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Climate change and agricultural workers' health in Ecuador: occupational exposure to UV radiation and hot environments.

Harari Arjona, Raul; Piñeiros, Jessika; Ayabaca, Marcelo; Harari Freire, Florencia
| Idioma(s): Inglés
Climate change is a global concern but little is known about its potential health effects in workers from non-industrialized countries. Ecuadorian workers from the coast (hot environments) and Andean region (elevated UV radiation) might be at particular risk of such effects. In the Andean region, measurements of UV index show maximum levels exceeding 11, a level considered being extreme according to the WHO. Also, an increased incidence of skin cancer was reported the last decennium, this being the second most common cancer type in men and women. In the coast, a high reported prevalence of kidney disease in agricultural workers is suggested to be related to exposure to hot temperatures. The scarce data available on occupational health in Ecuadorian agricultural workers raise the need for further investigation. Data worldwide shows an increasing prevalence of UV radiation- and heat stress-related illnesses in agricultural workers and urges the adoption of preventive measures.
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Familias Unidas for high risk adolescents: Study design of a cultural adaptation and randomized controlled trial of a U.S. drug and sexual risk behavior intervention in Ecuador.

Jacobs, Petra; Estrada, Yannine A; Tapia, Maria I; Quevedo Terán, Ana M; Condo Tamayo, Cecilia; Albán García, Mónica; Valenzuela Triviño, Gilda M; Pantin, Hilda; Velazquez, Maria R; Horigian, Viviana E; Alonso, Elizabeth; Prado, Guillermo
| Idioma(s): Inglés
BACKGROUND: Developing, testing and implementing evidence-based prevention interventions are important in decreasing substance use and sexual risk behavior among adolescents. This process requires research expertise, infrastructure, resources and decades of research testing, which might not always be feasible for low resource countries. Adapting and testing interventions proven to be efficacious in similar cultures might circumvent the time and costs of implementing evidence-based interventions in new settings. This paper describes the two-phase study, including training and development of the research infrastructure in the Ecuadorian university necessary to implement a randomized controlled trial. METHODS/DESIGN: Familias Unidas is a multilevel parent-centered intervention designed in the U.S. to prevent drug use and sexual risk behaviors in Hispanic adolescents. The current study consisted of Phase 1 feasibility study (n=38) which adapted the intervention and study procedures within a single-site school setting in an area with a high prevalence of drug use and unprotected sexual behavior among adolescents in Ecuador, and Phase 2 randomized controlled trial of the adapted intervention in two public high schools with a target population of families with adolescents from 12 to 14 years old. DISCUSSION: The trial is currently in Phase 2. Study recruitment was completed with 239 parent-youth dyads enrolling. The intervention phase and the first follow-up assessment have been completed. The second and third follow-up assessments will be completed in 2016. This project has the potential of benefitting a large population of families in areas of Ecuador that are disproportionally affected by drug trafficking and its consequences. TRIAL REGISTRATION: MSP-DIS-2015-0055-0, Ministry of Public Health (MSP), Quito, Ecuador.
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A qualitative exploration of the impact of the economic recession in Spain on working, living and health conditions: reflections based on immigrant workers' experiences.

Ronda, Elena; Briones-Vozmediano, Erica; Galon, Tanyse; García, Ana M; Benavides, Fernando G; Agudelo-Suárez, Andrés A
| Idioma(s): Inglés
BACKGROUND: This study aimed to analyse how immigrant workers in Spain experienced changes in their working and employment conditions brought about Spain's economic recession and the impact of these changes on their living conditions and health status. METHOD: We conducted a grounded theory study. Data were obtained through six focus group discussions with immigrant workers (n = 44) from Colombia, Ecuador and Morocco, and two individual interviews with key informants from Romania living in Spain, selected by theoretical sample. RESULTS: Three categories related to the crisis emerged--previous labour experiences, employment consequences and individual consequences--that show how immigrant workers in Spain (i) understand the change in employment and working conditions conditioned by their experiences in the period prior to the crisis, and (ii) experienced the deterioration in their quality of life and health as consequences of the worsening of employment and working conditions during times of economic recession. CONCLUSION: The negative impact of the financial crisis on immigrant workers may increase their social vulnerability, potentially leading to the failure of their migratory project and a return to their home countries. Policy makers should take measures to minimize the negative impact of economic crisis on the occupational health of migrant workers in order to strengthen social protection and promote health and well-being.
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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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Addressing Disease-Related Malnutrition in Healthcare: A Latin American Perspective.

Correia, Maria Isabel; Hegazi, Refaat A; Diaz-Pizarro Graf, José Ignacio; Gomez-Morales, Gabriel; Fuentes Gutiérrez, Catalina; Goldin, Maria Fernanda; Navas, Angela; Pinzón Espitia, Olga Lucia; Tavares, Gilmária Millere
| Idioma(s): Inglés
Alarmingly high rates of disease-related malnutrition have persisted in hospitals of both emerging and industrialized nations over the past 2 decades, despite marked advances in medical care over this same interval. In Latin American hospitals, the numbers are particularly striking; disease-related malnutrition has been reported in nearly 50% of adult patients in Argentina, Brazil, Chile, Costa Rica, Cuba, Dominican Republic, Ecuador, Mexico, Panama, Paraguay, Peru, Puerto Rico, Venezuela, and Uruguay. The tolls of disease-related malnutrition are high in both human and financial terms-increased infectious complications, higher incidence of pressure ulcers, longer hospital stays, more frequent readmissions, greater costs of care, and increased risk of death. In an effort to draw attention to malnutrition in Latin American healthcare, a feedM.E. Latin American Study Group was formed to extend the reach and support the educational efforts of the feedM.E. Global Study Group. In this article, the feedM.E. Latin American Study Group shows that malnutrition incurs excessive costs to the healthcare systems, and the study group also presents evidence of how appropriate nutrition care can improve patients' clinical outcomes and lower healthcare costs. To achieve the benefits of nutrition for health throughout Latin America, the article presents feedM.E.'s simple and effective Nutrition Care Pathway in English and Spanish as a way to facilitate its use.
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Bananas, pesticides and health in southwestern Ecuador: A scalar narrative approach to targeting public health responses.

Brisbois, Benjamin
| Idioma(s): Inglés
Public health responses to agricultural pesticide exposure are often informed by ethnographic or other qualitative studies of pesticide risk perception. In addition to highlighting the importance of structural determinants of exposure, such studies can identify the specific scales at which pesticide-exposed individuals locate responsibility for their health issues, with implications for study and intervention design. In this study, an ethnographic approach was employed to map scalar features within explanatory narratives of pesticides and health in Ecuador's banana-producing El Oro province. Unstructured observation, 14 key informant interviews and 15 in-depth semi-structured interviews were carried out during 8 months of fieldwork in 2011-2013. Analysis of interview data was informed by human geographic literature on the social construction of scale. Individual-focused narratives of some participants highlighted characteristics such as carelessness and ignorance, leading to suggestions for educational interventions. More structural explanations invoked farm-scale processes, such as uncontrolled aerial fumigations on plantations owned by elites. Organization into cooperatives helped to protect small-scale farmers from 'deadly' banana markets, which in turn were linked to the Ecuadorian nation-state and actors in the banana-consuming world. These scalar elements interacted in complex ways that appear linked to social class, as more well-off individuals frequently attributed the health problems of other (poorer) people to individual behaviours, while providing more structural explanations of their own difficulties. Such individualizing narratives may help to stabilize inequitable social structures. Research implications of this study include the possibility of using scale-focused qualitative research to generate theory and candidate levels for multi-level models. Equity implications include a need for public health researchers planning interventions to engage with scale-linked inequities, such as disparities within nation-states. Finally, the prominence of the global North in explanatory narratives is a useful reminder that 'structural factors' prominently include inequities related to the legacies of colonialism.
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Social determination of the oral health-disease process: a social-historical approach in four Latin American countries/ Determinación social del proceso salud enfermedad bucal: una aproximación socio-histórica en cuatro países de Latinoamérica/ Determinação social do processo saúde doença bucal: uma aproximação sócio-histórica em quatro países da América Latina

Ruiz Mendoza, Diana Carolina; Morales Borrero, María Carolina
| Idioma(s): Inglés
Objective. This study sought to contrast the perspectives on the social determination of oral health present in the scientific literature published in Colombia, Brazil, Ecuador, and Mexico since 1970 until 2012. Methodology. This was a cross-sectional descriptive study on the Latin American scientific production published in specialized databases between 1970 and 2012. Results. The social determination of oral health in Latin America is characterized by the conflict among the players when seeking to overcome the limitations and traditional perspectives in health. The differences among the countries studied are explained by the existing relationship among research, higher education, and the socio-political trajectories of the countries and the similarities by health systems that have permitted accumulation of inequities in health. In Brazil, the concern for the individual and collective in local settings is important, while in Ecuador, Mexico, and Colombia the explanation based on the social determinants of the diseases predominates. Conclusion. The view of the social determination of the oral health-disease process in Latin America is characterized by a continuous dispute between emancipation and accumulation approaches. The scant impact of social determination in oral health obeys to the history of the odontology profession, the predominance of care policies and services of technical care nature. Objetivo. Contrastar las perspectivas sobre determinación social de la salud bucal presentes en la literatura científica publicada en Colombia, Brasil, Ecuador y México desde 1970 hasta 2012. Metodología. Estudio descriptivo transversal sobre la producción científica latinoamericana publicada en bases de datos especializadas entre 1970 y 2012. Resultados. La determinación social de la salud bucal en Latinoamérica se caracteriza por la conflictividad entre los actores al intentar superar las limitaciones de las perspectivas tradicionales en salud. Las diferencias entre países estudiados se explican por la relación existente entre la investigación, la educación superior y las trayectorias sociopolíticas de los países; las similitudes, por los sistemas de salud que han permitido la acumulación de inequidades en salud. En Brasil la preocupación por lo individual y colectivo en ámbitos locales es importante, mientras que en Ecuador, México y Colombia predomina la explicación basada en los determinantes sociales de las enfermedades. Conclusión. La mirada de la determinación social del proceso salud enfermedad bucal en Latinoamérica se caracteriza por una disputa continua entre enfoques de emancipación y acumulación. El escaso impacto de la determinación social en salud bucal obedece a la historia de la profesión odontológica, al predominio de políticas y servicios de atención de carácter técnico asistencial. Objetivo. Contrastar as perspectivas sobre determinação social da saúde bucal presentes na literatura científica publicada na Colômbia, no Brasil, no Equador e no México desde 1970 até 2012. Metodologia. Estudo descritivo transversal sobre a produção científica latino-americana publicada em bases de dados especializadas entre 1970 e 2012. Resultados. A determinação social da saúde bucal na América Latina se caracteriza pelos conflitos entre os atores ao tentar superar as limitações das perspectivas tradicionais em saúde. As diferenças entre países estudados se explicam pela relação existente entre a investigação, a educação superior e as trajetórias sociopolíticas dos países e, as similitudes por sistemas de saúde que permitiram a acumulação de inequidades na saúde. No Brasil a preocupação pelo individual e coletivo em âmbitos locais é importante, enquanto no Equador, no México e na Colômbia predomina a explicação baseada nos determinantes sociais das doenças Conclusão. A mirada da determinação social do processo saúde doença bucal na América Latina se caracteriza por uma disputa contínua entre enfoques de emancipação e acumulação. O escasso impacto da determinação social em saúde bucal obedece à história da profissão odontológica, ao predomínio de políticas e serviços de atendimento de caráter técnico assistencial.
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El sistema nacional de salud en el Perú/ The national health system in Peru

Sánchez-Moreno, Francisco
| Idioma(s): Español
Un grupo de profesionales en el Perú, conocedores de sistemas nacionales de salud, conformado desde 1975, comenzó un proceso que llevó al país a ser el primero en América del Sur en iniciar la organización moderna de este sistema. El avance pionero que significó la creación del Sistema Nacional de Servicios de Salud en 1978 ocurrió antes de las reformas de los sistemas de salud en Chile (1980), Brasil (1990), Colombia (1993) y Ecuador (2008). El alentador inicio tuvo vaivenes reformistas permanentes desde entonces, con evolución negativa por falta de una política de Estado. Las características actuales del sistema peruano son el desempeño ineficiente y la discontinuidad, sin evaluación alguna, lo que determina un gran atraso con relación a los sistemas de salud de América. En el siglo XXI se han desaprovechado importantes esfuerzos técnicos para modernizar el sistema y sus funciones. El futuro es preocupante y el papel de las nuevas generaciones será decisivo. In 1975, a group of professionals in Peru who were experts on national health systems began a process that led the country to be the first in South America to initiate a modern organization of the health system. This pioneering development meant that the creation of the National Health Services System [in Peru] in 1978 occurred before the health system reforms in Chile (1980), Brazil (1990), Colombia (1993), and Ecuador (2008). This encouraging start has had permanent reformist fluctuations since then, with negative development because of the lack of a State policy. Current features of the Peruvian system are inefficient performance, discontinuity, and lack of assessment, which creates a major setback in comparison with other health systems in America. In the 21st century, significant technical efforts have been missed to modernize the system and its functions. The future is worrying and the role of new generations will be decisive.
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Lessons learned in evaluating the Familias Fuertes program in three countries in Latin America/ Lecciones aprendidas al evaluar el programa Familias Fuertes en tres países de América Latina

Orpinas, Pamela; Ambrose, Ashley; Maddaleno, Matilde; Vulanovic, Lauren; Mejia, Martha; Butrón, Betzabé; Gutierrez, Gonzalo Sosa; Soriano, Ismael
| Idioma(s): Inglés
This report describes 1) the evaluation of the Familias Fuertes primary prevention program in three countries (Bolivia, Colombia, and Ecuador) and 2) the effect of program participation on parenting practices. Familias Fuertes was implemented in Bolivia (10 groups, 96 parents), Colombia (12 groups, 173 parents), and Ecuador (five groups, 42 parents) to prevent the initiation and reduce the prevalence of health-compromising behaviors among adolescents by strengthening family relationships and enhancing parenting skills. The program consists of seven group sessions (for 6-12 families) designed for parents/caregivers and their 10-14-year-old child. Parents/caregivers answered a survey before the first session and at the completion of the program. The survey measured two important mediating constructs: "positive parenting" and "parental hostility." The Pan American Health Organization provided training for facilitators. After the program, parents/caregivers from all three countries reported significantly higher mean scores for "positive parenting" and significantly lower mean scores for "parental hostility" than at the pre-test. "Positive parenting" practices paired with low "parental hostility" are fundamental to strengthening the relationship between parents/caregivers and the children and reducing adolescents' health-compromising behaviors. More research is needed to examine the long-term impact of the program on adolescent behaviors. Este informe describe 1) la evaluación del programa de prevención primaria Familias Fuertes en tres países (Bolivia, Colombia y Ecuador) y 2) el efecto de la participación en el programa sobre las prácticas de crianza. El programa Familias Fuertes se llevó a cabo en Bolivia (10 grupos, 96 padres), Colombia (12 grupos, 173 padres) y Ecuador (5 grupos, 42 padres) para prevenir el inicio y reducir la prevalencia de comportamientos que constituyen un riesgo para la salud de los adolescentes, mediante el fortalecimiento de las relaciones familiares y la mejora de las habilidades de crianza. El programa consta de siete sesiones de grupo (para 6 a 12 familias) dirigidas a padres o cuidadores y sus hijos de 10 a 14 años de edad. Los padres o cuidadores respondieron a una encuesta antes de la primera sesión y al término del programa. La encuesta midió dos conceptos importantes: la "crianza positiva" y la "hostilidad parental". La Organización Panamericana de la Salud capacitó a los facilitadores. Después del programa, los padres o cuidadores de los tres países presentaron puntuaciones ­ medias significativamente mayores en "crianza positiva" y significativamente menores en "hostilidad parental" que en la encuesta previa. La prácticas de "crianza positiva" asociadas con una baja "hostilidad parental" son fundamentales para fortalecer la relación entre los padres o cuidadores y los niños, y reducen los comportamientos que constituyen un riesgo para la salud de los adolescentes. Es necesaria una investigación más amplia para analizar la repercusión a largo plazo del programa sobre los comportamientos de los adolescentes.
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"Peri-border" health care programs: the Ecuador-Peru experience/ Programas de atención de salud en zonas fronterizas: la experiencia de Ecuador y Perú

Cafagna, Gianluca; Beingolea, Rosa Luz Benites de; Missoni, Eduardo
| Idioma(s): Inglés
OBJECTIVE: To identify the main strengths, weaknesses, and challenges of the Ecuador-Peru "peri-border" health care program and to analyze the legislative, managerial, and organizational arrangements adopted to integrate the two country's national health systems in the border area. METHODS: A descriptive, qualitative case study was carried out using three complementary methods: literature review and analysis of official Peruvian and Ecuadoran national and binational documents, 18 semi-structured interviews of key informants, and a survey of the entire health worker population of the Suyo-Macará binational micro-network. RESULTS: The key program challenge was the absence of reciprocity; Peruvian citizens were entitled to free health care services in Ecuador but Ecuadoran citizens did not receive the same benefit in Peru. The need for improvements in the binational system's human resources was also identified. The program's main strength was its organizational structure, which is designed mainly for the implementation of 1) the binational network and 2) a patient referral / counter-referral system that includes the transfer of patient clinical information. CONCLUSIONS: Notwithstanding considerable challenges, peri-border programs are feasible and replicable. Program success seems to be highly dependent on the completion of a number of steps, including 1) consolidation of the original binational memorandum into a binding binational agreement between the two countries; 2) achievement of similar standards in both countries for the provision and quality of health care services, focusing on complementarities; and 3) development of an integrated binational information system. OBJETIVO: Determinar los principales puntos fuertes y débiles, y las dificultades del programa de atención de salud en la zona fronteriza entre Ecuador y Perú, y analizar las disposiciones legislativas, de gestión y de organización adoptadas para integrar los sistemas nacionales de salud de ambos países en la zona fronteriza. MÉTODOS: Se llevó a cabo un estudio de casos descriptivo y cualitativo mediante el empleo de tres métodos complementarios: la revisión bibliográfica y el análisis de documentos oficiales peruanos y ecuatorianos, nacionales y binacionales; 18 entrevistas semiestructuradas a informantes clave; y una encuesta dirigida a todo el personal sanitario de la microrred binacional Suyo-Macará. RESULTADOS: La principal dificultad del programa estribó en la ausencia de reciprocidad; los ciudadanos peruanos tenían derecho a servicios de atención de salud gratuitos en Ecuador, pero los ciudadanos ecuatorianos no recibían la misma prestación en Perú. También se señaló la necesidad de mejoras en materia de recursos humanos del sistema binacional. La principal fortaleza del programa fue su estructura organizativa, diseñada principalmente para la implantación de 1) la red binacional; y 2) un sistema de referencia y contrarreferencia de los pacientes que incluye la transferencia de la información clínica de los pacientes. CONCLUSIONES: A pesar de las considerables dificultades, los programas de atención de salud en zonas fronterizas son factibles y reproducibles. El éxito de los programas parece depender en gran medida de que se cumplan una serie de condiciones tales como 1) la consolidación del memorándum binacional original mediante un acuerdo binacional vinculante entre ambos países; 2) la consecución de estándares similares en ambos países en cuanto a la provisión y la calidad de los servicios de atención de salud, con especial hincapié en la complementariedad; y 3) la creación de un sistema binacional de información integrado.
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