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We investigated the causal impact of conflict-related violence on individual mental health and its potential pathways in Colombia. Using data from before and after the 2016 peace accord between the Colombian government and the Revolutionary Armed Forces of Colombia (FARC), we adopted a difference-in-differences empirical design combined with instrumental variables estimation. We also used formal mediation analysis to investigate a possible mediating role of alcohol consumption in the relationship between conflict exposure and mental health. Our results did not support the hypothesis that changes in exposure to conflict violence after the peace accord causally led to any changes in individual mental health. We were unable to identify a statistically significant mediating effect of alcohol consumption in the relationship between exposure to conflict violence and mental health.
RESUMO
Internal armed conflicts have become more common and more physically destructive since the mid-20th century, with devastating consequences for health and development in low- and middle-income countries. This paper investigates the causal impacts of the long-term internal conflict on child health in Colombia, following an identification strategy based on the temporal and geographic variation of conflict intensity. We estimate the effect of different levels of conflict intensity on height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height z-scores among children under five years old, and explore the underlying potential mechanisms, through maternal health behavior and health care utilization. We find a harmful effect of exposure to conflict violence in utero and in early childhood for HAZ and WAZ, in the full sample and even more strongly in the rural sample, yet these estimates are smaller than those found for shorter term conflicts. The underlying pathways appear to operate around the time of the pregnancy and birth (in the form of maternal alcohol use, use of antenatal care and skilled birth attendance), rather than during the post-birth period (via breastfeeding or vaccination), and the impacts accumulate over the childhood. The most adverse impacts of conflict violence on child health and utilization of maternal healthcare were observed in municipalities which suffered from intermittent presence of armed groups.
Assuntos
Conflitos Armados , Saúde da Criança , Aleitamento Materno , Criança , Pré-Escolar , Colômbia/epidemiologia , Feminino , Humanos , Gravidez , Cuidado Pré-NatalRESUMO
BACKGROUND: The present study analyzes inequalities in catastrophic health expenditures in conflict-affected regions of Meta, Colombia and socioeconomic factors contributing to the existence and changes in catastrophic expenditures before and after the sign of Colombian Peace Agreement with FARC-EP guerilla group in 2016. METHODS: The study uses the results of the survey Conflicto, Paz y Salud (CONPAS) conducted in 1309 households of Meta, Colombia, a territory historically impacted by armed conflict, for the years 2014 and 2018. We define catastrophic expenditures as health expenditures above 20% of the capacity to pay of a household. We disaggregate the changes in inequalities in catastrophic expenditures through the Oaxaca-Blinder change decomposition method. RESULTS: The incidence of catastrophic expenditures slightly increased between 2014 to 2018, from 29.3 to 30.7%. Inequalities in catastrophic expenditures, measured through concentration indexes (CI), also increased from 2014 (CI: -0.152) to 2018 (CI: -0.232). Results show that differences in catastrophic expenditures between socioeconomic groups are mostly attributed to an increased influence of specific sociodemographic variables such as living in rural zones, being a middle-aged person, living in conflict-affected territories, or presenting any type of mental and physical disability. CONCLUSIONS: Conflict-deescalation and the peace agreement may have facilitated lower-income groups to have access to health services, especially in territories highly impacted by conflict. This, consequently, may have led to higher levels of out-of-pocket expenditures and, therefore, to higher chances of experiencing catastrophic expenditures for lower-income groups in comparison to higher-income groups. Therefore, results indicate the importance of designing policies that guarantee access to health services for people in conflict -affected regions but also, that minimize health care inequalities in out-of-pocket payments that may arouse between people at different socioeconomic groups.
Assuntos
Conflitos Armados , Doença Catastrófica , Gastos em Saúde , Conflitos Armados/prevenção & controle , Conflitos Armados/estatística & dados numéricos , Doença Catastrófica/economia , Colômbia , Gastos em Saúde/estatística & dados numéricos , HumanosRESUMO
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.