To analyze the consumption of ultra-processed foods in the Colombian population across sociodemographic factors. We used data from the 2005 National Survey of the Nutritional Status in Colombia. Food consumption was assessed using a 24-hour food recall in 38,643 individuals. The food items were classified according to the degree and extent of industrial processing using the NOVA classification. The mean calorie contribution of ultra-processed foods ranged from 0.2% in the lowest quintile of consumers to 41.1% in the highest quintile of consumers. The greatest increases were due to the consumption of industrialized breads, sweet and savory snacks, sugary drinks, processed meats, and confectionery. No major differences were found in the consumption of ultra-processed foods between men and women. We observed significant differences by age, socioeconomic status, area of residence, and geographic region. Children and adolescents showed a higher intake of ultra-processed foods, almost double that of participants over 50 years of age. Children consumed significantly more snacks, confectionery products, processed cereals, milk-based drinks and desserts. Participants over 50 years consumed fewer products from these sub-groups of ultra-processed foods but had the highest consumption of industrialized bread. Individuals from urban areas, those with high socioeconomic status, participants residing in the Bogotá region had 1.5 to 1.7 times higher calorie intake from ultra-processed foods compared with those from a lower socioeconomic status and those residing in rural regions. In Colombia, industrialized bread is the ultra-processed product that is most easily assimilated into the traditional diet, along with snacks and sugary drinks. Children and adolescents residing in urban areas and households with greater purchasing power have some of the highest intakes of ultra-processed foods in the country. These products are characterized by being ready to consume, hyperpalatable, extensively marketed, and having a long shelf life1.Ultra-processed foods are industrial formulations made from substances derived from whole foods. Generally, they contain little or no natural foods, and have a high content of fat, salt, or/and sugar, and a low content of dietary fiber, proteins, micronutrients, and bioactive compounds. Examples of ultra-processed foods include snacks like industrialized ice cream, sugary drinks, chocolates, confectionery, french fries, hamburgers, and hot dogs2. These products dominate the food environment in developed countries, contributing almost 60.0% of the total energy consumed in the United States6, and 50.0% in Canada7. The high consumption of ultra-processed foods and the evidence showing an association with adverse health outcomes, such as obesity, metabolic syndrome, and breast cancer9, have resulted in efforts to reduce the intake of these products through regulation 11.Ultra-processed foods reflect a dietary pattern associated with a high content of nutrients related to chronic diseases5. However, the combination of market forces, the increase in confidence to invest in the country following the end of the armed conflict, and the increase in purchasing power suggest an accelerated growth in the purchase and consumption of ultra-processed foods in the country12. Colombia is experiencing a nutritional, economic, and demographic transition, characterized by the decrease in the consumption of traditional meals, and an increase in urbanization and income, influenced by changing structures in the labor market14. Changes in market regulation in Colombia and the introduction of free trade agreements with countries that export ultra-processed foods ensure an increasing supply of these products12. Euromonitor International data show an annual percentage growth of more than 6.0% in the sales of all types of ultra-processed foods in Colombia, including frozen foods, sweet and savory snacks, canned/preserved foods, and dairy products15. The relative growth in sales of such product categories was higher in developing countries including Colombia than in industrialized countries between 1998 and 2012. Data from other Latin American countries such as Brazil, Chile, and Mexico have shown a substantial incorporation of ultra-processed foods in the diets of their populations ranging from 21.5% in 2008–2009, 28.6% in 2010, and 30% in 2012, respectively 17. These trends suggest that Colombia’s population, like it’s neighboring countries, is vulnerable to a very significant increase in the consumption of ultra-processed foods.Ultra-processed foods contributed an average of 16.0% of the total daily calories in Colombia in 2005There has been no prior evaluation of the types of ultra-processed foods most consumed in Colombia. In this context of increasing foreign investment of food companies, expanding the diversity of ultra-processed foods on offer, and the growing trends of chronic diseases, it is important to assess the consumption pattern of these products. The study aimed to analyze the consumption of ultra-processed foods in the Colombian population, across sociodemographic factors.18.This study used data from the first National Survey of the Nutritional Status of Colombia  and the National Survey of Demography and Health of Colombia , conducted between October 2004 and July 2005 by the Colombian Institute of Family Welfare (ICBF) and Profamilia. The survey used a stratified, multi-stage, and cross-sectional design to obtain national and subregional representativeness (16 subregions), with over-sampling of rural areas and low socioeconomic (SES) groups. It included 99.0% of the urban and rural population with a response rate of 74.0%. The ENSIN sample size and sample design aimed to estimate proportion and prevalence18.The dietary data were obtained from participants aged between 2 – 64 years using a 24-hour food recall. The 24-hour recall captured data from random days of the week including weekends. The interviewers used 60 standardized plastic models and photographs to improve the accuracy of the quantity and weight of the food and beverages consumed. They obtained information about the type of food, the name of the preparation, the ingredients, and the amount consumed. The person responsible for preparing the food was present at the time of the interview. In cases in which the food consumed by a child was in school or in a daycare center, the interviewer visited the school to obtain detailed information about the preparations. The quality of the data was monitored throughout the process, and the interview was repeated in case of inconsistencies1. The foods were categorized into one of 33 subgroups. In 5.6% of the cases, it was not possible to disaggregate the typical culinary dishes into their constituent ingredients , and these products were classified as minimally processed foods (“freshly prepared food” ). The intake of energy and nutrients for each food at an individual level was calculated using software developed by the School of Nutrition and Dietetics at the University of Antioquia, Medellín, Colombia18.A total of 1,053 foods were classified into one of the four NOVA categories by the authors of this study. The categories are mutually exclusive and vary according to their extent and purpose of processing. They include unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foodsper capita19. SISBEN level 1 indicates low SES, while “Level 4 and higher” indicates high SES. The area of residence indicator comprised of urban, central, and rural categories. The geographical regions included Atlantic, Eastern, Central, Pacific, Bogota, Orinoquía, and the Amazon.This study used self-reported data on sex , age , SES, and geographic regions compiled by the ENDS. The SES of the sample was evaluated using the SISBEN composite index. This is a family welfare index composed of 24 variables across four dimensions: health, education, housing, and vulnerability, and it includes indicators such as social security, years of schooling, employment, and income 5, and responses from pregnant women were excluded from the analysis. The final sample size included 38,643 individuals. Sample weights were used in all analyses to consider the differential probabilities of selection. Individuals were classified into quintiles according to the dietary contribution of the ultra-processed foods . We analyzed the relative energy consumption  for the four NOVA categories and subgroups across quintiles. Gross and adjusted linear regression analyses were performed with sociodemographic indicators and all NOVA categories and subgroups of ultra-processed foods. The significance level was established as an alpha of 5.0% and a p-value of 0.05. Visual diagnostic tests for the ordinary least squares (OLS) regression suggested a fairly normal distribution of errors, and slight deviations from normality in the upper and lower tails. Data analyses were performed in STATA 14, and the consumption map was designed in R version 3,4,4.The ENSIN data were combined with the ENDS data to link food consumption with demographic information at the individual level. Responses with missing information for total energy, with extreme total energy intakes The participants’ mean age was 26.5 years [standard deviation (SD) = 0.2], 51.9% of the sample was composed of women, 29.4% represented low SES, and 5.1% represented high SES. Three quarters of the population resided in urban areas, and the highest number of participants were from the Atlantic (25.3%) and Central (23.8%) regions . NaturalThe percentage contribution of total calories from natural or minimally processed foods, and culinary ingredients and their subgroups, decreased across the quintiles of consumption of ultra-processed foods. Calories from natural or minimally processed foods decreased by 32.0% between the first quintile (76.1%) and last quintile (44.1%). The consumption of natural yogurt increased between the quintiles, while the consumption of vegetables was not very high (1.5%) and remained unchanged between the quintiles. The percentage of calories from all processed foods remained relatively unchanged, increasing marginally between quintiles 2 and 3, before decreasing again.The mean calorie contribution of ultra-processed foods ranged from 0.2% in the first quintile to 41.1% in the last quintile. The greatest increases came from the consumption of industrialized breads, followed by sweet and savory snacks, sugary drinks, processed meats, and confectionery products. Ready-to-eat foods, desserts, industrialized breakfast cereals, and dairy drinks also increased between quintiles, but to a lesser degree.No major differences were found in the consumption of ultra-processed foods between men and women. We observed significant differences by age, SES, area of residence, and geographic region. The oldest participants had the highest consumption of natural or minimally processed foods, while the youngest participants (2–9 years old) had the highest intake of ultra-processed foods: almost double that of the participants aged over 50 years. The highest consumers of natural or minimally processed foods and the lowest consumers of ultra-processed foods were from the lowest SES, resided in rural areas, or in the Atlantic region. Individuals from the urban area, with high SES, residing in the Bogotá region had 1.5 to 1.7 times higher calorie intake from ultra-processed foods compared to those with low SES and individuals residing in rural areas .Women consumed more breads, snacks and confectionery products while men consumed more sugary drinks and ready-to-eat meals. Children aged below 9 years consumed significantly more snacks, confectionery products, processed cereals, dairy drinks, and desserts. Participants older than 50 years consumed fewer products from these subgroups but had the highest consumption of industrialized bread. As for sugary drinks, a different trend was also observed. People aged 20–34 years had the highest intakes  compared with the older adults (1.3%) and children (2.1%). Similarly, we observed higher intake of ultra-processed foods in the high SES class for most ultra-processed foods such as snacks, sugary drinks, processed meat, ready-to-eat foods, and desserts. These consumers had an intake comparable to that of those with low SES in processed bread and confectionery .Participants that resided in urban areas consumed more ultra-processed foods. However, their consumption was not significantly different compared with residents in rural regions, with regards to confectionery sweets. We observed similar trends among residents of the Bogotá region who consumed significantly more industrialized bread, confectionery, snacks, ready-to-eat foods, and desserts compared to other regions. However, the consumption of processed meats was the lowest. The residents of Orinoquía and the Amazon had the highest intake of sugary drinks, while those of the Central region exceeded the consumption of processed meat. Almost no differences were observed between geographic regions for the intake of dairy drinks.The data showed a wide range in the consumption patterns of ultra-processed foods in Colombia across various sociodemographic factors. Those individuals with the lowest consumption of ultra-processed foods  obtained more than 95% of their energy from natural or minimally processed foods and culinary ingredients. On the other hand, individuals with higher consumption of ultra-processed foods replaced almost half of the calories from natural or minimally processed foods – they obtained 41% of their energy consumption from ultra-processed foods and 44% from natural or minimally processed foods. Industrialized bread was the largest contributor to total energy from ultra-processed foods. Adolescents and urban residents were the largest consumers of ultra-processed foods, especially snacks, processed cereals, dairy drinks, and junk food. Men consumed more sugary drinks and ready-to-eat meals.20. Desserts, fast foods, and sugary drinks are the main contributors in Brazil4. Confectionery, processed meats, and ready-to-eat meals also increased in Colombia, but to a lesser extent. In general, the consumption of ultra-processed foods in Colombia remains relatively low, but with enormous potential for growth in all subgroups according to recent purchase trend data15.As the total consumption of ultra-processed foods increased, industrialized bread, snacks, and sugary drinks provided the greatest amount of energy, surpassing the consumption of bananas, roots and tubers, and cereals from the group of natural or minimally processed foods. The subgroups of ultra-processed foods that supply most calories vary among other countries in South America. Desserts, cookies, cakes, and sugary drinks are the main contributors to energy in Mexico and Chile9. A dietary pattern characterized by the consumption of subgroups of ultra-processed foods such as hamburgers and hot dogs was associated with overweight among Colombian children aged 5–12 years, particularly those in the high SES21. Rural residents and older adults are likely to have more traditional cooking and eating practices and more stable dietary patterns. These groups may also be more resistant to marketing practices that appeal to the younger generation, with less stable dietary patterns, and therefore more likely to try these products.In Colombia, people aged below 19 years living in the capital Bogotá, and with a high SES were the main consumers of ultra-processed foods. Of these, children were the most vulnerable group for the consumption of these products. This is particularly worrying considering the long-term health consequences of eating ultra-processed foodsAspects such as exposure, availability, access, and penetration of these ultra-processed foods in Colombia’s food environment may also explain the highest consumption of these products in urban areas, high SES areas, and in large cities . These segments may have greater exposure to marketing, greater purchasing power to access these products, and a wider palate to adapt to new tastes. Colombians residing in rural areas, in the Atlantic, Central, and Pacific regions, or those in the lower SES seem protected from exposure to these ultra-processed foods, while retaining traditional culinary preparations. This is probably due to lower exposure to the commercial marketing of these products and to a lower disposable income.20. On the other hand, consumption is not as consistent by SES. In Mexico and Brazil, as in Colombia, the richest and most educated consume more ultra-processed foods, with a dose-response in relation to the increase according to SES24. Chile also showed higher consumption in those with higher incomes, but no differences were found by education16. However, the consumption of ultra-processed foods was higher among those with lowest education and income level in the United Kingdom, France, and the United States. These results indicate a distinction in consumption patterns according to the nutritional transition stage of each country. In developing countries in the intermediate stage (patterns 3 and 4) of nutritional transition, the purchase and consumption of ultra-processed foods were boosted by individuals with high income levels. These countries move away from the intake of starchy foods  and protein-energy deficiencies towards noncommunicable diseases25. The opposite was observed in developed countries that are nearing the end (pattern 4) of nutritional transition. In these countries, consumption was relatively low among the richest, however, their percentage of daily energy from ultra-processed foods was greater than 50%25.The Colombian consumption pattern of ultra-processed foods among children and adolescents reflects the global pattern: the United Kingdom, the United States, Canada, Chile, France, and Mexico show a higher consumption of ultra-processed foods in these age groups26. Those with a high level of education were less likely to consume ultra-processed foods at dinner and snacks and sugary drinks during the day compared with those with a low level of education. These results were different from those seen in this study and are probably explained by the later stage of the nutritional transition (pattern 4) in Norway. Among children, there is some consistency in the types of ultra-processed foods consumed. Analyses of the main components of food consumption in 12 countries show that ultra-processed foods such as fast foods, ice cream, fried foods, fries, and sugary drinks more strongly characterize unhealthy eating patterns among children aged 9–11 years27. Recent data from Colombia on the frequency of consumption of sugary drinks show that 85.3% of the children aged 5–17 years consume these drinks 0.71 time per day28. The percentage contribution of sugary drinks to daily energy was not available, but frequency trends indicate a very present and worrying consumption pattern among children and adolescents.Few studies have examined the differences within the ultra-processed food subgroups. In Norway, men were more likely to be classified as large consumers of ultra-processed dinner products and fast foods, but not of snacks and sugary drinks, compared with women12. Strategies may include: (i) prohibiting the sale of ultra-processed food in schools and playgrounds; (ii) better disseminating health promotion tools, such as food-based dietary guidelines that consider the extent and purpose of the processing implemented in Brazil29 and Uruguay30; (iii) including appropriate warning labels and imposing initiatives to encourage healthier options at points of purchase as has been done in Chile10.Regulation is necessary to protect nutritional status and well-being, especially of children and adolescentsThis study has its limitations. All dietary information was collected by 24-hour dietary recalls. In addition to the memory bias, participants may choose not to disclose information about certain food products that are considered socially undesirable, both in terms of product categories and quantities consumed. This single point of dietary information may not capture the participants’ usual diet and, therefore, be less representative of their intake. Although the analyses controlled for several sociodemographic variables, residual confusion is difficult to eliminate. However, the probabilistic nature of the sample studied, the national representativeness of the Colombian population, the use of the latest national survey with 24-hour dietary recall available, and the standardization of the collection of dietary data are some of the strengths of this study. It is probable that the consumption of ultra-processed foods in Colombia has changed since the publication of these data. This study provides reference intake levels and could serve as a baseline for comparison with more recent dietary assessments, when available, to capture trends in the consumption of ultra-processed foods in Colombia.This study characterizes the ultra-processed products that are consumed most frequently and that can be considered as the entry points of ultra-processed foods into the Colombian diet. Sociodemographic differences are explored to identify segments of the population that can be considered the most vulnerable to the consumption of these foods. Industrialized bread is the ultra-processed food that is most easily assimilated into the traditional diet, along with snacks and sugary drinks. Children and adolescents adapt more easily to these products and, therefore, are more vulnerable to their deleterious effects on health. In general, the consumption of ultra-processed foods is not as high in Colombia as in other countries, but has great potential to increase. These data also encourage a review of the current health promotion and prevention policy and regulatory efforts in Colombia related to the promotion and sale of these products, particularly with regards to vulnerable sub-groups such as children and adolescents. 2. Estos productos se caracterizan por ser listos para consumir, hiperpalatables, muy publicitados, y por tener una larga vida útil1.Los alimentos ultraprocesados son formulaciones industriales fabricadas de sustancias derivadas de alimentos o sintetizadas de otras fuentes orgánicas. Generalmente, contienen poco o nada de alimentos naturales, un alto contenido de grasas, sal o azúcar y bajo contenido de fibra dietética, proteínas, micronutrientes y compuestos bioactivos. Entre los ejemplos de alimentos ultraprocesados se incluyen: productos snacks con alto contenido de azúcar, grasa o sal, helados industrializados, bebidas azucaradas, chocolates, confitería, papas fritas, hamburguesas, y perros calientes2. Estos productos dominan el sistema alimentario en los países desarrollados, contribuyendo con casi el 60,0% de la energía total consumida en los Estados Unidos6, y con el 50,0% en Canadá7. El alto consumo de alimentos ultraprocesados, y la evidencia mostrando una asociación con resultados adversos para la salud, como el obesidad, síndrome metabólico y cáncer de mama9, han impulsado esfuerzos para reducir la ingesta de estos productos a través de la regulación y fiscalización11Los alimentos ultraprocesados generan un patrón dietético asociado a un alto contenido de nutrientes relacionados con enfermedades crónicas5. Sin embargo, la combinación de las fuerzas del mercado, el aumento en la confianza para invertir en el país por el pacto del término del conflicto armado y el mejoramiento en el poder adquisitivo sugieren un aumento acelerado en la compra y el consumo de alimentos ultraprocesados en el país12. Colombia experimenta una transición nutricional, económica y demográfica, caracterizada por la disminución en el consumo de preparaciones tradicionales, el aumento de la urbanización y en los ingresos influenciado por estructuras cambiantes en el mercado laboral14. Los cambios en la regulación del mercado y la introducción de acuerdos de libre comercio con países exportadores de alimentos ultraprocesados aseguran un suministro cada vez mayor de estos productos12. Los datos de Euromonitor International muestran en Colombia un crecimiento porcentual anual de más del 6,0% en las ventas de todos los tipos de alimentos ultraprocesados, incluyendo los alimentos congelados, aperitivos dulces y salados, alimentos enlatados/conservados y productos lácteos15. El crecimiento relativo en las ventas dentro de tales categorías de productos fue mayor en países en desarrollo incluyendo Colombia que en los países industrializados entre 1998 y 2012. Otros países de América Latina como Brasil, Chile y México han encontrado una incorporación sustancial de los alimentos ultraprocesados en las dietas de sus poblaciones de 21,5% en 2008-2009, 28,6% en 2010 y 30% en 2012, respectivamente17. Estas tendencias sugieren que la población de Colombia, al igual que en países vecinos, es vulnerable a un aumento dramático en el consumo de alimentos ultraprocesados.Los alimentos ultraprocesados contribuyeron en promedio con un 16,0% del total de calorías diarias en Colombia en el año 2005No existe un reporte previo de los tipos de alimentos ultraprocesados de mayor consumo en Colombia. En este contexto de aumento de la inversión extranjera de las empresas de fabricación de alimentos, ampliando la diversidad en alimentos ultraprocesados en oferta, y de las crecientes tendencias de las enfermedades crónicas, es importante conocer el patrón de consumo de esos productos. El objetivo del estudio fue analizar el consumo de alimentos ultraprocesados en la población colombiana, según factores sociodemográficos.18.Este estudio utilizó datos de la primera Encuesta Nacional de la Situación Nutricional de Colombia  y la Encuesta Nacional de Demografía y Salud de Colombia , realizada entre octubre de 2004 y julio de 2005 por el Instituto Colombiano de Bienestar Familiar (ICBF) y Profamilia. La encuesta utilizó un diseño estratificado, de etapas múltiples y de corte transversal para obtener representatividad nacional y subregional (16 subregiones), con sobre-muestreo de áreas rurales y grupos de bajo estatus socioeconomico (ESE). Incluyó el 99,0% de la población urbana y rural con una tasa de respuesta del 74,0%. El tamaño de la muestra y el diseño muestral de la ENSIN fueron realizados para calcular los estimativos de proporción y de prevalencias, como también modelos estadísticos para evaluar asociaciones18.Los datos dietéticos se obtuvieron utilizando un recordatorio de 24 horas, administrado por el entrevistador, en edades entre los 2 y 64 años para ambos sexos. El recordatorio de 24 horas capturó datos de días aleatorios en semana y fines de semana. Los entrevistadores utilizaron 60 modelos estandarizados de plástico y fotografías para mejorar la precisión de la cantidad y peso de los alimentos y bebidas consumidas. Se registró la información sobre el tipo de alimento, el nombre de la preparación, los ingredientes y la cantidad consumida. La persona responsable de preparar el alimento estuvo presente en el momento de la entrevista. En los casos en los cuales la comida consumida por un niño estaba en la escuela o en una guardería, el entrevistador visitó la escuela para obtener información detallada de las preparaciones. La calidad de los datos se controló durante todo el proceso y la entrevista se repitió en caso de inconsistencias1. Los alimentos se categorizaron en uno de los 33 subgrupos. En 5,6% de los casos, no fue posible desglosar las preparaciones culinarias típicas en sus ingredientes constituyentes  y se clasificaron como alimentos mínimamente procesados en la categoría de ‘comida recién preparada’. Se calculó la ingesta de energía y nutrientes para cada alimento a nivel individual utilizando un software desarrollado por la Escuela de Nutrición y Dietética de la Universidad de Antioquia, Medellín, Colombia18.Se clasificaron 1.053 alimentos en una de las cuatro categorías de NOVA por los autores de este estudio. Las categorías son mutuamente excluyentes y varían según su extensión y propósito de procesamiento. Incluyen alimentos no procesados o mínimamente procesados, ingredientes culinarios procesados, alimentos procesados y alimentos ultraprocesadosper capita19. El nivel 1 de SISBEN indica bajo ESE, mientras que el ‘Nivel 4 y más’ indica alto ESE. El indicador del área residencial abarca categorías urbana, central y rural. Las regiones geográficas incluyen Atlántica, Oriental, Central, Pacífica, Bogotá, Orinoquia y la Amazonia.Este estudio utilizó datos auto informados sobre sexo (masculino/femenino), edad , ESE y regiones geográficas recopilados por la ENDS. El ESE de la muestra se evaluó utilizando el índice compuesto SISBEN. Este es un índice de bienestar familiar construido a partir de 24 variables en cuatro dimensiones: salud, educación, vivienda y vulnerabilidad e incluye indicadores como seguridad social, años de educación, empleo e ingreso 5 y las respuestas de las mujeres embarazadas fueron excluidas del análisis. El tamaño de muestra final incluyó 38.643 individuos. Se usaron ponderaciones de muestra en todos los análisis para tener en cuenta las probabilidades diferenciales de la selección. Los individuos se clasificaron en quintiles según la contribución dietética de los alimentos ultraprocesados . Se analizó el consumo relativo de energía  para las cuatro categorías y subgrupos de NOVA en los quintiles. Se realizaron análisis lineales de regresión bruta y ajustada con indicadores sociodemográficos y todas las categorías de NOVA y subgrupos de alimentos ultraprocesados. El nivel de significación se estableció como un alfa del 5,0% y un valor de p de 0,05. Las pruebas de diagnóstico visual para la regresión de ordinary least squares (OLS) sugirieron una distribución bastante normal de los errores, y desviaciones leves de lo normal en la cola superior e inferior. Los análisis de datos se realizaron en STATA 14 y el mapa fue diseñado con el programa R3,4,4.Los datos de la ENSIN se combinaron con los datos de la ENDS para vincular el consumo de alimentos con la información demográfica a nivel individual. Las respuestas con información faltante sobre la energía total, con ingestas de energía total extrema La edad promedio de los participantes fue de 26,5 años , 51,9% de la muestra era de sexo femenino, 29,4% tenía ESE bajo y 5,1% tenía ESE alto. Tres cuartas partes de la población residía en áreas urbanas y las regiones con mayor numero de participantes fueron Atlántico , y Central  . Los aliEl porcentaje de contribución de las calorías totales de los alimentos naturales o mínimamente procesados, y los ingredientes culinarios y sus subgrupos, disminuyó a través de los quintiles de consumo de alimentos ultraprocesados. Las calorías de los alimentos naturales o mínimamente procesados disminuyeron un 32,0% entre el primer quintil  y ultimo quintil . El consumo de yogur natural aumentó entre los quintiles, mientras que el consumo de verduras no fue muy alto  y se mantuvo sin cambios entre los quintiles. El porcentaje de calorías de todos los alimentos procesados se mantuvo relativamente sin cambios, aumentando marginalmente entre los quintiles 2 y 3, antes de volver a disminuir.La contribución promedio de calorías de los alimentos ultraprocesados varió del 0,2% en el primer quintil al 41,1% en el ultimo quintil. Los mayores incrementos vinieron del consumo de panes industrializados, seguidos de los snacks dulces y salados, las bebidas azucaradas, las carnes procesadas y los productos de confitería. Los alimentos listos para el consumo, los postres, los cereales industrializados para el desayuno y las bebidas lácteas también aumentaron entre los quintiles, pero en un grado menor.No hubo diferencias en el consumo de alimentos ultraprocesados entre hombres y mujeres. Se observaron diferencias significativas por edad, ESE, área de residencia y región geográfica. Los participantes de mayor edad fueron los consumidores con mayor consumo de alimentos naturales o mínimamente procesados, mientras que la categoría más joven de los participantes (de dos a nueve años) tuvo la mayor ingesta de alimentos ultraprocesados: casi el doble que la de los participantes mayores de 50 años. Los mayores consumidores de alimentos naturales o mínimamente procesados y los consumidores más bajos de alimentos ultraprocesados estuvieron en los niveles socioeconómicos más bajos, en áreas rurales o en la región Atlántica. Los habitantes urbanos, con alto ESE, que residían en la región de Bogotá tenían entre 1,5 y 1,7 más veces de ingesta calórica de alimentos ultraprocesados en comparación con sus contrapartes de bajo ESE, y sus contrapartes rurales .Las mujeres consumieron mayor cantidad de panes, snacks y productos de confitería y los hombres consumieron mayor cantidad de bebidas azucaradas y comidas listas para consumir. Los niños menores de nueve años consumieron significativamente mayor cantidad de snacks, productos de confitería, cereales procesados, bebidas lácteas y postres. Los participantes mayores de 50 años consumieron menor cantidad de productos de estos subgrupos, pero tenían el consumo más alto de pan industrializado. En las bebidas azucaradas, también se observó una tendencia diferente. Las personas entre los 20 a 34 años tuvieron las ingestas más altas  en comparación con las personas de edad avanzada  y los niños . De manera similar, se observó una mayor ingesta de alimentos ultraprocesados en la clase de alto ESE para la mayoría de los alimentos ultraprocesados como snacks, bebidas azucaradas, carne procesada, alimentos listos para el consumo y postres. Estos consumidores tuvieron una ingesta comparable a los de bajo ESE en pan procesado y confitería .Los participantes que residían en áreas urbanas consumieron mayor cantidad de alimentos ultraprocesados. Sin embargo, su consumo no fue significativamente diferente comparado con los residentes rurales respecto a los dulces de confitería. Se observaron tendencias similares entre los residentes de la región de Bogotá que consumieron significativamente mayor cantidad de pan industrializado, confitería, aperitivos, alimentos listos para el consumo y postres que otras regiones. Sin embargo, el consumo de carnes procesadas fue el más bajo. Los residentes de Orinoquia y la Amazonia tuvieron la mayor ingesta de bebidas azucaradas, mientras que los de la región Central superaron el consumo de carne procesada. Casi no se observaron diferencias entre regiones geográficas para la ingesta de bebidas lácteas.Los datos mostraron una amplia gama en los patrones de consumo de alimentos ultraprocesados en Colombia según factores sociodemográficos. Aquellos individuos con el consumo más bajo de alimentos ultraprocesados , obtuvieron más del 95,0% de su consumo de energía de alimentos naturales o mínimamente procesados e ingredientes culinarios. Por otra parte, los individuos con mayor consumo de alimentos ultraprocesados desplazan casi la mitad de las calorías provenientes de los alimentos naturales o mínimamente procesados - obtuvieron el 41% de su consumo de energía de los alimentos ultraprocesados y el 44% de los alimentos naturales o mínimamente procesados. El pan industrializado fue el mayor contribuyente a la energía total proveniente de alimentos ultraprocesados. Los adolescentes y los residentes urbanos fueron los mayores consumidores de alimentos ultraprocesados, especialmente snacks, cereales procesados, bebidas lácteas y comida chatarra. Los hombres consumían mayor cantidad de bebidas azucaradas y comidas listas para comer.16. Los postres, las comidas rápidas y las bebidas azucaradas son los principales contribuyentes en Brasil4. La confitería, las carnes procesadas y las comidas listas para el consumo también aumentaron en Colombia, pero en menor medida. En general, el consumo de alimentos ultraprocesados en Colombia sigue relativamente bajo, pero con un enorme potencial de crecimiento del consumo en todos los subgrupos según datos de tendencia de compra en los últimos años15.A medida que el consumo total de alimentos ultraprocesados aumentó, el pan industrializado, los aperitivos y las bebidas azucaradas proporcionaron la mayor cantidad de energía, desplazando el consumo de plátanos, raíces y tubérculos, y cereales provenientes del grupo de los alimentos naturales o mínimamente procesados. Los subgrupos de alimentos ultraprocesados que contribuyen a la mayoría de las calorías varían en otros países de América del Sur. Los postres, las galletas, pasteles y bebidas azucaradas son los principales contribuyentes a la energía en México y Chile9. Un patrón dietético caracterizado por el consumo de subgrupos de alimentos ultraprocesados como hamburguesas y hot dogs  se asoció con mayor sobrepeso entre los niños colombianos de 5 a 12 años, particularmente aquellos en el alto ESE21. Es probable que los residentes rurales y adultos mayores tengan prácticas de cocina y alimentación más tradicionales y patrones dietéticos más estables. Estos grupos también pueden ser más resistentes a las prácticas de comercialización que atraen a la generación más joven, con patrones dietéticos menos estables, y por lo tanto más propensos a experimentar con estos productos.En Colombia, los residentes urbanos, menores de 19 años de la capital Bogotá y de alto ESE son los principales consumidores de alimentos ultraprocesados. De estos, los niños son el grupo más vulnerable para el consumo de estos productos. Esto es particularmente preocupante considerando las consecuencias a largo plazo para la salud de la ingesta de alimentos ultraprocesadosAspectos como la exposición, la disponibilidad, el acceso, y la penetración de estos alimentos ultraprocesados en el entorno alimentario de Colombia también pueden explicar el más alto consumo de estos productos en las zonas urbanas, de alto ESE y en las grandes ciudades . Es probable que estos segmentos tengan una mayor exposición al marketing, mayor poder adquisitivo para el acceso a estos productos y un paladar más amplio para adaptarse a los gustos nuevos. Los colombianos que residen en las zonas rurales, en las regiones del Atlántico, Central y el Pacífico o los del bajo ESE, están protegidos de la exposición a estos alimentos ultraprocesados, conservando las preparaciones culinarias tradicionales. Eso se debe probablemente a la menor exposición a los determinantes comerciales y marketing de estos productos y a los bajos ingresos disponibles.20. Por otro lado, el consumo no es tan consistente para el ESE en México y Brasil, así como en Colombia, los más ricos y educados consumen más alimentos ultraprocesados, con una dosis-respuesta vista al aumento según ESE24. Chile también tuvo un mayor consumo para aquellos con mayores ingresos, pero no se encontraron diferencias por educación16. Sin embargo, el consumo de alimentos ultraprocesados fue mayor entre los que tenían educación y el nivel de ingresos más bajo el Reino Unido, Francia y los Estados Unidos. Estos resultados apuntan a una distinción en los patrones de consumo según la etapa de transición nutricional de cada país. En los países en desarrollo en la etapa intermedia (patrones 3 y 4) de transición nutricional, la compra y el consumo de alimentos ultraprocesados fueron impulsados por individuos con altos niveles de ingresos. Estos países se alejan de la ingesta de alimentos amiláceos  y de las deficiencias proteico-energéticas hacia las enfermedades no transmisibles25. Lo contrario se observó para los países desarrollados que se acercan al final (patrón 4) de transición nutricional. En estos países, aunque el consumo fue relativamente bajo entre los más ricos, el porcentaje de energía diaria de los alimentos ultraprocesados es superior al 50,0%25.El patrón colombiano de consumo de alimentos ultraprocesados entre los niños y adolescentes refleja el patrón global: el Reino Unido, Estados Unidos, Canadá, Chile, Francia y México muestran un mayor consumo de alimentos ultraprocesados dentro de estos segmentos de edad de la sociedad26. Aquellos con un alto nivel de educación tenían menor probabilidad de consumir alimentos ultraprocesados en la cena y aperitivos y bebidas azucaradas durante el día en comparación con aquellos con un bajo nivel de educación. Estos resultados fueron diferentes a los que se vieron en este estudio y probablemente se explican por la etapa posterior de la transición nutricional (patrón 4) en Noruega. Entre los niños, hay cierta consistencia en los tipos de alimentos ultraprocesados consumidos. En análisis de componentes principales del consumo de alimentos en 12 países muestran que los alimentos ultraprocesados como comidas rápidas, helados, frituras, papas fritas, pasteles y bebidas azucaradas caracterizan con mayor fuerza los patrones alimentarios no saludables entre los niños de nueve a 11 años27. Los datos recientes de Colombia sobre la frecuencia del consumo de bebidas azucaradas muestran que el 85,3% de los niños entre 5 y 17 años consumen estas bebidas 0,71 veces/día28. La contribución porcentual de las bebidas azucaradas a la energía diaria no estaba disponible, pero las tendencias de la frecuencia apuntan a un patrón de consumo muy presente y preocupante entre los niños y adolescentes.Pocos estudios han examinado las diferencias dentro de los subgrupos de alimentos ultraprocesados. En Noruega, los hombres fueron más propensos a ser clasificados como grandes consumidores de productos de cena ultraprocesados y comidas rápidas, pero no de aperitivos y bebidas azucaradas, en comparación con las mujeres12. Las estrategias pueden incluir: (i) la prohibición de la venta de alimentos ultraprocesados en escuelas y patios de recreo, (ii) una mejor diseminación de herramientas de promoción de la salud, tal como las guías dietéticas basadas en alimentos que consideren la extensión y el propósito del procesamiento implementadas en Brasil29 y Uruguay30, (iii) un etiquetado de advertencia e iniciativas impositivas apropiadas para alentar opciones más saludables en los puntos de compra como se ha realizado en Chile10.Es necesaria una regulación para proteger el estado nutricional y el bienestar, especialmente de los niños y adolescentesEste estudio tiene sus limitaciones. Toda la información dietética se recopiló mediante recordatorio dietético de 24 horas. Más allá del sesgo de la memoria, los participantes pueden optar por retener información sobre ciertos productos alimenticios que se consideran socialmente indeseables, tanto en términos de categorías de productos como de cantidades consumidas. Este único punto de información dietética puede no capturar la dieta habitual de los participantes y, por lo tanto, ser menos representativa de su ingesta. Aunque los análisis controlaron varias variables sociodemográficas, la confusión residual es difícil de eliminar. Sin embargo, la naturaleza probabilística de la muestra estudiada, la representatividad nacional de la población colombiana usando la última encuesta nacional con recordatorio dietético de 24 horas disponible, y la estandarización de la recolección de datos dietéticos son algunas de las fortalezas de este estudio. Es probable que el consumo de alimentos ultraprocesados en Colombia haya cambiado desde la publicación de estos datos. Este estudio proporciona niveles de referencia de ingesta y podría ser una línea de base que podría compararse con evaluaciones dietéticas más recientes, cuando estén disponibles, para captar las tendencias en el consumo de alimentos ultraprocesados en Colombia.Este estudio caracteriza los alimentos ultraprocesados que se consumen con mayor frecuencia y que se pueden considerar como los puntos de entrada de los alimentos ultraprocesados dentro de la dieta colombiana. Se exploran las diferencias sociodemográficas para identificar los segmentos de la población que pueden considerarse los más vulnerables al consumo de estos alimentos. El pan industrializado es el alimento ultraprocesado más fácilmente asimilable en la dieta tradicional, junto con los snacks y las bebidas azucaradas. Los niños y adolescentes se adaptan más fácilmente a estos productos y, por lo tanto, son más vulnerables a sus efectos deletéreos sobre la salud. En general, el consumo de alimentos ultraprocesados no es tan alto en Colombia como en otros países, pero con una mayor probabilidad al aumento. Estos datos también estimulan una revisión de la política actual de promoción y prevención de la salud y a los esfuerzos regulatorios en Colombia relacionados con la promoción y la venta de estos productos, particularmente en poblaciones vulnerables como los niños y adolescentes.


To evaluate the cost-effectiveness of clinical education models for undergraduate nursing programs. A model-based cost-effectiveness analysis. Settings were universities with undergraduate nursing courses. Participants consisted of the decision tree that guided the structure of the model, filled in with effectiveness results from a hypothetical cohort of undergraduate nursing students. Interventions were Clinical Preceptor or Clinical Facilitator or Clinical Education Unit. Main outcome measure was effectiveness, defined as improvement of clinical education. The projected economic outcomes included incremental costs, incremental effectiveness, and incremental cost-effectiveness ratio. Monte Carlo probabilistic sensitivity analysis was employed to assess uncertainty in the model and robustness of our results. The model based on Clinical Education Unit could be defined as the best, followed by Clinical Facilitator and Clinical Preceptor. The incremental cost of telephone-support intervention was US$ 59,604.40 higher than the second-best performing intervention , and US$ 32,661.86 higher than the last best performing intervention . In addition, Clinical Education Unit model showed 7% and 19% more effectiveness than Clinical Facilitator and Clinical Preceptor, respectively. Clinical Education Unit represents the best choice to promote better development of skills, knowledge and socialization in undergraduate nursing programs considering its effectiveness and costs. In the nursing context, the traditional model of clinical instruction predominates and, in many cases, has remained unchanged for decades.-5 Although this model had been enough for decades, recent trends in education, health systems, and care of patients require that nursing education programs investigate innovative clinical teaching models to ensure optimal student preparation for practice.-8Health care services and education organizations have currently sought alternatives to optimize learning of students. Clinical education models were developed to improve clinical learning of future nurses, resulting in better quality of care provided to patients. The clinical education model is based on patient’s total care experiences, permeating a project of learning activities and adequate skills at undergraduate level.,4,10-12In this context, there is evidence that the clinical education model promotes a better development of skills, knowledge and socialization.Although there is evidence evaluating various clinical education models for nursing undergraduate students, no attention has been given to the cost-effectiveness ratio of these models. Thus, there is a clear need for a complete cost-effectiveness assessment to examine the effectiveness of different models of clinical education, considering their costs and providing the best evidence available, so that managers of education organizations can choose the model that best fits in their financial scope.To evaluate the cost-effectiveness of clinical education models for undergraduate nursing programs. The analysis was also performed from the perspective of the Australian Education System (payer perspective). The result of this analysis was expressed as a ratio of incremental costs and incremental health intervention outcomes. The incremental cost-effectiveness ratios (ICER) were calculated in American dollars, in 2018.This study is a cost-effectiveness analysis comparing models to improve clinical education in undergraduate nursing programs, conducted at University of South Australia, Australia, in December 2018. It was carried out according to the recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine.The models of clinical education in undergraduate nursing programs define the model structure. They are Clinical Preceptor, Clinical Facilitator, and Clinical Education Unit (CEU).Clinical Preceptor involves assignment of students to practice, for a defined period, with experienced clinicians employed in the clinical facility. In the Clinical Facilitator model, healthcare workers  are employed by the education organizations to oversee aspects of the clinical placement for undergraduate nursing students across different clinical venues, including offering direct supervision and evaluation. Clinical Facilitators are experienced clinicians, mostly seconded from the hospital to the university. The CEU or Dedicated Education Unit (DEU) is a health care unit, developed by lecturers and clinicians, dedicated to the clinical education of nursing students. In Australia, a university collaborated with healthcare units to design a DEU that provides clinical placements of undergraduate nursing students during any year of the program. that evaluated the effectiveness of clinical education models for undergraduate nursing programs and additional literature searches.We derived model inputs from one systematic reviewCosts were simulated based on the hour value of the professionals involved during the whole course of the nursing students. The values are measured by the student training cycle (considering the beginning and end of the undergraduate program). The cost was obtained from an estimate of the syllabus of the School of Nursing and Midwifery .Cost and effectiveness outcomes were discounted by 5%. Discounting was used in sensitivity analyses assessing differential effectiveness between strategies. All data of model inputs are present in  The three clinical education models for undergraduate nursing programs included in this analysis conferred statistically significantly improved clinical education, as compared to the Clinical Preceptor. The Clinical Preceptor was used for reference.Effectiveness was defined as advance of clinical education by improving clinical decision-making and critical thinking skills.The projected economic outcomes included incremental costs, incremental effectiveness, and incremental cost-effectiveness ratio. We did not use a cost-effectiveness threshold. Results of cost-effectives analysis will be classified as possibly cost-effective (intervention more effective and less costly than the next least costly intervention), weakly dominated , and dominated (intervention less effective and with a higher cost than the next least costly scenario).Monte Carlo probabilistic sensitivity analysis was employed to assess uncertainty of the model and robustness of our results. We ran our model 100,000 times to estimate the mean costs and effectiveness, and used an informal method to produce equal distributions in a formal Bayesian analysis with uninformative priors.Our base-case results are presented in The ICER of Clinical Facilitator compared to Clinical Preceptor was US$ 278,271.66, and the ICER of CEU comparing to Clinical Preceptor was US$ 909,825.50 per percent increase in clinical education .The probabilistic sensitivity analysis verified that our base-case cost-effectiveness analysis was robust. The probabilistic sensitivity analysis showed, in the most hypothetical scenarios, the intervention based in CEU is the best choice, considering a willingness-to-pay of 1,000,000 .This model suggested that CEU represents an additional effectiveness and cost to education models for undergraduate nursing programs, when compared to Clinical Facilitator or Clinical Preceptor. An educational model focused on education organizations, as herein considered, is likely to reduce duplication of costs and results in savings, when considering the different undergraduate courses using CEU. However, the model assumed that the costs were unique to the undergraduate nursing course, regardless of the number of students. In the future, models involving the maintenance of different undergraduate courses can be developed.The CEU promotes learning and allows time and space for reflection, besides developing a professional group identity, and learning to recognize and implement the responsibilities related to the nurse professional role.,12,16 However, no study was able to determine the effectiveness and long-term cost when these undergraduate students would be working as nurses. We know that as an educational administrator, it is very attractive to have a model that allows training more students with similar results and at a lower financial cost. However, the current focus should be on the quality that these professionals can provide while they are working. The costs of complications arising from inadequate health care can be much higher than the investment in setting up and maintaining a CEU.The cost to implement and maintain CEU was significantly higher than the tradition model .,10,11 Aiming to assist in the shortage of nurses, health services are challenged to release part of the nursing team to become supervisors in clinical supervision models, and require a significant investment in nurses’ education to achieve adequate teaching effectiveness.,10,11 In this way, CEU provides a simulation, and the academic-practice partnership model can offer innovative approaches to clinical training, aiming to produce graduates who can provide safe and quality care services within the complex environment based on system practice of health.,5,10,11Educational factors have limited the number of undergraduate nursing students in advanced practice and consequent delay in training human resources.This study has some limitations. However, we should emphasize that the long-term advantages of CEU can be even greater, since professionals that are more qualified improve patients’ clinical outcomes, reduce costs and have better productivity.This analysis demonstrated that Clinical Preceptor, Clinical Facilitator and Clinical Education Unit are cost-effective models for clinical education of undergraduate nursing students. However, the probabilistic sensitivity analysis showed that, in the most hypothetical scenarios, the intervention based on Clinical Education Unit is the best choice. This suggests that Clinical Education Unit represents the best choice to promote better development of skills, knowledge and socialization for undergraduate nursing programs, considering effectiveness and costs. Nursing programs should encourage the implementation of Clinical Education Unit, so that the training of professionals will be more appropriate to the real needs of patients.  No contexto da enfermagem, há um predomínio do modelo tradicional de instrução clínica que, em muitos casos, permanece inalterado há décadas.-5 Embora esse modelo tenha sido suficiente por muito tempo, tendências mais recentes no ensino, nos sistemas de saúde e no atendimento aos pacientes exigem que os programas de formação de enfermeiros estudem modelos inovadores de ensino clínico, os quais devem garantir o melhor preparo possível para a prática profissional.-8Atualmente, os serviços de saúde e as instituições de ensino têm buscado alternativas para otimizar a aprendizagem dos alunos. Os modelos de educação clínica foram desenvolvidos para melhorar a formação clínica dos futuros enfermeiros, levando a uma melhor qualidade de atendimento aos pacientes. O modelo de educação clínica baseia-se em experiências de assistência total ao paciente, permeando um projeto com atividades de ensino e habilidades apropriadas para o nível de graduação.,4,10-12Neste contexto, há evidências de que o modelo de educação clínica promove um melhor desenvolvimento de habilidades, conhecimentos e socialização.Embora existam avaliações dos vários modelos de educação clínica de estudantes de enfermagem, não há análises específicas da relação de custo-efetividade desses modelos. Assim, existe claramente a necessidade de uma avaliação completa de custo-efetividade, examinando a efetividade dos diferentes modelos de educação clínica, considerando os respectivos custos e fornecendo as melhores evidências disponíveis, para que os gestores das instituições de ensino possam escolher o modelo que mais se encaixa em sua realidade financeira.Avaliar a custo-efetividade dos modelos de educação clínica para cursos de graduação em enfermagem.University of South Australia, Austrália, em dezembro de 2018. O estudo foi conduzido conforme as recomendações do Second Panel on Cost-Effectiveness in Health and Medicine. A análise também foi realizada na perspectiva do sistema australiano de educação (perspectiva do financiador). O resultado desta análise foi expresso como uma razão dos custos incrementais e dos resultados incrementais de saúde da intervenção. As razões de custo-efetividade incremental (RCEI) foram calculadas em dólares americanos, em 2018.Este estudo é uma análise de custo-efetividade que compara modelos para melhoria da educação clínica nos cursos de graduação em enfermagem, realizado na Os modelos de educação clínica dos cursos de graduação em enfermagem definem a estrutura do modelo. Eles são Preceptor Clínico, Facilitador Clínico e Unidade de Educação Clínica (UEC).O Preceptor Clínico envolve a nomeação de alunos para atuar, durante um período determinado, com clínicos experientes que trabalhem na instituição. No modelo de Facilitador Clínico, os profissionais de saúde (facilitadores clínicos) são funcionários das organizações de ensino, que supervisionam aspectos da colocação de estudantes de enfermagem em diferentes instituições clínicas, oferecendo, inclusive, supervisão e avaliação diretas. Os facilitadores clínicos são clínicos experientes, geralmente recomendados pelo hospital para a universidade. A UEC, ou Unidade de Educação Dedicada (UED), é uma unidade de saúde desenvolvida por acadêmicos e clínicos, dedicada à educação clínica dos estudantes de enfermagem. Na Austrália, uma universidade trabalhou junto das unidades de saúde para desenvolver uma UED encarregada pela colocação clínica de estudantes, em qualquer ano do curso de enfermagem. que avaliou a efetividade de modelos de educação clínica para cursos de graduação em enfermagem, além de buscas adicionais na literatura.Derivamos os dados de base do modelo de uma revisão sistemática,School of Nursing and Midwifery .Os custos foram simulados com base no valor-hora dos profissionais envolvidos durante todo o curso dos estudantes de enfermagem. Os valores são medidos por ciclo de capacitação dos estudantes (considerando-se o início e o fim do curso de graduação). O custo foi obtido a partir de uma estimativa do programa curricular da Descontamos 5% dos resultados de custo e efetividade. O desconto foi usado nas análises de sensibilidade que avaliaram a efetividade diferencial entre as estratégias. Todos os dados de base dos modelos são apresentados na  Os três modelos de educação clínica para cursos de graduação em enfermagem incluídos na análise geraram melhoria na educação clínica com significância estatística, em comparação ao Preceptor Clínico. O Preceptor Clínico foi usado como referência.Efetividade foi definida como aprimoramento da educação clínica, com melhores habilidades de tomada de decisões e pensamento crítico.ranking) e dominado .Os desfechos econômicos projetados incluíram custos incrementais, efetividade incremental e custo incremental por efetividade. Não usamos limiar de custo-efetividade. Os resultados da análise de custo-efetividade serão classificados como possivelmente custo-efetivo (intervenção mais efetiva e com custo menor do que a próxima intervenção com menor custo), fracamente dominado .,10,11 Para auxiliar nessa escassez de enfermeiros, os serviços de saúde têm o desafio de liberar uma parte da equipe de enfermeiros para atuarem como supervisores em modelos de supervisão clínica, sendo necessário um investimento considerável na formação de enfermeiros, para atingir um nível de efetividade adequado.,10,11 Assim, a UEC permite a simulação, e o modelo de parceria de prática acadêmica oferece abordagens inovadoras para a capacitação clínica, visando produzir graduandos que possam prestar serviços seguros e de qualidade, dentro do ambiente complexo baseado na prática sistêmica da saúde.,5,10,11Fatores educacionais têm limitado o número de alunos de graduação em enfermagem com acesso à prática avançada e, consequentemente, gerado atrasos na capacitação de recursos humanos.Este estudo tem algumas limitações. No entanto, devemos destacar que as vantagens da UEC no longo prazo podem ser ainda maiores, já que profissionais mais bem qualificados levam a melhores desfechos para os pacientes, reduzem custos e apresentam maior produtividade.Esta análise demonstrou que Preceptor Clínico, Facilitador Clínico e Unidade de Educação Clínica são modelos custo-efetivos de educação clínica para alunos de graduação em enfermagem. No entanto, a análise de sensibilidade probabilística mostra que, nos cenários mais hipotéticos, a intervenção com Unidade de Educação Clínica é a melhor opção. A Unidade de Educação Clínica representa a melhor opção para um melhor desenvolvimento de habilidades, conhecimentos e socialização nos cursos de graduação em enfermagem, considerando-se efetividade e custo. Os cursos de enfermagem devem promover a implementação da Unidade de Educação Clínica, para que a capacitação dos profissionais seja mais adequada às necessidades reais dos pacientes.


To analyze factors associated with diarrheal disease in the rural Caribbean region of Colombia.A cross-sectional study conducted in the rural area of the Cesar Department, Colombia, between November 2017 and June 2018. Self-reported cases of diarrheal disease were surveyed, and water samples from 42 households were collected and analyzed. Descriptive statistics were employed in the analysis of socioeconomic status, environmental and sanitary conditions, and we evaluated their association with the diarrheal disease using the Poisson regression models. Each model was adjusted with variables suggested by specific directed acyclic graphs.Poor water supply conditions, hygiene and basic sanitation were reported in the study area. All water samples were classified either as high risk for health problems or unfit for human consumption. The diarrheal disease had a prevalence of 7.5% across all ages and of 23.5% in children under five years old. The variables rainy season , children under five years old , water from deep wells , water from artificial ponds , toilets availability , and swine presence  were significantly associated with the occurrence of diarrheal disease.Water supply, hygiene and basic sanitation conditions have been associated with the diarrheal disease, affecting almost a quarter of the population under five years old. There is an urge for the design of effective policies that improve environmental and sanitation conditions in rural areas. Fifty-seven per cent of the households located in the rural area of Colombia lack access to drinking water and 94% lack access to sewage systems; in the Cesar Department, such percentages increase up to 87 and 98%, respectively Red Unidos (United Network) for the reduction of poverty, Sistema para la Protección y Control de la Calidad del Agua  for human consumption, and the Colombia National System of Public Health Surveillance, among others. Such projects contribute to the improvement of living conditions of the population. However, larger efforts are required in the elaboration of differential and intersectoral policies, which should be adjusted to the context of rural areas and contribute to reducing the current gap ,Within the framework of the Sustainable Development Goals (ended in 2015), projects were created and implemented in Colombia, such as: For such purposes, it is essential do recognize key factors of the diarrheal disease in rural areas to propose solutions with larger sanitation and environmental reaches. To meet this need, we analyzed factors associated with diarrheal disease in the rural Caribbean region of Colombia.This study was conducted in the rural district of La Delfina  and El Cascajo , located 40 and 194 km away, respectively, from Valledupar city, the capital of the Cesar Department. The study area was selected by prioritizing the municipalities using the Electre Then we selected two rural districts  through an Analytic Hierarchy Process The rural districts were censused in September 2017 to identify population size, sanitation conditions, and water supply for human consumption. A geographic information system (GIS) was created with the household coordinates. The results of the census were used to elaborate a tool for data collection and identify the type of sampling for water collection.Censo Nacional Agropecuario  from 2014 and other similar studies ,A questionnaire was elaborated based on the In order to comprehend the dry and rainy seasons, monthly rates of precipitation (1985–2015) were extracted from weather stations close to the study areas. The interviews and sample collection were randomly performed in November 2017, and March and June 2018.The interviews were conducted by a trained group  with the household chief or a resident older than 18 years old. The water samples were collected from the storage containers in each household, according to the Colombian guidelines. Analysis of the physical, chemical and biological parameters was carried out in the Environmental Engineering Laboratory of Los Andes University.Besides household conditions, there was a survey on the occurrence of diarrheal cases within seven days before the visit. Pre-existing conditions were inquired to prevent interferences in the identification of cases of diarrheal disease: pregnancy, stomach surgery, gastric ulcers or any colon-related disease.Índice de Riesgo de la Calidad del Agua para Consumo Humano , according to the guidelines of the Resolution No. 2115, from 2007 To classify the water quality, we used the The diarrheal disease was the dependent variable, and it had been defined as the occurrence of three or more loose stools within a 24-hour window. The prevalence of the disease within the seven days before data collection was estimated as the proportion of residents that had presented at least one event in the seven-day period before the interview.The socioeconomic, basic sanitation and water supply conditions in the household, along with the demographic conditions collected were exposure variables.The absence of poultry in only two households absolutely ruled out the occurrence of the event, given that all cases of diarrheal disease had occurred in households keeping poultry. Thus, this variable had not been included in the model due to the impossibility of getting adjusted measures of association.A Directed Acyclic Graph (DAG) was elaborated using the web version of DAGitty software The categorical variables were reported in frequencies and percentages, while the quantitative variable was chosen to be reported with median range and interquartile range, as they have shown a distribution significantly different from normal. Fisher's exact tests were performed to evaluate association between qualitative variables, and Mann-Withney or Kruskall-Wallis tests were performed on quantitative variables.For each independent variable, a univariable model for diarrheal disease was obtained by using the robust Poisson regression. The measure of association used was the Prevalence Ratio (PR) with a 95% confidence interval (95%CI). To estimate the total effect of each one of the exposure variables, a multivariable robust Poisson regression model was specified adjusting for the variables suggested by DAG. Individuals whose health conditions  was unknown were not included in the model. Due to the high prevalence of diarrheal disease in children under five years old and since after this age a clear increase was not observed, the variable age was analyzed as a dichotomous variable.Although residents were the analysis units, some variables were measured in the household context level. Thus, in the regression models, the option “cluster” was used to account for the household aggregation. A significance level of 0.05 was established.The resulting data were analyzed in Stata Release 12 . This study was approved by the Research Ethics Committee of Los Andes University under the Act no. 965, dated October 30, 2017. An informed consent form was read to the respondents before the survey. Non-disclosure agreements were celebrated by the collaborators of the project. Codes were assigned to the survey forms and samples so that people's identities could be protected.Of the 45 censused households, 42 engaged in the study. Altogether 176 people lived in the two rural districts, aged between 0 and 78 years old. Out of 105 people over 16 years old, 14.3% had never attended school, 21.9% finished high school and 2.9% started a technical or vocational career. Out of the household chiefs, 78% of men and 86.5% of women were able to read and write.Dirt was the predominant material on the floors, so as wood was on the walls. Wall materials presented a statistical significance to the income of the household. Forty four percent of the households with incomes higher than the minimum wage had their walls built in cement. Out of those with incomes lower than the minimum wage, 3% had walls in cement.None of the households of the rural districts have access to natural gas and electricity supplies. All households in La Delfina use firewood for cooking. In El Cascajo, some households presented a combined usage of firewood and bottled gas.In the totality of households there was at least one domestic animal , which wandered freely inside and outside of the households.None of the households had access to a water supply network. Water supply was classified under four types of individual sources: rainwater, artificial pond , deep well, and river. In four of the households, they treated water occasionally by applying sodium hypochlorite or alum. The source type presented statistical significance to the rural district, being the river water predominant in La Delfina (7/8) and the water from deep wells (14/34) predominant in El Cascajo. Equally, the weather showed a statistical significance to the type of source, with a higher occurrence of the use of artificial pond water (6/16) during the dry season and rainwater (10/26) during rainy season.Escherichia coli , total coliforms, and aerobic mesophilic. All IRCA results were classified as high risk and unfit for human consumption, being the latter entirely collected from artificial ponds  compared with El Cascajo (11.8%). The same was observed regarding the presence of septic tanks, with 87.5% and 44.1%, respectively. The waste was burnt down in most households (78.6%) and some of them employed a combination of burning and open air disposals (28.6%).During the period, 7.4% cases of diarrheal disease were identified. In addition, 10.2% cases of pre-existing conditions were reported. Data regarding three people were not provided, as they could not answer the questionnaire. The diarrheal disease did not present statistical significance to the cases of pre-existing conditions nor to the rural districts. The prevalence of diarrheal disease was 6.1% in men and 9.5% in women and was unrelated to gender.In the univariable analysis, the variables season and children under five years old were the only ones whose results showed statistical significance   .When ajusted by covariates, the variables rainy season, presence of swine, presence of toilet facilities, children under five years old, water from a tank source, and well water presented statistical significance to diarrheal disease   .Poor basic sanitation and water supply conditions for human consumption were observed in the rural districts located in the rural Caribbean region of Colombia. The households had no waste collection services, sewage and water supply systems nor a community service of water supply. Individual water supply systems were used, from different sources , in some cases, located hundreds of feet away. This makes transportation harder and limits the amount of water supplied. Such characteristics match those of the peri-urban and rural populations in developing countries, as reported by Razzolini y Günther ,Water samples collected in several sources of supply had presented different qualities, influenced by sources and contamination spots. A high indicator of fecal coliforms was a universal factor in the water samplings. Such contamination is commonly found in rural areas due to cattle breeding The prevalence of diarrheal disease in the rural districts of El Cascajo and La Delfina was 7.5% at all ages. Regardless, in children under five years old, this figure went as higher as 23.5%, which is 91% higher than the medium prevalence rate reported in Colombia (12.3%) We also found a larger occurrence of diarrheal disease during the dry season in comparison to the rainy season, a finding that matches the evidence reported by Wilopo et al. ,Divergently, some studies had detected an increased frequency of diarrheal disease during the rainy season In the non-adjusted model, none of the water sources presented statistical significance to the cases of diarrheal disease. In the adjusted model, we observed statistical significance in the water sourced from artificial ponds and deep wells, with a prevalence ratio that suggests them to be risk factors. The previous pattern reflected an error that could be mitigated by the variables set used in the model adjustment, including the variables season and rural district. The first variable could influence the exposure to the diarrheal disease by favoring the consumption of rainwater during the wet season. Moreover, the rural district may influence the access to certain types of water sources according to its geography.The possession of toilet facilities was associated with the outcome, seeming to be a protective factor. Even though further basic sanitation variables had not presented statistical significance, we observed a minor prevalence in the households that had sinks and/or septic tanks installed.The keeping of swine turned out to be a protective factor in the adjusted model. Some studies have found domestic animals to be a risk factor Future studies to analyze the association between diarrheal disease and the keeping of swine can diverge from our findings and determinate whether the presence of swine is a protective factor from diarrheal disease in places with poor basic sanitation conditions.We recorded high IRCA values in water sources for human consumption. This would explain the strong associations found between some of the water sources and the frequency of diarrheal disease. Thus, our results show the impacts of low rates in water treatment, reflecting the limited knowledge available on the health risks of such exposures.These results should promote local and regional programs in the long run to improve the water quality at consumption points, with actions such as solar water disinfection, coagulation, sodium chloride treatment or boiling. Such interventions must be paired with educational campaigns about hygiene and basic sanitation aimed at: a) advising the community about the health risks of consuming poor quality water and poor basic sanitation conditions; b) spreading knowledge on proper manipulation, transportation and storage of water, and c) raising awareness about the responsible keeping of domestic animals.These actions must be transitory measures towards stronger solutions that generate differential and cross-sectional policies for the rural sector, which take into full account the water supply and quality issues along with the proper disposal of waste and garbage. In order to assure the integration of the different sectors, such policies may incorporate strategies such as: a) incentive for the creation of social business focused on the design of alternative technologies rather than conventional solutions; b) educational programs in rural schools about hygiene and basic sanitation; c) technical assistance to the community; d) engagement of the community so that it plays an active role in the report of the water quality control and cases of the diarrheal disease. All of these policies aim to improve water quality for consumption, controlling thus the diarrheal disease, which hits especially the pediatric community.This study has a few limitations. Even though the seven-day recall window is commonly used in the practice to prevent the under-record of information In addition, when the physical, chemical, and microbiological properties of the water in each household was measured, the resulting water quality does not represent the water quality consumed in the seven days before the survey. However, the IRCA estimated shows the high risk posed by the water for human consumption in both rural districts at the moment of the study.Moreover, the limited size of the sampling had reflected a limited precision and, probably, a limited power in identifying further factors associated with the diarrheal disease. Nevertheless, the outcome exposes a diagnosis of the study area. Likewise, the directed acyclic graph elaborated can turn into a useful conceptual tool for future research that share the same context.The long distances between households and the difficult transport routes that characterize the rural area not only restrict the implementation of water supply networks and basic sanitation, but also hinder the logistics for these types of studies. These results are expected to be a referential evidence and to make easier for decision makers and other researchers to carry out complementary studies on the matter.Despite the efforts deployed on the issue of drinking water and improvement of living conditions of the most vulnerable population of Colombia, poor conditions regarding water supply, hygiene and basic sanitation are still seen in the rural area. There is an urge for effective design of policies to contribute to the improvement of environmental and sanitation conditions in households and reduce the prevalence of diarrheal disease, especially in children under five years old. ,-,-Bajo nivel socioeconómico Las comunidades rurales representan el 83,0% de la población mundial que carece de acceso a una fuente de agua mejorada, y el 71,0% de la que no cuenta con saneamiento ,En el marco del cumplimiento de la agenda de Objetivos de Desarrollo del Milenio , en Colombia se crearon e implementaron proyectos como: Red Unidos para la reducción de la pobreza, Sistema para la Protección y Control de la Calidad del Agua para consumo humano y Sistema Nacional de Vigilancia en Salud Pública, entre otros. Estos proyectos contribuyen a mejorar condiciones de vida de la población. Sin embargo, se requiere de mayores esfuerzos en la elaboración de políticas diferenciales e intersectoriales que se ajusten al contexto de la ruralidad y contribuyan a la reducción de la brecha actual Para estos fines, es esencial reconocer determinantes de la enfermedad diarreica en zonas rurales para la proposición de soluciones apropiadas y de mayor alcance sanitario y ambiental. Atendiendo a esta necesidad, el objetivo de este estudio fue analizar factores asociados con enfermedad diarreica en área rural del Caribe colombiano.Este estudio fue desarrollado en las veredas La Delfina  y El Cascajo , localizadas a 40 km y 194 km, respectivamente, de la ciudad de Valledupar, capital del departamento del Cesar. La selección de la zona de estudio se realizó priorizando dos municipios por medio de los métodos Electre Posteriormente, seleccionamos dos veredas (menor unidad administrativa) por medio de un Proceso Analítico Jerárquico Las veredas fueron censadas en septiembre de 2017 para identificar el tamaño de la población, condiciones sanitarias y fuente de suministro de agua para consumo humano. Un sistema de información geográfico (SIG) fue elaborado con las coordenadas de las viviendas. Los resultados del censo fueron utilizados para elaborar el instrumento de recolección de datos e identificar el tipo de muestreo para la colecta de agua.,Un cuestionario se elaboró tomando como base el formulario aplicado en el Censo Nacional Agropecuario (CNA) de 2014 Para abarcar estación seca y lluviosa, fueron analizados valores mensuales de precipitación (1985–2015) de estaciones meteorológicas cercanas a la zona de estudio. Las entrevistas y recolección de muestras fueron realizadas aleatoriamente en noviembre de 2017, y marzo y junio de 2018.La entrevista fue realizada por un equipo entrenado  al responsable del hogar o a una persona residente mayor de 18 años. Las muestras de agua fueron colectadas desde recipientes de almacenamiento en cada hogar bajo lineamientos de normatividad colombiana Además de las condiciones de las viviendas, se indagó acerca de la morbilidad relacionada con casos de diarrea, ocurridos en los siete días previos a la visita. Se preguntó acerca de condiciones médicas preexistentes para evitar interferencias en el momento de identificar los casos de enfermedad diarreica: embarazo, cirugía en el estómago, úlceras estomacales o alguna enfermedad relacionada con el colón.Para resumir la calidad del agua, calculamos el Índice de Riesgo de Calidad del Agua para consumo humano (IRCA), siguiendo los lineamientos de Resolución 2115 de 2007 Enfermedad diarreica fue la variable dependiente, la cual se definió como la ocurrencia de tres o más defecaciones blandas en un periodo de 24 horas. La prevalencia de periodo de enfermedad diarreica en los siete días previos a la recolección de datos fue calculada como la proporción de habitantes que presentaron al menos un evento en el periodo de los siete días previos a la entrevista.Las condiciones socioeconómicas, de saneamiento básico y de abastecimiento de agua en la vivienda, junto con las condiciones demográficas recolectadas, fueron variables de exposición.La ausencia de aves en las viviendas descartó perfectamente la ocurrencia del evento, dado que todos los casos de enfermedad diarreica se presentaron en viviendas con presencia de aves. Por lo tanto, esta variable no se incluyó en el modelo debido a la imposibilidad de obtener medidas de asociación ajustadas.Directed Acyclic Graph ) en la versión web del software DAGitty Se elaboró un Gráfico Acíclico Dirigido  con un intervalo de 95% de confianza (IC95%). Para estimar el efecto total de cada una de las variables de exposición, se obtuvo un modelo multivariable robusto de regresión de Poisson ajustado con las variables sugeridas por el DAG. Los individuos cuya condición de salud (enfermedad diarreica) fue desconocida no fueron incluidos dentro del modelo. Debido a la alta prevalencia de enfermedad diarreica en menores de cinco años, y a que después de esa edad no se observó un claro gradiente, la variable edad fue analizada como dicotómica.Aunque las unidades de análisis fueron los habitantes, algunas variables fueron medidas en un nivel contextual de vivienda. Por lo anterior, en los modelos de regresión se utilizó la opción “cluster” para considerar la agregación por vivienda. Fue preestablecido un nivel de significancia de 0,05.Stata versión 12 . Este estudio fue aprobado por el Comité de Ética de la Investigación de la Universidad de los Andes por medio de Acta Nº 965, del 30 de octubre de 2017. Un consentimiento informado fue leído a las personas encuestadas antes de aplicar el cuestionario. Actas de confidencialidad fueron diligenciadas por los colaboradores del proyecto. A los cuestionarios y formatos de toma de muestra les fueron asignados códigos para proteger la identidad de las personas.Los datos obtenidos fueron analizados en De las 45 viviendas que fueron censadas, 42 participaron en el estudio. Un total de 176 personas habitaban las dos veredas, en edades entre cero y 78 años. La De las 105 personas mayores de 16 años: 14,3% nunca fueron a la escuela, 21,9% terminaron la secundaria y 2,9% empezaron una carrera técnica o tecnológica. Entre las personas responsables del hogar, 78,0% de los hombres y 86,5% de las mujeres sabían leer y escribir.La tierra fue el material predominante de los pisos y la madera el de las paredes. El tipo de pared presentó asociación estadísticamente significativa con los ingresos del hogar. El 44,0% de las viviendas cuyos ingresos eran superiores a un salario mínimo tenían construida sus paredes en cemento. En aquellas que obtenían ganancias menores a un salario mínimo, el 3,0% tenían paredes en este material.En ninguna de las veredas las casas tenían suministro de gas natural y energía eléctrica. Todas las viviendas en La Delfina utilizaban leña para la cocción de alimentos. Por su parte, algunas viviendas combinaban el uso de leña con gas embotellado en El Cascajo.En todas las viviendas se observó por lo menos un animal doméstico , los cuales paseaban libremente dentro de las casas y en el exterior de estas.Ninguna de las casas contaba con red de distribución de agua. El abastecimiento de agua fue provisto desde cuatro tipos de fuentes individuales: agua lluvia, estanco , pozo profundo y río. En cuatro de las viviendas, manifestaron que realizaban tratamiento de agua esporádicamente por medio de la aplicación de hipoclorito de sodio o alumbre. El tipo de fuente presentó asociación estadísticamente significativa con la vereda, predominando el agua de río en la vereda La Delfina (7/8) y el agua de pozo profundo (14/34) en El Cascajo. De igual manera, la estación climática mostró asociación estadísticamente significativa con el tipo de fuente, con una mayor frecuencia en el uso de agua de estanco (6/16) en época seca y de agua lluvia (10/26) en época lluviosa.Escherichia coli , coliformes totales y aerobios mesófilos. Todos los valores de IRCA se clasificaron como alto riesgo e inviable sanitariamente, estos últimos todos provenientes de estanco  en comparación a El Cascajo . El mismo comportamiento fue observado para tenencia de pozo séptico, con respectivamente 87,5% y 44,1%. Los residuos eran quemados en la mayoría de las viviendas  y algunas combinaban la quema con la disposición a cielo abierto .Se identificaron 7,4% de casos de enfermedad diarreica para el periodo. Además, se reportaron 10,2% de casos de otras condiciones médicas preexistentes. No fue suministrada información de tres personas por desconocimiento de la persona encuestada. La enfermedad diarreica no presentó asociación estadísticamente significativa con los casos de condiciones preexistentes y tampoco con las veredas. La prevalencia de enfermedad diarreica en los hombres fue de 6,1% y en las mujeres de 9,5% y no estuvo asociada al sexo.En el análisis univariable (sin ajustar), las variables estación y niños menores de cinco años fueron las únicas cuyos resultados tuvieron asociación estadísticamente significativa   .Cuando se ajustaron las estimaciones, las variables estación lluviosa, presencia de cerdo, tenencia de baño, niños menores de cinco años, abastecimiento de agua desde estanco y abastecimiento de agua desde pozo profundo tuvieron asociación estadísticamente significativa con enfermedad diarreica   .Se observan condiciones precarias de saneamiento básico y abastecimiento de agua para consumo humano en las veredas ubicadas en área rural dispersa del Caribe colombiano. Ninguna de las viviendas contaba con servicio de recolección de residuos, alcantarillado y acueducto, tampoco con sistema comunitario de abastecimiento de agua. Sistemas individuales de provisión de agua fueron utilizados desde diferentes tipos de fuentes , en algunos casos, localizadas a cientos de metros de distancia. Esa situación dificulta el transporte y restringe la cantidad de agua para aprovisionamiento. Estas características coinciden con las de poblaciones periurbanas y rurales en países subdesarrollados reportadas por Razzolini y Günther ,Las muestras de agua provenientes desde diversas fuentes de abastecimiento tuvieron diferentes calidades, influenciadas por la naturaleza de estas y los puntos de contaminación circundantes. La alta carga de bacterias fecales fue un factor universal en las muestras de agua. Contaminación que es más probable encontrar en zonas rurales debido a actividades pecuarias La prevalencia de enfermedad diarreica en las veredas El Cascajo y La Delfina fue 7,5% en todas las edades. No obstante, en menores de cinco años, ese valor llegó a 23,5%, lo que es 91,0% mayor a la prevalencia promedio reportada para Colombia  Encontramos también una mayor ocurrencia de enfermedad diarreica en estación seca en comparación con la época de lluvia, resultado que concuerda con evidencias reportadas por Wilopo et al. ,En contraste, algunos estudios han detectado una mayor frecuencia de enfermedad diarreica en época de lluvias En el modelo sin ajustar, ninguna de las fuentes de agua presentó asociación estadísticamente significativa con los casos de enfermedad diarreica. En el modelo ajustado, observamos asociaciones estadísticamente significativas para el agua de estanco y pozo profundo, con una razón de prevalencia que las sugiere como factores de riesgo. Lo anterior refleja un fenómeno de confusión que pudo ser mitigado por el set de variables con el que se ajustó el modelo, en el cual se destacan las variables: estación y vereda. La primera variable podría influenciar la exposición a enfermedad diarreica al favorecer el consumo de agua lluvia en época de altas precipitaciones. Por otra parte, la vereda puede influenciar el acceso a determinados tipos de fuente de acuerdo con la geografía.La tenencia de baño estuvo asociada con el desenlace pareciendo un factor protector. Aunque las demás variables de saneamiento básico no arrojaron diferencias estadísticamente significativas, observamos menor prevalencia en aquellas viviendas que tenían instalado lavamanos y/o pozo séptico.La presencia de cerdo resultó ser un factor protector en el modelo ajustado. Algunos estudios exponen que los animales domésticos generalmente son factores de riesgo Futuros estudios que analicen la asociación entre enfermedad diarreica y la tenencia de cerdos podrán contrastar con los resultados observados y determinar si la presencia de cerdos es un factor protector de enfermedad diarreica en lugares con deficientes condiciones de saneamiento básico.Documentamos elevados valores de IRCA en fuentes de consumo humano. Eso explicaría las fuertes asociaciones encontradas entre algunas de las fuentes de agua y la frecuencia de enfermedad diarreica. De esta forma, nuestros resultados evidencian el impacto de la baja tasa de tratamiento de agua, reflejando el escaso conocimiento que se tiene acerca de los riesgos en la salud bajo estas exposiciones.Estos resultados deben promover programas locales y regionales a largo plazo para mejorar la calidad de agua en el punto de uso, mediante acciones como la desinfección solar, coagulación con alumbre, desinfección con hipoclorito de sodio o ebullición del agua. Estas intervenciones deben acompañarse de campañas educativas en higiene y saneamiento básico cuyos objetivos sean: a) advertir a la comunidad acerca de los riesgos para la salud del consumo de agua con calidad deficiente y de las condiciones precarias de saneamiento básico; b) capacitar acerca de los cuidados en el transporte, manipulación y almacenamiento de agua; e, c) informar sobre la tenencia responsable de animales domésticos.Lo anterior debe ser una medida transitoria a soluciones de mayor envergadura que involucre la generación de políticas diferenciales y transversales para el sector rural, que tenga en cuenta de manera integral la problemática de abastecimiento y calidad de agua junto con la adecuada disposición de excretas y residuos. Para garantizar la integración de diferentes sectores, estas políticas podrán incorporar estrategias como: a) incentivos para la creación de empresas sociales que opten por el diseño de tecnologías alternativas a las soluciones convencionales; b) programas educativos en escuelas rurales relacionadas con higiene y saneamiento básico; c) asistencia técnica a la comunidad; y, d) vinculación de la comunidad para que participe de manera activa en el reporte efectivo tanto del control de la calidad de agua como de los casos de enfermedades diarreicas. Todo esto con el fin de generar mejoras sostenibles en la calidad del agua de consumo para el control de las enfermedades diarreicas que afecta principalmente a la población pediátrica.Este estudio tiene algunas limitaciones. Aunque el período de recuerdo de siete días es comúnmente usado en la práctica para evitar el subregistro de información Aun cuando se midieron las características fisicoquímicas y microbiológicas del agua en cada uno de los hogares, la calidad de agua resultante no representa la calidad del agua consumida en los siete días anteriores a la encuesta. No obstante, el IRCA calculado señala el alto riesgo que presentó el agua de consumo humano en las dos veredas en el momento del estudio.Por otro lado, el limitado tamaño de la muestra se reflejó en una precisión limitada y, probablemente, en un poder reducido para identificar otros factores asociados con enfermedad diarreica. Sin embargo, los resultados obtenidos exponen un diagnóstico de la zona estudiada. De igual manera, el diagrama causal elaborado, cuyas implicaciones fueron evaluadas y mostraron consistencia con los datos, puede ser una herramienta conceptual útil para futuras investigaciones que compartan el mismo contexto rural.Las largas distancias entre viviendas y las difíciles vías de transporte que caracterizan el área rural dispersa no sólo limitan la implementación de servicios de acueducto y de saneamiento básico, sino que también dificultan la logística de este tipo de estudios. Se espera que estos resultados sirvan como evidencia de referencia y facilite el camino a tomadores de decisiones y a otros investigadores, para llevar a cabo estudios complementarios sobre el tema.A pesar de los esfuerzos realizados en materia de agua potable y de mejoramiento de las condiciones de vida de la población más vulnerable en Colombia, en área rural dispersa aún se observan condiciones deficientes relacionadas con abastecimiento de agua, higiene y saneamiento básico. Urge un diseño efectivo de políticas que contribuyan al mejoramiento de condiciones ambientales y saneamiento en viviendas, y que reduzcan la prevalencia de enfermedad diarreica, especialmente en niños menores de cinco años.