Pinzón-Flórez Carlos Eduardo, Fernández-Niño Julián Alfredo, Ruiz-Rodríguez Myriam, Idrovo Álvaro J, Arredondo López Abel Armando
Centre for Research in Health Systems (CISS), Instituto Nacional de Salud Pública de México, Cuernavaca, Mexico.
Information Center for Public Health Decisions (CENIDSP), Instituto Nacional de Salud Pública, Cuernavaca, Mexico.
PLoS One. 2015 Mar 30;10(3):e0120747. doi: 10.1371/journal.pone.0120747. eCollection 2015.
To assess the association of social determinants on the performance of health systems around the world.
A transnational ecological study was conducted with an observation level focused on the country. In order to research on the strength of the association between the annual maternal and child mortality in 154 countries and social determinants: corruption, democratization, income inequality and cultural fragmentation, we used a mixed linear regression model for repeated measures with random intercepts and a conglomerate-based geographical analysis, between 2000 and 2010.
Health determinants with a significant association on child mortality(<1year): higher access to water (βa Quartile 4(Q4) vs Quartile 1(Q1) = -6,14; 95%CI: -11,63 to -0,73), sanitation systems, (Q4 vs Q1 = -25,58; 95%CI: -31,91 to -19,25), % measles vaccination coverage (Q4 vs Q1 = -7.35; 95%CI: -10,18 to -4,52), % of births attended by a healthcare professional (Q4 vs Q1 = -7,91; 95%CI: -11,36 to -4,52) and a % of the total health expenditure (Q3 vs Q1 = -2,85; 95%CI: -4,93 to -0,7). Ethnic fragmentation (Q4 vs Q1 = 9,93; 95%CI: -0.03 to 19.89) had a marginal effect. For child mortality<5 years, an association was found for these variables and democratization (not free vs free = 11,23; 95%CI: -0,82 to 23,29), out-of-pocket expenditure (Q1 vs Q4 = 17,71; 95%CI: 5,86 to 29,56). For MMR (Maternal mortality ratio), % of access to water for all the quartiles, % of access to sanitation systems, (Q3 vs Q1 = -171,15; 95%CI: -281,29 to -61), birth attention by a healthcare professional (Q4 vs Q1 = -231,23; 95%CI: -349,32 to -113,15), and having corrupt government (Q3 vs Q1 = 83,05; 95%CI: 33,10 to 133).
Improving access to water and sanitation systems, decreasing corruption in the health sector must become priorities in health systems. The ethno-linguistic cultural fragmentation and the detriment of democracy turn out to be two factors related to health results.
评估社会决定因素与全球卫生系统绩效之间的关联。
开展了一项跨国生态研究，观察层面聚焦于国家。为研究154个国家的年度孕产妇和儿童死亡率与社会决定因素（腐败、民主化、收入不平等和文化分裂）之间的关联强度，我们在2000年至2010年期间使用了具有随机截距的重复测量混合线性回归模型以及基于聚类的地理分析。
与1岁以下儿童死亡率有显著关联的卫生决定因素：更高的水供应可及性（四分位数4（Q4）与四分位数1（Q1）相比，β=-6.14；95%置信区间：-11.63至-0.73）、卫生系统（Q4与Q1相比，β=-25.58；95%置信区间：-31.91至-19.25）、麻疹疫苗接种覆盖率（Q4与Q1相比，β=-7.35；95%置信区间：-10.18至-4.52）、由医疗专业人员接生的分娩比例（Q4与Q1相比，β=-7.91；95%置信区间：-11.36至-4.52）以及卫生总支出的百分比（Q3与Q1相比，β=-2.85；95%置信区间：-4.93至-0.7）。种族分裂（Q4与Q1相比，β=9.93；95%置信区间：-0.03至19.89）有边际效应。对于5岁以下儿童死亡率，发现这些变量与民主化（不自由与自由相比，β=11.23；95%置信区间：-0.82至23.29）、自付费用（Q1与Q4相比，β=17.71；95%置信区间：5.86至29.56）有关联。对于孕产妇死亡率（MMR），所有四分位数的水供应可及性百分比、卫生系统可及性百分比（Q3与Q1相比，β=-171.15；95%置信区间：-281.29至-61）、由医疗专业人员接生（Q4与Q1相比，β=-231.23；95%置信区间：-349.32至-113.15）以及存在腐败政府（Q3与Q1相比，β=83.05；95%置信区间：33.10至133）。
改善水和卫生系统的可及性、减少卫生部门的腐败必须成为卫生系统的优先事项。民族语言文化分裂和民主的损害是与卫生结果相关的两个因素。
