Educational inequalities in heart failure mortality and the cycles of the internal armed conflict in Colombia: An observational panel study of ecological data, 1999–2017

Abstract

Heart failure (HF) is a significant clinical problem and an important public health issue due to the morbidity and mortality that it causes, especially in a population that is aging and affected by social stressors such as armed conflict. We aim to describe the inequalities and trends of HF mortality by educational level in Colombia between 1999 and 2017 compared with the cycles of the internal armed conflict during the same period. An observational study of ecological data panels, with aggregates at the national level, was conducted. Information from death certificates with HF as the basic cause of death (COD) was used. Variables of the year of death, sex, age, department of residence, and educational level were considered. Mortality rates adjusted for age were calculated. A joinpoint regression was used to model the trend of rates by educational level. We found that both men and women with primary education had the highest adjusted mortality rates: among men, RR_primary = 19.06 deaths/100,000 inhabitants, SE = 0.13 vs. RR_tertiary = 4.85, SE = 0.17, and similar differences among women. Mortality rates tended to decrease at all educational levels, with a greater reduction in people with higher educational levels. In both sexes, the behavior of the relative index of inequality showed significant inequality, albeit with a strong reduction during the last decade. Mortality due to HF in Colombia shows inequalities by educational level. In the prevention of HF, education should be considered a structural social determinant. In addition, we analyzed the potential role of the Colombian long-term armed conflict in the observed trends. We highlighted the role of the health sector, together with other sectors (education, work, and housing), in developing intersectoral public policies that contribute to the reduction of cardiovascular mortality disparities.