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Introduction In Colombia, health and conflict research has focused on mental health, psychosocial care, displacement, morbidity and mortality. Few scientific studies have assessed health system functioning during armed conflict. In the context of a new period characterized by the implementation of the peace agreement with the FARC armed group, understanding the effects of armed conflict in the health system, the functions and institutions shaped by the conflict is an opportunity for understating pathways and the scope post-conflict health policy reforms. Therefore, this study was conceived to assess the effects of armed conflict on the health system, the response and mechanisms developed to protect medical mission during the armed conflict in Colombia. Methods A qualitative study was conducted using semi-structured interviews and focus group discussion. The qualitative guide collected information in four sections: 1) conflict and health system; effects and barriers in health service provision, 2) actions and coordination to cope with those barriers 3) health policies and armed conflict 4) post accord and current situation. A total of 22 people participated in the interviews, including 8 Policymakers at national level and 7 at local level – 2 NGO´s – 5 Members of international organizations. An academic project event in December 2019 and four focus group were developed (Coffee World technique), to discuss with national and local stakeholder, the effects of armed conflict in health system and an analytical framework to analyze its consequences Results The conflict affected the health-seeking behavior of the population, limited access to healthcare provision, affected health professionals, and was associated with inadequate medical supplies in conflict areas. The health system implemented mechanisms to protect the medical mission, regulate healthcare provision in conflict areas and committed to healthcare provision (mental and physical health services) for the population displaced by the conflict. Conclusion Presence, trust and legitimacy of the state has been truncated during recent years, but its recovery is essential and must be based on the real presence of the state and health services in the territories and dispersed rural areas.

Following the peace agreement process in Colombia and to guarantee the right to health, a national educational program to train community leaders in technical education in public health was designed and implemented. Using qualitative methodologies, we sought reflections about the impact of the training process on the 'participant's life projects, collecting information from previous and current experiences and expectations after the program. Participants (n = 44) included peasants, afro-Colombian and indigenous communities, displaced people, victims of the armed conflict, and ex-combatants of the Revolutionary Armed Forces of Colombia - Army of the People (FARC-EP). Data collection through ethnographic observation, focus groups, and individual semi-structured interviews took place between October and November 2018. Results indicate that the participants saw the program as an opportunity to meet their goals and have better opportunities for their lives; change their way of thinking, and be reflective and open to discussion. Historical governmental and institutional abandonment was identified as a barrier for trust in the program and uncertainty on its potential benefits. Daily life co-existence during the training was a challenge between participants given their diverse backgrounds in the context of conflict in Colombia. It is important to create friendly and explanatory strategies to generate trust with and among participants accompanied with psychological support, ease successful interaction, and generate wellbeing through the program's implementation.

Purpose We assessed the validity of the EQ-5D instrument; explored correlations between area of residence’s conflict intensity and individual health-related quality of life (HRQoL); and identified factors associated with HRQoL in a conflict-affected population in Colombia. Methods We conducted a household survey among residents of the Meta province, collecting longitudinal information about HRQoL (EQ-5D-3L instrument), health, demographic and socio-economic indicators, for years 2014 (pre-2016 peace accord), 2018 (post-peace accord) and 2019 (follow-up). After examining EQ-5D’s validity, we analysed panel data using multivariate random effects models to explore associations between area conflict levels (and other factors) and HRQoL. We scrutinised these results further through multivariate linear regressions using cross-sectional data, and provided preliminary estimates of quality-adjusted life years (QALYs) gained since the Colombian peace accord. Results In total, 1309 individuals provided information for years 2014 and 2018; 1106 individuals were followed-up in 2019. Mean EQ-5D scores in 2014, 2018 and 2019 were 0.898, 0.846 and 0.902, respectively. The tests confirmed the validity of EQ-5D. Our estimations indicated a dose–response relationship between conflict levels and HRQoL: people in lightly and heavily affected areas had 0.019 and 0.037 lower EQ-5D scores (respectively) than people in non-affected areas. Other relevant factors included age, marital status, education, assets and health status. We estimated QALY gain of 0.0343 per individual and 20,752 for all Meta adults since the peace accord. Conclusion We found EQ-5D to be a valid instrument for HRQoL measurement in a conflict-affected population. Area conflict intensity was negatively associated with individual HRQoL.

Background Much applied research on the consequences of conflicts for health suffers from data limitations, particularly the absence of longitudinal data spanning pre-, during- and post-conflict periods for affected individuals. Such limitations often hinder reliable measurement of the causal effects of conflict and their pathways, hampering also the design of effective post-conflict health policies. Researchers have sought to overcome these data limitations by conducting ex-post surveys, asking participants to recall their health and living standards before (or during) conflict. These questions may introduce important analytical biases due to recall error and misreporting. Methods We investigate how to implement ex-post health surveys that collect recall data, for conflict-affected populations, which is reliable for empirical analysis via standard quantitative methods. We propose two complementary strategies based on methods developed in the psychology and psychometric literatures—the Flashbulb and test-retest approaches—to identify and address recall bias in ex-post health survey data. We apply these strategies to the case study of a large-scale health survey which we implemented in Colombia in the post-peace agreement period, but that included recall questions referring to the conflict period. Results We demonstrate how adapted versions of the Flashbulb and test-retest strategies can be used to test for recall bias in (post-)conflict survey responses. We also show how these test strategies can be incorporated into post-conflict health surveys in their design phase, accompanied by further ex-ante mitigation strategies for recall bias, to increase the reliability of survey data analysis—including by identifying the survey modules, and sub-populations, for which empirical analysis is likely to yield more reliable causal inference about the health consequences of conflict. Conclusions Our study makes a novel contribution to the field of applied health research in humanitarian settings, by providing practical methodological guidance for the implementation of data collection efforts in humanitarian contexts where recall information, collected from primary surveys, is required to allow assessments of changes in health and wellbeing. Key lessons include the importance of embedding appropriate strategies to test and address recall bias into the design of any relevant data collection tools in post-conflict or humanitarian contexts.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. Pre-exposure prophylaxis (PrEP) access is increasing in Latin America. We explored PrEP use among Spanish-speaking, Hornet geosocial networking application users from Latin American countries with limited PrEP data via an online survey completed between December 2018 and February 2019. A total of 718 Hornet users from 10 countries were included, of whom 72.1% reported PrEP awareness. Few (5.6%) were currently taking PrEP, though 32.1% intended to take PrEP in the subsequent 6 months. PrEP awareness was lower in 18–25 year olds compared to 26+ (62.4% vs. 75.6%, aOR 0.67, [95% CI 0.46–0.97]), and higher among those living in larger versus smaller cities (74.4% vs. 58.8%, aOR 1.96, [95% CI 1.25–3.07]) or countries with at least partial versus no PrEP policy adoption (79.1% vs. 60.8%, aOR 2.20, [95% CI 1.56–3.12]). Intention to use PrEP was higher among PrEP-eligible respondents (51.8% vs. 29.6%, aOR 2.26, [95% CI 1.26–4.07]) and those recently tested for a sexually transmitted infection (35.4% vs. 25.5%, aOR 1.58, [95% CI 1.01–2.48]). Efforts to expand PrEP use in Latin America should focus on national PrEP policy adoption, and research should explore barriers to awareness and use among young men who have sex with men. National Institute of Mental Health Revisión por pares

Resumen Introduccion y objetivos Colombia es uno de los paises del mundo con mayor volumen de desplazamiento interno a causa de un conflicto armado interno. Esta poblacion tiene mayores posibilidades de sufrir un trastorno de salud mental, sobre todo en territorios afectados historicamente por el conflicto. El objetivo es comparar la prevalencia de posibles trastornos de la salud mental entre las personas en condicion de desplazamiento en Meta, departamento de Colombia historicamente afectado por el conflicto armado, frente a poblacion desplazada en todo el pais segun la Encuesta Nacional de Salud Mental (ENSM) de 2015. Metodos Analisis de datos recolectados en la ENSM 2015, estudio a escala nacional, y la encuesta Conflicto, Salud y Paz (CONPAS) de 2014, estudio representativo del grado de afectacion por el conflicto en el municipio, realizado en el departamento del Meta. Para medir un posible trastorno de la salud mental, se utiliza el Self Report Questionnaire-25 (SRQ-25). La condicion de desplazamiento fue declarada por los encuestados en ambos estudios. Se hizo un analisis descriptivo sobre el posible trastorno de la salud mental en la poblacion desplazada de la ENSM 2015 y la CONPAS 2014. Resultados Se encuesto a 1.089 adultos en la CONPAS 2014 y 10.870 adultos en la ENSM 2015. El 42,9% (468) y el 8,7% (943) de las personas reportaron estar en condicion de desplazamiento en la CONPAS 2014 y la ENSM 2015 respectivamente. En ambos estudios, la poblacion desplazada tiene mayores posibilidades de sufrir cualquier trastorno de la salud mental que la poblacion no desplazada. En la CONPAS 2014, el 21,8% (intervalo de confianza del 95% [IC95%], 18,1-25,8) de esta poblacion tenia un posible trastorno de la salud mental (SRQ+) frente al 14,0% (IC95%, 11,8-16,3) en la ENSM 2015. Los encuestados en condicion de desplazamiento de la CONPAS 2014 tuvieron mayor probabilidad que los de la ENSM 2015 en depresion —el 12,4% (IC95%, 9,5-15,7) frente al 5,7% (IC95%, 4,3-7,4)—, ansiedad —el 21,4% (IC95%, 17,7-25,3) frente al 16,5% (IC95%, 14,2-19,1)— y trastornos psicosomaticos —el 52,4% (IC95%, 47,5-56,7) frente al 42,2% (IC95%, 39,0-45,4)—. Los desplazados de la ENSM 2015 tenian mayor probabilidad de ideacion suicida, el 11,9% (IC95%, 9,3-14,1) frente al 7,3% (IC95%, 5,0-10,0) en la CONPAS 2014, y trastorno bipolar, el 56,5% (IC95%, 53,2-59,7) frente al 39,3% (IC95%, 34,8-43,9). Conclusiones La mayor probabilidad de trastornos de la salud mental (SRQ+) de la poblacion regional en condicion de desplazamiento frente a toda la poblacion nacional en esa condicion puede representar una mayor necesidad de servicios de atencion en salud mental en los territorios afectados por el conflicto. Asi pues, y dada la necesidad de facilitar el acceso y la atencion medica en salud mental a poblaciones especialmente afectadas por el conflicto armado, es importante el diseno de politicas de atencion en salud que faciliten la recuperacion de poblaciones afectadas por la guerra y, simultaneamente, reducir inequidades y promover el cumplimiento de uno de los objetivos en salud mas importantes y, a la vez, usualmente menos priorizados en el desarrollo internacional: la salud mental.

Background The present study seeks to evaluate the change in mental health inequalities in the department of Meta after the signing of Colombia’s Peace Agreement in 2016 with the FARC guerrilla group. Using a validated survey instrument composed of 20 questions (‘SRQ-20’), we measure changes in mental health inequalities from 2014, before the signing of the agreement, to 2018, after the signing. We then decompose the changes in inequalities to establish which socioeconomic factors explain differences in mental health inequalities over time. Methods Our study uses information from the Conflicto, Salud y Paz (CONPAS) survey conducted in the department of Meta, Colombia, in 1309 households in 2018, with retrospective information for 2014. To measure inequalities, we calculate the concentration indices for both years. Through the Oaxaca change decomposition method, we disaggregate changes in mental health inequalities into its underlying factors. This method allows us to explain the relationship between changes in mental health inequalities and changes in inequalities in several sociodemographic factors. It also identifies the extent to which these factors help explain the changes in mental health inequalities. Results Mental health inequalities in Meta were reduced almost by half from 2014 to 2018. In 2018, the population at the lower and middle socioeconomic levels had fewer chances of experiencing mental health disorders in comparison to 2014. The reduction in mental health differences is mostly attributed to reductions in the influence of certain sociodemographic variables, such as residence in rural zones and conflict-affected territories, working in the informal sector, or experiencing internal displacement. However, even though mental health inequalities have diminished, overall mental health outcomes have worsened in these years. Conclusions The reduction in the contribution of conflict-related variables for explaining mental health inequalities could mean that the negative consequences of conflict on mental health have started to diminish in the short run after the peace agreement. Nevertheless, conflict and the presence of other socioeconomic inequalities still contribute to persistent adverse mental health outcomes in the overall population. Thus, public policy should be oriented towards improving mental health care services in these territories, given the post-accord context.

Pre-exposure prophylaxis (PrEP) has limited availability across Latin America, though access is increasing. We explored PrEP uptake in Mexico via an online survey completed by Spanish-speaking, Hornet geosocial networking application (GSN app) users without HIV (n = 2020). Most (81.3%) had heard of PrEP, 3.5% were current users, and 34.2% intended to take PrEP within six months. Current PrEP use was associated with PrEP eligibility (aOR 26.07 [95%CI 13.05-52.09], p0.001), recent STI testing (aOR 3.79 [95%CI 1.10-13.11], p = 0.035), and recent chemsex (aOR 3.02 [95%CI 1.02-8.93], p = 0.046). Recent STI testing was associated with hearing about PrEP from a doctor (aOR 3.26 [95%CI 1.98-5.36], p0.001), and those who lived in large cities were less likely to have learned about PrEP via Hornet (aOR 0.52 [95%CI 0.32-0.85], p = 0.009). Interventions to increase PrEP uptake in Mexico should build upon existing health networks and utilize GSN apps for PrEP information dissemination, particularly in less populated areas.La profilaxis pre-exposición (PrEP) tiene disponibilidad limitada en América Latina, aunque su acceso está aumentando. Exploramos el uso de PrEP en México a través de una encuesta en línea para sujetos hispanohablantes sin VIH usuarios de la aplicación de redes geosociales (GSN app) Hornet (n=2020). La mayoría (81,3%) había escuchado sobre PrEP, el 3,5% eran usuarios actuales, y el 34,2% tenían intención de tomar PrEP en seis meses o menos. El uso actual de PrEP estuvo asociado con la elegibilidad de tomar PrEP (aOR 26.07 [95%CI 13.05–52.09], p0.001), tener prueba reciente para ITS (aOR 3.79 [95%CI 1.10–13.11], p = 0.035), y chemsex reciente (aOR 3.02 [95%CI 1.02–8.93], p = 0.046). Tener prueba reciente para ITS se asoció con escuchar sobre PrEP de un médico (aOR 3.26 [95%CI 1.98–5.36], p0.001), y quienes vivían en ciudades grandes tenían menos probabilidad de conocer acerca de PrEP a través de Hornet (aOR 0.52 [95%CI 0.32–0.85], p = 0.009). Las intervenciones para aumentar el uso de PrEP en México deberían basarse en redes de salud existentes y usar las GSN apps para difundir información sobre PrEP, particularmente en áreas menos pobladas.

Colombia is one of the countries with the highest levels of internal displacement resulting from armed conflict. This population has greater chances of experiencing a mental health disorder, especially in territories historically affected by armed conflict. Our objective was to compare the levels of possible mental health disorder in people experiencing internal displacement in Meta, Colombia, a department historically affected by armed conflict, compared to the internally displaced population in the National Mental Health Survey of 2015.Analysis of data collected in the National Mental Health Survey (ENSM) of 2015, study with representative data at national level and the Conflict, Peace and Health survey (CONPAS) of 2014, representative study of the degree of impact of the conflict on the municipality, conducted in the department of Meta, Colombia. To measure possible mental health disorder, the Self-Report Questionnaire - 25 (SRQ-25) was used. Internal displacement is self-reported by people surveyed in both studies. An exploratory analysis is used to measure possible mental health disorders in the displaced population in the ENSM 2015 and CONPAS 2014.1,089 adults were surveyed in CONPAS 2014 and 10The greater possibilities of displaced populations at the regional level of experiencing a mental health disorder, compared to this same population at the national level, may represent and indicate greater needs in mental health care services in territories affected by conflict. Therefore, and given the need to facilitate access to health services in mental health for populations especially affected by armed conflict, there is a need to design health care policies that facilitate the recovery of populations affected by war and, simultaneously, that reduce inequities and promote the fulfilment of one of the most important and, at the same time, least prioritised health objectives in international development: mental health.

We assessed the validity of the EQ-5D instrument; explored correlations between area of residence's conflict intensity and individual health-related quality of life (HRQoL); and identified factors associated with HRQoL in a conflict-affected population in Colombia.We conducted a household survey among residents of the Meta province, collecting longitudinal information about HRQoL (EQ-5D-3L instrument), health, demographic and socio-economic indicators, for years 2014 (pre-2016 peace accord), 2018 (post-peace accord) and 2019 (follow-up). After examining EQ-5D's validity, we analysed panel data using multivariate random effects models to explore associations between area conflict levels (and other factors) and HRQoL. We scrutinised these results further through multivariate linear regressions using cross-sectional data, and provided preliminary estimates of quality-adjusted life years (QALYs) gained since the Colombian peace accord.In total, 1309 individuals provided information for years 2014 and 2018; 1106 individuals were followed-up in 2019. Mean EQ-5D scores in 2014, 2018 and 2019 were 0.898, 0.846 and 0.902, respectively. The tests confirmed the validity of EQ-5D. Our estimations indicated a dose-response relationship between conflict levels and HRQoL: people in lightly and heavily affected areas had 0.019 and 0.037 lower EQ-5D scores (respectively) than people in non-affected areas. Other relevant factors included age, marital status, education, assets and health status. We estimated QALY gain of 0.0343 per individual and 20,752 for all Meta adults since the peace accord.We found EQ-5D to be a valid instrument for HRQoL measurement in a conflict-affected population. Area conflict intensity was negatively associated with individual HRQoL.