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  • 1.
    Acosta, Naydú
    et al.
    Universidad Industrial de Santander .
    Pollard, Jennifer
    National University of Colombia.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Reveiz, Ludovic
    National University of Colombia.
    Equidad en el desarrollo de guias de practica clinica: [The concept of equity when developing clinical practice guidelines]2011In: Revista de Salud Pública, ISSN 0124-0064, Vol. 13, no 2, p. 327-38Article in journal (Refereed)
    Abstract [en]

    This systematic literature review sought to identify methodologies and technical strategies emphasising healthcare services and outcomes when incorporating the concept of equity into Clinical Practice Guidelines (CPG). 940 references were identified, of which 20 fulfilling the inclusion criteria were selected. While no reports were found describing or evaluating an explicit methodology for incorporating considerations of equity into CPG, some studies revealed related strategies or processes, summarised as follows: 1. Target population involvement during all phases of designing, implementing and evaluating CPG; 2. "Cultural capacity" seen as being necessary in CPGs' "cultural translation" for interventions to have less disparity regarding their application and results; 3. Considering psycho-social factors which could affect implementing CPG, and; 4. Considering system inequities so that any health intervention would also confront risks and obstacles to health care due to socioeconomic status. It was concluded that CPGs could be a potential route for promoting more equitable healthcare effects by standardising health interventions if, by incorporating some of the processes described above, they actively seek to avoid unjust differences in access to and/or the quality of the interventions that they prescribe.

  • 2.
    Amroussia, Nada
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Explaining mental health inequalities in Northern Sweden: a decomposition analysis2017In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, article id 1305814Article in journal (Refereed)
    Abstract [en]

    Background: There has been a substantial increase of income inequalities in Sweden over the last 20 years, which also could be reflected in health inequalities, including mental health inequalities. Despite the growing body of literature focusing on health inequalities in Sweden, income-related inequalities in mental health have received little attention. Particularly scarce are research from Northern Sweden and examinations of the social determinants of health inequalities.

    Objectives: The present study seeks to provide evidence regarding inequalities in mental health in Northern Sweden. The specific aims were to (1) quantify the income-related inequality in mental health in Northern Sweden, and (2) determine the contribution of social determinants to the inequality.

    Methods: The study population comprised 25,646 participants of the 2014 Health on Equal Terms survey in the four northernmost counties of Sweden, aged 16 to 84 years old. Income-related inequalities in mental health were quantified by the concentration index and further decomposed by applying Wagstaff-type decomposition analysis.

    Results: The overall concentration index of mental health in Northern Sweden was −0.15 (95% CI: −0.17 to −0.13), indicating income inequalities in mental health disfavoring the less affluent population. The decomposition analysis results revealed that socio-economic conditions, including employment status (31%), income (22.6%), and cash margin (14%), made the largest contribution to the pro-rich inequalities in mental health. The second-largest contribution came from demographic factors, mainly age (11.3%) and gender (6%). Psychosocial factors were of smaller importance, with perceived discrimination (8%) and emotional support (3.4%) making moderate contributions to the health inequalities. 

    Conclusions: The present study demonstrates substantial income-related mental health inequalities in Northern Sweden, and provides insights into their underpinnings. These findings suggest that addressing the root causes is essential for promoting mental health equity in this region.

  • 3. Eslava-Schmalbach, Javier H
    et al.
    Welch, Vivian A
    Tugwell, Peter
    Amaya, Ana C
    Gaitán, Hernando
    Mosquera, Paola
    Molina, Felipe
    Peralta, Fernando
    Romero-Vanegas, Sara
    Pardo, Rodrigo
    Alzate, Juan Pablo
    Incorporating equity issues into the development of Colombian clinical practice guidelines: suggestions for the GRADE approach2016In: Revista de Salud Pública, ISSN 0124-0064, Vol. 18, no 1, p. 72-81Article in journal (Refereed)
    Abstract [en]

    Objective To propose how to incorporate equity issues, using the GRADE approach, into the development and implementation of Colombian Clinical Practice Guidelines.

    Methodology This proposal was developed in four phases: 1. Included literature review and and the development of a preliminary proposal about how to include equity issues, 2. Involved an informal discussion to reach a consensus on improving the first proposal; 3. Was a survey of the researchers´acceptance levels of the proposal, and; 4. A final informal consensus was formed to adjust the proposal.

    Results A proposal on how to incorporate equity issues into the GRADE approach was developed. It places particular emphasis on the recognition of disadvantaged populations in the development and implementation of the suggested guideline. PROGRESS-Plus is recommended for use in exploring the various categories of disadvantaged people. The proposal suggests that evidence be rated differentially by giving higher ratings to studies that consider equity issues than those that do not. The proposal also suggests the inclusion of indicators to monitor the impacts of the implementation of CPGs on disadvantaged people.

    Conclusions A consideration of equity in the development and implementation of clinical practice guidelines and quality assessments of the evidence would achieve more in the participation of potential actors in the process and reflect on the effectiveness of the proposed interventions across all social groups. 

  • 4. Eslava-Schmalbach, Javier
    et al.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Pablo Alzate, Juan
    Pottie, Kevin
    Welch, Vivian
    Akl, Elie A.
    Jull, Janet
    Lang, Eddy
    Katikireddi, Srinivasa Vittal
    Morton, Rachel
    Thabane, Lehana
    Shea, Bev
    Stein, Airton T.
    Singh, Jasvinder
    Florez, Ivan D.
    Guyatt, Gordon
    Schunemann, Holger
    Tugwell, Peter
    Considering health equity when moving from evidence-based guideline recommendations to implementation: a case study from an upper-middle income country on the GRADE approach2017In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 32, no 10, p. 1484-1490Article in journal (Refereed)
    Abstract [en]

    The availability of evidence-based guidelines does not ensure their implementation and use in clinical practice or policy making. Inequities in health have been defined as those inequalities within or between populations that are avoidable, unnecessary and also unjust and unfair. Evidence-based clinical practice and public health guidelines ('guidelines') can be used to target health inequities experienced by disadvantaged populations, although guidelines may unintentionally increase health inequities. For this reason, there is a need for evidence-based clinical practice and public health guidelines to intentionally target health inequities experienced by disadvantaged populations. Current guideline development processes do not include steps for planned implementation of equity-focused guidelines. This article describes nine steps that provide guidance for consideration of equity during guideline implementation. A critical appraisal of the literature followed by a process to build expert consensus was undertaken to define how to include consideration of equity issues during the specific GRADE guideline development process. Using a case study from Colombia we describe nine steps that were used to implement equity-focused GRADE recommendations: (1) identification of disadvantaged groups, (2) quantification of current health inequities, (3) development of equity-sensitive recommendations, (4) identification of key actors for implementation of equity-focused recommendations, (5) identification of barriers and facilitators to the implementation of equity-focused recommendations, (6) development of an equity strategy to be included in the implementation plan, (7) assessment of resources and incentives, (8) development of a communication strategy to support an equity focus and (9) development of monitoring and evaluation strategies. This case study can be used as model for implementing clinical practice guidelines, taking into account equity issues during guideline development and implementation.

  • 5.
    Eslava-Schmalbach, Javier
    et al.
    National University of Colombia.
    Sandoval-Vargas, Gisella
    National University of Colombia.
    Mosquera Mendez, Paola
    Incorporating equity into developing and implementing evidence-based clinical practice guidelines2011In: Revista de Salud Pública, ISSN 0124-0064, Vol. 13, no 2, p. 339-351Article in journal (Refereed)
    Abstract [en]

    Clinical practice guidelines (CPG) are useful tools for clinical decision making, processes standardization and quality of care improvements. The current General Social Security and Health System (GSSHS) in Colombia is promoting the initiative of developing and implementing CPG based on evidence in order to improve efficiency and quality of care. The reduction of inequalities in health should be an objective of the GSSHS. The main propose of this analysis is to argue why it is necessary to consider the incorporation of equity considerations in the development and implementation of clinical practice guidelines based on the evidence. A series of reflections were made. Narrative description was used for showing the arguments that support the main findings. Among them are: 1. Differential effectiveness by social groups of interventions could diminish final effectiveness of CPG in the GSSHS; 2. To not consider geographical, ethnic, socioeconomic, cultural and access diversity issues within the CPG could have a potential negative impacts of the CPG; 3. Overall effectiveness of GPC could be better if equity issues are included in the quality verification checklist of the guideline questions; 4. Incorporating equity issues in the process of developing CPG could be cost effective, because improve overall effectiveness of CPG. Conclusions To include equity issues in CPG can help in achieving more equitable health outcomes. From this point of view CPG could be key tools to promote equity in care and health outcomes.

  • 6.
    Goicolea, Isabel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Grupo de Investigación de Salud Pública, Universidad de Alicante, Alicante, Spain.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Briones-Vozmediano, Erica
    Otero-García, Laura
    García-Quinto, Marta
    Vives-Cases, Carmen
    Primary health care attributes and responses to intimate partner violence in Spain2017In: Gaceta Sanitaria, ISSN 0213-9111, E-ISSN 1578-1283, Vol. 31, no 3, p. 187-193Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: This study provides an overview of the perceptions of primary care professionals on how the current primary health care (PHC) attributes in Spain could influence health-related responses to intimate partner violence (IPV).

    METHODS: A qualitative study was conducted using semi-structured interviews with 160 health professionals working in 16 PHC centres in Spain. Data were analysed using a qualitative content analysis.

    RESULTS: Four categories emerged from the interview analysis: those committed to the PHC approach, but with difficulties implementing it; community work relying on voluntarism; multidisciplinary team work or professionals who work together?; and continuity of care hindered by heavy work load. Participants felt that person-centred care as well as other attributes of the PHC approach facilitated detecting IPV and a better response to the problem. However, they also pointed out that the current management of the health system (workload, weak supervision and little feedback, misdistribution of human and material resources, etc.) does not facilitate the sustainability of such an approach.

    CONCLUSION: There is a gap between the theoretical attributes of PHC and the "reality" of how these attributes are managed in everyday work, and how this influences IPV care.

  • 7.
    Gustafsson, Per E.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Linander, Ida
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Embodying pervasive discrimination: a decomposition of sexual orientation inequalities in health in a population-based cross-sectional study in Northern Sweden.2017In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, article id 22Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Studies from Sweden and abroad have established health inequalities between heterosexual and non-heterosexual people. Few studies have examined the underpinnings of such sexual orientation inequalities in health. To expand this literature, the present study aimed to employ decomposition analysis to explain health inequalities between people with heterosexual and non-heterosexual orientation in Sweden, a country with an international reputation for heeding the human rights of non-heterosexual people.

    METHODS: Participants (N = 23,446) came from a population-based cross-sectional survey in the four northernmost counties in Sweden in 2014. Participants completed self-administered questionnaires, covering sexual orientation, mental and general physical health, social conditions and unmet health care needs, and sociodemographic data was retrieved from total population registers. Sexual orientation inequalities in health were decomposed by Blinder-Oaxaca decomposition analysis.

    RESULTS: Results showed noticeable mental and general health inequalities between heterosexual and non-heterosexual orientation groups. Health inequalities were partly explained (total explained fraction 64-74%) by inequalities in degrading treatment (24-26% of the explained fraction), but to a considerable degree also by material conditions (38-45%) and unmet care needs (25-43%).

    CONCLUSIONS: Psychosocial experiences may be insufficient to explain and understand health inequalities by sexual orientation in a reputedly 'gay-friendly' setting. Less overt forms of structural discrimination may need to be considered to capture the pervasive material discrimination that seems to underpin the embodiment of sexual minority inequalities. This ought to be taken into consideration in research, policy-making and monitoring aiming to work towards equity in health across sexual orientations.

  • 8.
    Gustafsson, Per E.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sebastián, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Meddling with middle modalities: a decomposition approach to mental health inequalities between intersectional gender and economic middle groups in northern Sweden2016In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 32819Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Intersectionality has received increased interest within population health research in recent years, as a concept and framework to understand entangled dimensions of health inequalities, such as gender and socioeconomic inequalities in health. However, little attention has been paid to the intersectional middle groups, referring to those occupying positions of mixed advantage and disadvantage.

    OBJECTIVE: This article aimed to 1) examine mental health inequalities between intersectional groups reflecting structural positions of gender and economic affluence and 2) decompose any observed health inequalities, among middle groups, into contributions from experiences and conditions representing processes of privilege and oppression.

    DESIGN: Participants (N=25,585) came from the cross-sectional 'Health on Equal Terms' survey covering 16- to 84-year-olds in the four northernmost counties of Sweden. Six intersectional positions were constructed from gender (woman vs. men) and tertiles (low vs. medium vs. high) of disposable income. Mental health was measured through the General Health Questionnaire-12. Explanatory variables covered areas of material conditions, job relations, violence, domestic burden, and healthcare contacts. Analysis of variance (Aim 1) and Blinder-Oaxaca decomposition analysis (Aim 2) were used.

    RESULTS: Significant mental health inequalities were found between dominant (high-income women and middle-income men) and subordinate (middle-income women and low-income men) middle groups. The health inequalities between adjacent middle groups were mostly explained by violence (mid-income women vs. men comparison); material conditions (mid- vs. low-income men comparison); and material needs, job relations, and unmet medical needs (high- vs. mid-income women comparison).

    CONCLUSIONS: The study suggests complex processes whereby dominant middle groups in the intersectional space of economic affluence and gender can leverage strategic resources to gain mental health advantage relative to subordinate middle groups.

  • 9.
    Kinsman, John
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Angrén, John
    Umeå University, Faculty of Science and Technology, European CBRNE Center.
    Elgh, Fredrik
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology.
    Furberg, Maria
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Otero-García, Laura
    Snacken, René
    Derrough, Tarik
    Carrillo Santisteve, Paloma
    Ciotti, Massimo
    Tsolova, Svetla
    Preparedness and response against diseases with epidemic potential in the European Union: a qualitative case study of Middle East Respiratory Syndrome (MERS) and poliomyelitis in five member states2018In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, no 1, article id 528Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: EU Decision 1082/2013/EU on serious cross-border health threats provides a legal basis for collaboration between EU Member States, and between international and European level institutions on preparedness, prevention, and mitigation in the event of a public health emergency. The Decision provides a context for the present study, which aims to identify good practices and lessons learned in preparedness and response to Middle East Respiratory Syndrome (MERS) (in UK, Greece, and Spain) and poliomyelitis (in Poland and Cyprus).

    METHODS: Based on a documentary review, followed by five week-long country visits involving a total of 61 interviews and group discussions with experts from both the health and non-health sectors, this qualitative case study has investigated six issues related to preparedness and response to MERS and poliomyelitis: national plans and overall preparedness capacity; training and exercises; risk communication; linking policy and implementation; interoperability between the health and non-health sectors; and cross-border collaboration.

    RESULTS: Preparedness and response plans for MERS and poliomyelitis were in place in the participating countries, with a high level of technical expertise available to implement them. Nevertheless, formal evaluation of the responses to previous public health emergencies have sometimes been limited, so lessons learned may not be reflected in updated plans, thereby risking mistakes being repeated in future. The nature and extent of inter-sectoral collaboration varied according to the sectors involved, with those sectors that have traditionally had good collaboration (e.g. animal health and food safety), as well as those that have a financial incentive for controlling infectious diseases (e.g. agriculture, tourism, and air travel) seen as most likely to have integrated public health preparedness and response plans. Although the formal protocols for inter-sectoral collaboration were not always up to date, good personal relations were reported within the relevant professional networks, which could be brought into play in the event of a public health emergency. Cross-border collaboration was greatly facilitated if the neighbouring country was a fellow EU Member State.

    CONCLUSIONS: Infectious disease outbreaks remain as an ongoing threat. Efforts are required to ensure that core public health capacities for the full range of preparedness and response activities are sustained.

  • 10. La Parra-Casado, Daniel
    et al.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Vives-Cases, Carmen
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Nursing I, University of the Basque Country, 48940 Bilbao, Spain.
    Socioeconomic Inequalities in the Use of Healthcare Services: Comparison between the Roma and General Populations in Spain2018In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 15, no 1, article id 121Article in journal (Refereed)
    Abstract [en]

    This paper explores whether the principles of horizontal and vertical equity in healthcare are met by the Spanish national health system in the case of the Roma and general populations. The 2011/2012 Spanish National Health Survey (n = 21,650) and the 2014 National Health Survey of the Spanish Roma Population (n = 1167) were analyzed. Use of healthcare services was measured in terms of visits to a general practitioner (GP), visits to an emergency department, and hospitalizations. Healthcare need was measured using (a) self-rated health and (b) the reported number of chronic diseases. The Roma reported worse self-rated health and a higher prevalence of chronic diseases. A redistributive effect (increased healthcare service use among Roma and those in lower socio-economic classes) was found for hospitalizations and emergency visits. This effect was also observed in GP visits for women, but not for men. Vertical inequity was observed in the general population but not in the Roma population for GP visits. The results suggest the existence of horizontal inequity in the use of GP services (Roma women), emergency department visits (Roma and general population), and hospitalizations (Roma population) and of vertical inequity in the use of GP services among the general population.

  • 11.
    Mamani-Ortiz, Yercin
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Biomedical and Social Research Institute, Faculty of Medicine, San Simon University, Cochabamba, Bolivia.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastián Chasco, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Armaza Céspedes, Ada Ximena
    Luizaga López, Jenny Marcela
    Illanes Velarde, Daniel Elving
    Mosquera Méndez, Paola A.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Underpinnings of entangled ethnical and gender inequalities in obesity in Cochabamba-Bolivia: an intersectional approach2019In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, no 1, article id 153Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Social inequalities in obesity have been observed not only by gender but also between ethnic groups. Evidence on combined dimensions of inequality in health, and specifically including indigenous populations, is however scarce, and presents a particularly daunting challenge for successful prevention and control of obesity in Bolivia, as well as worldwide.

    OBJECTIVE: The aims of this study were i) to examine intersectional inequalities in obesity and ii) to identify the factors underlying the observed intersectional inequalities.

    METHODS: An intersectional approach study was employed, using the information collected in a cross-sectional community-based survey. The sample consisted of youth and adults with permanent residence in Cochabamba department (N = 5758), selected through a multistage sampling technique. An adapted version of the WHO-STEPS survey was used to collect information about Abdominal obesity and risk factors associated. Four intersectional positions were constructed from gender (woman vs. men) and ethnic group (indigenous vs. mestizo). Joint and excess intersectional disparities in obesity were estimated as absolute prevalence differences between binary groups, using binomial regression models. The Oaxaca-Blinder decomposition was applied to estimate the contributions of explanatory factors underlying the observed intersectional disparities, using Oaxaca command in Stata software v15.1.

    RESULTS: The prevalence of abdominal obesity had a higher prevalence in mestizos (men 35.01% and women 30.71%) as compared to indigenous (men 25.38% and women 27.75%). The joint disparity was estimated at 7.26 percentage points higher prevalence in the doubly advantaged mestizo men than in the doubly disadvantaged indigenous women. The gender referent disparity showed that mestizo-women had a higher prevalence than indigenous-women. The ethnic referent disparity showed that mestizo-men had a higher prevalence than indigenous men. The behavioural risk factors were the most important to explain the observed inequalities, while differences in socioeconomic and demographic factors played a less important role.

    CONCLUSION: Our study illustrates that abdominal obesity is not distributed according to expected patterns of structural disadvantage in the intersectional space of ethnicity and gender in Bolivia. In the Cochabamba case, a high social advantage was related to higher rates of abdominal obesity, as well as the behavioural risk factors associated with them.

  • 12.
    Mamani-Ortiz, Yercin
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Biomedical and Social Research Institute, Faculty of Medicine, San Simon University, Aniceto Arce Avenue, 371 Cochabamba, Bolivia.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Armaza, Ada X.
    Luizaga, Jenny M.
    Illanes, Daniel E.
    Ferrel, Marcia
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Prevalence and determinants of cardiovascular disease risk factors using the WHO STEPS approach in Cochabamba, Bolivia2019In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 786Article in journal (Refereed)
    Abstract [en]

    Background: Cardiovascular diseases (CVDs) are considered the number one cause of death worldwide, especially in low- and middle-income countries, Bolivia included. Lack of reliable estimates of risk factor distribution can lead to delay in implementation of evidence-based interventions. However, little is known about the prevalence of risk factors in the country. The aim of this study was to assess the prevalence of preventable risk factors associated with CVDs and to identify the demographic and socioeconomic factors associated with them in Cochabamba, Bolivia.

    Methods: A cross-sectional community-based study was conducted among youth and adults (N = 10,704) with permanent residence in Cochabamba, selected through a multistage sampling technique, from July 2015 to November 2016. An adapted version of the WHO STEPS survey was used to collect information. The prevalence of relevant behavioural risk factors and anthropometric measures were obtained. The socio-demographic variables included were age, ethnicity, level of education, occupation, place of residence, and marital status. Proportions with 95% confidence intervals were first calculated, and prevalence ratios were estimated for each CVD risk factor, both with crude and adjusted models.

    Results: More than half (57.38%) were women, and the mean age was 37.89 ± 18 years. The prevalence of behavioural risk factors were: current smoking, 11.6%; current alcohol consumption, 42.76%; low consumption of fruits and vegetables, 76.73%; and low level of physical activity, 64.77%. The prevalence of overweight was 35.84%; obesity, 20.49%; waist risk or abdominal obesity, 54.13%; and raised blood pressure, 17.5%. Indigenous populations and those living in the Andean region showed in general a lower prevalence of most of the risk factors evaluated.

    Conclusion: We provide the first CVD risk factor profile of people living in Cochabamba, Bolivia, using a standardized methodology. Overall, findings suggest that the prevalence of CVD risk factors in Cochabamba is high. This result highlights the need for interventions to improve early diagnosis, monitoring, management, and especially prevention of these risk factors.

  • 13.
    Mosquera Mendez, Paola A.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernandez, Jinneth
    Vega, Roman
    Martinez, Jorge
    Labonte, Ronald
    Sanders, David
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Primary health care contribution to improve health outcomes in Bogota-Colombia: a longitudinal ecological analysis2012In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 13, article id 84Article in journal (Refereed)
    Abstract [en]

    Background: Colombia has a highly segmented and fragmented national health system that contributes to inequitable health outcomes. In 2004 the district government of Bogota initiated a Primary Health Care (PHC) strategy to improve health care access and population health status. This study aims to analyse the contribution of the PHC strategy to the improvement of health outcomes controlling for socioeconomic variables.

    Methods: A longitudinal ecological analysis using data from secondary sources was carried out. The analysis used data from 2003 and 2007 (one year before and 3 years after the PHC implementation). A Primary Health Care Index (PHCI) of coverage intensity was constructed. According to the PHCI, localities were classified into two groups: high and low coverage. A multivariate analysis using a Poisson regression model for each year separately and a Panel Poisson regression model to assess changes between the groups over the years was developed. Dependent variables were infant mortality rate, under-5 mortality rate, infant mortality rate due to acute diarrheal disease and pneumonia, prevalence of acute malnutrition, vaccination coverage for diphtheria, pertussis, tetanus (DPT) and prevalence of exclusive breastfeeding. The independent variable was the PHCI. Control variables were sewerage coverage, health system insurance coverage and quality of life index.

    Results: The high PHCI localities as compared with the low PHCI localities showed significant risk reductions of under-5 mortality (13.8%) and infant mortality due to pneumonia (37.5%) between 2003 and 2007. The probability of being vaccinated for DPT also showed a significant increase of 4.9%. The risk of infant mortality and of acute malnutrition in children under-5 years was lesser in the high coverage group than in the low one; however relative changes were not statistically significant.

    Conclusions: Despite the adverse contextual conditions and the limitations imposed by the Colombian health system itself, Bogota's initiative of a PHC strategy has successfully contributed to the improvement of some health outcomes.

  • 14.
    Mosquera Mendez, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernandez, Jinneth
    Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Vega, Roman
    Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Martinez, Jorge
    Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Labonte, Ronald
    Faculty of Medicine, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada.
    Sanders, David
    School of Public Health, University of the Western Cape, Bellville, South Africa.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The impact of primary healthcare in reducing inequalities in child health outcomes, Bogota, Colombia: an ecological analysis2012In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 11, article id 66Article in journal (Refereed)
    Abstract [en]

    Background: Colombia is one of the countries with the widest levels of socioeconomic and health inequalities. Bogota, its capital, faces serious problems of poverty, social disparities and access to health services. A Primary Health Care (PHC) strategy was implemented in 2004 to improve health care and to address the social determinants of such inequalities. This study aimed to evaluate the contribution of the PHC strategy to reducing inequalities in child health outcomes in Bogota.

    Methods: An ecological analysis with localities as the unit of analysis was carried out. The variable used to capture the socioeconomic status and living standards was the Quality of Life Index (QLI). Concentration curves and concentration indices for four child health outcomes (infant mortality rate (IMR), under-5 mortality rate, prevalence of acute malnutrition in children under-5, and vaccination coverage for diphtheria, pertussis and tetanus) were calculated to measure socioeconomic inequality. Two periods were used to describe possible changes in the magnitude of the inequalities related with the PHC implementation (2003 year before - 2007 year after implementation). The contribution of the PHC intervention was computed by a decomposition analysis carried out on data from 2007.

    Results: In both 2003 and 2007, concentration curves and indexes of IMR, under-5 mortality rate and acute malnutrition showed inequalities to the disadvantage of localities with lower QLI. Diphtheria, pertussis and tetanus (DPT) vaccinations were more prevalent among localities with higher QLI in 2003 but were higher in localities with lower QLI in 2007. The variation of the concentration index between 2003 and 2007 indicated reductions in inequality for all of the indicators in the period after the PHC implementation. In 2007, PHC was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-5 mortality (24%), IMR (19%) and acute malnutrition (7%). PHC also contributed approximately 20% to inequality in DPT coverage, favoring the poorer localities.

    Conclusion: The PHC strategy developed in Bogota appears to be contributing to reductions of the inequality associated with socioeconomic and living conditions in child health outcomes.

  • 15.
    Mosquera Mendez, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Postgraduate programs in Health Administration and Public Health, Pontificia Universidad Javeriana, Bogota, Colombia.
    Hernández, Jineth
    Vega, Román
    Labonte, Ronald
    Sanders, David
    Dahlblom, Kjerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Challenges of implementing a primary health care strategy in a context of a market-oriented health care system: the experience of Bogota, Colombia2014In: International Journal of Health Planning and Management, ISSN 0749-6753, E-ISSN 1099-1751, Vol. 29, no 4, p. E347-E367Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although Colombia has a health system based on market and neoliberal principles, in 2004, the government of the capital-Bogota-took the decision to formulate a health policy that included the implementation of a comprehensive primary health care (PHC) strategy. This study aims to identify the enablers and barriers to the PHC implementation in Bogota. METHODS: The study used a qualitative multiple case study methodology. Seven Bogota's localities were included. Eighteen semi-structured interviews with key informants (decision-makers at each locality and members of the District Health Secretariat) and fourteen FGDs (one focus group with staff members and one with community members) were carried out. Data were analysed using a thematic analysis approach. RESULTS: The main enablers found across the district and local levels showed a similar pattern, all were related to the good will and commitment of actors at different levels. Barriers included the approach of the national policies and a health system based on neoliberal principles, the lack of a stable funding source, the confusing and rigid guidelines, the high turnover of human resources, the lack of competencies among health workers regarding family focus and community orientation, and the limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation. CONCLUSION: Significant efforts are required to overcome the market approach of the national health system. Interventions must be designed to include well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.

  • 16.
    Mosquera Mendez, Paola
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Granados Hidalgo, Gema
    Pontificia Universidad Javeriana.
    Vega, Roman
    Pontificia Universidad Javeriana.
    The Strategy of Primary Health Care for Bogotá - Colombia and its Relationship with the decrease of inequities in Health Results2008In: Revista Gerencia y Políticas de Salud, ISSN 1657-7027, Vol. 7, no 14Article in journal (Refereed)
    Abstract [en]

    Objective: To describe the tendency of a set of health indicators and analyze the behavior of the disparities in health in the localities of Bogota with most and least development in the strategy of Comprehensive Primary Health Care. Methodology: The design of the study is Ecological Observation. It describes the tendencies of the mortality indicators for children below five years of age utilizing official information from the mortality database, vital statistics, and home health characterization. Results: the findings illustrate that the strategy of Comprehensive Primary Health Care has been able to contribute to the improvement of health results an the reduction of mortality disparities among children under 5 years of age within the socially disadvantaged population in the localities with a higher degree of coverage of the strategy, as part of a general tendency in decreasing the child mortality rate in the city.

  • 17. Mosquera Mendez, Paola
    et al.
    Hernández Torres, Jineth
    Pontificia Universidad Javeriana.
    Vega, Roman
    Pontificia Universidad Javeriana.
    Junca, Cesar
    Pontificia Universidad Javeriana.
    Experience of implementing the strategy of primary health care in the locality of Bosa2011In: Revista Gerencia y Políticas de Salud, ISSN 1657-7027, Vol. 10, no 21, p. 124-152Article in journal (Refereed)
    Abstract [en]

    In order to describe the way in which a strategy APS was implemented at Hospital Pablo VI Bosa (HPVI) and to describe predisposing factors and limitations of such an implementation, a qualitative analysis of documentary material, in-depth interviewing with institutional actors and officials and community workshops was performed. From the triangulation of structured information was drafted a narrative synthesis that describes the experience in the area. Among the main findings is an interesting bet management model that views the APS as a central strategy and complements other strategies proposed by the District for the implementation of its public policy emphasizes the strengthening of community dynamics that although, mainly limited to institutional issues, have been significant in terms of sustainability. Favoring and limiting factors identified are diverse, but all related to how to implement public policy and institutional dynamics.

  • 18. Mosquera Mendez, Paola
    et al.
    Reveiz, Ludovic
    National University of Colombia.
    Cattivera, Claudia
    Pacientes online Argentina.
    Guevara, Oscar Alexander
    National University of Colombia.
    The process of incorporating a user perspective to the development of clinical practice guidelines: literature reviewing2011In: Revista Gerencia y Políticas de Salud, ISSN 1657-7027, Vol. 10, no 21, p. 176-195Article in journal (Refereed)
    Abstract [en]

    In order to identify methodologies for effective identification and incorporation of the user considerations and perspective to the development of clinical practice guidelines, a systematic review of the literature was conducted. A total of 729 articles were identified from the initial search of these, 18 met the criteria and were included in the review. The items were valued according to methodological quality and extracted relevant information from them. No methodological items were found that described or evaluated a specific methodology that incorporates considerations of the patients in the development of GPC. The techniques used for these processes were the formal ones such as Delphi, focus groups, stakeholder analysis, surveys, workshops and preference scales. The reported experiences agree on the need to link patients during the stages of prioritization and approval of the recommendations.

  • 19.
    Mosquera Mendéz, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hernandez, Jinneth
    Vega, Roman
    Martinez, Jorge
    Sebastian, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Performance evaluation of the essential dimensions of the primary health care services in six localities of Bogota-Colombia: a cross-sectional study2013In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 13, p. 315-Article in journal (Refereed)
    Abstract [en]

    Background: The high segmentation and fragmentation in the provision of services are some of the main problems of the Colombian health system. In 2004 the district government of Bogota decided to implement a Primary Health Care (PHC) strategy through the Home Health program. PHC was conceived as a model for transforming health care delivery within the network of the first-level public health care facilities. This study aims to evaluate the performance of the essential dimensions of the PHC strategy in six localities geographically distributed throughout Bogota city.

    Methods: The rapid assessment tool to measure PHC performance, validated in Brazil, was applied. The perception of participants (users, professionals, health managers) in public health facilities where the Home Health program was implemented was compared with the perception of participants in private health facilities not implementing the program. A global performance index and specific indices for each primary care dimension were calculated. A multivariate logistic regression analysis was conducted to determine possible associations between the performance of the PHC dimensions and the self-perceived health status of users.

    Results: The global performance index was rated as good for all participants interviewed. In general, with the exception of professionals, the differences in most of the essential dimensions seemed to favor public health care facilities where the Home Health program was implemented. The weakest dimensions were the family focus and community orientation-rated as critical by users; the distribution of financial resources-rated as critical by health managers; and, accessibility-rated as intermediate by users.

    Conclusions: The overall findings suggest that the Home Health program could be improving the performance of the network of the first-level public health care facilities in some PHC essential dimensions, but significant efforts to achieve its objectives and raise its visibility in the community are required.

  • 20.
    Mosquera Méndez, Paola Andrea
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Evaluation of a primary health care strategy implemented in a market-oriented health system: the case of Bogota, Colombia.2014Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Introduction: Despite Colombia having adopted a health system based on an insurance market, Bogota in 2004, as part of a left-wing government (elected for first time in the city), decided to implement a Primary Health Care (PHC) strategy to improve quality of life, level of population health and reduce health inequities. The PHC strategy has been implemented through the HomeHealth program by three consecutive governments over the last eight years in the context of continuous political tension stemming from differences between national and district health policies.

    This thesis is an attempt to provide a better understanding of the overall experience of implementing a PHC strategy in the context of a market-oriented health care system. The research aimed to evaluate results of the PHC strategy through the intervention of the Home Health program and to identify factors that have enabled or limited the on-going PHC implementation process in Bogota.

    Methods: This study used a combination of quantitative and qualitative methods. A descriptive analysis was performed to assess direct results of the PHC strategy in terms of progress in the Home Health program coverage and increases in health personnel ratios reaching out to poor and vulnerable groups in Bogota. A cross sectional analysis was carried out to evaluate qualities of the delivery of PHC services through the attainment of PHC essential dimensions in the network of first-level public health care facilities. An ecological analysis was performed to estimate the contribution of the PHC strategy, through the Home Health program, to improve child health outcomes and to reduce health inequalities. A qualitative multiple case study was conducted to identify contextual factors that have enabled or limited the on-going PHC implementation process in Bogota.

    Results: The descriptive analysis showed a notable initial increase and rapid expansion in the development of the PHC strategy between 2004 and 2007, followed by a period of slower growth and stagnation between 2007 and 2010. The cross-sectional analysis suggested that the Home Health program could be helping to improve the performance of first-level public health care facilities. Ratings assigned to PHC dimensions by different participants pointed out the need to strengthen family focus, community orientation, financial resources distribution, and accessibility. The ecological analysis showed that localities with high PHC coverage had a lower risk of under-five mortality, infant mortality and acute malnutrition as well as a higher probability of being vaccinated than low PHC coverage localities. The belonging to a high-coverage locality was significantly associated with risk reductions of under-five mortality (13.8%) and infant mortality by pneumonia (37.5%) as well as increases in the probability of being vaccinated for DPT (4.9%). Concentration curves and concentration indices indicated inequality reductions in all child indicators betwen 2003 and 2007. In 2007 (period after implementation), the PHC strategy was associated with a reduction in the effect of the inequality that affected disadvantaged localities in under-five mortality (24%), infant mortality rate (19%), acute malnutrition (7%) and DPT vaccination coverage (20%). The main facilitators of the results achieved so far by the PHC strategy were all related to the commitment and good will of actors at different levels. Longterm political commitment, support by local mayors and hospital managers, organized communities historically active in the process of social participation, as well as extramural work carried out by community health workers and health care teams were highly valued. Barriers to the implementation included the structure of the national health system itself, lack of a stable funding source, unsatisfactory working conditions, lack of competencies among health workers regarding family focus and community orientation, and limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation.

    Conclusion: Despite adverse contextual conditions and limitations imposed by the Colombian health system itself, Bogota’s initiative of a PHC strategy has helped to improve the performance of first-level public health care facilities in the essential dimensions of PHC and has also contributed to improvement of child health outcomes and reduction of health inequalities associated with socioeconomic and living conditions. Significant efforts are required to overcome the market approach of the national health system. Structural changes to social policies at the national and district level are needed if the PHC strategy is expected to achieve its full potential. Specific interventions must be designed to have well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.

  • 21.
    Mosquera, Paola A.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Decomposition of gendered income-related inequalities in multiple biological cardiovascular risk factors in a middle-aged population2018In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, article id 102Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Socioeconomic inequalities in cardiovascular disease seem to widen or endure in Sweden. However, research on inequalities in antecedent cardiovascular risk factors (CVRFs), and particularly what underpins them, is scarce. The present study aimed 1) to estimate income-related inequalities in eight biological cardiovascular risk factors in Swedish middle-aged women and men; and 2) to examine the contribution of demographic, socioeconomic, behavioural and psychosocial determinants to the observed inequalities.

    METHODS: Participants (N = 12,481) comprised all 40- and 50-years old women and men who participated in the regional Västerbotten Intervention Programme in Northern Sweden during 2008, 2009 and 2010. All participants completed a questionnaire on behavioural and psychosocial conditions, and underwent measurements with respect to eight CVRFs (body mass index; waist circumference; total cholesterol; high-density lipoprotein cholesterol; low-density lipoprotein cholesterol; triglycerides; systolic/diastolic blood pressure; glucose tolerance). Data on cardiovascular risk, psychosocial and health behaviours were linked to national register data on income and other socioeconomic and demographic factors. To estimate income inequalities in each CVRF concentration indexes were calculated, and to examine the contribution of the underlying determinants to the observed inequalities a Wagstaff-type decomposition analysis was performed separately for women and men.

    RESULTS: Health inequalities ranged from small to substantial with generally greater magnitude in women. The highest inequalities among women were seen in BMI, triglycerides and HDL-cholesterol (Concentration index = - 0.1850; - 0.1683 and - 0.1479 respectively). Among men the largest inequalities were seen in glucose regulation, BMI and abdominal obesity (Concentration index = - 0.1661; - 0.1259 and - 0.1172). The main explanatory factors were, for both women and men socioeconomic conditions (contributions ranging from 54.8 to 76.7% in women and 34.0-72.6% in men) and health behaviours (contributions ranging from 6.9 to 20.5% in women and 9.2 to 26.9% in men). However, the patterns of specific dominant explanatory factors differed between CVRFs and genders.

    CONCLUSION: Taken together, the results suggest that the magnitude of income-related inequalities in CVRFs and their determinants differ importantly between the risk factors and genders, a variation that should be taken into consideration in population interventions aiming to prevent inequalities in manifest cardiovascular disease.

  • 22.
    Mosquera, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Are health inequalities rooted in the past? Income inequalities in metabolic syndrome decomposed by childhood conditions2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no 2, p. 223-233Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Early life is thought of as a foundation for health inequalities in adulthood. However, research directly examining the contribution of childhood circumstances to the integrated phenomenon of adult social inequalities in health is absent. The present study aimed to examine whether, and to what degree, social conditions during childhood explain income inequalities in metabolic syndrome in mid-adulthood.

    METHODS: The sample (N = 12 481) comprised all 40- and 50-year-old participants in the Västerbotten Intervention Program in Northern Sweden 2008, 2009 and 2010. Measures from health examinations were used to operationalize metabolic syndrome, which was linked to register data including socioeconomic conditions at age 40-50 years, as well as childhood conditions at participant age 10-12 years. Income inequality in metabolic syndrome in middle age was estimated by the concentration index and decomposed by childhood and current socioeconomic conditions using decomposition analysis.

    RESULTS: Childhood conditions jointed explained 7% (men) to 10% (women) of health inequalities in middle age. Adding mid-adulthood sociodemographic factors showed a dominant contribution of chiefly current income and educational level in both gender. In women, the addition of current factors slightly attenuated the contribution of childhood conditions, but with paternal income and education still contributing. In contrast, the corresponding addition in men removed all explanation attributable to childhood conditions.

    CONCLUSIONS: Despite that the influence of early life conditions to adult health inequalities was considerably smaller than that of concurrent conditions, the study suggests that early interventions against social inequalities potentially could reduce health inequalities in the adult population for decades to come.

  • 23.
    Mosquera, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Income-related inequalities in cardiovascular disease from mid-life to old age in a Northern Swedish cohort: a decomposition analysis2016In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 149, p. 135-144Article in journal (Refereed)
    Abstract [en]

    While the social determinants of cardiovascular disease (CVD) are fairly well-known, the determinants of socioeconomic inequalities in CVD are scarcely studied and almost completely based on cross-sectional designs in which the changing circumstances across the life course are not taken into account. The present study seeks to incorporate a life course approach to the social determinants of socioeconomic inequalities in CVD. The specific aims were to 1) examine how income-related inequalities in CVD change over two decades of the mid-late life course, and 2) identify the key social determinants of the inequalities at each time period. The cohort (N = 44,039) comprised all individuals aged 40-60 years in 1990 who during 1990-2010 were enrolled in the county-wide preventive effort :"Västerbotten Intervention Program" (VIP). The cohort was followed over these two decades by Swedish population register data linked within the Umeå SIMSAM Lab micro data infrastructure. First-time hospitalization for CVD and mean earned income were used to calculate the concentration index (C) during four periods of 5-6 years. The C for each period was decomposed by sociodemographic factors, using Wagstaff-type decomposition analysis. Results suggest that inequalities in CVD increase gradually from mid-life to old age; from initially non-significant to particularly marked among the elderly. The decomposition showed that, from middle to old age, educational and employment inequalities underwent a transition from initially dominant to a moderate role in explaining the health inequalities, coupled with an increasing importance of age and a stable role of income. In conclusion, the study illustrates the need for incorporating a dynamic life course perspective into research, policy and practice concerned with equity in health.

  • 24.
    Mosquera, Paola A
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Goicolea, Isabel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Equitable health services for the young?: A decomposition of income-related inequalities in young adults' utilization of health care in Northern Sweden2017In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 16, article id 20Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite the goal of the Swedish health system to offer health care according to the principle of horizontal equity, little is known about the equality in access to health care use among young people. To explore this issue, the present study aimed i) to assess horizontal inequity in health care utilization among young people in Northern Sweden; and ii) to explore the contribution of different factors to explain the observed inequalities.

    METHODS: Participants (N = 3016 youths aged 16-25 years) came from the "Health on Equal terms" survey conducted in 2014 in the four northernmost counties in Sweden. Concentration indices (C) and horizontal inequity indices (HI) were calculated to measure inequalities in the utilization of two health care services (general practitioners (GP) and youth clinics). The HI was calculated based on health care utilization and variables representing socioeconomic status (household income), health care needs factors and non-need factors affecting health care use. A decomposition analysis was carried out to explain the income-related inequalities.

    RESULTS: Results showed a significant positive income-related inequality for youth clinic utilization in women (C = 0.166) and total sample (C = 0.097), indicating that services were concentrated among the better-off. In contrast, general practitioner visits showed inequality pointing toward a higher utilization among less affluent individuals; significant in women (C = -0.079), men (C = -0.101) and pooled sample (C = -0.097). After taking health care needs into consideration, the utilization of youth clinics remained significantly pro-rich in women (HI = 0.121) and total sample (HI = 0.099); and consistently pro-poor for the GP visits in the pooled sample (HI = -0.058). The decomposition analyses suggest that socioeconomic inequalities explain a considerable portion of the pro-rich utilization of youth clinics services among young women. The corresponding analyses for GP visits showed that need factors and socioeconomic conditions accounted for the pro-poor concentration of GP visits.

    CONCLUSION: The distribution of GP visits among young people in Northern Sweden slightly favored the low-income group, and thus seems to meet the premises of horizontal equity. In contrast, the findings suggest substantial pro-rich horizontal inequity in the utilization of youth clinics among young women, which are largely rooted in socioeconomic inequalities.

  • 25.
    Ramadani, Royasia Viki
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastián, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The moderating effect of income on the relationship between body mass index and health-related quality of life in Northern Sweden2018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: This study aimed to investigate the relationship between body mass index (BMI) and health-related quality of life (HRQoL) and whether this relationship is influenced by the level of income in Northern Sweden. Overweight and obesity are rising major public health problems which also affect HRQoL. While socioeconomic inequalities in health are persisting or increasing in many countries, including Sweden, little attention has been paid to the more complex roles of income in relation to health.

    METHODS: Data were drawn from a 2014 cross-sectional survey from Northern Sweden (Health on Equal Terms), comprising individuals aged 20-84 years ( N = 20,082 individuals included for analysis). BMI and HRQoL were self-reported and individual disposable income in 2012 was retrieved from population registers. Multiple linear regressions were performed with HRQoL scores regressed on BMI and income, their interaction and additional covariates.

    RESULTS: The underweight, overweight and obesity groups reported significantly lower HRQoL compared to the normal weight group. Moreover, the relationship between BMI and HRQoL varied significantly by level of income, with a stronger association among those with the lowest level of income.

    CONCLUSIONS: Income has a role as an effect modifier in the relationship between BMI and HRQoL that can be construed as an indirect income inequality. Efforts to promote HRQoL in populations should consider the different impact of being overweight and obese in different socioeconomic groups.

  • 26.
    Reveiz, Ludovic
    et al.
    National University of Colombia.
    Guerrero-Lozano, Rafael
    National University of Colombia.
    Camacho, Angela
    National University of Colombia.
    Yara, Lina
    National University of Colombia.
    Mosquera Méndez, Paola Andrea
    Stress ulcer, gastritis, and gastrointestinal bleeding prophylaxis in critically ill pediatric patients: a systematic review2010In: Pediatric Critical Care Medicine, ISSN 1529-7535, E-ISSN 1947-3893, Vol. 11, no 1, p. 124-132Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To identify and evaluate the quality of evidence supporting prophylactic use of treatments for stress ulcers and upper gastrointestinal bleeding. Stress ulcers, erosions of the stomach and duodenum, and upper gastrointestinal bleeding are well-known complications of critical illness in children admitted to the pediatric intensive care unit.

    DATA SOURCES: Studies were identified from the Cochrane Central Register of Controlled Trials, PUBMED; LILACS; Scirus. We also scanned bibliographies of relevant studies.

    STUDY SELECTION: This systematic review of randomized controlled trials assessed the effects of drugs for stress-related ulcers, gastritis, and upper gastrointestinal bleeding in critically ill children admitted to the pediatric intensive care unit.

    DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted the relevant data. Most randomized controlled trials were judged as having unclear risk of bias. When pooling two randomized controlled trials, treatment was significantly more effective in preventing upper gastrointestinal bleeding (macroscopic or important bleeding) compared with no treatment (two studies = 300 participants; relative risk, 0.41; 95% confidence interval, 0.19-0.91; I = 12%). Meta-analysis of two studies found no significant difference in death rates among groups (two randomized controlled trials = 132 participants; relative risk, 1.39; 95% confidence interval, 0.70-2.79; I = 4%). The rate of pneumonia was not significantly different when comparing treatment and no treatment in one study. When comparing ranitidine with no treatment, significant differences were found in the proportion of mechanically ventilated children with normal gastric mucosal endoscopic findings by histologic specimens (one randomized controlled trial = 48 participants; relative risk, 3.53; 95% confidence interval, 1.34-9.29). No significant differences were found when comparing different drugs (omeprazole, ranitidine, sucralfate, famotidine, amalgate), doses, or regimens for main outcomes (deaths, endoscopic findings of erosion or ulcers, upper gastrointestinal bleeding, or pneumonia).

    CONCLUSIONS: Although pooled data of two studies suggested that critically ill pediatric patients may benefit from receiving prophylactic treatment to prevent upper gastrointestinal bleeding, we found that high-quality evidence to guide clinical practice is still limited.

  • 27.
    Reveiz, Ludovic
    et al.
    National University of Colombia.
    Tellez, Diana R
    National University of Colombia.
    Castillo, Juan S
    National University of Colombia.
    Mosquera Mendez, Paola
    Torres, Marcela
    National University of Colombia.
    Cuervo, Luis G
    World Health Organization.
    Cardona, Andres F
    National University of Colombia.
    Pardo, Rodrigo
    National University of Colombia.
    Prioritization strategies in clinical practice guidelines development: a pilot study2010In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 8, article id 7Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Few methodological studies address the prioritization of clinical topics for the development of Clinical Practice Guidelines (CPGs). The aim of this study was to validate a methodology for Priority Determination of Topics (PDT) of CPGs.

    METHODS AND RESULTS: Firstly, we developed an instrument for PDT with 41 criteria that were grouped under 10 domains, based on a comprehensive systematic search. Secondly, we performed a survey of stakeholders involved in CPGs development, and end users of guidelines, using the instrument. Thirdly, a pilot testing of the PDT procedure was performed in order to choose 10 guideline topics among 34 proposed projects; using a multi-criteria analysis approach, we validated a mechanism that followed five stages: determination of the composition of groups, item/domain scoring, weights determination, quality of the information used to support judgments, and finally, topic selection. Participants first scored the importance of each domain, after which four different weighting procedures were calculated (including the survey results). The process of weighting was determined by correlating the data between them. We also reported the quality of evidence used for PDT. Finally, we provided a qualitative analysis of the process. The main domains used to support judgement, having higher quality scores and weightings, were feasibility, disease burden, implementation and information needs. Other important domains such as user preferences, adverse events, potential for health promotion, social effects, and economic impact had lower relevance for clinicians. Criteria for prioritization were mainly judged through professional experience, while good quality information was only used in 15% of cases.

    CONCLUSION: The main advantages of the proposed methodology are supported by the use of a systematic approach to identify, score and weight guideline topics selection, limiting or exposing the influence of personal biases. However, the methodology was complex and included a number of quantitative and qualitative approaches reflecting the difficulties of the prioritization process.

  • 28. Saidi, Olfa
    et al.
    Zoghlami, Nada
    Bennett, Kathleen E
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Malouche, Dhafer
    Capewell, Simon
    Romdhane, Habiba Ben
    O'Flaherty, Martin
    Explaining income-related inequalities in cardiovascular risk factors in Tunisian adults during the last decade: comparison of sensitivity analysis of logistic regression and Wagstaff decomposition analysis2019In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 18, article id 177Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: It is important to quantify inequality, explain the contribution of underlying social determinants and to provide evidence to guide health policy. The aim of the study is to explain the income-related inequalities in cardiovascular risk factors in the last decade among Tunisian adults aged between 35 and 70 years old.

    METHODS: We performed the analysis by applying two approaches and compared the results provided by the two methods. The methods were global sensitivity analysis (GSA) using logistic regression models and the Wagstaff decomposition analysis.

    RESULTS: Results provided by the two methods found a higher risk of cardiovascular diseases and diabetes in those with high socio-economic status in 2005. Similar results were observed in 2016. In 2016, the GSA showed that education level occupied the first place on the explanatory list of factors explaining 36.1% of the adult social inequality in high cardiovascular risk, followed by the area of residence (26.2%) and income (15.1%). Based on the Wagstaff decomposition analysis, the area of residence occupied the first place and explained 40.3% followed by income and education level explaining 19.2 and 14.0% respectively. Thus, both methods found similar factors explaining inequalities (income, educational level and regional conditions) but with different rankings of importance.

    CONCLUSIONS: The present study showed substantial income-related inequalities in cardiovascular risk factors and diabetes in Tunisia and provided explanations for this. Results based on two different methods similarly showed that structural disparities on income, educational level and regional conditions should be addressed in order to reduce inequalities.

  • 29.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Mosquera, Paola A.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Do cardiovascular disease prevention programs in northern Sweden impact on population health?: An interrupted time series analysis2019In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 202Article in journal (Refereed)
    Abstract [en]

    Background: Cardiovascular disease (CVD) is the main cause of morbidity and mortality in Sweden. This study aims to assess the impact of a CVD intervention implemented in 1993 in northern Sweden on the reduction of premature ischemic heart disease (IHD) morbidity and mortality in women and men during the period 1987-2013.

    Methods: An ecological controlled interrupted time series design, with pre-intervention period defined as 1987-1993 and post-intervention period 1994-2013 was carried out. For each year, IHD events, stratified by sex, were retrieved from national registers.

    Results: Impressive reductions on IHD premature morbidity and mortality were observed to a similar degree in both the intervention county and the other comparison counties across the last 27years. Significant differences in the pre-post intervention trends indicating the intervention group had smaller reductions than expected from its pre-intervention trend and the trend of control counties were found among men for both IHD morbidity and mortality. A similar pattern was observed among women but without significant differences.

    Conclusions: Taken together, the data do not support that the intervention has contributed to an additional reduction on IHD morbidity and mortality, above and beyond that which is already seen in neighbouring counties without similar programs.

  • 30.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mine, yours or ours?: Income inequality and mental health in Northern Sweden2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no suppl_3, p. 40-41Article in journal (Other academic)
    Abstract [en]

    Background: The relationship between income and population health has received considerable attention in the last decades. Three main explanations of the relationship have been identified: the absolute, the contextual, and the relative income effects hypotheses. The evidence about their relevance, particularly in egalitarian societies like the Scandinavian one, is however inconsistent. The present study aimed to test the three hypotheses in relation to psychological distress in northern Sweden.

    Methods: Data come from the 2014 cross sectional survey “Health on equal terms”, from the four northern-most counties in Sweden, and included people 25-84 years (n = 21,004). Psychological distress was measured by the General Health Questionnaire-12 and information on disposable income came from population registers. Absolute income was operationalized by individual disposable income, contextual income as the municipal-level Gini coefficient and relative income by the Yitzaki index. The research questions were tested by log-binomial regression analysis.

    Results: First, a strong individual income gradient in mental ill health was observed, with the very poor more likely to report poor health (PR = 1.56; 95% CI = 1.19, 2.04) compared to the highest income quintile. Second, municipalities in the quintiles 2-4 of the Gini coefficient had a better mental health than those municipalities in the extremes of the distribution. Third, a clear statistically significant gradient in the association of relative deprivation and ill mental health was also found (PR = 1.37 95% CI = 1.06, 1.76).

    Conclusions: This study suggests a strong, moderate and lack of support for the absolute, relative and contextual income effect hypotheses, respectively. Interventions targeting a reduction in the individual income gap are probably necessary in order to reduce psychosocial distress differences in this population of northern Sweden.

    Key messages:

    • A strong, moderate and lack of support for the absolute, relative and contextual income effect hypotheses, respectively was found in northern Sweden.
    • A reduction in the individual income gap is probably necessary in order to decrease the psychosocial distress differences observed.
  • 31.
    San Sebastian, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Whose income is more important: mine, yours or ours? Income inequality and mental health in northern Sweden2018In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 28, no 6, p. 1056-1061Article in journal (Refereed)
    Abstract [en]

    Background: Three main explanations of the relationship between income and population health have been identified: the absolute, the contextual and the relative income hypotheses. The evidence about their relevance particularly in egalitarian societies is, however, inconsistent. This study aimed to test the three hypotheses in relation to psychological distress in northern Sweden.

    Methods: Data come from the 2014 cross-sectional survey from the four northern-most counties in Sweden, and included people aged 25-84 years (n = 21 004). Psychological distress was measured by the General Health Questionnaire-12 and income information came from population registers. Absolute income was operationalized by individual disposable income, contextual income as the municipal-level Gini coefficient and relative income by the Yitzhaki index. Prevalence ratios (PR) were calculated from log-binomial regression analyses.

    Results: A gradient in poor mental health was observed across quintiles of individual income, with the poorest substantially more likely to report poor health compared with the highest quintile (PR = 1.56; 95% CI = 1.19, 2.04). Second, municipalities in the quintiles 2-3 of the Gini coefficient had a better mental health compared with those in the most equal municipalities. Third, a gradient in poor mental health across quintiles of relative deprivation was also found, with the most deprived quintile the most likely to report poor health (PR = 1.37; 95% CI = 1.06, 1.76).

    Conclusion: This study suggests a strong, moderate and lack of support for the absolute, relative and contextual income effect hypotheses, respectively. Interventions targeting a reduction in the individual income gap may be necessary in order to reduce psychosocial distress differences in northern Sweden.

  • 32.
    San Sebastián, Miguel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Nursing I, University of Basque Country, Bilbao, Spain.
    Mosquera, Paola A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health care on equal terms?: assessing horizontal equity in health care use in northern Sweden2017In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 27, no 4, p. 637-643Article in journal (Refereed)
    Abstract [en]

    Background: The Swedish health care system has successively moved toward increased market-orientation, which has raised concerns as to whether Sweden still offers health on equal terms. To explore this issue, this study aimed (i) to assess if the principles of horizontal equity (equal access for equal need regardless of socio-economic factors) are met in Northern Sweden 2006-14; and (ii) to explore the contribution of different factors to the inequalities in access along the same period. Data came from cross sectional surveys known in 2006, 2010 and 2014 targeting 16-84-year-old residents in the four northern-most counties in Sweden. The horizontal inequity index was calculated based on variables representing (i) the individual socioeconomic status, (ii) the health care needs, (iii) non-need factors as well as (iv) health care utilization: general practitioner (GP), specialist doctors, hospitalization. Decomposition analysis of the concentration index for need-standardized health care utilization was applied. Adjusting for needs, there was a higher use of GP services by rich people during the two last surveys, a roughly equal use of specialists, and hospitalization concentrated among the poor but with a clear time trend toward equality. The pro-rich inequalities in GP use were to a large part explained by the income gap. While health care utilization can be considered equitable regarding specialist and hospital use, the increasing pro-rich trend in the use of GP is a concern. Further studies are required to investigate the reasons and a constant monitoring of socioeconomic differences in health care access is recommended.

  • 33.
    Szilcz, Máté
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mosquera, Paola A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sebastián, Miguel San
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Time trends in absolute and relative socioeconomic inequalities in leisure time physical inactivity in northern Sweden2018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 46, no 1, p. 112-123Article in journal (Refereed)
    Abstract [en]

    AIMS: The aim was to investigate the time trends in educational, occupational, and income-related inequalities in leisure time physical inactivity in 2006, 2010, and 2014 in northern Swedish women and men.

    METHODS: This study was based on data obtained from the repeated cross-sectional Health on Equal Terms survey of 2006, 2010, and 2014. The analytical sample consisted of 20,667 (2006), 31,787 (2010), and 21,613 (2014) individuals, aged 16-84. Logistic regressions were used to model the probability of physical inactivity given a set of explanatory variables. Slope index of inequality (SII) and relative index of inequality (RII) were used as summary measures of the social gradient in physical inactivity. The linear trend in inequalities and difference between gender and years were estimated by interaction analyses.

    RESULTS: The year 2010 displayed the highest physical inactivity inequalities for all socioeconomic position indicators, but educational and occupational inequalities decreased in 2014. However, significant positive linear trends were found in absolute and relative income inequalities. Moreover, women had significantly higher RII of education in physical inactivity in 2014 and significantly higher SII and RII of income in physical inactivity in 2010, than did men in the same years.

    CONCLUSIONS: The recent reduction in educational and occupational inequalities following the high inequalities around the time of the great recession in 2010 suggests that the current policies might be fairly effective. However, to eventually alleviate inequities in physical inactivity, the focus of the researchers and policymakers should be directed toward the widening trends of income inequalities in physical inactivity.

  • 34.
    Szilcz, Máté
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Income inequalities in leisure time physical inactivity in northern Sweden: a decomposition analysis2019In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905Article in journal (Refereed)
    Abstract [en]

    AIMS: Increasing income inequalities in leisure time physical inactivity have been reported in the relatively socially equal setting of northern Sweden. The present report seeks to contribute to the literature by exploring the contribution of different factors to the income inequalities in leisure time physical inactivity in northern Sweden.

    METHODS: This study was based on the 2014 Health on Equal Terms survey, distributed in the four northernmost counties of Sweden. The analytical sample consisted of 21,000 respondents aged 16-84. Six thematic groups of explanatory variables were used: demographic variables, socioeconomic factors, material resources, family-, psychosocial conditions and functional limitations. Income inequalities in leisure time physical inactivity were decomposed by Wagstaff-type decomposition analysis.

    RESULTS: Income inequalities in leisure time physical inactivity were found to be explained to a considerable degree by health-related limitations and unfavourable socioeconomic conditions. Material and psychosocial conditions seemed to be of moderate importance, whereas family and demographic characteristics were of minor importance.

    CONCLUSIONS: This study suggests that in order to achieve an economically equal leisure time physical inactivity, policy may need to target the two main barriers of functional limitations and socioeconomic disadvantages.

  • 35.
    Vega, Roman
    et al.
    Pontificia Universidad Javeriana.
    Acosta Ramirez, Naydu
    Pontificia Universidad Javeriana.
    Mosquera Mendez, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Restrepo Velez, Ofelia
    Pontificia Universidad Javeriana.
    Health Policy in Bogota (2004-2008):An Analysis of the Experience with Primary Health Care2008In: Social Medicine, ISSN 1557-7112, Vol. 3, no 2Article in journal (Refereed)
    Abstract [en]

    This study summarizes the health policy and the Primary Health Care strategies developed by the Bogota municipal government from 2004-2008. The experiences and outcomes during this time period indicate that, despite the market-oriented health policy that exists in Colombia, it was beneficial to implement health policies and strategies at the local level so as to guarantee the right to health and equitable access to health care. National level restrictions, however, impose constraints on the potential implementation of such policies and strategies. This suggests that in order to achieve effective and sustainable changes at the local level, it is necessary to promote substantial reforms within national health care policy.

  • 36.
    Vega, Roman
    et al.
    Pontificia Universidad Javeriana.
    Hernández Torres, Jinneth
    Pontificia Universidad Javeriana.
    Mosquera Mendez, Paola
    Pontificia Universidad Javeriana – Bogotá, Colombia.
    An explanation from context and content of health policies to a hybrid and segmented primary health care model in Bogotá2012In: Saúde em Debate, ISSN 0103-1104, Vol. 36, no 94, p. 392-401Article in journal (Refereed)
    Abstract [en]

    This study has answered the issue on how the context and content of Colombian health policies have influenced the primary health care model that was implemented in Bogotá, from 2004 to 2010, despite another primary care in integral health has already been created. Thus, a qualitative and documental analysis was carried out, which indicated that despite having formulated a CPHC conception, a hybrid and segmented approach emerged during the implementation. This approach is due to a segmented and fragmented health system driven by a market of insurance and health services and by a social policy based on social risk social management, which, together, impose structural limitations to the initial comprehensive formulation of the primary health care.

  • 37.
    Waenerlund, Anna-Karin
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mosquera, Paola
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Per E
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Trends in educational and income inequalities in cardiovascular morbidity in middle age in Northern Sweden 1993–20102018In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, article id 1403494818790406Article in journal (Refereed)
    Abstract [en]

    AIMS: Research is scarce regarding studies on income and educational inequality trends in cardiovascular disease in Sweden. The aim of this study was to assess trends in educational and income inequalities in first hospitalizations due to cardiovascular disease (CVD) from 1993 to 2010 among middle-aged women and men in Northern Sweden.

    METHODS: The study comprised repeated cross-sectional register data from year 1993-2010 of all individuals aged 38-62 years enrolled in the Västerbotten Intervention Programme (VIP). Data included highest educational level, total earned income and first-time hospitalization for CVD from national registers. The relative and slope indices of inequality (RII and SII, respectively) were used to estimate educational and income inequalities in CVD for six subsamples for women and men, and interaction analyses were used to estimate trends across time periods.

    RESULTS: Educational RII and SII were stable in women, while they decreased in men. Income inequalities in CVD developed differently compared with educational inequalities, with RII and SII for both men and women increasing during the study period, the most marked for RII in women rising from 1.52 in the 1990s to 2.62 in the late 2000s.

    CONCLUSIONS: The trend of widening income inequalities over 18 years in the middle-aged in Northern Sweden, in the face of stable or even decreasing educational inequalities, is worrisome from a public health perspective, especially as Swedish authorities monitor socioeconomical inequalities exclusively by education. The results show that certain social inequalities in CVD rise and persist even within a traditionally egalitarian welfare regime.

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