Precarity in the Modes of Living: Proposing an Index for Studying Health Inequities at the Ecological Level in Colombia

Abstract

Deprivation indices are used to monitor health inequities. However, their theoretical underpinnings have been based on the context of Western industrialized countries, which have distinct social and historical backgrounds compared to Latin America and the Caribbean and countries in the Global South. Following the Latin American Social Determination of Health perspective, particularly the category Modes of Living supported by the construct of precarity, we aimed to develop an index of precarity in the modes of living at the department level in Colombia and assess its geographical distribution and potential value for public health. We conducted an ecological cross-sectional study with national administrative records. We developed a precarity index through Principal Component Analysis and performed spatial autocorrelation analyses and regression models with child mortality indicators. Our final index comprised twenty indicators representing four dimensions of the modes of living and power relations. We found precarity not to distribute randomly in Colombia, with a center-periphery divide and higher precarity observed in the country's margin. We also found an association of our index with under-five mortality (SMR = 1.19; 95%CI 1.08-1.31) and infant mortality (SMR = 1.13; 95%CI 1.00-1.26). Our index highlights the relevance of considering the modes of living when devising deprivation indices or similar measures from Colombia or Latin America. This approach may provide different perspectives on the health-disease process and potential value for public health planning.

Keywords: Latin American social medicine; child mortality; collective health; deprivation; modes of living; precarity; social determination of health.

Figure 1

Correlation matrix between indicators constitutive of the index and the index of precarity. Results from Spearman correlation. Darker circle shows positive correlation, lighter circle shows negative correlation. Numbers in indicator’s labels refer to the order in Table 1.

Figure 2

Geographical distribution of the precarity index at the department level in Colombia. Higher values (darker) represent higher deprivation. The Islands of San Andrés and Providencia (88) were enlarged from their original size for visualization purposes and do not follow the depicted scale and location. For reference, Bogotá (the capital city) is labeled with the number 11.

Figure 3

LISA clusters of the precarity index. High-High corresponds to a cluster of high values surrounded by high values. Low-Low corresponds to a cluster of low values surrounded by low values. High-Low corresponds to a high value surrounded by low values. White corresponds to non-significant values (non-significant). The Islands of San Andrés and Providencia were classified as non-significant.

Figure 4

Geographical distribution of under-five mortality rates by quintiles in Colombia between 2017 and 2019. The Islands of San Andrés and Providencia (88) were enlarged from their original size for visualization purposes and do not follow the depicted scale and location. For reference, Bogotá (the capital city) is labeled with the number 11.