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Global road mortality is a leading cause of death in many low-income and middle-income countries. Data to support priority setting under current resource constraints are urgently needed to achieve Sustainable Development Goal (SDG) 3.6. This Series paper estimates the potential number of lives saved if each country implemented interventions to address risk factors for road injuries. We did a systematic review of all available evidence-based, preventive interventions for mortality reduction that targeted the four main risk factors for road injuries (ie, speeding, drink driving, helmet use, and use of seatbelt or child restraint). We used literature review variables and considered three key country-level variables (gross domestic product per capita, population density, and government effectiveness) to generate country-specific estimates on the potential annual attributable number of lives that would be saved by interventions focusing on these four risk factors in 185 countries. Our results suggest that the implementation of evidence-based road safety interventions that target the four main road safety risk factors could prevent between 25% and 40% of all fatal road injuries worldwide. Interventions addressing speed could save about 347 258 lives globally per year, and at least 16 304 lives would be saved through drink driving interventions. The implementation of seatbelt interventions could save about 121 083 lives, and 51 698 lives could be saved by helmet interventions. We identify country-specific estimates of the potential number of lives saved that would be attributable to these interventions. Our results show the potential effectiveness of the implementation and scaling of these interventions. This paper presents key evidence for priority setting on road safety interventions and shows a path for reaching SDG 3.6.

Evidence-based interventions recommended in the Framework Convention on Tobacco Control of the World Health Organization (WHO FCTC) are subject to implementation factors that might affect their actual effectiveness. The Colombian law enacting key commitments from WHO’s FCTC was signed in 2009. This study aims at evaluating the potential impact of the enactment and implementation of these WHO FCTC on four outcomes for tobacco consumption (last-year cigarette smoking prevalence, prevalence of heavy smokers, prevalence of lower-intensity smokers and monthly smoking incidence). We used data from the National Psychoactive Substances Consumption Survey (NPSCS) in 2008 (n = 29 164) and 2013 (n = 32 605), and assessed changes in these four outcomes WHO FCTC using propensity score matching (PSM). Propensity scores were obtained using key socio-demographic variables and by matching through a ‘Kernel’ estimation. Matching quality tests were performed. The common support for both survey samples was 60 793. Sub-analyses were conducted using a governance index to assess the effect of heterogeneous governance levels, proxying implementation, over the country. We found that cigarette year-prevalence and cigarette month-incidence decreased after matching around 8 and 1.2 percentage points between 2008 and 2013, respectively. Consumption might have shifted, at least partially, from heavy smoking towards lower-intensity smoking. Departments with a higher governance index showed larger reductions of tobacco use, possibly associated to a stronger WHO FCTC implementation. This study highlights the impact that the WHO FCTC had on tobacco consumption in a middle-income country and shows the importance of governance strength as a mediating mechanism for WHO FCTC impact. These results advance current knowledge on the effectiveness of WHO FCTC and shed light on the relevance of governance as a key factor in the WHO FCTC implementation.

BackgroundThe use of communication interventions to promote vaccination has been more frequent in this century. These types of interventions have proven to be effective in reaching the majority of the population. Knowing the characteristics and results of communication interventions to foster vaccine uptake is important, especially with the outbreak of new infectious diseases such as the novel coronavirus (SARS CoV-2). This protocol will guide the development of a systematic review of the literature aiming to identify and analyze the evidence of communication interventions to incentivize vaccine uptake among populations living in low and middle-income countries (LMICs).MethodsThis systematic review protocol is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P). The searches for the systematic review will be carried out through five electronic databases PubMed, Scopus, Web of Science, Redalyc and PyscInfo. Two individuals will review each paper individually and in parallel using the software Rayyan. Duplicate elimination, title and abstract screening, and full text screening will be performed by the two reviewers. A matrix constructed in Excel will be used to extract data and to review the quality of the studies Quality assessment will be conducted using the QATSDD Critical Appraisal Tool.DiscussionThe results of this systematic review will contribute to the public health literature in the area of behavior change communication in general, and vaccination communication in particular. Findings from this study would also inform the development of communication interventions to improve vaccination uptake in LMICs.Systematic review registrationPROSPERO CRD42022355541

Latin American and Caribbean countries will face significant increases in future health expenditures. A variety of factors are responsible - population growth and aging, the epidemiological transition to noncommunicable diseases (NCDs), and economic growth and technology, among others. Increasing health expenditures are particularly concerning to countries in Latin America and the Caribbean (LAC) given growing levels of debt, insufficient fiscal revenues, and high out-of-pocket payments. The projected average annual per capita CHE growth rate from 2018-2050 is slightly higher in Latin American countries (3.2%) than in the Caribbean (2.4%). The share of health expenditure in GDP is projected to increase to 2030 in all LAC countries except for Guyana. The effect of demographics and epidemiology on health spending growth are more modest. Among strategies to control NCD risk factors, a focus on hypertension control generally had the strongest effect on restraining CHE growth except in countries where smoking is particularly prevalent. The main driver of health expenditure growth is economic growth and technology, demonstrating the importance of adopting policies such as explicit prioritization systems and benefit plans that establish common rules for payers and providers that encourage cost-effective decisions. The underlying model for making projections and analyzing alternative scenarios is publicly available.

Public health surveys deployed through automated mobile phone calls raise a set of ethical challenges, including succinctly communicating information necessary to obtain respondent informed consent. This study aimed to capture the perspectives of key stakeholders, both experts and community members, on consent processes and preferences for participation in automated mobile phone surveys (MPS) of non-communicable disease risk factors in Colombia. We conducted semi-structured interviews with ethics and digital health experts and focus group discussions with community representatives. There was meaningful disagreement within both groups regarding the necessity of consent, when the purpose of a survey is to contribute to the formulation of public policies. Respondents who favored consent emphasized that consent communications ought to promote understanding and voluntariness, and implicitly suggested that information disclosure conform to a reasonable person standard. Given the automated and unsolicited nature of the phone calls and concerns regarding fraud, trust building was emphasized as important, especially for national MPS deployment. Community sensitization campaigns that provide relevant contextual information (such as the name of the administering institution) were thought to support trust-building. Additional ways to achieve the goals of consent while building trust in automated MPS for disease surveillance should be evaluated in order to inform ethical and effective practice.

In Bogotá, Colombia, motorcyclists represent a concern as the proportion of motorcycle users between 2013 and 2018 has increased from 18% to 35%. Despite available risk reduction strategies, the fatality rates are also growing, notably in young adults (15-29 years old). This study aims at identifying correct helmet use patterns and its relationship with official records of injuries and casualties in the city over time.Between 2015 and 2018, semiannual observational studies of motorcycle users in six randomly selected sites in Bogotá were conducted. Data was collected and analyzed on the number of occupants per vehicle (driver and passengers), gender, approximate age, type of helmet, and whether it was correctly used (strapped) or not. Bivariate and multivariate analyses were performed to identify the determinants of correct helmet use. Additionally, a spatial analysis was conducted to estimate the relationship between motorcycle's casualties and correct use of the helmet (full-face helmet use) prevalence.A total of 77,932 motorcycles were observed, showing a high prevalence of helmet use (99% for drivers and passengers), but only 88% use it correctly (89% drivers and 82% passengers). The presence of enforcement (camera or police personnel) increases the correct use of the helmet, especially in principal roads. Female, adults, and single riders are more likely to correctly wear the helmet. Finally, there is a relationship between the concentration of the fatalities and the incorrect helmet use in 80% of the observational sites.Incorrect helmet use has been found by the study to be related to higher mortality among motorcycle occupants in Bogotá. Our data shows that enforcement increases correct helmet use with the potential to reduce deaths among motorcycle occupants.

Introduction Automated mobile phone surveys (MPS) can be used to collect public health data of various types to inform health policy and programs globally. One challenge in administering MPS is identification of an appropriate and effective participant consent process. This study investigated the impact of different survey consent approaches on participant disposition (response characteristics and understanding of the purpose of the survey) within the context of an MPS that measured noncommunicable disease (NCD) risk factors across Colombia and Uganda. Methods Participants were randomized to one of five consent approaches, with consent modules varying by the consent disclosure and mode of authorization. The control arm consisted of a standard consent disclosure and a combined opt-in/opt-out mode of authorization. The other four arms consist of a modified consent disclosure and one of four different forms of authorization (i.e., opt-in, opt-out, combined opt-in/opt-out, or implied). Data related to respondent disposition and respondent understanding of the survey purpose were analyzed. Results Among 1889 completed surveys in Colombia, differences in contact, response, refusal, and cooperation rates by study arms were found. About 68% of respondents correctly identified the survey purpose, with no significant difference by study arm. Participants reporting higher levels of education and urban residency were more likely to identify the purpose correctly. Participants were also more likely to accurately identify the survey purpose after completing several survey modules, compared to immediately following the consent disclosure (78.8% vs 54.2% correct, p Conclusion This study contributes to the limited available evidence regarding consent procedures for automated MPS. Future studies should develop and trial additional interventions to enhance consent for automated public health surveys, and measure other dimensions of participant engagement and understanding.

Background The C-Score, which is an individual health score, is based on a predictive model validated in the UK and US populations. It was designed to serve as an individualized point-in-time health assessment tool that could be integrated into clinical counseling or consumer-facing digital health tools to encourage lifestyle modifications that reduce the risk of premature death. Objective Our study aimed to conduct an external validation of the C-Score in the US population and expand the original score to improve its predictive capabilities in the US population. The C-Score is intended for mobile health apps on wearable devices. Methods We conducted a literature review to identify relevant variables that were missing in the original C-Score. Subsequently, we used data from the 2005 to 2014 US National Health and Nutrition Examination Survey (NHANES; N=21,015) to test the capacity of the model to predict all-cause mortality. We used NHANES III data from 1988 to 1994 (N=1440) to conduct an external validation of the test. Only participants with complete data were included in this study. Discrimination and calibration tests were conducted to assess the operational characteristics of the adapted C-Score from receiver operating curves and a design-based goodness-of-fit test. Results Higher C-Scores were associated with reduced odds of all-cause mortality (odds ratio 0.96, P0.72. A sensitivity analysis using NHANES III data (1988-1994) was performed, yielding similar results. The inclusion of sociodemographic and clinical variables in the basic C-Score increased the AUCs from 0.72 (95% CI 0.71-0.73) to 0.87 (95% CI 0.85-0.88). Conclusions Our study shows that this digital biomarker, the C-Score, has good capabilities to predict all-cause mortality in the general US population. An expanded health score can predict 87% of the mortality in the US population. This model can be used as an instrument to assess individual mortality risk and as a counseling tool to motivate behavior changes and lifestyle modifications.

BACKGROUND The C-Score, which is an individual health score, is based on a predictive model validated in the UK and US populations. It was designed to serve as an individualized point-in-time health assessment tool that could be integrated into clinical counseling or consumer-facing digital health tools to encourage lifestyle modifications that reduce the risk of premature death. OBJECTIVE Our study aimed to conduct an external validation of the C-Score in the US population and expand the original score to improve its predictive capabilities in the US population. The C-Score is intended for mobile health apps on wearable devices. METHODS We conducted a literature review to identify relevant variables that were missing in the original C-Score. Subsequently, we used data from the 2005 to 2014 US National Health and Nutrition Examination Survey (NHANES; N=21,015) to test the capacity of the model to predict all-cause mortality. We used NHANES III data from 1988 to 1994 (N=1440) to conduct an external validation of the test. Only participants with complete data were included in this study. Discrimination and calibration tests were conducted to assess the operational characteristics of the adapted C-Score from receiver operating curves and a design-based goodness-of-fit test. RESULTS Higher C-Scores were associated with reduced odds of all-cause mortality (odds ratio 0.96, P0.72. A sensitivity analysis using NHANES III data (1988-1994) was performed, yielding similar results. The inclusion of sociodemographic and clinical variables in the basic C-Score increased the AUCs from 0.72 (95% CI 0.71-0.73) to 0.87 (95% CI 0.85-0.88). CONCLUSIONS Our study shows that this digital biomarker, the C-Score, has good capabilities to predict all-cause mortality in the general US population. An expanded health score can predict 87% of the mortality in the US population. This model can be used as an instrument to assess individual mortality risk and as a counseling tool to motivate behavior changes and lifestyle modifications.

Background This is the first study to examine the costs of conducting a mobile phone survey (MPS) through interactive voice response (IVR) to collect information on risk factors for noncommunicable diseases (NCD) in three low- and middle-income countries (LMIC); Bangladesh, Colombia, and Uganda. Methods This is a micro-costing study conducted from the perspective of the payer/funder with a 1-year horizon. The study evaluates the fixed costs and variable costs of implementing one nationally representative MPS for NCD risk factors of the adult population. In this costing study, we estimated the sample size of calls required to achieve a population-representative survey and associated incentives. Cost inputs were obtained from direct economic costs incurred by a central study team, from country-specific collaborators, and from platform developers who participated in the deployment of these MPS during 2017. Costs were reported in US dollars (USD). A sensitivity analysis was conducted assessing different scenarios of pricing and incentive strategies. Also, costs were calculated for a survey deployed targeting only adults younger than 45 years. Results We estimated the fixed costs ranging between $47,000 USD and $74,000 USD. Variable costs were found to be between $32,000 USD and $129,000 USD per nationally representative survey. The main cost driver was the number of calls required to meet the sample size, and its variability largely depends on the extent of mobile phone coverage and access in the country. Therefore, a larger number of calls were estimated to survey specific harder-to-reach sub-populations. Conclusion Mobile phone surveys have the potential to be a relatively less expensive and timely method of collecting survey information than face-to-face surveys, allowing decision-makers to deploy survey-based monitoring or evaluation programs more frequently than it would be possible having only face-to-face contact. The main driver of variable costs is survey time, and most of the variability across countries is attributable to the sampling differences associated to reaching out to population subgroups with low mobile phone ownership or access.

BackgroundIn the context of the COVID-19 pandemic, public health teams have struggled to conduct monitoring for confirmed or suspicious COVID-19 patients. However, monitoring these patients is critical to improving the chances of survival, and therefore, a prioritization strategy for these patients is warranted. This study developed a monitoring algorithm for COVID-19 patients for the Colombian Ministry of Health and Social Protection (MOH).MethodsThis work included 1) a literature review, 2) consultations with MOH and National Institute of Health officials, and 3) data analysis of all positive COVID-19 cases and their outcomes. We used clinical and socioeconomic variables to develop a set of risk categories to identify severe cases of COVID-19.ResultsThis tool provided four different risk categories for COVID-19 patients. As soon as the time of diagnosis, this tool can identify 91% of all severe and fatal COVID-19 cases within the first two risk categories.ConclusionThis tool is a low-cost strategy to prioritize patients at higher risk of experiencing severe COVID-19. This tool was developed so public health teams can focus their scarce monitoring resources on individuals at higher mortality risk. This tool can be easily adapted to the context of other lower and middle-income countries. Policymakers would benefit from this low-cost strategy to reduce COVID-19 mortality, particularly during outbreaks.

Background: Globally, there are 1.35 million road traffic deaths annually, with 90% of these deaths occurring in low- and middle-income countries (LMICs). Road traffic injury is now the leading cause of death in children older than five years of age. To achieve the Stockholm Declaration of halving the number of road traffic deaths by 2030, and Sustainable Development Goal 11.7 to provide safe transport systems, particularly for vulnerable individuals, drastic action needs to be taken in LMICs. In 2007, Bloomberg Philanthropies launched the Initiative for Global Road Safety. The …

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Background: The WHO recommends use of masks and social distancing to reduce transmission and death from COVID-19. Governments worldwide also rely on test-trace-isolate (TTI) programs for additional risk mitigation. This study aims to estimate the cost-effectiveness of implementing a national TTI strategy to reduce the number of severe and fatal cases of COVID-19 in Colombia. Methods: We developed a simulation model of COVID-19 infection combined with a Susceptible-Infected-Recovered structure. We estimated the incremental cost-effectiveness of a comprehensive TTI strategy compared to no intervention over a one-year horizon, from both a health system and a societal perspective. Hospitalization and mortality rates were retrieved from Colombian surveillance data. We included program costs of TTI intervention, health services utilization, PCR diagnosis test, productivity lost, and government social program costs. We used the number of deaths and quality-adjusted life years (QALYs) as health outcomes. Sensitivity analyses were performed. Findings: Compared with no intervention, the TTI strategy reduced COVID-19 mortality by 67%. In addition, the program saved an average of $1,045 and $850 per case in the social and health system perspective, respectively. These savings are equivalent to almost four to ten times the annual Colombia per capita healthcare spending. Interpretation: The TTI strategy in Colombia is a highly cost-effective public health intervention to reduce the burden of COVID-19. TTI is dependent on its capacity to identify and give early medical and social assistance to new cases. Our findings exemplify the success of using comprehensive strategies integrating telemedicine and predictive analysis to improve prevention programs. Funding Information: This study was supported by the Colombian Ministry of Health through award number PUJ-04519-20 received by E.P. AVO and SDS declined to receive any funding support for this study. Declaration of Interests: Three of the authors (JFN, MRB, and FR) are direct employees of the funding institution (Colombian Ministry of Health). The other authors do not present any conflict of interest. Ethics Approval Statement: This study was approved by the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health and deemed not human subjects research (IRB number: 14144).

This chapter talks about health care as a universal concern and health policy. It provides an overview of policy analysis within the health care sector across problem definition, policy development and implementation stages at the national, departmental, and local levels of government. It also identifies four concrete examples of opportunities for policy analysis in the health sector, as well as two substantial obstacles or “bottlenecks.” The chapter discusses the development of policy analysis studies in the Colombian health sector since the health reform in 1993, and the heterogeneity of such development across different health sector institutions in Colombia. It assesses how policy analysis in the health sector evolved over time, highlighting the divergent development in national-level and local-level institutions.

Background Data collection on noncommunicable disease (NCD) behavioral risk factors has traditionally been carried out through face-to-face surveys. However, its high costs and logistical difficulties can lead to lack of timely statistics for planning, particularly in low and middle-income countries. Mobile phone surveys (MPS) have the potential to fill these gaps. Objective This study explores perceptions, feasibility and strategies to increase the acceptability and response rate of health surveys administered through MPS using interactive voice response in Colombia. Method A sequential multimodal exploratory design was used. We conducted key informant interviews (KII) with stakeholders from government and academia; focus group discussions (FGDs) and user-group tests (UGTs) with young adults and elderly people living in rural and urban settings (men and women). The KII and FGDs explored perceptions of using mobile phones for NCD surveys. In the UGTs, participants were administered an IVR survey, and they provided feedback on its usability and potential improvement. Results Between February and November 2017, we conducted 7 KII, 6 FGDs (n = 54) and 4 UGTs (n = 34). Most participants consider MPS is a novel way to explore risk factors in NCDs. They also recognize challenges for their implementation including security issues, technological literacy and telecommunications coverage, especially in rural areas. It was recommended to promote the survey using mass media before its deployment and stressing its objectives, responsible institution and data privacy safeguards. The preferences in the survey administration relate to factors such as skills in the use of mobile phones, age, availability of time and educational level. The participants recommend questionnaires shorter than 10 minutes. Conclusions The possibility of obtaining data through MPS at a population level represents an opportunity to improve the availability of risk-factor data. Steps towards increasing the acceptability and overcoming technological and methodological challenges need to be taken.

In urban streets, pedestrians compete with vehicles for right-of-way. In some situations, it may be very challenging for pedestrians to deal with complex, sometimes hostile, traffic conflicts, especially in urban areas. This paper provides an exploratory analysis of pedestrian behavior on four types of mid-blocks crossing facilities in the city of Fortaleza, Brazil. The analysis was based on descriptive statistics and logistic regression models of variables related to signal control, facilities, and pedestrian characteristics and behavior. The models considered the following binary variables: (i) crossing vs no crossing while pedestrian red phase; (ii) driver yielded vs did not yield while pedestrian crossing; (iii) normal vs aggressive/risked pedestrian behavior while crossing. A total of 2,400 crossings were considered in this study. The results showed that, in general, the increase of traffic demand is related to easier crossings. Moreover, the presence of raised crosswalks increased in about 20 times the number of drivers that yielded to pedestrians in comparison to the only-marked site. As well as the implementation of mechanisms that help the performance of crossings, like raised platforms or traffic signals, reduced considerably the number of aggressive/risked crossings.

Summary Background Between 1990 and 2015, the global injury mortality declined, but in countries where the poorest billion live, injuries are becoming an increasingly prevalent cause of death. The vulnerability of this population requires immediate attention from policy makers to implement effective interventions that lessen the burden of injuries in these countries. Our aim was two-fold; first, to review all the evidence on effective interventions for the five main types of unintentional injury; and second, to estimate the potential number of lives saved by effective injury interventions among the poorest billion. Methods For our systematic review we used references in the Disability Control Priorities third edition, and searched PubMed and the Cochrane database for papers published until Sept 10, 2016, using a comprehensive search strategy to find interventions for the five major causes of unintentional injuries: road traffic crashes, falls, drowning, burns, and poisoning. Studies were included if they presented evidence with significant effects sizes for any outcome; no inclusions or exclusions made on the basis of where the study was carried out (ie, low-income, middle-income, or high-income country). Then we used data from the Global Burden of Disease 2015 study and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved among the poorest billion by these evidence-based injury interventions. We estimated results for 84 countries where the poorest billion live. Findings From the 513 papers identified, 47 were eligible for inclusion. We identified 11 interventions that had an effect on injury mortality. For road traffic deaths, the most successful interventions in preventing deaths are speed enforcement (>80 000 lives saved per year) and drink-driving enforcement (>60 000 lives saved per year). Interventions potentially most effective in preventing deaths from drowning are formal swimming lessons for children younger than 14 years (>25 000 lives saved per year) and the use of creches to supervise younger children (younger than 5 years; >10 000 lives saved per year). We did not find sufficient evidence on interventions for other causes of unintentional injuries (poisoning, burns, and falls) to run similar simulations. Interpretation Based on the little available evidence, key interventions have been identified to prevent lives lost from unintentional injuries among the poorest billion. This Article provides guidance to national authorities on evidence-based priority interventions that can reduce the burden of injuries among the most vulnerable members of the population. We also identify an important gap in knowledge on the effectiveness and the mortality impacts of injury interventions. Funding Partly supported by the Fogarty International Center of the US National Institutes of Health (Chronic Consequences of Trauma, Injuries, Disability Across the Lifespan: Uganda; #D43TW009284).

Comparability of population surveys across countries is key to appraising trends in population health. Achieving this requires deep understanding of the methods used in these surveys to examine the extent to which the measurements are comparable. In this study, we obtained detailed protocols of 8 nationally representative surveys from 2007–2013 from Brazil, Chile, Colombia, Mexico, the United Kingdom (England and Scotland), and the United States—countries that that differ in economic and inequity indicators. Data were collected on sampling frame, sample selection procedures, recruitment, data collection methods, content of interview and examination modules, and measurement protocols. We also assessed their adherence to the World Health Organization's “STEPwise Approach to Surveillance” framework for population health surveys. The surveys, which included half a million participants, were highly comparable on sampling methodology, survey questions, and anthropometric measurements. Heterogeneity was found for physical activity questionnaires and biological samples collection. The common age range included by the surveys was adults aged 18–64 years. The methods used in these surveys were similar enough to enable comparative analyses of the data across the 7 countries. This comparability is crucial in assessing and comparing national and subgroup population health, and to assisting the transfer of research and policy knowledge across countries.

To assess the effect of a permanent gun-carrying restriction on gun-related mortality in Colombia between 2008 and 2014, and determine differences in the effect of the restriction by place of death and sex.In 2012, Bogotá and Medellín introduced a permanent gun-carrying restriction. We compared gun-related mortality rates in these cities (intervention cities) with the rates in all other Colombian cities with more than 500 000 inhabitants (control cities). We used data from the Colombian National Department of Statistics to calculate monthly gun-related mortality rates between 2008 and 2014 for intervention and control cities. We used a differences-in-differences method with fixed effects to assess differences in gun-related mortality in intervention and control cities before and after the introduction of the gun-carrying restriction. We stratified effects by place of death (public area or residence) and sex. We made robustness checks to test the assumptions of the models.Gun-related deaths in the control and intervention cities decreased between 2008 and 2014; however, the decrease was greater in the intervention cities (from 20.29 to 14.93 per 100 000 population; 26.4%) than in the control cities (from 37.88 to 34.56 per 100 000 population; 8.8%). The restriction led to a 22.3% reduction in the monthly gun-related mortality rate in Bogotá and Medellín. The reduction was greater in public areas and for males. Robustness checks supported the assumptions of the models.The permanent restriction on carrying guns reduced gun-related deaths. This policy could be used to reduce gun-related injuries in urban centres of other countries with large numbers of gun-related deaths.Évaluer l'impact d'une restriction permanente du port d'armes sur le taux de mortalité lié aux armes à feu en Colombie entre 2008 et 2014, et déterminer les différences d'impact de cette restriction en fonction du lieu du décès et du sexe.En 2012, Bogotá et Medellín ont instauré une restriction permanente du port d'armes. Nous avons comparé les taux de mortalité liés aux armes à feu dans ces villes (villes d'intervention) avec les taux observés dans l'ensemble des autres villes colombiennes de plus de 500 000 habitants (villes de contrôle). Les données fournies par le Département administratif national de la statistique en Colombie nous ont permis de calculer les taux de mortalité liés aux armes à feu entre 2008 et 2014 dans les villes d'intervention et de contrôle. Nous avons utilisé la méthode des doubles différences à effets fixes pour mesurer les disparités entre la mortalité liée aux armes à feu dans les villes d'intervention et de contrôle, avant et après l'instauration de la restriction du port d'armes. Nous avons ensuite segmenté les résultats en fonction du lieu du décès (espace public ou domicile) et du sexe. Nous avons également procédé à des tests de robustesse pour évaluer les hypothèses des modèles.Les décès causés par des armes à feu dans les villes de contrôle et d'intervention ont diminué entre 2008 et 2014. Cependant, la diminution était plus importante dans les villes d'intervention (de 20,29 à 14,93 par 100 000 habitants ; 26,4 %) que dans les villes de contrôle (de 37,88 à 34,56 par 100 000 habitants ; 8,8 %). La restriction a entraîné une baisse de 22,3 % de la mortalité mensuelle liée aux armes à feu, tant à Bogotá qu'à Medellín. Cette baisse s'est avérée plus importante dans les espaces publics et pour les individus de sexe masculin. Les tests de robustesse ont confirmé les hypothèses des modèles.La restriction permanente du port d'armes a un impact positif sur la mortalité liée aux armes à feu. Cette politique pourrait être employée par d'autres pays où le nombre de décès attribuables aux armes à feu est élevé, afin de réduire le nombre de blessures par balles dans les centres urbains.Evaluar el efecto de una restricción permanente al porte de armas en la mortalidad relacionada con las armas en Colombia entre 2008 y 2014, y determinar las diferencias en el efecto de la restricción por lugar de muerte y sexo.En 2012, Bogotá y Medellín establecieron una restricción permanente al porte de armas. Se compararon las tasas de mortalidad por arma de fuego en estas ciudades (ciudades de intervención) con las tasas en todas las demás ciudades colombianas con más de 500.000 habitantes (ciudades de control). Se utilizaron los datos del Departamento Nacional de Estadística de Colombia para calcular las tasas mensuales de mortalidad por armas de fuego entre 2008 y 2014 para las ciudades de intervención y control. Se utilizó un método de diferencia en diferencias con efectos fijos para evaluar las diferencias en la mortalidad relacionada con armas de fuego en las ciudades de intervención y control antes y después del establecimiento de la restricción al porte de armas. Se estratificaron los efectos por lugar de muerte (área pública o residencia) y sexo. Se realizaron controles de solidez para probar los supuestos de los modelos.Las muertes relacionadas con armas de fuego en las ciudades de control e intervención disminuyeron entre 2008 y 2014; sin embargo, la disminución fue mayor en las ciudades de intervención (de 20, 29 a 14,93 por cada 100.000 habitantes; 26,4 %) que en las ciudades de control (de 37,88 a 34,56 por cada 100.000 habitantes; 8,8 %). La restricción condujo a una reducción del 22,3 % en la tasa mensual de mortalidad relacionada con armas de fuego en Bogotá y Medellín. La reducción fue mayor en las áreas públicas y en los hombres. Los controles de solidez apoyaron los supuestos de los modelos.La restricción permanente al porte de armas redujo las muertes relacionadas con las armas. Esta política podría ser utilizada para reducir las lesiones relacionadas con armas de fuego en los centros urbanos de otros países con un gran número de muertes relacionadas con este tipo de armas.تقييم تأثير التقييد الدائم لحمل السلاح على الوفيات المرتبطة بالأسلحة في كولومبيا بين عامي 2008 و2014، وتحديد الاختلافات في تأثير التقييد حسب مكان الوفاة والجنس.قامت كل من بوجوتا وميديلين في عام 2012، بفرض تقييد دائم على حمل السلاح. وقمنا بمقارنة معدلات الوفيات المرتبطة بالأسلحة في هاتين المدينتين (مدن التدخل)، بالمعدلات المقابلة لها في جميع المدن الكولومبية الأخرى التي يزيد عدد سكانها عن 500000 نسمة (مدن السيطرة). وقمنا بالاستعانة بالبيانات من إدارة الإحصاءات الوطنية الكولومبية لحساب معدلات الوفيات الشهرية المرتبطة بالسلاح بين عامي 2008 و2014 في مدن التدخل والسيطرة. كما استخدمنا طريقة الاختلافات في الفارق ذات التأثيرات الثابتة، لتقييم الاختلافات في الوفيات المرتبطة بالأسلحة النارية في مدن التدخل والسيطرة قبل وبعد فرض قيود حمل السلاح. وقمنا بتصنيف التأثيرات حسب مكان الوفاة (المنطقة العامة أو مقر الإقامة) والجنس. كما أجرينا فحوصات فعالية لاختبار افتراضات النماذج.انخفض معدل الوفيات المرتبطة بالأسلحة في مدن السيطرة والتدخل بين عامي 2008 و2014؛ إلا أن الانخفاض كان أكبر في مدن التدخل (من 20.29 إلى 14.93 لكل 100000 نسمة؛ 26.4%)، منه في مدن السيطرة (من 37.88 إلى 34.56 لكل 100000 نسمة؛ 8.8%). أدى التقييد إلى انخفاض بنسبة 22.3% في معدل الوفيات الشهرية المرتبطة بالسلاح في بوجوتا وميديلين. كان الانخفاض أكبر في المناطق العامة، وبالنسبة للذكور. كما أيدت فحوصات الفعالية افتراضات النماذج.أدى التقييد الدائم على حمل السلاح إلى خفض الوفيات المرتبطة بالأسلحة. يمكن استخدام هذه السياسة للحد من الإصابات المرتبطة بالأسلحة في المراكز الحضرية في البلدان الأخرى ذات الأعداد الكبيرة من الوفيات المرتبطة بالأسلحة.旨在评估 2008 年至 2014 年哥伦比亚实施的永久性持枪限制对涉枪死亡率的影响，并根据死亡地点和性别确定限制效果的差异。.2012 年，波哥大和梅德林实施了永久性持枪限制。我们比较了这两座城市（干预城市）与居住人口超过 500 000 的所有其他哥伦比亚城市（控制城市）的涉枪死亡率。我们使用哥伦比亚国家统计局的数据，计算 2008 年至 2014 年干预城市和控制城市每月涉枪事件的死亡率。我们采用具有固定效应的倍差法来评估实施持枪限制前后干预城市和控制城市涉枪死亡率的差异。我们根据死亡地点（公共区域或居民区）和性别对影响进行分层。我们开展了稳健性检验来验证模型的假设。.2008 年至 2014 年间，控制城市和干预城市中涉枪事件的死亡人数有所下降；但干预城市的下降幅度（从每 100 000 人口 20.29 下降至 14.93；26.4%）大于控制城市（从每 100 000 人口 37.88 下降至 34.56；8.8%）。这一限制导致波哥大和梅德林每月涉枪死亡率下降 22.3%。这一数字在公共区域和男性中的减少幅度更大。稳健性检验支持模型的假设。.对携带枪支的永久性限制减少了涉枪死亡率。对于涉枪死亡人数较多的其他国家而言，这项政策可以用来减少其城市中心地区涉枪事件带来的损伤。.Оценить влияние постоянного ограничения на ношение оружия на уровень смертности от огнестрельных ранений в Колумбии в период с 2008 по 2014 годы и определить различия в эффективности ограничения в зависимости от места гибели и пола жертвы.В 2012 году в городах Богота и Медельин были введены постоянные ограничения на ношение оружия. Авторы сравнили уровень смертности от огнестрельного оружия в этих городах (города проведения вмешательства) с показателями в других колумбийских городах с населением более 500 000 жителей (контрольные города). Для расчета показателей смертности от огнестрельных ранений в городах проведения вмешательства и контрольных городах использовались данные Национального административного департамента статистики Колумбии за период с 2008 по 2014 годы. Авторы применили метод «разность разностей» с фиксированными эффектами для оценки разницы в показателях смертности от огнестрельных ранений в городах проведения вмешательства и контрольных городах до и после вступления в силу ограничений на ношение оружия. Эффекты были стратифицированы по месту гибели (в общественном месте или дома) и полу жертв. Для проверки модельных предположений авторы провели проверку надежности результатов.Уровень смертности от огнестрельных ранений в период с 2008 по 2014 годы снизилась как в городах проведения вмешательства, так и в контрольных городах; однако в городах проведения вмешательства снижение было значительнее (с 20,29 до 14,93 человека на 100 000 населения; 26,4%), чем в контрольных городах (с 37,88 до 34,56 человека на 100 000 населения; 8,8%). Ежемесячный показатель смертности от огнестрельных ранений в городах Богота и Медельин вследствие введенного ограничения снизился на 22,3%. Снижение было значительнее выражено для общественных мест и для мужчин. Проверка надежности результатов подтвердила основные предположения модели.Постоянное ограничение на ношение оружия уменьшило количество погибших от огнестрельных ранений. Этот подход может использоваться для уменьшения травматизма от огнестрельных ранений в городских центрах других стран с высокими показателями смертности от огнестрельных ранений.

Background Contact tracing is a crucial part of the public health surveillance toolkit. However, it is labor-intensive and costly to carry it out. Some countries have faced challenges implementing contact tracing, and no impact evaluations using empirical data have assessed its impact on COVID-19 mortality. This study assesses the impact of contact tracing in a middle-income country, providing data to support the expansion and optimization of contact tracing strategies to improve infection control. Methods We obtained publicly available data on all confirmed COVID-19 cases in Colombia between March 2 and June 16, 2020. (N = 54,931 cases over 135 days of observation). As suggested by WHO guidelines, we proxied contact tracing performance as the proportion of cases identified through contact tracing out of all cases identified. We calculated the daily proportion of cases identified through contact tracing across 37 geographical units (32 departments and five districts). Further, we used a sequential log-log fixed-effects model to estimate the 21-days, 28-days, 42-days, and 56-days lagged impact of the proportion of cases identified through contact tracing on daily COVID-19 mortality. Both the proportion of cases identified through contact tracing and the daily number of COVID-19 deaths are smoothed using 7-day moving averages. Models control for the prevalence of active cases, second-degree polynomials, and mobility indices. Robustness checks to include supply-side variables were performed. Results We found that a 10 percent increase in the proportion of cases identified through contact tracing is related to COVID-19 mortality reductions between 0.8% and 3.4%. Our models explain between 47%-70% of the variance in mortality. Results are robust to changes of specification and inclusion of supply-side variables. Conclusion Contact tracing is instrumental in containing infectious diseases. Its prioritization as a surveillance strategy will substantially impact reducing deaths while minimizing the impact on the fragile economic systems of lower and middle-income countries. This study provides lessons for other LMIC.

Road traffic injuries (RTIs) are an important cause of death and injury in Colombia and Brazil. This burden is not uniform across countries and cities. Understanding these differences and similarities in road traffic behaviors is key in designing effective RTI interventions. This study is aimed to assess such differences by comparing observed road safety behaviors in three South American cities, Bogota (Colombia), and Sao Paulo and Fortaleza (Brazil). As part of the Bloomberg Initiative for Global Road Safety (BIGRS), observational studies were conducted in Bogota, Fortaleza, and Sao Paulo. Trained observers recorded road safety behavior (speeding, helmet use, seatbelt use and drink driving) every six months between August 2015 and September 2017. Around 1.5 million observations in these risk factors have been collected throughout six rounds of data collection. It was found that Bogota and Sao Paulo had varying rates of speeding, very dependent on changes in policy and enforcement circumstances, whereas Fortaleza maintained relatively high and stables rates. Rates of seatbelt and correct helmet use among all passengers were higher in Sao Paulo than Bogota and Fortaleza. Drink driving prevalence was higher in Sao Paulo than Fortaleza and Bogota. Fortaleza has experienced a reducing trend in drink driving prevalence throughout the project. In Sao Paulo, refusal rates reached 76%. Important regional differences in road safety risk factors highlight the need for tailored interventions in South American cities. Speeding is a priority for Bogota and Fortaleza. Sao Paulo’s alcohol results illustrate the urgency for drink driving-based interventions and correct helmet use is an increasingly important need in Bogota and Fortaleza. These results are being used to develop specific interventions for BIGRS. These results are of interest for policy makers in Latin American cities and other middle-income countries where these interventions can be piloted and if effective, scaled up and replicated.

Background Sao Paulo is one of the world’s largest urban areas and it was selected as one of the ten cities for the Bloomberg Initiative for Global Road Safety (BIGRS) project. With nearly 12 million inhabitants and 8 million vehicles, the city has reached a significant decline in road traffic mortality during the last decade (7 deaths per 1 00 000 inhabitants in 2016). Objective To evaluate the performance of interventions aiming to reduce the prevalence of four key road safety risk factors (speeding, drink and driving, seatbelt and helmet use) during 2015–2017 in the city of Sao Paulo, Brazil. Methods Following a baseline study performed in 2015, observational studies monitoring these risk factors were performed twice a year. Six to eight different locations were randomly selected to represent the main regions of the city, where drivers’ behaviors were observed during all days of the week using an internationally validated protocol. Findings The prevalence of speeding at baseline (10%) decreased substantially to 5% in 2016 following citywide speed limit reduction interventions, but increased again (9%) by the end of 2017 after interventions were reverted. Drivers testing above the legal blood alcohol concentration (BAC) limit (0.01%) presented a decreasing trend (from 4.1% to 1.2%); however, more than half of drivers currently refuse breathalyzer tests. Driver’s seatbelt use rate has kept constant at approximately 90%, as well as rear’s passengers usage rate, but at a much smaller proportion (22%). Helmet use among drivers and passengers presented a highly consistent percentage, with nearly all motorcycle drivers wearing helmets correctly. Conclusion and policy implications Speeding and drink driving are the most prevalent risk factors observed among drivers, but interventions addressing these behaviors have demonstrated a positive association with their reduction. Future strategies addressing rear seatbelt use and correct helmet wearing should also be promoted.

The Sustainable Development Goals (SDG) aim to halve road traffic deaths and provide safe, affordable, accessible and sustainable transport systems for all. Achieving these targets will be challenging if multi-sectoral evidence-based interventions are not implemented and scaled up, particularly in low- and middle-income countries (LMIC) where 90% of all deaths due to road traffic injuries (RTI) take place and the poorest billion live. The objective of this study is to (1) review the literature for effective evidence-based interventions for RTI, and (2) conduct estimations on the number of lives potentially saved by each intervention in LMIC. We conducted a systematic review of all evidence available on interventions on RTI. Furthermore, we estimated the potential effect that these interventions would have if implemented in each country. We obtained parameters from the GBD2015 study and the GSRRS2015. We estimated the number of lives saved using a Monte Carlo simulation and a triangular distribution with 10 000 iterations for each intervention and country. We obtained values for the point estimates and standard deviations of the lives saved by each intervention for each type of injury and country. Statistically significant results on mortality were presented by only six interventions for road injures and three for drowning. The most effective interventions are speed and drinking and driving enforcement for RTI and formal swimming lessons and the use of creches for drowning. In this study, we provide evidence on the lives saved by different road safety intervention and highlight the scarcity of data on the effectiveness and mortality impacts of injury interventions. These results will be of interest for policy makers in LMIC as well as funders committed to road safety. This work has been published in: Lancet Global Health 6 (5):523–534. 2018.

BackgroundIn Colombia, smoking is the second leading modifiable risk factor for premature mortality. In December 2016, Colombia passed a major tax increase on tobacco products in an effort to decrease smoking and improve population health. While tobacco taxes are known to be highly effective in reducing the prevalence of smoking, they are often criticised as being regressive in consumption. This analysis attempts to assess the distributional impact (across socioeconomic groups) of the new tax on selected health and financial outcomes.MethodsThis study builds on extended cost-effectiveness analysis methods to study the new tobacco tax in Colombia, and estimates, over a time period of 20 years and across income quintiles of the current urban population (80% of the country population), the years of life gained with smoking cessation and the increased tax revenues, all associated with a 70% relative price increase of the pack of cigarettes. Where possible, we use parameters that vary by income quintile, including price elasticity of demand for cigarettes (average of −0.44 estimated from household survey data).FindingsOver 20 years, the tax increase would lead to an estimated 191 000 years of life gained among Colombia’s current urban population, with the largest gains among the bottom two income quintiles. The additional annual tax revenues raised would amount to about 2%–4% of Colombia’s annual government health expenditure, with the poorest quintiles bearing the smallest tax burden increase.ConclusionsThe tobacco tax increase passed by Colombia has substantial implications for the country’s population health and financial well-being, with large benefits likely to accrue to the two poorest quintiles of the population.

Colombia has a high prevalence of overweight (56%) and obesity (19%) among adults and is experiencing a growing trend in the prevalence of associated chronic conditions. Evidence suggests that sugar sweetened beverages (SSB) are associated to overweight/obesity, and that taxes on these beverages could reduce their associated health consequences. This paper assesses the potential effect of different levels of a SSB tax in Colombia on overweight and obesity prevalence. Using peer-reviewed local data on own-price elasticity of SSB, we applied a comparative risk assessment strategy to simulate the effect of the SSB tax on a nationally representative nutritional survey with 7140 adults in 2010 (ENSIN, 2010). Our results varied depending on the tax scenario, pass-through assumption and household socio economic strata (SES). We found that among individuals belonging to lower SES households, the SSB tax would reduce overweight and obesity between 1.5-4.9 and 1.1-2.4 percentage points (p 0.05), respectively. Among individuals belonging to higher SES households, we found no statistically significant effects on obesity, and a reduction on overweight prevalence between 2.9 and 3.9 percentage points (p 0.05). In the most conservative scenario (40% pass-through), a tax rate of at least 75 cents of Colombian peso (0.75 COP) per milliliter (24% of the average price) is needed to have statistically significant effects on both overweight and obesity prevalence among lower SES households. The results of this study suggest that a SSB tax could reduce the overweight and obesity prevalence in Colombia, especially among lower SES households. This study shows that SSB taxes have a particularly beneficial effect in the most vulnerable population. Additional social and individual benefits, or individual costs arising from the tax are not assessed in this research, implying that even larger health gains could be observed.

This proposal offers a unique solution for a unique challenge: using oil to pay for Venezuela’s debt. Venezuela and PDVSA’s creditors currently receive little in the way of coupon payments and have minimal means of recourse over limited assets located outside Venezuela’s borders. We suggest using a creditor trust to consolidate creditors into a single entity that would purchase the oil from Venezuela with bonds tendered by the creditors to the trust. This transaction would give the creditors trust a priority claim over oil as title holders. It allows a restructuring process with relatively few changes to current bonds, thus reducing the possibility of litigation. In addition to the legal and structural benefits offered to both Venezuela and the creditors, this proposal offers something that no other proposal does — the potential for successful execution under current U.S. sanctions based on the issuance of a specific license from OFAC. Although there is no assurance as to whether such license would be obtained, it is arguable that this structure runs outside the scope of the Executive Order No. 13,808, and that there is precedent supporting the issuance of such a license authorizing commercial transactions.

Road injuries are an important cause of global mortality especially in low- and middle-income countries. While these countries undergo major urban transformations, an integral part of their development has often been the implementation of mass transportation systems, including Bus Rapid Transit (BRT) systems. However, the net effect of BRT systems on road safety is still unclear, and while there is reason to believe that BRT systems improve safety, very few available empirical studies have tested this hypothesis using observational data. Furthermore, the existing evidence is mixed and sparse. This paper reviews the available literature on the links of BRT systems and road safety and calls for more research to strengthen the body of evidence on the effect of BRT systems on road safety in the future.

ObjectivesTo evaluate the prevalence of drink driving and speeding during 2015–2018 in Sao Paulo, Brazil.DesignCross-sectional observational study.SettingRoads representing the five main regions of the city of Sao Paulo in Brazil, one of the world’s largest urban areas.ParticipantsDrivers (N=10 294) stopped at routine roadside breath testing checkpoints and those driving in selected roads for speeding measurement (N=414 664).Primary and secondary outcome measuresMicrowave radar guns were used to measure the speed of vehicles, while the prevalence of drivers under the influence of alcohol was observed in police checkpoints. Data were collected during three consecutive years (2016–2018) following a baseline study established in 2015 using a city-level representative sample of observational data representing all days of the week.ResultsAlcohol-related fatalities kept at a constantly high percentage, with 39% of road traffic deaths involving alcohol in 2016. Drivers testing above the legal breath alcohol concentration limit showed a decreasing trend, from 4.1% (95% CI 2.9% to 5.5%) at baseline to 0.6% (95% CI 0.2% to 1.2%) in the end of 2018 (pConclusionsDrink driving rates have reduced, likely due to an increase in drivers refusing breath alcohol tests, while speeding rates have increased significantly by the end of the study period, particularly among motorcycles. Future strategies aiming at reducing road traffic injuries in the major Brazilian city should tailor drink driving and speeding enforcement based on the new evidence provided here.

Background Cost–benefit analysis is a useful tool for priority setting in road safety. The value of statistical life (VOSL) is a metric used to estimate the benefits of road interventions in cost–benefit analyses. The International Road Assessment Program (iRAP), for example, created a rule-of-thumb to calculate VOSL benefits of road infrastructure when performing cost–benefit assessments in countries where data on VOSL are sparse. Aim To evaluate the rapid assessment metric developed by iRAP and provide suggestions for improvement in these methods. Methods We replicated iRAP calculations in order to make a critical assessment of the sources, results and conclusions. Conclusions We found the iRAP metric a good example for highlighting some relevant aspects that should be considered in any VOSL estimation in order to enhance its use as a guiding principle for assessing road interventions. Specifically, we recommend the explicit disclosure of the assumptions, the use of sensitivity analysis and the avoidance of omitted variables bias.

Objectives To estimate productivity losses due to absenteeism and presenteeism and their determinants in patients with depression from five Colombian cities. Methods We used data from a multicenter, mixed-methods study of adult patients diagnosed with major depressive disorder or double depression (major depressive disorder plus dysthymia) during 2010. The World Health Organization’s Health and Work Performance Questionnaire was used to assess absenteeism and presenteeism. We explored the determinants of productivity losses using a two-part model. We also used a costing model to calculate the corresponding monetary losses. Results We analyzed data from 107 patients employed in the last 4 weeks. Absenteeism was reported by 70% of patients; presenteeism was reported by all but one. Half of the patients reported a level of performance at work at least 50% below usual. Average number of hours per month lost to absenteeism and presenteeism was 43 and 51, respectively. The probability of any absenteeism was 17 percentage points lower in patients rating their mental health favorably compared with those rating it poorly (standard error [SE] 0.09; P < 0.10) and 19 percentage points higher in patients with at least one comorbidity compared with patients with none (SE 0.10; P < 0.10). All other covariates showed no significant associations on hours lost to absenteeism. Patients with favorable mental health self-ratings had 16.4 fewer hours per month of presenteeism compared with those with poor self-ratings (SE 4.52; P < 0.01). The 2015 monetary value of productivity losses amounted to US $840 million. Conclusions This study in a middle-income country confirms the high economic burden of depression. Health policies and workplace interventions ensuring adequate diagnosis and treatment of depression are recommended.

In the South American nation of Colombia, as elsewhere, patients with type 2 diabetes often avoid care that could prevent their condition from worsening. Availability of health insurance may play a role in explaining this behavior. Some patients with diabetes skip preventive measures because they have insurance and calculate that they can access curative services later in life. Insurers may limit preventive services coverage because they can't be assured of sharing in the eventual savings that emerge when a chronic condition such as diabetes is managed properly. Our analysis of a nationally representative sample of Colombians who have type 2 diabetes and who pay premiums into the country's "contributory" insurance program, found no evidence that insurance influences those individuals to avoid preventive services. The evidence is less clear for those participating in a different, fully subsidized insurance program, who-despite the availability of preventive care-are no more likely to seek preventive visits than are uninsured patients. We propose controlled experiments to identify and measure the true causal effects of insurance on prevention and, more broadly, steps to increase patients' understanding of the benefits of prevention.

In recent years, interest on researching on antenatal care issues and other health promotion and prevention interventions has increased. However, even though there is a growing interest in publishing about antenatal care use, evidence concerning which, and how socioeconomic conditions influence whether a pregnant woman demands or not antenatal consultations on the assumption that the theoretical access to this service has not entry barriers, is still limited. In order to generate this evidence, a two-stage analysis was performed with data gathered on the Demographic and Health Survey (DHS) carried out by Profamilia in Colombia during 2005. The first stage was run as a logistic regression model showing the marginal effects on the probability of attending the first visit and an ordinary least squares model was performed for the second stage accounting for the absences to antenatal consultations once at least one visit was carried out. It was found that mothers living in the Pacific Ocean region as well as young mothers seem to have a lower probability of attending the first visit but these factors are not related to the number of absences to antenatal consultation once the first visit has been achieved. The effect of health insurance was surprising because of the differing effects that the health insurers showed. Some familiar and personal conditions such as willingness to have the last children and number of previous children, demonstrated to be important in the determination of demand. The effect of mother's educational attainment was proved as important whereas the father's educational achievement was not. This paper provides some elements for policy making in order to increase the demand inducement of antenatal care, as well as stimulating research on demand for specific issues on health.

Objectives: To assess the issue of hospital variations in Colombia and to contribute to the methodology on health care variations by using a model that clusters the variance between hospitals while accounting for individual-level reimbursement rates and objective health-status variables. Methods: We used data on all births (N ¼ 11,954) taking place in a contributory-regimen insurer network in Colombia during 2007. A multilevel logistic regression model was used to account for the share of unexplained variance between hospitals. In addition, an alternative variance decomposition specification was further carried out to measure the proportion of such unexplained variance due to the region effect. Results: Hospitals account for 20% of the variation in performing cesarean sections, whereas region explains only onethird of such variance. Variables accounting for preferences on the demand side as well as reimbursement rates are found to predict the probability of performing cesarean sections. Conclusions: Hospital variations explain large variances within a single-payer’s network. Because this insurer company is highly regarded in terms of performance and finance, these results might provide a lower bound for the scale of hospital variation in the Colombian health care market. Such lower bound provides guidance on the relevance of this issue for Colombia. Some factors such as demand-side preferences and physician reimbursement rates increase variations in health care even within a single-payer network. This is a source of inefficiencies, threatening the quality of health care and financial sustainability. The proposed methodology should be considered in further research on health care variations.

In settings with low seatbelt use prevalence, self-reported seatbelt use estimates often lack validity, and routine observational studies are scarce. In this paper, we aim to describe the prevalence of seatbelt use and associated factors in drivers and front-seat passengers across eight sites in four countries (Egypt, Mexico, Russia, Turkey) using observational studies as well as to produce estimates of country-level and site-level variance. As part of the Bloomberg Philanthropies Global Road Safety Program, data on driver and passenger seatbelt use across four middle-income countries was collected between October 2010 and May 2011 (n=122,931 vehicles). Logistic regression and Intraclass Correlation Coefficient analyses for sites- and country-level clustering were performed. We found high variability of seatbelt wearing rates ranging from 4 to 72% in drivers and 3-50% in front-seat passengers. Overall, average seatbelt wearing rates were low (under 60% in most sites). At the individual level, older and female drivers were more likely to wear seatbelts, as well as drivers of vehicles transiting at times of increased vehicle flow. We also found that 26-32% and 37-41% of the variance in seatbelt use among drivers and front-seat passengers respectively was explained by differences across sites and countries. Our results demonstrate that there is room for improvement on seatbelt use in middle-income countries and that standardized cross-country studies on road safety risk factors are feasible, providing valuable information for prevention and monitoring activities. Language: en

Background Body Mass Index (BMI) and waist circumference (WC) are anthropometric indicators strongly associated with diabetes, cardiovascular disease, cancer and mortality. Focusing on secular changes in the mean values of BMI and WC can mask differences at the lower- and upper-tails of the distribution. Our network of health examination survey researchers from the Americas and the UK quantified secular changes in the BMI and WC distributions in England, Scotland, and the United States (US). Methods Nationally-representative surveys of adults aged 25–64 y from similar time periods: Health Survey for England (1999–2012; n = 75,813); Scottish Health Survey (1998–2011; n = 33,010) and US National Health and Nutrition Examination Survey (1999–2012; n = 22,340). Comparisons across time for mean values of measured height, weight, BMI, and WC and prevalence of obesity (BMI ≥ 30 kg/m2) and abdominal obesity (WC ≥ 88 cm) were performed by age-standardising descriptive estimates by the direct-method to the 2000 US population. Quantile regression was used to evaluate whether BMI and WC values increased across survey years at pre-specified centiles of the distribution (5th, 50th, 95th). Models were adjusted for age, age-squared and survey year. Results Mean BMI values for men (women) at baseline were 27.1 kg/m2 (26.6 kg/m2) in England; 27.1 kg/m2 (26.8 kg/m2) in Scotland; and 27.8 kg/m2 (28.6 kg/m2) in the US. Obesity and abdominal obesity increased for both sexes in England and in Scotland. In the US, obesity increased only for men; abdominal obesity increased only for women. Mean BMI increased by 0.4 kg/m2 (0.7 kg/m2) for men (women) in England; 0.8 kg/m2 for both sexes in Scotland; and 1.0 kg/m2 for men in the US. BMI at the 5th centile was unchanged in England, but increased in Scotland and the US. Increases at the median and upper-tail occurred in each country: the increase at the 95th BMI percentile was 2.1 kg/m2 (1.3 kg/m2) for men (women) in England; 1.9 kg/m2 for both sexes in Scotland; and 2.0 kg/m2 (1.9 kg/m2) in the US (each P Mean WC increased by 2.1 cm (4.7 cm) for men (women) in England; 3.4 cm (6.5 cm) in Scotland; and 2.4 cm (3.8 cm) in the US. The increase at the 95th WC percentile was 6.3 cm (5.4 cm) for men (women) in England; 3.6 cm (8.4 cm) in Scotland; and 4.5 cm (18.3 cm) in the US (each P Ongoing analyses will incorporate data from Chile, Colombia, Mexico, and Brazil. Conclusion Secular increases in BMI and WC were fairly consistent by country for both sexes, with clear evidence of increases across the whole distribution in Scotland and the US.

In order to assess the differences between articles about public health published in national vs. international journals, we undertook a comparison of quantitative analysis methodologies and topics for five indexed journals (3 international, 2 national) during 1991-2005. A total of 2511 articles were reviewed from: European Journal of Public Health, American Journal of Public Health, Cuadernos de Saude Publica, Revista Nacional de Salud Publica and Revista de la Facultad Nacional de Salud Publica. International journals employed quantitative analysis techniques with more innovation and use of multivariate analysis than those employed by national journals. More reviews were found in the latter. Frequent topics for national journals included: child health, mental health, infectious diseases, zoonosis, sanitation, and health systems and policy. Frequent subjects for international journals included: social determinants, chronic disease and cancer. Both types of journals include local topics. We concluded that lack of multivariate techniques in national articles becomes a barrier for publication in international journals.(El siguiente documento muestra las diferencias tematicas y metodologicas de la publicacion internacional en salud publica con respecto a la produccion cientifica de las revistas colombianas. Se seleccionaron 5 revistas, de alto impacto y con indizacion internacional de caracter general de salud publica en el periodo de 1991-2005, y se compararon por la complejidad de la metodologias utilizadas para el analisis de los datos y por los temas publicados en cada revista. Se revisaron un total de 2511 articulos de las revistas: European Journal of Public Health, American Journal of Public Health, Cadernos de Saude Publica, Revista Nacional de Saud Publica, Revista de la Facultad Nacional de Saud Publica. En las metodologias se encontro: mayor presencia de estudios cuantitativos en revistas internacionales que en las nacionales, mayor porcentaje de revisiones en la publicacion nacional, mayor utilizacion de metodologias cuantitativas innovadoras en las revistas internacionales, incluyendo Cuadernos de Saude Publica. Las revistas internacionales, estandarizan la metodologia de sus articulos en analisis bivariado y multivariado. Todas las publicaciones presentan un gran enfasis en lo local. En temas, la publicacion nacional se centra en temas de salud infantil, salud mental, enfermedades transmisibles y zoonosis, salud sanitaria y ambiental y sistemas y politicas en salud.La publicacion internacional en temas de determinantes socioeconomicos enfermedades cronicas no transmisibles y cancer. Conclusiones: La publicacion nacional se encuentra rezagada en el uso de metodologias cuantitativas complejas para el analisis de los problemas de salud. La brecha muestra que para las publicaciones nacionales existen barreras de entrada, relacionadas no solo con idioma sino con la complejidad de metodos cuantitativos empleados y para la indizacion internacional de revistas las nacionales no han superado los estandares para entrar.)