data on TA fatalities in Ecuador. Mortality rates were calculated per 100,000 population and analyzed by year, gender, age group, geographic region, and accident type. Annual percentage variation (APV) was determined using linear regression models. Inequality analyses examined associations between TA mortality and socioeconomic factors like per capita income and literacy rates. Complex measures such as the Slope Inequality Index (SII) were calculated to assess the magnitude of inequalities.

RESULTS

There were 38,355 TA fatalities in Ecuador from 2011 to 2022, with an overall mortality rate of 19.4 per 100,000 inhabitants. The rate showed a non-significant decreasing trend (APV - 0.4%, p = 0.280). Males had significantly higher mortality rates than females (31.99 vs. 7.19 per 100,000), with the gender gap widening over time (APV 0.85%, p = 0.003). The Amazon region had the highest rate (24.4 per 100,000), followed by the Coast (20.4 per 100,000). Adults aged ≥ 60 years had the highest mortality (31.0 per 100,000), followed by those aged 25-40 years (28.6 per 100,000). The ≥ 60 age group showed the most significant rate decrease over time (APV - 2.25%, p < 0.001). Pedestrians were the most affected group after excluding unspecified accidents, with a notable decreasing trend (APV - 5.68%, p < 0.001). Motorcyclist fatalities showed an increasing trend, ranking third in TA-related deaths. Lower literacy rates and per capita income were associated with higher TA mortality risks. Inequality in TA mortality between provinces with the highest and lowest per capita income increased by 247.7% from 2011 to 2019, as measured by the SII.

CONCLUSION

While overall TA mortality slightly decreased in Ecuador, significant disparities persist across demographic groups and geographic regions. Older adults, males, pedestrians, and economically disadvantaged populations face disproportionately higher risks. The increasing trend in motorcycle-related fatalities and widening socioeconomic inequalities are particularly concerning.

Income inequality as a determinant of neonatal mortality in the Americas during 2000-2019: implications for the attainment of Sustainable Development Goal target 3.2

BACKGROUND

The work of the WHO Commission on the Social Determinants of Health has been fundamental to provide a conceptual framework of the social determinants of health. Based on this framework, this study assesses the relationship of income inequality as a determinant of neonatal mortality in the Americas and relates it to the achievement of the Sustainable Development Goal target 3.2 (reduce neonatal mortality to at least as low as 12 deaths per 1,000 live births). The rationale is to evaluate if income inequality may be considered a social factor that influences neonatal mortality in the Americas.

METHODS

Yearly data from 35 countries in the Americas during 2000-2019 was collected. Data sources include the United Nations Inter-agency Group for Child Mortality Estimation for the neonatal mortality rate (measured as neonatal deaths per 1,000 live births) and the United Nations University World Institute for Development Economics Research for the Gini index (measured in a scale from 0 to 100). This is an ecological study that employs a linear regression model that relates the neonatal mortality rate (dependent variable) to the Gini index (independent variable), while controlling for other factors that influence neonatal mortality. Coefficient estimates and their robust standard errors were obtained using panel data techniques.

RESULTS

A positive relationship between income inequality and neonatal mortality is found in countries in the Americas during the period studied. In particular, the analysis suggests that a unit increase in a country's Gini index during 2000-2019 is associated with a 0.27 (95% CI [- 0.04, 0.57], P =.09) increase in the neonatal mortality rate.

CONCLUSION

The analysis suggests that income inequality may be positively associated with the neonatal mortality rate in the Americas. Nonetheless, given the modest magnitude of the estimates and Gini values and trends during 2000-2019, the findings suggest a potential limited scope for redistributive policies to support reductions in neonatal mortality in the region. Thus, policies and interventions that address higher coverage and quality of services provided by national health systems and reductions in socio-economic inequalities in health are of utmost importance.

Cholangiohydatidosis. Clinical features, postoperative complications and hospital mortality. A systematic review

BACKGROUND

Cholangiohydatidosis (CH) is an evolutionary complication of hepatic cystic echinococcosis, associated with increased morbidity and mortality. The aim of this study was to describe the available evidence regarding clinical characteristics of CH, postoperative complications and hospital mortality.

METHODOLOGY/PRINCIPAL FINDINGS

Systematic review. Studies related to CH with no language or publication restriction were included. Sensitive searches were performed in Trip Database, SciELO, BIREME-BVS, WoS, PubMed, EMBASE and SCOPUS. MeSH and free terms were used, including articles up to April 2023. The main outcome variables were postoperative complications and hospital mortality; the secondary ones were publication year, origin and design of primary studies, main clinical manifestation, anatomical location and type of cysts, hospital stay, surgical procedure performed, reinterventions; and methodological quality of primary studies, which was assessed using MInCir-T and MInCir-P scales. Descriptive statistics, calculation of weighted averages and their comparison by least squares logistic regression were applied. 446 studies were retrieved from the searches performed, 102 of which met the inclusion and exclusion criteria. The studies analyzed represent 1241 patients. The highest proportion of articles was published in the last decade (39.2%). Reports are mainly from Turkey (28.4%), Greece (9.8%), Morocco and Spain (8.8% each). With a weighted mean of 14.3 days of hospital stance; it was verified that 26.2% of patients developed postoperative complications (74,3% Clavien y Dindo III y IV), 6.7% needed re-interventions, and 3.7% died. When comparing the variables age, postoperative complications, hospital mortality, and reinterventions in two periods of time (1982-2006 vs. 2007-2023), no statistically significant differences were found. When applying the MInCir-T and MInCir-P scales, the methodological quality of the primary studies was 9.6±1.1 and 14.5±4.3 points, respectively.

CONCLUSION/SIGNIFICANCE

CH is associated with severe postoperative complications and significant hospital mortality, independent of the development of therapeutic support associated with the passage of time.

Neonatal mortality in countries of the Americas, 2000-2020: trends, inequalities, and target-setting

Objective

To analyze temporal trends and inequalities in neonatal mortality between 2000 and 2020, and to set neonatal mortality targets for 2025 and 2030 in the Americas.

Methods

A descriptive ecological study was conducted using 33 countries of the Americas as units of analysis. Both the percentage change and average annual percentage change in neonatal mortality rates were estimated. Measurements of absolute and relative inequality based on adjusted regression models were used to assess cross-country social inequalities in neonatal mortality. Targets to reduce neonatal mortality and cross-country inequalities were set for 2025 and 2030.

Results

The estimated regional neonatal mortality rate was 12.0 per 1 000 live births in 2000-2004 and 7.4 per 1 000 live births in 2020, representing a percentage change of -38.3% and an average annual percentage change of -2.7%. National average annual percentage changes in neonatal mortality rates between 2000-2004 and 2020 ranged from -5.5 to 1.9 and were mostly negative. The estimated excess neonatal mortality in the 20% most socially disadvantaged countries, compared with the 20% least socially disadvantaged countries, was 17.1 and 9.8 deaths per 1 000 live births in 2000-2004 and 2020, respectively. Based on an extrapolation of recent trends, the regional neonatal mortality rate is projected to reach 7.0 and 6.6 neonatal deaths per 1 000 live births by 2025 and 2030, respectively.

Conclusions

National and regional health authorities need to strengthen their efforts to reduce persistent social inequalities in neonatal mortality both within and between countries.

Homicide among young people in the countries of the Americas

Objective

To examine the homicide trends among young people (10-24 years), adolescents (10-19 years), and young adults (20-24 years) in 33 countries in the Americas between 2000 and 2019, with a focus on inequalities between countries in the burden of homicides.

Methods

An ecological study was performed using estimated deaths from 33 countries. Age-adjusted rates, percentage change (PC), average annual percentage change (AAPC), and relative risk (RR) were estimated; besides, analysis on social inequalities was performed.

Results

In the Americas between 2000 and 2019, homicide has been the leading cause of death with 54 515 deaths on average each year and an age-adjusted rate of 23.6 per 100 000 among young people. The highest rate was found in the Andean subregion (41.1 per 100 000 young people), which also produced the highest decrease (PC = -37.1% and AAPC = -2.4%) in the study period. The risk of homicide in young men is 8.1 times the risk in young women, and the risk in young adults is 2.5 times the risk in adolescents. The three countries with highest risk of homicide for young people are Venezuela (relative risk [RR] = 35.1), El Salvador (RR = 28.1), and Colombia (RR = 26.7). The estimated excess mortality was 26.8 homicides per 100 000 in the poorest 20% of countries compared to the richest 20% of countries in the period 2000-2009, and it decreased to 13.9 in the period 2010-2019.

Conclusions

The results of this study add to the knowledge of homicide among young people and can be used to inform policy and programming in countries. Given the great burden of homicide on young people in the region, it is critical that prevention opportunities are maximized, beginning early in life.

Recent trends in maternal and child health inequalities in Latin America and the Caribbean: analysis of repeated national surveys

BACKGROUND

Although most Latin American and the Caribbean (LAC) countries made important progress in maternal and child health indicators from the 1990s up to 2010, little is known about such progress in the last decade. This study aims at documenting progress for each country as a whole, and to assess how within-country socioeconomic inequalities are evolving over time.

METHODS

We identified LAC countries for which a national survey was available between 2011-2015 and a second comparable survey in 2018-2020. These included Argentina, Costa Rica, Cuba, the Dominican Republic, Guyana, Honduras, Peru, and Suriname. The 16 surveys included in the analysis collected nationally representative data on 221,989 women and 152,983 children using multistage sampling. Twelve health-related outcomes were studied, seven of which related to intervention coverage: the composite coverage index, demand for family planning satisfied with modern methods, antenatal care (four or more visits and eight or more visits), skilled attendant at birth, postnatal care for the mother and full immunization coverage. Five additional impact indicators were also investigated: stunting prevalence among under-five children, tobacco use by women, adolescent fertility rate, and under-five and neonatal mortality rates. For each of these indicators, average annual relative change rates were calculated between the baseline and endline national level estimates, and changes in socioeconomic inequalities over time were assessed using the slope index of inequality.

RESULTS

Progress over time and the magnitude of inequalities varied according to country and indicator. For countries and indicators where baseline levels were high, as Argentina, Costa Rica and Cuba, progress was slow and inequalities small for most indicators. Countries that still have room for improvements, such as Guyana, Honduras, Peru and Suriname, showed faster progress for some but not all indicators, although also had wider inequalities. Among the countries studied, Peru was the top performer in terms of increasing coverage and reducing inequalities over time, followed by Honduras. Declines in family planning and immunization coverage were observed in some countries, and the widest inequalities were present for adolescent fertility and antenatal care coverage with eight or more visits.

CONCLUSIONS

Although LAC countries are well placed in terms of current levels of health indicators compared to most low- and middle-income countries, important inequalities remain, and reversals are being observed in some areas. More targeted efforts and actions are needed in order to leave no one behind. Monitoring progress with an equity lens is essential, but this will require further investment in conducting surveys routinely.

Scenarios of maternal mortality reduction by 2030 in the Americas: insights from its tempo

BACKGROUND

The enduring threat of maternal mortality to health worldwide and in the Americas has been recognized in the global and regional agendas and their targets to 2030. To inform the direction and amount of effort needed to meet those targets, a set of equity-sensitive regional scenarios of maternal mortality ratio (MMR) reduction based on its tempo or speed of change from baseline year 2015 was developed.

METHODS

Regional scenarios by 2030 were defined according to: i) the MMR average annual rate of reduction (AARR) needed to meet the global (70 per 100,000) or regional (30 per 100,000) targets and, ii) the horizontal (proportional) or vertical (progressive) equity criterion applied to the cross-country AARR distribution (i.e., same speed to all countries or faster for those with higher baseline MMR). MMR average and inequality gaps -absolute (AIG), and relative (RIG)- were scenario outcomes.

RESULTS

At baseline, MMR was 59.2 per 100,000; AIG was 313.4 per 100,000 and RIG was 19.0 between countries with baseline MMR over twice the global target and those below the regional target. The AARR needed to meet the global and regional targets were -7.60% and -4.54%, respectively; baseline AARR was -1.55%. In the regional MMR target attainment scenario, applying horizontal equity would decrease AIG to 158.7 per 100,000 and RIG will remain invariant; applying vertical equity would decrease AIG to 130.9 per 100,000 and RIG would decrease to 13.5 by 2030.

CONCLUSION

The dual challenge of reducing maternal mortality and abating its inequalities will demand hefty efforts from countries of the Americas. This remains true to their collective 2030 MMR target while leaving no one behind. These efforts should be mainly directed towards significantly speeding up the tempo of the MMR reduction and applying sensible progressivity, targeting on groups and territories with higher MMR and greater social vulnerabilities, especially in a post-pandemic regional context.

Trends and inequities in adolescent childbearing in Latin American and Caribbean countries across generations and over time: a population-based study

BACKGROUND

Latin America and the Caribbean present the second highest adolescent fertility rate in the world, only after sub-Saharan Africa, and have reached the third position globally in the incidence of motherhood in adolescence. We aimed to explore trends and inequities in adolescent childbearing in the region.

METHODS

We used nationally representative household surveys from Latin American and Caribbean countries to address trends in early childbearing (proportion of women having their first livebirth before age 18 years) over generations and in adolescent fertility rates (AFRs; livebirths per 1000 women aged 15-19 years) over time. For early childbearing, we analysed the most recent survey conducted since 2010 from 21 countries (2010-20); for AFR, we analysed nine countries with two or more surveys, with the most recent being conducted from 2010 onwards. For both indicators, variance-weighted least-square regression was used to estimate the average absolute changes (AACs) at the national level and by wealth (bottom 40% vs top 60%), urban versus rural residence, and ethnicity.

FINDINGS

Among 21 countries studied, we noted a decrease in early childbearing along generations in 13 of them, with declines varying from -0·6 percentage points (95% CI -1·1 to -0·1) in Haiti to -2·7 percentage points (-4·0 to -1·4) in Saint Lucia. We observed increases over generations in Colombia (1·2 percentage points [0·8 to 1·5]) and Mexico (1·3 percentage points [0·5 to 2·0]) and no changes in Bolivia and Honduras. The fastest early childbearing decline occurred among rural women, whereas no clear pattern was observed for wealth groups. Decreasing estimates from oldest to youngest generations were found among Afro-descendants and non-Afro-descendant and non-indigenous groups, but results were mixed for indigenous people. All nine countries with data for AFR presented reductions over time (-0·7 to -6·5 births per 1000 women per year), with the steepest declines observed in Ecuador, Guyana, Guatemala, and the Dominican Republic. In general, adolescents in rural areas and the poorest adolescents had the largest reductions in AFR. If current trends persist, by 2030 most countries will present AFR values ranging between 45 and 89 births per 1000 women, with notable wealth-related inequalities.

INTERPRETATION

Our results indicate a reduction in AFR in Latin American and Caribbean countries that was not necessarily accompanied by a decrease in early childbearing overall. Large inequalities both between countries and within countries were observed, with no clear reduction over time. Understanding trends in adolescent childbearing and its determinants is essential for planning and designing programmes to ensure the desired reductions in rates and gaps across population subgroups.

FUNDING

PAHO, Bill & Melinda Gates Foundation, and Wellcome Trust.

TRANSLATIONS

For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Inequalities in Violent Death across Income Levels among Young Males and Females in Countries of the Americas

BACKGROUND

Violent deaths (i.e., those due to road traffic injury, homicide, and suicide) are among the most important causes of premature and preventable mortality in young people. This study aimed at exploring inequalities in violent death across income levels between males and females aged 10 to 24 years from the Americas in 2015, the SDG baseline year.

METHODS

In a cross-sectional ecological study design, eleven standard summary measures of health inequality were calculated separately for males and females and for each cause of violent death, using age-adjusted mortality rates and average income per capita for 17 countries, which accounted for 87.9% of the target population.

RESULTS

Premature mortality due to road traffic injury and homicide showed a pro-poor inequality pattern, whereas premature mortality due to suicide showed a pro-rich inequality pattern. These inequalities were statistically significant (p < 0.001), particularly concentrated among young males, and dominated by homicide. The ample array of summary measures of health inequality tended to generate convergent results.

CONCLUSIONS

Significant inequalities in violent death among young people seems to be in place across countries of the Americas, and they seem to be socially determined by both income and gender. These findings shed light on the epidemiology of violent death in young people and can inform priorities for regional public health action. However, further investigation is needed to confirm inequality patterns and to explore underlying mechanisms, age- and sex-specific vulnerabilities, and gender-based drivers of such inequalities.

La iniciativa Todas las Mujeres Todos los Niños brinda apoyo a los países de América Latina y el Caribe para reducir las desigualdades sociales en la salud

La iniciativa Todas las Mujeres Todos los Niños América Latina y el Caribe (EWEC-LAC, por su sigla en inglés) se estableció en el 2017 como un mecanismo interinstitucional regional. Coordina la implementación regional de la Estrategia Mundial para la Salud de la Mujer, el Niño y el Adolescente 2016-2030 en América Latina y el Caribe (ALC), lo que incluye su adaptación a necesidades específicas de la Región, para poner fin a las muertes evitables, garantizar la salud y el bienestar, y ampliar los entornos propicios para la salud y el bienestar de mujeres, niños y adolescentes. Para promover el logro equitativo de estos objetivos, los tres grupos de trabajo de EWEC-LAC apoyan colectivamente a los países de ALC en la medición y el monitoreo de las desigualdades sociales en la salud, la promoción de la disminución de estas y el diseño e implementación de estrategias, políticas e intervenciones orientadas a la equidad. Este apoyo para cerrar las brechas actuales asegura que nadie se quede atrás. Los miembros de la iniciativa EWEC-LAC incluyen al UNFPA, la OPS, ONU-Mujeres, ONUSIDA, UNICEF, el Banco Mundial, el Banco Interamericano de Desarrollo, USAID, la Alianza Regional Neonatal para ALC y el Grupo de Trabajo Regional para la Reducción de la Mortalidad Materna. A la fecha, EWEC-LAC ha desarrollado y recopilado herramientas y recursos innovadores, y ha comenzado a colaborar con los países para utilizarlos a fin de reducir las brechas en la equidad. Estos incluyen un marco de medición de las desigualdades sociales en la salud, herramientas de promoción de datos, como un tablero de datos para visualizar tendencias en las desigualdades sociales en la salud, una metodología para establecer metas en la disminución de las desigualdades, y un compendio de herramientas y métodos para identificar y abordar las desigualdades sociales en la salud. EWEC-LAC ha trabajado en la Región para enfatizar la importancia de reconocer estas desigualdades a los niveles sociales y políticos, y ha abogado por su disminución. La atención para cerrar las brechas de equidad en la salud es cada vez más crítica frente a la pandemia de COVID-19, que ha agudizado las vulnerabilidades existentes. Los sistemas de salud más equitativos estarán mejor preparados para hacer frente a futuras crisis de salud.

Inequalities in the health, nutrition, and wellbeing of Afrodescendant women and children: A cross-sectional analysis of ten Latin American and Caribbean countries

BACKGROUND

Afrodescendants are systematically affected by discrimination in the Americas and few multi-country studies addressed ethnic inequalities in health and wellbeing in the region. We aimed to investigate gaps in coverage of key health outcomes and socioeconomic inequalities between Afrodescendants and non-Afrodescendants populations in Latin American and Caribbean countries.

METHODS

Using national household surveys (2011-2019) from ten countries, we analyzed absolute inequalities between Afrodescendants and a comparison group that includes non-Afrodescendants and non-Indigenous individuals (henceforth non-Afrodescendants) across 17 indicators in the continuum of reproductive, maternal, newborn, child, and adolescent health. These include indicators of family planning, antenatal care, delivery assistance, child nutrition, immunization coverage, child protection, access to improved water, sanitation and hygiene, adolescent fertility, and early childhood mortality. Inequalities between country-specific subgroups of Afrodescendants were also explored. The slope index of inequality was used to assess wealth-based inequalities within each ethnic group.

FINDINGS

Afrodescendants represented from 2·8% (Honduras) to 59·1% (Brazil) of the national samples. Of the 128 combinations of country and indicators with data, Afrodescendants fared worse in 78 (of which 33 were significant) and performed better in 50 (15 significant). More systematic disadvantages for Afrodescendants were found for demand for family planning satisfied, early marriage, and household handwashing and sanitation facilities. In contrast, Afrodescendants tended to present lower c-section rates and lower stunting prevalence. Honduras was the only country where Afrodescendants performed better than non-Afrodescendants in several indicators. Wealth gaps among Afrodescendants were wider than those observed for non-Afrodescendants for most indicators and across all countries.

INTERPRETATION

Gaps in health outcomes between Afrodescendants and non-Afrodescendants were observed in most countries, with more frequent disadvantages for the former although, in many cases, the gaps were reversed. Wealth inequalities within Afrodescendants tended to be wider than for non-Afrodescendants.

FUNDING

Pan American Health Organization, Bill and Melinda Gates Foundation, and the Wellcome Trust.

[SDG3-related inequalities in women's, children's and adolescents' health: an SDG monitoring baseline for Latin America and the Caribbean using national cross-sectional surveysDesigualdades relacionadas ao ODS 3 na saúde da mulher, da criança e do adolescente: linha de base para o monitoramento do ODS na América Latina e no Caribe por meio de pesquisas transversais nacionais]

Objectives

Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored.

Setting

We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016.

Participants

The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries.

Outcome measures

Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures.

Results

In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman's age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries.

Conclusions

Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.

The Every Woman Every Child initiative: supporting countries in Latin America and the Caribbean to reduce social inequalities in health

The Every Woman Every Child Latin America and the Caribbean (EWEC-LAC) initiative was established in 2017 as a regional inter-agency mechanism. EWEC-LAC coordinates the regional implementation of the Global Strategy for Women’s, Children’s and Adolescents’ Health in Latin America and the Caribbean (LAC), including adaptation to region specific needs, to end preventable deaths, ensure health and well-being and expand enabling environments for the health and well-being of women, children and adolescents. To advance the equitable achievement of these objectives, EWEC-LAC’s three working groups collectively support LAC countries in measuring and monitoring social inequalities in health, advocating for their reduction, and designing and implementing equity-oriented strategies, policies and interventions. This support for data-driven advocacy, capacity building, and policy and program solutions toward closing current gaps ensures that no one is left behind. Members of EWEC-LAC include PAHO, UNAIDS, UNFPA, UNICEF, UN WOMEN, the World Bank, the Inter-American Development Bank, USAID, LAC Regional Neonatal Alliance, and the LAC Regional Task Force for the Reduction of Maternal Mortality. To date, EWEC-LAC has developed and collected innovative tools and resources and begun to engage with countries to utilize them to reduce equity gaps. These resources include a framework for the measurement of social inequalities in health, data use and advocacy tools including a data dashboard to visualize trends in social inequalities in health in LAC countries, a methodology for setting targets for the reduction of inequalities, and a compendium of tools, instruments and methods to identify and address social inequalities in health. EWEC-LAC has also engaged regionally to emphasize the importance of recognizing these inequalities at social and political levels, and advocated for the reduction of these gaps. Attention to closing health equity gaps is ever more critical in the face of the COVID-19 pandemic which has exploited existing vulnerabilities. More equitable health systems will be better prepared to confront future health shocks.

SDG3-related inequalities in women's, children's and adolescents' health: an SDG monitoring baseline for Latin America and the Caribbean using national cross-sectional surveys

OBJECTIVES

Latin America and the Caribbean (LAC) countries have made important progress towards achieving the Sustainable Development Goal (SDG) targets related to health (SDG3) at the national level. However, vast within-country health inequalities remain. We present a baseline of health inequalities in the region, against which progress towards the SDGs can be monitored.

SETTING

We studied 21 countries in LAC using data from Demographic and Health Surveys and Multiple Indicator Cluster Survey carried out from 2011 to 2016 PARTICIPANTS: The surveys collect nationally representative data on women and children using multistage sampling. In total, 288 207 women and 195 092 children made part of the surveys in the 21 countries.

OUTCOME MEASURES

Five health intervention indicators were studied, related to reproductive and maternal health, along with adolescent fertility and neonatal and under-five mortality rates. Inequalities in these indicators were assessed through absolute and relative measures.

RESULTS

In most countries, subnational geographical health gradients were observed for nearly all women, child, and adolescent (WCA) indicators. Coverage of key interventions was higher in urban areas and among the richest, compared with rural areas and poorer quintiles. Analyses by woman's age showed that coverage was lower in adolescent girls than older women for family planning indicators. Pro-urban and pro-rich inequalities were also seen for mortality in most countries.

CONCLUSIONS

Regional averages hide important health inequalities between countries, but national estimates hide still greater inequalities between subgroups of women, children and adolescents. To achieve the SDG3 targets and leave no one behind, it is essential to close health inequality gaps within as well as between countries.

JB. Leaving no one behind: a methodology for setting health inequality reduction targets for Sustainable Development Goal 3

OBJECTIVES

To present a methodology for the simultaneous setting of quantitative targets that reflect both an improvement in the national average of an indicator for Sustainable Development Goal 3 (SDG3), as well as a reduction in its geographic inequality.

METHODS

A five-step algorithm was developed: (a) calculate the national average annual percent change (AAPC) for an SDG3 indicator; (b) normatively define geographic strata from the subnational distribution of the indicator in a baseline year; (c) apply a proportional progressivity criterion to the AAPC to project the stratum-specific indicator value for the target year; (d) set the national target as the weighted average of the indicator in the subnational territorial units for the target year; and (e) set the inequality reduction targets by calculating the absolute and relative gaps between the bottom and top strata for the target year.

RESULTS

The algorithm was applied to SDG indicator 3.1.1 (maternal mortality ratio, MMR), disaggregated by Guatemala's 22 departments at the baseline year 2014 (MMR = 113 per 100,000 live births). By sustaining the AAPC rate attained from 2009 to 2014 (-4.3%) and focalizing its actions with territorial progressivity, by 2030 the country could reduce its MMR to 53 per 100,000 and its absolute and relative inequality gaps by 72% and 48%, respectively.

CONCLUSIONS

The proposed methodology allows for simultaneously setting targets for overall progress and inequality reduction in health, making explicit the primacy of the equity principle contained in the SDG commitment to leave no one behind, whose urgency takes on renewed relevance in the current pandemic scenario.

[Suicide in adolescents and young adults in Chile: relative risks, trends, and inequalitiesSuicídio em adolescentes e jovens no Chile: riscos relativos, tendências e desigualdades]

Objetivo.

Describir cuantitativamente el riesgo relativo, la tendencia y la desigualdad geográfica del suicidio en adolescentes y jóvenes entre las regiones de Chile, en el periodo 2000 al 2017.

Método.

Estudio ecológico poblacional a partir de los registros de defunciones por suicidio. Se estimaron tasas de mortalidad y riesgos relativos (RR) de suicidio por sexo, edad y región. Se estudió la tendencia y desigualdad geográfica del suicidio entre las regiones de Chile; medidas absolutas y relativas de desigualdades geográficas fueron estimadas.

Resultados.

Entre 2000 y 2017 se registraron 6 292 suicidios en adolescentes y jóvenes en Chile. Las tasas promedio de mortalidad por suicidio en Chile fueron de 8,5; 5,4 y 14.7 por 100 000 en los grupos 10-24, 10-19 y 20-24 años, respectivamente, en el periodo 2000-2017. Las tasas más altas de mortalidad por suicidio se encontraron en las regiones de Aisén, Los Lagos, Magallanes y Los Ríos. El riesgo más alto de suicidio se estimó en los hombres (RR=3,5), los jóvenes (RR=2,7) y en la región de Aisén (RR=2,0). La tasa promedio nacional en el grupo 10-24 años se mantuvo en 8,5 por 100 000 en los periodos 2000-2008 y 2009-2017. La mayor desigualdad geográfica se encontró en hombres de 20-24 años en el periodo 2000-2008.

Conclusiones.

El suicidio en jóvenes y adolescentes de Chile se ha mantenido sin mayores cambios en el periodo de estudio. Los hombres tienen un mayor riesgo de suicidio que las mujeres. Existen desigualdades geográficas entre las regiones de Chile en el suicidio y son más elevadas en hombres de 20 a 24 años. Se recomienda evaluar y fortalecer los programas de prevención del suicidio en los adolescentes y jóvenes, en especial en las regiones y los grupos poblacionales específicos en situación de mayor vulnerabilidad.

Transport modes and road traffic mortality in the Americas: Deaths among pedestrian and motorcycle users through the lifespan

INTRODUCTION

In the Americas, almost half of road traffic deaths occur among motorcycle users and pedestrians (23% and 22%, respectively). Recent individual country trends show that nations are experiencing changes in deaths depending on the mode of transport used. While national trends are useful, analyses of disaggregated data by sex and age may provide more information about the impact of traffic crashes at different stages of the life course. Methods: We used mortality data from all land transport modes reported to PAHO/WHO (2000-2015) and included them in an ecological study to quantify temporal trends and estimate the association between mortality by mode, age group, sex, and selected socio-economic indicators. Results: Motorcycle and pedestrian mortality rates remain extremely high. Males younger less than 45 years have a higher burden of motorcycle-related mortality while older persons tend to die more as pedestrians. Discussion: Policies differentially aimed at addressing deaths by mode of transport and age are necessary because active living improves wellbeing especially among older individuals. For this to occur, safe environments must be created or maintained.

[Leaving no one behind: Methodology to set health inequality reduction targets for Sustainable Development Goal 3Não deixar ninguém para trás: uma metodologia para estabelecer metas de redução das desigualdades em saúde sob o Objetivo de Desenvolvimento Sustentável 3]

OBJECTIVES

Present methodology for the concurrent development of quantitative targets that reflect improvement in the national average of an indicator for Sustainable Development Goal 3 (SDG3), as well as a reduction in geographic inequality.

METHODS

A five-step algorithm was developed: a) calculate the national average annual percentage change (AAPC) for an SDG3 indicator; b) standardize the definition of geographic strata based on subnational distribution of the indicator in a base year; c) apply a criterion for proportional progress in the AAPC in order to project the stratum-specific indicator to the target year; d) set the national target as the weighted average of the indicator in the subnational territorial units for the target year; and e) develop inequality reduction targets by calculating absolute and relative gaps between the top and bottom strata for the target year.

RESULTS

The algorithm was applied to SDG indicator 3.1.1 (maternal mortality ratio, MMR), disaggregated by Guatemala's 22 departments for base year 2014 (MMR = 113/100,000 live births). By sustaining the average AAPC rate attained from 2009 to 2014 (-4.3%) and targeting its actions to territorial progress, the country would reduce its MMR to 53/100,000 by 2030 and its absolute and relative gaps by 72% and 48%, respectively.

CONCLUSIONS

The proposed methodology makes it possible to concurrently develop targets for the reduction of geographic inequalities in health and improvements in the national average, with explicit reference to the primacy of the principle of equity expressed in the SDGs' commitment to leaving no one behind, whose urgency is newly important in the current post-pandemic scenario.

[Health and social inequalities in maternal and child health in Paraguay]

OBJECTIVE

To describe health and social inequalities in maternal and child health indicators defined in Sustainable Development Goal (SDG) 3.1 and SDG 3.2 targets based on administrative data among the departments of Paraguay in 2017.

METHODS

Quantitative descriptive study with ecological design. Simple gap measures and complex gradient measures based on the adjustment of negative binomial and logistic regression models were used.

RESULTS

Fifty percent of Paraguay's departments have estimated maternal mortality ratio (MMR) values higher than the national value. The percentage of births attended by a qualified professional in the country is 98.1%, with a range between 82.4% and 99.9%. In 13 of 18 departments, under-five mortality rate (U5MR) is higher than the national average, ranging from 4.2 to 49.2 deaths per 1 000 live births. Neonatal mortality rates (NMR) in the departments vary from 2.6 to 45.1 deaths per 1 000 live births. There are major health and social inequalities in the MMR, U5MR and NMR between the departments. There are no high inequalities in the percentage of births attended by a qualified professional between the departments.

CONCLUSIONS

Paraguay needs to make significant efforts to reduce the health and social inequalities that exist in the MMR, U5MR and NMR between departments. Numerical targets must be established to improve national values and reduce inequalities in these indicators, which will allow for accountability on the commitment to "leave no one behind" established in the SDG, and will help generate strategies to improve the health of women and children in Paraguay.

[Behavior and social inequalities in prioritized indicators of Sustainable Development Goal 3 in Bolivia]

Objective

To describe the behavior and social inequalities in prioritized indicators of Sustainable Development Goal 3 (ODS-3) among subpopulations and departments of Bolivia.

Methods

An analysis of the behavior of selected ODS-3 indicators over time was conducted. In addition, a study of social inequalities in these indicators was carried out for selected equity stratifiers. Simple measures (absolute gap and relative gap) and complex measures (slope inequality index and concentration index) were obtained to explore the magnitude of social inequalities.

Results

The ODS-3 indicators that have increased significantly at the national and departmental levels are the prevalence of four prenatal controls and the prevalence of births attended by qualified health personnel. Social inequalities in these indicators have decreased significantly over time. The prevalence of adolescent pregnancy and its social inequalities have remained unchanged, although with low inequalities. The prevalence of modern contraceptive methods use has decreased slightly, although social inequality has declined more rapidly. The maternal mortality rate has decreased nationally and in most departments, but social inequality on this indicator still needs to be addressed.

Conclusions

National averages hide differences between subpopulations and departments in Bolivia. The findings show that the behavior and social inequality of some ODS-3 indicators have improved, but regarding other indicators interventions by different stakeholders must be strengthened to reduce social inequalities in health.

Characterizing Shigella species distribution and antimicrobial susceptibility to ciprofloxacin and nalidixic acid in Latin America between 2000-2015

BACKGROUND

Shigellosis is the second leading cause of diarrheal death globally. The global burden has been complicated by the emergence of Shigella strains resistant to first line antibiotic treatments such as ciprofloxacin. This study aims to describe the epidemiologic distribution of the most common Shigella species, and their antimicrobial susceptibility patterns to ciprofloxacin and nalidixic acid (NA) in Latin America.

METHODS

Laboratory data from 19 countries were obtained through the Latin American Network for Antimicrobial Resistance Surveillance (ReLAVRA) from 2000-2015. The Clinical Laboratory Standards Institute reduced susceptibility breakpoints for Enterobacteriaceae was used to interpret the disc diffusion tests for Shigella susceptibility to ciprofloxacin and NA. Negative binominal regression was used to analyze longitudinal trends of Shigella isolates antimicrobial susceptibility.

RESULTS

79,548 Shigella isolates were tested and reported between 2000-2015. The most common isolated species were S. flexneri (49%), and S. sonnei (28%). There was a steady increase in the proportion of S. sonnei isolates within the region(p<0.001). The average annual percentage increase (AAPI) in nonsusceptibility was 18.4% (p<0.001) for ciprofloxacin (baseline = 0.3); and 13.2%(p<0.001) for NA (baseline = 3). AAPI nonsusceptibility to ciprofloxacin was 13.3% for S. flexneri (p<0.04); and 39.9% for S. sonnei (p<0.001). Honduras, Dominican Republic, Venezuela, and Chile reported the highest increase in nonsusceptibility to ciprofloxacin among all Shigella isolates.

CONCLUSION

There is an increasing trend in Shigella nonsusceptibility to ciprofloxacin and NA, including among the most common shigella species, in Latin America. This rise of nonsusceptibility among Shigella species to commonly used treatments such as ciprofloxacin is alarming and threatens the control and management of this currently treatable infection. Improved data quality, collection and reporting is needed in Latin America to respond effectively to the rising trends observed. This includes the need for quality isolate level epidemiological data; molecular data, and data on antibiotic consumption and use.

Contraceptive use in Latin America and the Caribbean with a focus on long-acting reversible contraceptives: prevalence and inequalities in 23 countries

BACKGROUND

The rise in contraceptive use has largely been driven by short-acting methods of contraception, despite the high effectiveness of long-acting reversible contraceptives. Several countries in Latin America and the Caribbean have made important progress increasing the use of modern contraceptives, but important inequalities remain. We assessed the prevalence and demand for modern contraceptive use in Latin America and the Caribbean with data from national health surveys.

METHODS

Our data sources included demographic and health surveys, multiple indicator cluster surveys, and reproductive health surveys carried out since 2004 in 23 countries of Latin America and the Caribbean. Analyses were based on sexually active women aged 15-49 years irrespective of marital status, except in Argentina and Brazil, where analyses were restricted to women who were married or in a union. We calculated contraceptive prevalence and demand for family planning satisfied. Contraceptive prevalence was defined as the percentage of sexually active women aged 15-49 years who (or whose partners) were using a contraceptive method at the time of the survey. Demand for family planning satisfied was defined as the proportion of women in need of contraception who were using a contraceptive method at the time of the survey. We separated survey data for modern contraceptive use by type of contraception used (long-acting, short-acting, or permanent). We also stratified survey data by wealth, area of residence, education, ethnicity, age, and a combination of wealth and area of residence. Wealth-related absolute and relative inequalities were estimated both for contraceptive prevalence and demand for family planning satisfied.

FINDINGS

We report on surveys from 23 countries in Latin America and the Caribbean, analysing a sample of 212 573 women. The lowest modern contraceptive prevalence was observed in Haiti (31·3%) and Bolivia (34·6%); inequalities were wide in Bolivia, but almost non-existent in Haiti. Brazil, Colombia, Costa Rica, Cuba, and Paraguay had over 70% of modern contraceptive prevalence with low absolute inequalities. Use of long-acting reversible contraceptives was below 10% in 17 of the 23 countries. Only Cuba, Colombia, Mexico, Ecuador, Paraguay, and Trinidad and Tobago had more than 10% of women adopting long-acting contraceptive methods. Mexico was the only country in which long-acting contraceptive methods were more frequently used than short-acting methods. Young women aged 15-17 years, indigenous women, those in lower wealth quintiles, those living in rural areas, and those without education showed particularly low use of long-acting reversible contraceptives.

INTERPRETATION

Long-acting reversible contraceptives are seldom used in Latin America and the Caribbean. Because of their high effectiveness, convenience, and ease of continuation, availability of long-acting reversible contraceptives should be expanded and their use promoted, including among young and nulliparous women. In addition to suitable family planning services, information and counselling should be provided to women on a personal basis.

FUNDING

Wellcome Trust, Pan American Health Organization.

[Epidemiology of suicide among adolescents and young adults in EcuadorEpidemiologia do suicídio em adolescentes e jovens no Equador]

Objective

To collect information - and provide it to decision-makers in health programs in general and mental health programs in particular - on epidemiological patterns in suicide deaths among young adults and adolescents in Ecuador.

Methods

A cross-sectional ecological study was conducted using data obtained from records of deaths by suicide among young adults and adolescents in Ecuador from 2001 to 2014. For analysis, results were disaggregated by geographic region, sex, age, ethnic group and suicide method. Rates of death by suicide (per 100,000 population) and relative risks (RR) for suicide were estimated by sex and region.

Results

Between 2001 and 2014, 4,855 suicides were recorded among adolescents and young adults. The highest estimated risk was found among males aged 15 to 24 years and adolescents living in the Amazon region, followed by those living in the Andean region. Mestizos were the ethnic group with the greatest number of suicides, although 40% of young people who commit suicide in the Amazon region are indigenous. The most frequent method was by hanging, followed by pesticide poisoning.

Conclusions

Suicide among adolescents and young adults is an important public health problem in Ecuador. Since various psychological, social, and cultural influences come into play, there is wide variation among regions, age groups, and ethnic groups. Restricting access to pesticides and other chemical products, implementing universal prevention programs and programs in education centers in the areas with the highest rates, and targeting vulnerable populations for specific interventions could help reduce the suicide rate among young people in Ecuador.