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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.

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.

Background Healthcare workers are at a higher risk of COVID-19 infection during care encounters compared to the general population. Personal Protective Equipment (PPE) have been shown to protect COVID-19 among healthcare workers, however, Kenya has faced PPE shortages that can adequately protect all healthcare workers. We, therefore, examined the health and economic consequences of investing in PPE for healthcare workers in Kenya. Methods We conducted a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model following the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines. We examined two outcomes: 1) the incremental cost per healthcare worker death averted, and 2) the incremental cost per healthcare worker COVID-19 case averted. We performed a multivariate sensitivity analysis using 10,000 Monte Carlo simulations. Results Kenya would need to invest $3.12 million (95% CI: 2.65–3.59) to adequately protect healthcare workers against COVID-19. This investment would avert 416 (IQR: 330–517) and 30,041 (IQR: 7243 – 102,480) healthcare worker deaths and COVID-19 cases respectively. Additionally, such an investment would result in a healthcare system ROI of $170.64 million (IQR: 138–209) – equivalent to an 11.04 times return. Conclusion Despite other nationwide COVID-19 prevention measures such as social distancing, over 70% of healthcare workers will still be infected if the availability of PPE remains scarce. As part of the COVID-19 response strategy, the government should consider adequate investment in PPE for all healthcare workers in the country as it provides a large return on investment and it is value for money.

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 …

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.

BackgroundIn this paper, we predict the health and economic consequences of immediate investment in personal protective equipment (PPE) for health care workers (HCWs) in low- and middle-income countries (LMICs).MethodsTo account for health consequences, we estimated mortality for health care workers (HCW), and present a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model with Bayesian multivariate sensitivity analysis and Monte Carlo simulation. Inputs were used from the World Health Organization Essential Supplies Forecasting Tool and the Imperial College of London epidemiologic model.ResultsAn investment of $9.6 billion USD would adequately protect HCWs in all LMICs. This intervention saves 2,299,543 lives across LMICs, costing $59 USD per HCW case averted and $4,309 USD per HCW life saved. The societal ROI is $755.3 billion USD, the equivalent of a 7,932% return. Regional and national estimates are also presented. In scenarios where PPE remains scarce, 70-100% of HCWs will get infected, irrespective of nationwide social distancing policies. Maintaining HCW infection rates below 10% and mortality below 1% requires inclusion of a PPE scale-up strategy as part of the pandemic response.DiscussionIn conclusion, wide-scale procurement and distribution of PPE for LMICs is an essential strategy to prevent widespread HCW morbidity and mortality. It is cost-effective and yields a large downstream return on investment.

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).

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.

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.

The performance of the Enigma MiniLab assay for influenza A and B viruses and respiratory syncytial virus (RSV) was compared to a centralized laboratory respiratory virus panel. The positive and negative percent agreement for influenza A virus, influenza B virus, and RSV were 79.2% (95% confidence interval [95% CI], 57.8 to 92.9%) and 99.4% (95% CI, 98.4 to 99.9), 100% (95% CI, 47.8 to 100%) and 100% (95% CI, 99.3 to 100%), 98.5% (95% CI, 94.6 to 99.8%) and 94.5% (95% CI, 91.9 to 96.4%), respectively.

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.

Undetected diabetes (UD) worsens prognosis, increases healthcare costs and reduces productivity in the long term. However, its determinants have not been previously explored in developing countries. In this paper, we assess the determinants of UD in Colombia. We conducted logistic regression analyses using the 2007 Colombian National Health Survey. Taking into account undetected cases (individuals with fasting glucose tests ≥ 126 mg/dL reporting no previous diabetes diagnosis), we found a diabetes prevalence of 5% in Colombia, where 1/3 are undetected cases. Undetected individuals are as likely as detected diabetics to visit a physician during the last 12 months. Despite we found no differences in prevalence between urban and rural settings, diagnoses rates were lower in the later, challenging traditional conceptions on urban diabetes and supporting the hypothesis of a supply-side issue driving undetected diabetes in Colombia. We discuss UD in Colombia using a supply-demand framework. These lessons may be extrapolated to other Latin American countries where policymakers will find them useful to improve diabetes screening activities.