Carlos Castillo-Salgado

Health Status of Mexican-Origin Persons: Do Proxy Measures of Acculturation Advance our Understanding of Health Disparities?

Objectives This paper compares select health status indicators between the U.S. and Mexico, and within the Mexican-origin population using proxy measures of acculturation. Methods Statistical data were abstracted and a Medline literature review conducted of English-language epidemiologic articles on Mexican-origin groups published during 1976–2005. Results U.S.-born Mexican-Americans have higher morbidity and mortality compared to Mexico-born immigrants. Mexico has lower healthcare resources, life expectancy, and circulatory system and cancer mortality rates, but similar infant immunization rates compared to the U.S. Along the U.S.-Mexico border, the population on the U.S. side has better health status than the Mexican side. The longer in the U.S., the more likely Mexican-born immigrants engage in behaviors that are not health promoting. Conclusions Researchers should consider SEP, community norms, behavioral risk and protective factors when studying Mexican-origin groups. It is not spendingtime in the U.S. that worsens health outcomes but rather changes in health promoting behaviors.

Métodos de medición de las desigualdades de salud

RESUMEN La medicion de las desigualdades en el campo de la salud es una condicion indispensable para avanzar en la mejoria de la situacion de salud de la Region, donde el analisis de los valores medios ha dejado de ser suficiente. Este tipo de analisis es una herramienta fundamental para la accion en busca de una mayor equidad en salud. Existen diferentes metodos de medicion y niveles de complejidad cuya eleccion depende del objetivo del estudio. Este articulo tiene como objetivo familiarizar a los profesionales de la salud y a las instancias decisorias con los aspectos metodologicos de la medicion y el analisis simple de las desigualdades en el campo de la salud, utilizando datos basicos registrados con regularidad y agregados por unidades geopoliticas. Se presenta la forma de calcular los siguientes indicadores y se comentan sus ventajas y desventajas: la razon y la diferencia de tasas, el indice de efecto, el riesgo atribuible poblacional, el indice de disimilitud, el indice de desigualdad de la pendiente y el indice relativo de desigualdad, el coeficiente de Gini y el indice de concentracion. Los metodos presentados son aplicables a la medicion de las desigualdades de diferentes tipos y a distintos niveles de analisis.Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.

Overview of social inequalities in health in the Region of the Americas, using various methodological approaches

Over the past decade, according to several important indicators, health conditions have improved in the Region of the Americas. However, inequalities persist among the countries of the Region. This article has two primary objectives: 1) to provide some unbiased evidence on health inequalities among countries of the Region of the Americas and 2) to illustrate the application of some of the more frequently used methods for measuring inequalities, including effect measurements, population attributable risk, the slope index of inequality, the relative index of inequality, and the concentration index. Analyses have shown that there are great health disparities in the Region of the Americas. For example, residents of the poorest countries of the Region live nearly 10 years less, on average, than do residents of the richest countries. If the other countries of the Americas had the same incidence of tuberculosis as does the subregion of North America (Bermuda, Canada, and the United States of America), there would be 76% fewer cases of this disease in the Region. In the Americas, nearly 35% of deaths of infants under 1 year old are concentrated in the 20% of live births that occur in the group with the lowest income. As for maternal mortality in the Americas, fewer than 2% of maternal deaths occur in association with the 20% of live births in the group with the highest income. The analyses of health inequalities based on the use of various methods highlight the existence of important disparities among subregions and countries of the Americas that are not readily seen when using only the more-traditional methods for analyzing mortality and morbidity. There is also a need to incorporate the concepts of distribution and socioeconomic dimensions of health when interpreting a given situation. Using this approach will allow decisionmakers to target areas and populations that are in less-favorable conditions. A considerable body of aggregate data at the Regional and country levels from routine information systems is already available--especially on morbidity, mortality, and other health-related factors--that can be used on a regular basis to analyze health inequalities. These kinds of analyses may be regarded as a first step toward the identification of health inequities.

Life expectancy at birth and mortality in Brazil, 1999: exploratory analysis of regional differences

OBJECTIVE To analyze the inequalities found using health indicators in the states and regions of Brazil, according to 1999 socioeconomic and demographic indicators. METHODS An exploratory ecological cross-sectional study was carried out. The units of analysis were Brazilian states (n = 27) and regions (n = 5). Descriptive measures of inequality were calculated. Pearsons correlation and also linear regression analysis were used to identify associations between health indicators and selected socio-economic and demographic indicators. The health indicators analyzed were: life expectancy at birth, infant mortality rate, mortality rate for children < 5 years due to acute diarrheal diseases and to acute respiratory infections, and deaths due to homicides and traffic accidents. RESULTS Important gains were seen in life expectancy at birth over the 1991-1999 period, especially for males. There was a trend towards larger gains in states that had had lower life expectancy at birth in 1991, which produced greater homogeneity across Brazil in this indicator in recent years. The infant mortality rate decreased by 28% between 1991 and 1999. However, this indicator still varies widely among the regions--from 52.5 per 1,000 live births in the northeast to 17.1 per 1,000 in the south--and among states--from 64.0 per 1,000 in Alagoas to 15.1 per 1,000 in Rio Grande do Sul. With respect to children < 5 years, the mortality rate due to acute diarrheal diseases was equal to or higher than the national median (4.1 per 10,000) in all the north-eastern states, and the mortality rate due to acute respiratory infections was equal to or higher than the national median (10.8 per 10,000) in all the southern, southeastern, and central-western states. The mortality rates (standardized by sex and age) due to traffic accidents and to homicides in 1999 were 17.7 and 26.0 per 100,000 inhabitants, respectively. Extreme values were found in some states for mortality due to homicide (57.8 per 100,000 in Pernambuco) and traffic accidents (54.5 per 100,000 in Roraima). The mortality rate due to homicide was strongly associated with urbanization (P = 0.001). Higher mortality rates due to traffic accidents were associated with lower poverty levels (beta = -0.93; P < 0.001), lower literacy rates (beta = -1.16; P = 0.005), and larger population growth over the past decade (beta = 3.10; P = 0.016). CONCLUSIONS The pattern of health inequality in Brazil indicates a polarization among regions and states as well as a juxtaposition of diseases associated with under-development and diseases linked to development, suggesting the need for a health system that is committed to addressing these issues.

Equality, equity: why bother?

The excellent papers in this theme section of the Bulletin aim mainly at defining the inequalities in health that occur, and Gwatkin presents some interesting aspects of the problem of how to reduce them. It is usually assumed that inequalities in health are undesirable and should be reduced, but the reasons for this are not always made explicit. The reason most commonly adduced is that it is morally indefensible not to allow all human beings to enjoy what is often posed by Amartya Sen as one of the essential freedoms and the mechanism through which other freedoms can be enjoyed. There is a cap on the level of health that can be attained if one uses commonly accepted measures such as mortality and morbidity indicators. For material goods, however, there is in theory no limit to the potential gap between those who are best and worst off. The case is made that for an essential requirement such as health the gaps that can be reduced should be. In addition we concern ourselves with inequalities in health because we believe that they may be a cause of social instability. Inequality in health or in access to measures that ensure it can foment discontent and intergroup enmities that disturb the social order within a country. Likewise the differences between countries contribute significantly to the instability of the world. Unfavourable conditions in human health and the environment in some countries are seen to be threats to the security of the more favoured ones. Men and women do not usually use health as a yardstick of achievement or strive to be healthier than others, but they do regard it almost as a right to be as healthy as others and to have access to the means of being so. Finally there is the prosaic consideration that health is one of the ingredients of human capital that is so essential to other aspects of development. Unequal access to measures that lead to formation of human capital inhibits the reduction or alleviation of poverty. Improvement of health status and the reduction of health inequalities are more and more recognized as essential ingredients for schemes to reduce poverty. Our concern is not only instrumental. We wish to ground our comment firmly within the historical background of thinking and practice in the World Health Organization over the last two decades. We place the concern for health differentials squarely within the context of the goal of health for all, which has equity as its underlying value and sees inequalities in terms of the social injustice implied by inequity. This framework is in no way inimical to efforts to identify the inequalities that represent inequities and seek measures to reduce them. The policy issues that these papers raise include the need to establish with more precision some measure of the inequality that exists with regard to health status or outcome. These inequalities can only be deemed inequities if they are unjust and their determinants lend themselves to being manipulated so as to reduce them. Thus, while we acknowledge the need for a measure of the distribution of health status in order to establish the degree of inequality, this can only be a first step if we believe that these differences can be reduced. The real issue is the relation of these differences or inequalities to the distribution of the social determinants of the state of health or the distribution of that state itself. Gwatkin makes a powerful argument for the significance of the distribution of health outcomes. National averages hide the differences that need to be tackled in order to reduce inequity. But this welcome focus has very, practical implications: most of the countries in the Americas do not have the tools to make these determinations, and in many cases they do not see the need for producing the data in a form that shows the relevant distribution and gaps. Only recently has it been possible to organize health data with the degree of geographical disaggregation that will determine the inequalities that exist between the different areas and population groups concerned. …

Los sistemas de información geográfica como herramienta para monitorear las desigualdades de salud

OBJETIVOS: Mostrar la aplicacion de los sistemas de informacion geografica (SIG) como instrumento tecnologico para apoyar las actividades en las areas de politica sanitaria y salud publica. METODOS: Se evaluo la relacion entre la mortalidad infantil y diversos factores determinantes de caracter socioeconomico y geografico. Al ilustrar la aplicacion, se hace hincapie en la capacidad integradora de los SIG, que permite simplificar, agilizar y automatizar la evaluacion epidemiologica, tomando en cuenta el analisis multiple simultaneo de variables determinantes con diferentes niveles de agregacion. La aplicacion de los SIG abarco, en este estudio, el analisis de la mortalidad infantil en tres niveles de agregacion en paises de las Americas entre 1995 y 2000. RESULTADOS: La mortalidad infantil estimada para la Region tuvo un promedio de 24,4 defunciones por 1 000 nacidos vivos, pero las desigualdades observadas indican que la probabilidad de una muerte infantil es casi 20 veces mayor en los paises de menos recursos que en los mas prosperos. El mapeo de la mortalidad infantil a escala regional permitio identificar los paises que requieren mayor atencion en sus politicas y programas de salud, pero no distinguir donde se requerian acciones mas prioritarias. Un analisis de las unidades geopoliticas mas pequenas (estados y municipios) revelo importantes diferencias dentro de los paises y permitio reproducir el patron de desigualdad regional, que no se ve reflejado por el valor promedio de los indicadores a escala nacional. Al analizarse la relacion entre el analfabetismo femenino y la desnutricion como factores determinantes de la mortalidad infantil en Brasil y Ecuador, se identificaron estratos sociales y epidemiologicos con distribuciones diferenciales de factores de riesgo que requieren intervenciones sanitarias adecuadas para sus respectivos perfiles socioepidemiologicos. CONCLUSIONES: Gracias a este tipo de analisis epidemiologico a escala local de los servicios de salud mediante el uso de los SIG, es facil reconocer como se comportan un fenomeno de salud y sus factores de riesgo determinantes en un periodo definido. Asimismo, es posible identificar patrones en la distribucion espacial de los factores de riesgo y sus posibles efectos sobre la salud. La utilizacion adecuada de los SIG permitira lograr mayor eficacia y equidad en la prestacion de los servicios de salud publica.

Methods for measuring inequalities in health

RESUMEN La medicion de las desigualdades en el campo de la salud es una condicion indispensable para avanzar en la mejoria de la situacion de salud de la Region, donde el analisis de los valores medios ha dejado de ser suficiente. Este tipo de analisis es una herramienta fundamental para la accion en busca de una mayor equidad en salud. Existen diferentes metodos de medicion y niveles de complejidad cuya eleccion depende del objetivo del estudio. Este articulo tiene como objetivo familiarizar a los profesionales de la salud y a las instancias decisorias con los aspectos metodologicos de la medicion y el analisis simple de las desigualdades en el campo de la salud, utilizando datos basicos registrados con regularidad y agregados por unidades geopoliticas. Se presenta la forma de calcular los siguientes indicadores y se comentan sus ventajas y desventajas: la razon y la diferencia de tasas, el indice de efecto, el riesgo atribuible poblacional, el indice de disimilitud, el indice de desigualdad de la pendiente y el indice relativo de desigualdad, el coeficiente de Gini y el indice de concentracion. Los metodos presentados son aplicables a la medicion de las desigualdades de diferentes tipos y a distintos niveles de analisis.Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.

Índices para medir las desigualdades de salud de carácter social basados en la noción de entropía

Los indices descritos en la literatura para medir las desigualdades de salud de caracter social tienen facetas positivas pero tambien algunas insuficiencias, segun las circunstancias de su aplicacion. El objetivo de este articulo es proponer y demostrar, en los planos teorico y practico, las ventajas de las mediciones de la desigualdad basadas en la nocion de entropia, conocida ampliamente en la fisica y la teoria de la informacion. Se definen y exponen las principales propiedades de los indices basados en las nociones de entropia y redundancia. Se ilustra su aplicacion en dos conjuntos de datos ficticios y en datos reales, derivados de los indicadores basicos de salud para las Americas, de la Organizacion Panamericana de la Salud. Los indices basados en la nocion de entropia poseen, entre otras, las siguientes propiedades: a) no varian con los cambios de escala; b) son simetricos; c) incorporan la dimension social, y d) son faciles de interpretar gracias a la condicion de equivalencia entre la entropia y un sistema con dos clases.

Variación de los indicadores de mortalidad evitable entre comunas chilenas como aproximación a las desigualdades de salud

OBJETIVOS:Analizar variaciones de mortalidad evitable entre comunas, utilizando diversos indicadores, como aproximacion operacional para estimar desigualdades de salud. METODOS:Analisis de variacion de areas pequenas en una muestra de 117 de las 335 comunas chilenas en 1992. Usando datos secundarios, se desarrollaron y analizaron indicadores de mortalidad evitable, tales como los anos de vida potencial perdidos (AVPP), la mortalidad evitable (ME) (con antecedentes y criterios basados en fuentes publicadas), la mortalidad evitable mediante la atencion de salud (MEAS), y la esperanza de vida. Tambien se creo un indicador de desarrollo socioeconomico (IDSE). La amplitud de las variaciones observadas entre indicadores se estimo mediante el coeficiente ponderado de variacion, el coeficiente de Gini, la razon entre quintiles extremos del IDSE y la razon entre el quintil con el menor IDSE y el grupo de comunas con IDSE mayores de 0,90 (referencia empirica optima). El perfil socioeconomico de las variaciones se examino mediante curvas de concentracion y la comparacion de quintiles comunales segun IDSE. RESULTADOS:Los diversos indicadores de ME usados mostraron una relacion inversa estadisticamente significativa con el desarrollo socioeconomico, tendencia tambien observada en el perfil de los quintiles definidos por IDSE y en la mayoria de las causas especificas de mortalidad evitable. El uso de tres niveles de referencia (promedio, quintil con el mayor IDSE y referencia empirica optima) plantea la medicion de distintas brechas que podrian prevenirse. La razon entre el quintil con el menor IDSE y la referencia optima fue de 2,1 en el caso de la ME, de 2,0 en el caso de los AVPP, de 1,7 en el de la mortalidad infantil y de 1,5 en el de la MEAS. CONCLUSIONES:Los resultados, que coinciden con los hallados en otras fuentes publicadas previamente, ponderan la magnitud y el perfil de las variaciones entre comunas y proveen informacion, basada en datos de 1992, para iniciar un monitoreo de las desigualdades de salud entre areas geograficas pequenas, en este caso las comunas. Aunque las iniciativas por mejorar la equidad se concentran en las comunas de menor desarrollo socioeconomico y mayor mortalidad evitable, reducir esta ultima implica una tarea con un enfoque doble: dar prioridad de intervencion a las comunas mas postergadas por un lado, y cubrir la mayoria de las comunas para prevenir la mortalidad evitable por el otro.

Métodos de mensuração das desigualdades em saúde

RESUMEN La medicion de las desigualdades en el campo de la salud es una condicion indispensable para avanzar en la mejoria de la situacion de salud de la Region, donde el analisis de los valores medios ha dejado de ser suficiente. Este tipo de analisis es una herramienta fundamental para la accion en busca de una mayor equidad en salud. Existen diferentes metodos de medicion y niveles de complejidad cuya eleccion depende del objetivo del estudio. Este articulo tiene como objetivo familiarizar a los profesionales de la salud y a las instancias decisorias con los aspectos metodologicos de la medicion y el analisis simple de las desigualdades en el campo de la salud, utilizando datos basicos registrados con regularidad y agregados por unidades geopoliticas. Se presenta la forma de calcular los siguientes indicadores y se comentan sus ventajas y desventajas: la razon y la diferencia de tasas, el indice de efecto, el riesgo atribuible poblacional, el indice de disimilitud, el indice de desigualdad de la pendiente y el indice relativo de desigualdad, el coeficiente de Gini y el indice de concentracion. Los metodos presentados son aplicables a la medicion de las desigualdades de diferentes tipos y a distintos niveles de analisis.Measuring health inequalities is indispensable for progress in improving the health situation in the Region of the Americas, where the analysis of average values is no longer sufficient. Analyzing health inequalities is a fundamental tool for action that seeks greater equity in health. There are various measurement methods, with differing levels of complexity, and choosing one rather than another depends on the objective of the study. The purpose of this article is to familiarize health professionals and decision-making institutions with methodological aspects of the measurement and simple analysis of health inequalities, utilizing basic data that are regularly reported by geopolitical unit. The calculation method and the advantages and disadvantages of the following indicators are presented: the rate ratio and the rate difference, the effect index, the population attributable risk, the index of dissimilarity, the slope index of inequality and the relative index of inequality, the Gini coefficient, and the concentration index. The methods presented are applicable to measuring various types of inequalities and at different levels of analysis.