Structural Social Determinants and Catastrophic Illnesses in Municipalities in the Colombian Department of Valle Del Cauca
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Investigación original / Original research Structural social determinants and catastrophic illnesses in municipalities in the Colombian department of Valle del Cauca Luis Miguel Tovar Cuevas1 and Fernando Arteaga Suárez 2 Suggested citation Tovar Cuevas LM, Arteaga Suárez F. Structural social determinants and catastrophic illnesses in municipalities in the Colombian department of Valle del Cauca. Rev Panam Salud Publica. 2014;35(1):60–6. ABSTRACT Objective. To explore possible associations between self-reported prevalence of catastrophic illnesses such as chronic renal failure, HIV/AIDS and cancer and a set of structural social determinants. Methods. Ecological study using data from the 2005 Population Census conducted by the National Administrative Department of Statistics (DANE), focusing on municipalities in the Colombian department of Valle del Cauca that experienced the highest prevalence rates for catastrophic illnesses during 2000–2005. Associations were measured with Pearson’s chi-squared statistic and Fisher’s Exact Test. Prevalence ratios were calculated, with 95% confidence intervals. Results. Statistically significant associations were observed between catastrophic illnesses and social structural determinants in the form of illiteracy, deficient sanitary infrastructure, quality of housing units and access to health services. Conclusions. A role was observed for social determination of catastrophic illnesses in this context. However, additional analyses are required that recognize the complexity of health- determining processes and that explore the interrelationships among social, structural, behav- ioral and psychosocial determinants in depth. Key words Catastrophic illness; socioeconomic factors; ecological studies; neoplasms; HIV; kid- ney failure, chronic; Colombia. Catastrophic illnesses are character- Global figures with respect to the inci- threaten the financial sustainability of ized by high technical complexity and dence and prevalence of these illnesses health systems, and increase the risk of management, high costs, low incidence are not encouraging. It is predicted that impoverishment at the household level. and low cost-effectiveness of treatment. by 2020 the total incidence of cancer Determinants of catastrophic illnesses Although many illnesses have character- will have increased by 50% over current include genetic load, lifestyle, quality istics that would allow them to be clas- rates (3). From 2001 to 2010, the number of health care services, and socioeco- sified as catastrophic, Colombian health of people infected worldwide with HIV nomic conditions. Traditionally, public regulations (1, 2) recognize only a few, increased by 17% (4). In 2011, over 346 health studies have focused more on the among which are cancers, chronic renal million people worldwide had diabetes, first three factors than on socioeconomic failure (CRF) and HIV/AIDS. one of the principal causes of CRF (5). circumstances. This tendency is even The situation in Colombia is no better, more pronounced in Colombia, where with a prevalence of 0.7% for HIV and research on the social determinants of 1 Department of Economics, Pontificia Universidad Ja- 0.87% for CRF (6-8). These illnesses rep- health (SDH) in general and on cata- veriana, Cali, Colombia. Send correspondence to Luis resent a growing public health problem: strophic illnesses in particular is scarce. Miguel Tovar Cuevas, [email protected] 2 School of Public Health, Universidad del Valle, they increasingly claim more lives, af- This study contributes evidence on de- Cali, Colombia. fect a larger fraction of the population, terminants of catastrophic illness for a 60 Rev Panam Salud Publica 35(1), 2014 Tovar Cuevas and Arteaga Suárez • Structural social determinants and catastrophic illnesses in Colombia Original research particular region, in a developing country the marginal totals for each variable in cal conditions and health. More broadly, where such studies are limited. It differs its respective municipality. Any data that they indicate inequalities in the economic from other analyses of SDH in Colombia seemed unusual were verified through development of municipalities, which are in that it is an ecological study with mea- telephone consultation with DANE. generally associated closely with munici- sures aggregated at the municipal level The data for this study came from a sec- pal differentials in health. and in making use of a little-explored ondary source (i.e., the census), and were Questions from the housing unit mod- source of public information: the General accessed through the REDATAM+SP ule were used to construct one variable Census conducted by the National Ad- system, which compresses and encrypts to capture housing unit quality and an- ministrative Department of Statistics (9). the original census data to guarantee other related to municipal sanitary in- In this context, the objective of this confidentiality of information. To create frastructure. For the former, the housing study was to explore possible associa- the REDATAM database, three security unit was assumed to be of good quality if tions between the self-reported preva- controls are applied: 1) to avoid iden- the respondent selected responses 1, 2 or lence of catastrophic illnesses such as tification of individuals, identifiers on 3 on Question 3, or of inadequate quality CRF, HIV/AIDS, and cancer and a set of housing units, households and people for responses 4 or 5: potential structural social determinants are replaced with codes and geographic (SSDs) in those Colombian municipali- tags at the municipality level; 2) a system Q3: What is the PREDOMINANT flooring ties of Valle del Cauca that experienced of “key words” limits access to certain material? the highest prevalence rates for such users; and 3) the vector files of the da- 1. Wall-to-wall wool or synthetic fiber events during 2000–2005. A priori, it tabase are transformed and encrypted carpeting, marble, polished or lac- was expected that higher prevalences of to prevent their being accessed directly quered wood slats or parquet; catastrophic illnesses would be found to (11). The final dataset used in this study 2. Colored ceramic tile, vinyl, or tiles be associated with inadequate municipal thus consisted of, for each municipality, made of synthetic materials that look provision of health coverage and basic the total numbers of individuals for each like brick; sanitation services, as well as with sub- outcome and exposure pairing. 3. Cement mixed with fine gravel standard quality of housing units and The study was approved by the Eth- 4. Unfinished wood boards placed side by higher rates of illiteracy. ics Committee of the School of Health, side; or plant materials such as woven Universidad del Valle, Cali, Colombia. reed mats or palm leaves; MATERIALS AND METHODS 5. Bare floors (Dirt, sand). Study variables An ecological study of 42 municipali- The second variable was based ties from the Colombian department of Variable selection was conditioned by whether the housing unit had aque- Valle del Cauca was conducted. The data the availability of information and the duct services, as evaluated in Question were taken from the expanded question- processing alternatives offered by the 5 (N.B., each option is an independent naire of the General Census conducted by REDATAM system. Questions and re- question with a yes/no response; “1” DANE in 2005 (9), which comprised three sponse codes from the expanded ques- indicates “yes”): modules: housing units, households and tionnaire that are relevant for this analy- heads of household/respondents. sis are reproduced in the text here, as per Q5: The housing unit HAS services of: The census made use of a probability the original coding. 1. Electricity; sample of households selected in real Health variables related to cata- 1. Sewage system; time (i.e., in the field, based on standard strophic events were abstracted from 1. Aqueduct; criteria), and stratified so as to provide question 38 of the heads of household/ 1. Natural gas utility; estimates at the level of the commune respondents module of the expanded 1. Telephone landline. (an administrative unit that groups sec- questionnaire, with responses 7, 9, and tors of neighborhoods [barrios]) in large 10 indicating illness: A variable measuring level of illit- cities and the Bogotá district, and at the eracy for the municipality was based on level of the municipal seat and for urban Q38: During the LAST FIVE YEARS, have Question 41 of the head of households/ and rural areas in other municipalities you suffered OR DO YOU HAVE ANY respondents module: (10). The household was the unit of se- ILLNESS that has required: lection. To ensure quality of information, 7. Dialysis because of chronic kidney Q41: Do you know how to READ AND mobile computing devices with intelli- failure? WRITE? gent questionnaires were used. 9. Treatment for HIV-AIDS? 1 Yes; To verify data quality, all tables con- 10. Chemotherapy and radiotherapy for 2. No. sulted were checked through the pub- cancer? lic census information system—i.e., From the same module, responses 1-5 REDATAM+SP version 5 (CELADE- Four variables representing SSDs were for Question 36 were regrouped into División de Población, CEPAL. Santiago constructed on the basis of question 3 and two categories that represent affiliation de Chile)—that totals coincided with the question 5 of the housing unit module with the general social security system sum of their components (by variable and question 36 and