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1.

Identifying the social and environmental determinants of plague endemicity in Peru: insights from a case study in Ascope, La Libertad.

Rivière-Cinnamond, Ana; Santandreu, Alain; Luján, Anita; Mertens, Frederic; Espinoza, John Omar; Carpio, Yesenia; Bravo, Johnny; Gabastou, Jean-Marc
| Idioma(s): Inglés
BACKGROUND: Plague remains a public health problem in specific areas located in Bolivia, Brazil, Ecuador and Peru. Its prevention and control encompasses adequate clinical management and timely laboratory diagnosis. However, understanding communities' interaction with its surrounding ecosystem as well as the differences between community members and institutional stakeholders regarding the root causes of plague might contribute to understand its endemicity. We aim at bridging the traditionally separate biological and social sciences by elucidating communities' risk perception and identifying knowledge gaps between communities and stakeholders. This approach has been used in other areas but never in understanding plague endemicity, nor applied in the Latin American plague context. The objectives were to identify (i) plague risk perception at community level, (ii) perceived social and environmental determinants of plague endemicity, and (iii) institutions that need to be involved and actions needed to be taken as proposed by stakeholders and community members. The study was performed in 2015 and took place in Ascope rural province, La Libertad Region, in Peru, where the study areas are surrounded by intensive private sugarcane production. METHODS: We propose using a multi-level discourse analysis. Community households were randomly selected (n = 68). Structured and semi-structured questionnaires were applied. A stakeholder analysis was used to identify policy makers (n = 34). In-depth interviews were performed, recorded and transcribed. Descriptive variables were analyzed with SPSS®. Answers were coded following variables adapted from the Commission on Social Determinants of Health and analyzed with the assistance of ATLAS.ti®. RESULTS: Results showed that risk perception was low within the community. Policy-makers identified agriculture and sugarcane production as the root cause while community answers ranked the hygiene situation as the main cause. Stakeholders first ranked governmental sectors (education, housing, agriculture and transport) and the community prioritized the health sector. Social surveillance and improving prevention and control were first cited by policy-makers and community members, respectively. CONCLUSIONS: The determinants of plague endemicity identified by the two groups differed. Similarly, actions and sectors needed to be involved in solving the problem varied. The gaps in understanding plague root causes between these two groups might hinder the efficiency of current plague prevention and control strategies.
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2.

Applying the results based management framework to the CERCA multi-component project in adolescent sexual and reproductive health: a retrospective analysis.

Cordova-Pozo, Kathya; Hoopes, Andrea J; Cordova, Freddy; Vega, Bernardo; Segura, Zoyla; Hagens, Arnold
| Idioma(s): Inglés
BACKGROUND: Adolescent sexual and reproductive health (SRH), problems such as unplanned pregnancies are complex and multifactorial, thus requiring multifaceted prevention interventions. Evaluating the impact of such interventions is important to ensure efficiency, effectiveness and accountability for project funders and community members. In this study, we propose Results Based Management (RBM) as a framework for project management, using the Community Embedded Reproductive Health Care for Adolescents (CERCA) as a case study for RBM. The CERCA Project (2010-2014) tested interventions to reduce adolescent pregnancy in three Latin American countries, Bolivia, Ecuador and Nicaragua. Activities were designed to increase adolescent SRH behaviors in four domains: communication with parents, partners and peers; access to SRH information; access to SRH services; and use of contraception. When the project ended, the outcome evaluation showed limited impact with concerns about accuracy of monitoring and attrition of participants. METHODS: We reviewed and analyzed a series of CERCA documents and related data sources. Key findings from these documents were organized within an RBM framework (planning, monitoring, and impact evaluation) to understand how CERCA methodology and performance might have reaped improved results. RESULTS: Strengths and weaknesses were identified in all three elements of the RBM framework. In Planning, the proposed Theory of Change (ToC) differed from that which was carried out in the intervention package. Each country implemented a different intervention package without articulated assumptions on how the activities of intervention would bring about change. In Monitoring, the project oversight was mainly based on administrative and financial requirements rather than monitoring fidelity and quality of intervention activities. In Impact Evaluation, the original CERCA evaluation assessed intervention effects among adolescents, without identifying success and failure factors related to the outcomes, the nature of the outcomes, or cost-effectiveness of interventions. CONCLUSIONS: This analysis showed that multi-country projects are complex, entail risks in execution and require robust project management. RBM can be a useful tool to ensure a systematic approach at different phases within a multi-country setting.
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3.

Impacto económico del tabaquismo en los sistemas de salud de América Latina: un estudio en siete países y su extrapolación a nivel regional./ [Financial impact of smoking on health systems in Latin America: A study of seven countries and extrapolation to the regional level].

Pichon-Riviere, Andrés; Bardach, Ariel; Augustovski, Federico; Alcaraz, Andrea; Reynales-Shigematsu, Luz Myriam; Pinto, Márcia Teixeira; Castillo-Riquelme, Marianela; Torres, Esperanza Peña; Osorio, Diana Isabel; Huayanay, Leandro; Munarriz, César Loza; de Miera-Juárez, Belén Sáenz; Gallegos-Rivero, Verónica; Puente, Catherine De La; Navia-Bueno, María Del Pilar; Caporale, Joaquín
| Idioma(s): Español
Objective: Estimate smoking-attributable direct medical costs in Latin American health systems. Methods: A microsimulation model was used to quantify financial impact of cardiovascular and cerebrovascular disease, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer, and nine other neoplasms. A systematic search for epidemiological data and event costs was carried out. The model was calibrated and validated for Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, countries that account for 78% of Latin America's population; the results were then extrapolated to the regional level. Results: Every year, smoking is responsible for 33 576 billion dollars in direct costs to health systems. This amounts to 0.7% of the region's gross domestic product (GDP) and 8.3% of its health budget. Cardiovascular disease, COPD, and cancer were responsible for 30.3%, 26.9%, and 23.7% of these expenditures, respectively. Smoking-attributable costs ranged from 0.4% (Mexico and Peru) to 0.9% (Chile) of GDP and from 5.2% (Brazil) to 12.7% (Bolivia) of health expenditures. In the region, tax revenues from cigarette sales barely cover 37% of smoking-attributable health expenditures (8.1% in Bolivia and 67.3% in Argentina). Conclusions: Smoking is responsible for a significant proportion of health spending in Latin America, and tax revenues from cigarette sales are far from covering it. The region's countries should seriously consider stronger measures, such as an increase in tobacco taxes.
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4.

Impacto económico del tabaquismo en los sistemas de salud de América Latina: un estudio en siete países y su extrapolación a nivel regional/ Financial impact of smoking on health systems in Latin America: A study of seven countries and extrapolation to the regional level

Pichon-Riviere, Andrés; Bardach, Ariel; Augustovski, Federico; Alcaraz, Andrea; Reynales-Shigematsu, Luz Myriam; Pinto, Márcia Teixeira; Castillo-Riquelme, Marianela; Torres, Esperanza Peña; Osorio, Diana Isabel; Huayanay, Leandro; Munarriz, César Loza; de Miera-Juárez, Belén Sáenz; Gallegos-Rivero, Verónica; Puente, Catherine De La; Navia-Bueno, María del Pilar; Caporale, Joaquín
| Idioma(s): Español
RESUMEN Objetivo Estimar los costos médicos directos atribuibles al tabaquismo en los sistemas de salud de América Latina. Métodos Se utilizó un modelo de microsimulación para cuantificar el impacto económico en enfermedad cardiovascular y cerebrovascular, enfermedad pulmonar obstructiva crónica (EPOC), neumonía, cáncer de pulmón y otras nueve neoplasias. Se realizó una búsqueda sistemática de datos epidemiológicos y de costos de los eventos. El modelo se calibró y validó para Argentina, Bolivia, Brasil, Chile, Colombia, México y Perú, países que representan el 78% de la población de América Latina; luego se extrapolaron los resultados a nivel regional. Resultados Cada año el tabaquismo es responsable de 33 576 millones de dólares en costos directos para el sistema de salud. Esto equivale a 0,7% del producto interno bruto (PIB) de la región y a 8,3% del presupuesto sanitario. La enfermedad cardiovascular, la EPOC y el cáncer fueron responsables de 30,3%, 26,9% y 23,7% de este gasto, respectivamente. El costo atribuible al tabaquismo varió entre 0,4% (México y Perú) y 0,9% (Chile) del PIB y entre 5,2% (Brasil) y 12,7% (Bolivia) del gasto en salud. En la región, la recaudación impositiva por la venta de cigarrillos apenas cubre 37% del gasto sanitario atribuible al tabaquismo (8,1% en Bolivia y 67,3% en Argentina). Conclusiones El tabaquismo es responsable de una importante proporción del gasto sanitario en América Latina, y la recaudación impositiva por la venta de cigarrillos está lejos de llegar a cubrirlo. La profundización de medidas como el aumento de impuestos al tabaco debería ser seriamente considerada por los países de la región. ABSTRACT Objective Estimate smoking-attributable direct medical costs in Latin American health systems. Methods A microsimulation model was used to quantify financial impact of cardiovascular and cerebrovascular disease, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer, and nine other neoplasms. A systematic search for epidemiological data and event costs was carried out. The model was calibrated and validated for Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, countries that account for 78% of Latin America’s population; the results were then extrapolated to the regional level. Results Every year, smoking is responsible for 33 576 billion dollars in direct costs to health systems. This amounts to 0.7% of the region’s gross domestic product (GDP) and 8.3% of its health budget. Cardiovascular disease, COPD, and cancer were responsible for 30.3%, 26.9%, and 23.7% of these expenditures, respectively. Smoking-attributable costs ranged from 0.4% (Mexico and Peru) to 0.9% (Chile) of GDP and from 5.2% (Brazil) to 12.7% (Bolivia) of health expenditures. In the region, tax revenues from cigarette sales barely cover 37% of smoking-attributable health expenditures (8.1% in Bolivia and 67.3% in Argentina). Conclusions Smoking is responsible for a significant proportion of health spending in Latin America, and tax revenues from cigarette sales are far from covering it. The region’s countries should seriously consider stronger measures, such as an increase in tobacco taxes.
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5.

Adolescent injuries in Argentina, Bolivia, Chile, and Uruguay: Results from the 2012-2013 Global School-based Student Health Survey (GSHS).

Beck, Naja I; Arif, Issra; Paumier, Michelle F; Jacobsen, Kathryn H
| Idioma(s): Inglés
OBJECTIVES: The goals of this study were to identify the proportion of early adolescents in southern South America who were injured in the past year, to identify risk behaviours and other exposures associated with injuries, and to evaluate the most common types and causes of injury in this population. METHODS: We used complex samples analysis to examine cross-sectional data from more than 35,000 students from all four countries in South America that participated in the Global School-based Student Health Survey (GSHS) in 2012-2013. RESULTS: The proportion of students reporting at least one injury in the past year that required medical treatment or caused at least one full day of missed school or usual activities was 27.1% in Argentina, 29.5% in Uruguay, 30.9% in Chile, and 36.8% in Bolivia. Significantly more boys than girls reported injuries. Injured students were more likely than non-injured students to report anxiety-induced insomnia, being physically attacked, being in a physical fight, and being lonely in the past year, and they were also more likely to report being bullied, using tobacco, drinking alcohol, and missing school in the past month. For both boys and girls, the most common type of injury reported was a broken bone or dislocated joint and the most common injury cause was the student falling. However, most students were not able to provide a specific answer to either question. CONCLUSION: The GSHS has been conducted in 100 low- and middle-income countries and territories around the world, and new waves of data collection are currently being planned and implemented. The utility of the injury data from the GSHS would be improved if the injury type and cause response items were updated to better capture information about self-harm, sports injuries, and other statistics that will provide a stronger foundation for evidence-based injury prevention interventions in adolescent populations.
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6.

Impacto económico del tabaquismo en los sistemas de salud de América Latina: un estudio en siete países y su extrapolación a nivel regional/ Financial impact of smoking on health systems in Latin America: A study of seven countries and extrapolation to the regional level

Pichon-Riviere, Andrés; Bardach, Ariel; Augustovski, Federico; Alcaraz, Andrea; Reynales-Shigematsu, Luz Myriam; Pinto, Márcia Teixeira; Castillo-Riquelme, Marianela; Peña Torres, Esperanza; Osorio, Diana Isabel; Huayanay, Leandro; Loza Munarriz, César; Miera-Juárez, Belén Sáenz de; Gallegos-Rivero, Verónica; De La Puente, Catherine; Navia-Bueno, María del Pilar; Caporale, Joaquín
| Idioma(s): Español
Objetivo. Estimar los costos médicos directos atribuibles al tabaquismo en los sistemas de salud de América Latina. Métodos. Se utilizó un modelo de microsimulación para cuantificar el impacto económico en enfermedad cardiovascular y cerebrovascular, enfermedad pulmonar obstructiva crónica (EPOC), neumonía, cáncer de pulmón y otras nueve neoplasias. Se realizó una búsqueda sistemática de datos epidemiológicos y de costos de los eventos. El modelo se calibró y validó para Argentina, Bolivia, Brasil, Chile, Colombia, México y Perú, países que representan el 78% de la población de América Latina; luego se extrapolaron los resultados a nivel regional. Resultados. Cada año el tabaquismo es responsable de 33 576 millones de dólares en costos directos para el sistema de salud. Esto equivale a 0,7% del producto interno bruto (PIB) de la región y a 8,3% del presupuesto sanitario. La enfermedad cardiovascular, la EPOC y el cáncer fueron responsables de 30,3%, 26,9% y 23,7% de este gasto, respectivamente. El costo atribuible al tabaquismo varió entre 0,4% (México y Perú) y 0,9% (Chile) del PIB y entre 5,2% (Brasil) y 12,7% (Bolivia) del gasto en salud. En la región, la recaudación impositiva por la venta de cigarrillos apenas cubre 37% del gasto sanitario atribuible al tabaquismo (8,1% en Bolivia y 67,3% en Argentina). Conclusiones. El tabaquismo es responsable de una importante proporción del gasto sanitario en América Latina, y la recaudación impositiva por la venta de cigarrillos está lejos de llegar a cubrirlo. La profundización de medidas como el aumento de impuestos al tabaco debería ser seriamente considerada por los países de la Región. Objective. Estimate smoking-attributable direct medical costs in Latin American health systems. Methods. A microsimulation model was used to quantify financial impact of cardio-vascular and cerebrovascular disease, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer, and nine other neoplasms. A systematic search for epidemio-logical data and event costs was carried out. The model was calibrated and validated for Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, countries that account for 78% of Latin America’s population; the results were then extrapolated to the regional level. Results. Every year, smoking is responsible for 33 576 billion dollars in direct costs to health systems. This amounts to 0.7% of the region’s gross domestic product (GDP) and 8.3% of its health budget. Cardiovascular disease, COPD, and cancer were respon-sible for 30.3%, 26.9%, and 23.7% of these expenditures, respectively. Smoking-attributable costs ranged from 0.4% (Mexico and Peru) to 0.9% (Chile) of GDP and from 5.2% (Brazil) to 12.7% (Bolivia) of health expenditures. In the region, tax reve-nues from cigarette sales barely cover 37% of smoking-attributable health expenditu-res (8.1% in Bolivia and 67.3% in Argentina). Conclusions. Smoking is responsible for a significant proportion of health spending in Latin America, and tax revenues from cigarette sales are far from covering it. The region’s countries should seriously consider stronger measures, such as an increase in tobacco taxes.
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7.

Individual health and the visibility of village economic inequality: Longitudinal evidence from native Amazonians in Bolivia.

Undurraga, Eduardo A; Nica, Veronica; Zhang, Rebecca; Mensah, Irene C; Godoy, Ricardo A
| Idioma(s): Inglés
Mounting evidence suggests that income inequality is associated with worse individual health. But does the visibility of inequality matter? Using data from a horticultural-foraging society of native Amazonians in Bolivia (Tsimane'), we examined whether village inequality in resources and behaviors with greater cultural visibility is more likely to bear a negative association with health than village inequality in less conspicuous resources. We draw on a nine-year annual panel (2002-2010) from 13 Tsimane' villages for our main analysis, and an additional survey to gauge the cultural visibility of resources. We measured inequality using the Gini coefficient. We tested the robustness of our results using a shorter two-year annual panel (2008-2009) in another 40 Tsimane' villages and an additional measure of inequality (coefficient of variation, CV). Behaviors with low cultural visibility (e.g., household farm area planted with staples) were less likely to be associated with individual health, compared to more conspicuous behaviors (e.g., expenditures in durable goods, consumption of domesticated animals). We find some evidence that property rights and access to resources matter, with inequality of privately-owned resources showing a larger effect on health. More inequality was associated with improved perceived health - maybe due to improved health prospects from increasing wealth - and worse anthropometric indicators. For example, a unit increase in the Gini coefficient of expenditures in durable goods was associated with 0.24 fewer episodes of stress and a six percentage-point lower probability of reporting illness. A one-point increase in the CV of village inequality in meat consumption was associated with a 4 and 3 percentage-point lower probability of reporting illness and being in bed due to illness, and a 0.05 SD decrease in age-sex standardized arm-muscle area. In small-scale, rural societies at the periphery of market economies, nominal economic inequality in resources bore an association with individual health, but did not necessarily harm perceived health. Economic inequalities in small-scale societies apparently matter, but a thick cultural tapestry of reciprocity norms and kinship ties makes their effects less predictable than in industrial societies.
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8.

Caregivers' perception of patients' cognitive deficit in schizophrenia and its influence on their quality of life.

Caqueo-Urízar, Alejandra; Urzúa, Alfonso; Boyer, Laurent
| Idioma(s): Inglés
PURPOSE: The aim of the study was to explore the relationship between the caregivers’ perception of patients’ cognitive deficits (i.e., neurocognition and social cognition) and their quality of life (QoL), after adjusting on clinicians’ assessment of neurocognitive deficits and sociodemographic confounding factors. METHODS: The study included 253 patients with schizophrenia and their caregivers from public mental health clinics in Bolivia, Chile, and Peru. The caregivers’ perception of patients’ neurocognitive and social cognitive deficits was assessed using the the GEOPTE scale, caregivers’ QoL was assessed using the schizophrenia caregiver quality of life questionnaire (S-CGQoL) and clinicians’ ratings of patients’ neurocognitive deficits was based on the cognitive factor of the positive and negative syndrome scale for schizophrenia (PANSS). RESULTS: The degree of agreement between caregivers’ perception and health care professionals’ assessment of cognitive deficit of patients with schizophrenia was moderate. Caregivers’ perceptions of neurocognitive and social cognitive deficits were significantly associated with their QoL, contrary to clinicians’ assessment. CONCLUSIONS: Caregivers’ perception of patients’ cognitive deficit was significantly associated with their QoL. The caregivers’ perception regarding patients’ neurocognition and social cognition may enrich the knowledge of clinicians on patients and is important to be considered by clinicians to improve caregiver’s QoL.
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9.

Cost-Effectiveness of Blood Donation Screening for Trypanosoma cruzi in Mexico.

Sánchez-González, Gilberto; Figueroa-Lara, Alejandro; Elizondo-Cano, Miguel; Wilson, Leslie; Novelo-Garza, Barbara; Valiente-Banuet, Leopoldo; Ramsey, Janine M
| Idioma(s): Inglés
An estimated 2 million inhabitants are infected with Chagas disease in Mexico, with highest prevalence coinciding with highest demographic density in the southern half of the country. After vector-borne transmission, Trypanosoma cruzi is principally transmitted to humans via blood transfusion. Despite initiation of serological screening of blood donations or donors for T. cruzi since 1990 in most Latin American countries, Mexico only finally included mandatory serological screening nationwide in official Norms in 2012. Most recent regulatory changes and segmented blood services in Mexico may affect compliance of mandatory screening guidelines. The objective of this study was to calculate the incremental cost-effectiveness ratio for total compliance of current guidelines from both Mexican primary healthcare and regular salaried worker health service institutions: the Secretary of Health and the Mexican Institute for Social Security. We developed a bi-modular model to analyze compliance using a decision tree for the most common screening algorithms for each health institution, and a Markov transition model for the natural history of illness and care. The incremental cost effectiveness ratio based on life-years gained is US$ 383 for the Secretary of Health, while the cost for an additional life-year gained is US$ 463 for the Social Security Institute. The results of the present study suggest that due to incomplete compliance of Mexico's national legislation during 2013 and 2014, the MoH has failed to confirm 15,162 T. cruzi infections, has not prevented 2,347 avoidable infections, and has lost 333,483 life-years. Although there is a vast difference in T. cruzi prevalence between Bolivia and Mexico, Bolivia established mandatory blood screening for T.cruzi in 1996 and until 2002 detected and discarded 11,489 T. cruzi -infected blood units and prevented 2,879 potential infections with their transfusion blood screening program. In the first two years of Mexico's mandated program, the two primary institutions failed to prevent due to incomplete compliance more potential infections than those gained from the first five years of Bolivia's program. Full regulatory compliance should be clearly understood as mandatory for the sake of blood security, and its monitoring and analysis in Mexico should be part of the health authority's responsibility.
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10.

Different Patterns in Health Care Use Among Immigrants in Spain.

Villarroel, Nazmy; Artazcoz, Lucía
| Idioma(s): Inglés
This study aims to analyze the differences in the use of primary care (PC), hospital, and emergency services between people born in Spain and immigrants. Data were obtained from the 2006 Spanish National Health Survey. The sample was composed of individuals aged 16-64 years from Spain and the seven countries with most immigrants in Spain (n = 22,224). Hierarchical multiple logistic regression models were fitted. Romanian men were less likely to use health care at all levels compared to men from other countries. Women from Argentina, Bolivia and Ecuador reported a lower use of PC. Among women, there were no differences in emergency visits or hospitalizations between countries. Bolivian men reported more hospitalizations than Spanish men, whereas Argentinean men reported more emergency visits than their Spanish counterparts. In Spain, most immigrants made less than, or about the same use of health care services as the native Spanish population.
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