Antibiotic use without prescription in Ecuadorian children according to their families' socioeconomic characteristics / Uso de antibióticos sin prescripción en niños ecuatorianos según las características socioeconómicas de sus familias

AbstrAct background: among the many processes responsible for antimicrobial resistance, inappropriate antibiotic use and self-medication are major public health concerns. To tackle antibiotic resistance and its widespread misuse, is important to identify the social, cultural, and economic differences associated with the problem. Objective: to determine the percentage of antibiotics used without medical prescription in children under five years old with symptoms of upper respiratory tract infection according to their families' socioeconomic characteristics in Ecuador. Materials and Methods: a cross-sectional design was set, using a structured questionnaire to assess mothers who attended urban and rural primary health care units with their children under five years old and belonged to the middle or lower social strata. A sample of 947 individuals was obtained from February to April 2011. Informed consent was acquired from those willing and eligible participants. The descriptive analysis used frequencies, percentages, means, standard deviation and chi-square. Quantitative information was processed using SPSS version 17. Results: those from lower socioeconomic strata used antibiotics to treat symptoms of upper respiratory infections of their children without medical prescription in a higher percentage (35.57%) than middle socioeconomic strata (27.7%, p<0.01). Mothers who had university level education had more knowledge about measures to prevent antibiotic resistance (57.14%) than those with only a primary school education (13.59% p<0.05). Conclusion: antibiotic use in children under five years old with symptoms of upper respiratory infection is high, mainly among those study participants corresponding to lower socioeconomic strata who mostly live in the rural area. MÉD.UIs. 2017;30(2):21-7.

Resumen Introducción: entre los múltiples procesos responsables de la resistencia antimicrobiana, el uso inadecuado de los antibióticos y la automedicación son problemas alarmantes en salud pública. Para la contención de la resistencia a los antibióticos y la ampliación del mal uso, es importante identificar las diferencias sociales, culturales y económicas asociadas al problema. Objetivo: determinar el porcentaje de uso de antibióticos sin prescripción médica en niños menores de cinco años, con síntomas de infección del tracto respiratorio superior de acuerdo las características socioeconómicas de sus familias en Ecuador. Materiales y métodos: se realizó un diseño transversal utilizando un cuestionario estructurado para evaluar a madres pertenecientes a estratos sociales medio y bajo, quienes asistieron con sus hijos menores de cinco años a unidades urbanas y rurales de atención primaria de salud. Se obtuvo desde febrero a abril de 2011, una muestra de 947 individuos que dieron su consentimiento informado. Se hizo un análisis descriptivo mediante el uso de frecuencias, porcentajes, medias, desviación estándar y chi cuadrado. Para el procesamiento de la información cuantitativa se utilizó SPSS versión 17. Resultados: los estratos socioeconómicos más bajos usaron antibióticos sin prescripción médica para tratar síntomas de infecciones respiratorias del tracto respiratorio superior de sus hijos en un mayor porcentaje (35,57%), comparado con los del estrato económico medio (27,7%, p <0.01). Las madres con educación universitaria tuvieron más conocimiento sobre medidas para la prevención de la resistencia bacteriana (57,14%) que aquellas con solamente educación primaria (13,59% p<0,05). Conclusiones: el uso de antibióticos en niños menores de 5 años con síntomas de infección respiratoria alta es elevado, principalmente en aquellos participantes pertenecientes al estrato socioeconómico bajo, quienes viven en su mayoría en el área rural. MÉD.UIs. 2017;30(2):21-7.

Needs assessment for home-based care and the strengthening of social support networks: the role of community care workers in rural South Africa.

BACKGROUND: Community care workers (CCWs) in rural South Africa provide medical, personal, household, educational, and social care services to their clients. However, little understanding exists on how provision of services is approached within a household, taking into account available social support networks. OBJECTIVE: The aim of this study was to generate an understanding of the processes that underpin the provision of care by CCWs in rural households and their engagement with clients, primary caregivers (PCGs), and other members of the social support network. DESIGN: We analysed in-depth interviews conducted in a triad of participants involved in a home-based care (HBC) encounter - 32 clients, 32 PCGs, and 17 CCWs. For each triad, a purposefully selected CCW was linked with a purposefully selected client and the corresponding PCG using maximum variation sampling. Three coders used an inductive content analysis method to describe participants' references to the nuances of processes followed by CCWs in servicing HBC clients. Written informed consent was obtained from all participants. FINDINGS: The results suggest that, by intuition and prior knowledge, CCWs treated each household uniquely, depending on the clients' care needs, cooperation, availability of a social network, and the reliability and resilience of the social support system for the client. Four distinct processes took place in rural households: needs assessment for care, rationing of care, appraisal of care, and reinforcement of a social support system. However, there was no particular order or sequence established for these processes, and caregivers followed no prescribed or shared standards. CONCLUSIONS: CCWs bring a basket of services to a household, but engage in a constant, dynamic, and cyclical process of weighing needs against services provided. The service package is uniquely crafted and tailored for each household, depending on the absorptive capacity of the social support network available to the client, and preferences of the clients remain central to the process of negotiating care.

Moving toward universal access to health and universal health coverage: a review of comprehensive primary health care in Suriname.

OBJECTIVE: To provide an overview of comprehensive primary health care (CPHC) development and implementation in Suriname in peer-reviewed literature. METHODS: Building on work funded by the Teasdale-Corti Global Health Research Partnership Program/People's Health Movement, the authors searched MEDLINE, the Cochrane Library, and POPLINE for articles focused on CPHC within the Surinamese context. Two authors independently reviewed abstracts and then jointly reviewed the selected abstracts. The final selection was completed using a data extraction form. RESULTS: The initial search resulted in 1 556 abstracts. The initial review identified 58 articles. Only three of the 58 articles met the inclusion criteria for the final review. The three selected articles provided partial overviews of CPHC in Suriname and examples of its implementation, with a focus on the service delivery network in the interior of the country, which was designed to improve rural access to basic health care services by training community members as service providers. They also included examples of how preparations for health reform in Suriname in the late 1990s and early 2000s, influenced by global neoliberal reforms, led to expectations that disparities in health status, design of health system components, and service provision related to differences in power and historical context (e.g., the influence of medical professionals, political parties/ethnic groups, and wealthier populations concentrated in urban areas) would be addressed. CONCLUSIONS: Given the focus on primary health care in the Americas and the notable developments that have occurred in Surinamese health policy and health care, particularly in health care reform, the paucity of published research on CPHC in Suriname was an unexpected finding that may be partly due to prioritizing research on disease control rather than health policy and systems research. The limited amount of scientific literature on this topic 1) prevents clear understanding of CPHC development and implementation in Suriname and 2) underscores the need to strengthen the national health research system to better inform policies for moving the country toward universal health access and coverage to improve the health of all of its citizens.

Moving toward universal access to health and universal health coverage: a review of comprehensive primary health care in Suriname / Avanzando hacia el acceso universal a la salud y la cobertura universal de salud: un análisis de la atención primaria de salud integral en Suriname

OBJECTIVE: To provide an overview of comprehensive primary health care (CPHC) development and implementation in Suriname in peer-reviewed literature. METHODS: Building on work funded by the Teasdale-Corti Global Health Research Partnership Program/People's Health Movement, the authors searched MEDLINE, the Cochrane Library, and POPLINE for articles focused on CPHC within the Surinamese context. Two authors independently reviewed abstracts and then jointly reviewed the selected abstracts. The final selection was completed using a data extraction form. RESULTS: The initial search resulted in 1 556 abstracts. The initial review identified 58 articles. Only three of the 58 articles met the inclusion criteria for the final review. The three selected articles provided partial overviews of CPHC in Suriname and examples of its implementation, with a focus on the service delivery network in the interior of the country, which was designed to improve rural access to basic health care services by training community members as service providers. They also included examples of how preparations for health reform in Suriname in the late 1990s and early 2000s, influenced by global neoliberal reforms, led to expectations that disparities in health status, design of health system components, and service provision related to differences in power and historical context (e.g., the influence of medical professionals, political parties/ethnic groups, and wealthier populations concentrated in urban areas) would be addressed. CONCLUSIONS: Given the focus on primary health care in the Americas and the notable developments that have occurred in Surinamese health policy and health care, particularly in health care reform, the paucity of published research on CPHC in Suriname was an unexpected finding that may be partly due to prioritizing research on disease control rather than health policy and systems research. The limited amount of scientific literature on this topic 1) prevents clear understanding of CPHC development and implementation in Suriname and 2) underscores the need to strengthen the national health research system to better inform policies for moving the country toward universal health access and coverage to improve the health of all of its citizens.

OBJETIVO: Proporcionar una visión de conjunto de la implantación de la atención primaria de salud integral en Suriname en la bibliografía arbitrada. MÉTODOS: Aprovechando el trabajo financiado por el Programa de Alianza de Investigación en Salud Mundial Teasdale-Corti/Movimiento de Salud de los Pueblos, los autores efectuaron búsquedas en MEDLINE, la Biblioteca Cochrane y POPLINE de artículos que se centraran en la atención primaria de salud integral en el contexto surinamés. Dos autores analizaron los resúmenes independientemente y a continuación examinaron conjuntamente los resúmenes seleccionados. La selección final se completó mediante el empleo de un formulario de extracción de datos. RESULTADOS: La búsqueda inicial obtuvo como resultado 1 556 resúmenes. El análisis inicial seleccionó 58 artículos. Solo tres de estos 58 artículos satisficieron los criterios de inclusión en el análisis final. Los tres artículos seleccionados proporcionaban un panorama parcial de la atención primaria de salud integral en Suriname y ejemplos de su implantación, se centraban especialmente en la red de prestación de servicios del interior del país, diseñada para mejorar el acceso a los servicios de atención básica de salud en el entorno rural mediante la capacitación de los miembros de la comunidad como proveedores de servicios. También incluían ejemplos de cómo los preparativos para la reforma sanitaria de Suriname a fines de los años noventa y principios de siglo XXI, influidos por las reformas neoliberales a escala mundial, generaron expectativas de que se abordarían las disparidades en el estado sanitario, el diseño de los componentes del sistema sanitario, y la prestación de servicios de atención de salud relacionadas con diferencias de poder y contexto histórico (por ejemplo, la influencia de los profesionales de la medicina, partidos políticos y grupos étnicos, y las poblaciones más ricas concentradas en las zonas urbanas). CONCLUSIONES: Dada la importancia concedida a la atención primaria de salud en la Región de las Américas y el notable desarrollo experimentado por la política de salud y la atención de salud de Suriname, particularmente en la reforma del sector sanitario, la escasa investigación publicada sobre la atención primaria de salud integral en Suriname fue un hallazgo inesperado, que en parte puede ser debido a que se ha priorizado más la investigación sobre el control de enfermedades que la investigación sobre políticas y sistemas de salud. La limitada cantidad de bibliografía científica sobre este tema 1) impide una comprensión clara del desarrollo y la implantación de la atención primaria de salud integral en Suriname y 2) destaca la necesidad de fortalecer el sistema nacional de investigación en salud con objeto de fundamentar mejor las políticas que hagan avanzar al país hacia el acceso y la cobertura universales de salud para una mejora de la salud de todos sus ciudadanos.

El curriculum integrado de la Facultad de Medicina proyecto MHO FORTSALUD(2ª parte) / The integrated curriculum of the Faculty of Medicine MHO project FORTSALUD (Part 2)

El presente artículo es una descripción de un importante hito en la historia del desarrollo académico de la Facultad de Medicina de la Universidad Mayor de San Simón (FM-UMSS). Relata un proceso inicial de preparación de condiciones para un cambio curricular que incluye la capacitación del personal docente en una maestría en Educación, información sobre la estructura del denominado Curriculum y los principios que lo sustentan, finalmente, se hacen una breve referencia a las causas que determinaron su anulación luego de dos años de implementación.

This article is a description of an important milestone in the history of academic development of the Faculty of Medicine of the University of San Simón (FM-UMSS). Recounts an initial process of preparing conditions for curricular change that includes training of teachers in a masters in Education, information on the structure of so-called curriculum and the principles that underpin finally a brief reference to the causes that are made determined its cancellation after two years of implementation.

Community care workers, poor referral networks and consumption of personal resources in rural South Africa.

Although home-based care (HBC) programs are widely implemented throughout Africa, their success depends on the existence of an enabling environment, including a referral system and supply of essential commodities. The objective of this study was to explore the current state of client referral patterns and practices by community care workers (CCWs), in an evolving environment of one rural South African sub-district. Using a participant triangulation approach, in-depth qualitative interviews were conducted with 17 CCWs, 32 HBC clients and 32 primary caregivers (PCGs). An open-ended interview guide was used for data collection. Participants were selected from comprehensive lists of CCWs and their clients, using a diversified criterion-based sampling method. Three independent researchers coded three sets of data - CCWs, Clients and PCGs, for referral patterns and practices of CCWs. Referrals from clinics and hospitals to HBC occurred infrequently, as only eight (25%) of the 32 clients interviewed were formally referred. Community care workers showed high levels of commitment and personal investment in supporting their clients to use the formal health care system. They went to the extent of using their own personal resources. Seven CCWs used their own money to ensure client access to clinics, and eight gave their own food to ensure treatment adherence. Community care workers are essential in linking clients to clinics and hospitals and to promote the appropriate use of medical services, although this effort frequently necessitated consumption of their own personal resources. Therefore, risk protection strategies are urgently needed so as to ensure sustainability of the current work performed by HBC organizations and the CCW volunteers.

Percepciones y prácticas de los escolares sobre las causas, gravedad y tratamiento de las infecciones respiratorias agudas. Azuay, Ecuador, 2012 / School children's perceptions and practices on the causes, gravity and treatment of acute respiratory infection, Azuay, Ecuador, 2012

Objetivo: Identificar las percepciones y prácticas que sobre las causas, gravedad y tratamiento en la infección respiratoria aguda tienen los escolares pertenecientes a distintos estratos sociales de Cuenca en el año 2011. Metodología: Se realizó un estudio descriptivo en una muestra por conveniencia de 498 escolares del sexto y séptimo año de educación básica, de la zona urbana y rural de Azuay. Se explicó a los responsables del cuidado de los escolares el objetivo de la encuesta y se obtuvo el consentimiento informado. Para el control de calidad se realizó un estudio piloto en otra institución diferente a la del estudio. Los datos fueron analizados en el programa SPSS versión 15, se emplearon frecuencias, porcentajes y medidas de tendencia central como promedio y desvío estándar, además se usó el chi cuadrado para buscar significancia estadística. Resultado: La edad promedio fue de 10.8 años para la población urbana y rural, y de conglomerados sociales bajo y medio. Los servicios básicos completos estuvieron presentes en la población de zona urbana en el 83.9% y de conglomerado social medio en 73.8%. El conglomerado social bajo y los escolares de género femenino utilizaban con más frecuencia fármacos en el hogar antes de recibir atención médica (42.3% y 43%). Los escolares del género femenino (41.9%) en mayor porcentaje conocían sobre los antibióticos, mientras que los de género masculino tuvieron mejor conocimiento sobre resistencia bacteriana (26.3%). Los centros de salud y escuelas fueron la principal fuente de información sobre los antibióticos y la resistencia bacteriana, aunque el acceso de los niños a la información en general fue bajo. El nivel de conocimiento de las causas y la gravedad de la infección respiratoria aguda fue inadecuado en un alto porcentaje de los niños y las niñas. La mayoría de los escolares, independientemente de su estado, identificaron que "el cuidado en clima frío" es una medida adecuada de prevención y protección contra IRA, pero muy bajo porcentaje de ellos consideraron reposo, no fumar, alimentación saludable, protección y limpieza nasal como prácticas de autocuidado para prevenir infecciones respiratorias agudas. Conclusiones: Solo un porcentaje limitado de niños y niñas tienen conocimientos y percepciones apropiadas sobre la gravedad de la infección respiratoria aguda, el uso de antibióticos y la resistencia bacteriana. Los programas de contención de la resistencia bacteriana requieren de un enfoque integral y multilateral que involucre a la comunidad con énfasis en la escuela, los niños, las madres y sus familias.

Objective: To identify the perceptions and practices of schoolchildren belonging to different social strata about the causes, severity, and treatment of acute respiratory infection in Azuay province, Ecuador in 2012. Methodology: A descriptive study was conducted in a convenience sample of 498 schoolchildren in the sixth and seventh year of primary school, from both urban and rural areas of Azuay. We talk with the responsible people for the schoolchildren care about the aim of the study, and the informed consent was obtained. For quality control we performed a pilot study in a different institution than this study. Data were analyzed using SPSS version 15, we used frequencies, percentages and measures of central tendency such as middle and standard deviation, and chi-square was used to find statistical significance. Result: The average age of participants was 10.8 years. Children came from both urban and rural regions, and belonged to low or middle social strata. Those of low social strata and of feminine gender more commonly used drugs in the home before receiving medical care (42.3% and 45.0%). A higher percentage of female children (41.9 %) were aware of antibiotics, while the males had better knowledge of bacterial resistance (26.3%). The health-care centers and school were the main source of information on antibiotics and bacterial resistance, although children's access to information overall was low. The level of knowledge of the causes and the severity of acute respiratory infection was inadequate in a high proportion of both boys and girls. The majority of participating schoolchildren, independent of their status identified that "taking care in cold weather" is an appropriate measure of prevention and protection against ARI, but very low percentages of them considered rest, no smoking, healthy food, protection and nasal cleaning as self-care practices to prevent ARI. Conclusions: Only a limited percentage of boys and girls had appropriate knowledge and perceptions about the severity of acute respiratory infection, the use of antibiotics and antibiotic resistance. Programs to contain antibiotic resistance require multilateral and comprehensive approaches that involve the community with an emphasis on the school, children, parents and their families.

Aplicación de la estrategia de Atención Integral de Enfermedades Prevalentes de la Infancia en Ecuador / Implementation of the strategy of Integrated Management of Childhood Illnesses

Introducción: la estrategia de Atención Integral de Enfermedades Prevalentes de la Infancia desarrollada por la Organización Mundial de la Salud y la UNICEF, puede reducir la mortalidad infantil y estimular el uso racional de antibióticos. Objetivo: valorar el cumplimiento de la mencionada estrategia en términos de diagnóstico y tratamiento, en especial el tratamiento con antibióticos, en niños con infección respiratoria aguda en el Ecuador. Métodos: se revisaron las historias clínicas de pacientes que tenían entre dos meses y cinco años de edad, que habían sido atendidos en dos centros de atención primaria de salud en zonas urbanas y rurales, donde los niños reciben atención médica gratuita, entre julio de 2010 y Junio de 2011. Se recolectaron retrospectivamente los datos sobre las características del paciente, diagnóstico y tratamiento. Resultados: en ambos centros de salud y en la mayoría de las historias clínicas se constató la falta de información sobre el tratamiento y la administración de los antibióticos. Se recopilaron los datos de 1 063 pacientes, que revelaron que la prescripción excesiva de antibióticos se produjo con mayor frecuencia (6,50 %) en los centros de atención rural. Conclusiones: hay incumplimiento parcial en la aplicación de la estrategia y es importante en investigaciones futuras profundizar en sus causas. La inaccesibilidad a los servicios de salud podría ser una causa asociada, especialmente en las zonas rurales. La contextualización de la estrategia puede ser necesaria para mejorar la salud infantil, promover el uso racional de los antibióticos y reducir la diseminación de resistencias antimicrobianas.

Introduction: the strategy of Integrated Management of Childhood Illnesses (IMCI) developed by the World health Organization and the UNICEF is aimed at reducing infant mortality and at promoting the rational use of antibiotics. Objective: to evaluate the performance of the above-mentioned strategy for children with acute respiratory infections in Ecuador, in terms of diagnosis and treatment, particularly antibiotic therapy. Methods: the medical histories of patients aged two months to five-years old, who had been diagnosed with ARI and treated at 2 primary health care centers in urban or rural areas in the period of July 2010 through June 2011, were checked. Data about the characteristics of the patients, the diagnosis and the treatment followed were retrospectively collected. Results: in both primary health centers and in most of the medical records, information about the lines of treatment and administration of antibiotics was missing. Data collected on 1 063 patients revealed that over-prescription of antibiotics occurred more frequently in health centers located in rural areas (6.5 %). Conclusion: future research should focus on identifying the causes of failure in the IMCI implementation. The inaccessibility to health centers may be an example of associated causes, especially in rural areas. The contextualization of the IMCI strategy may be needed to improve child health, to promote the rational use of antibiotics and to reduce the spread of antimicrobial resistance.

Differences in antibiotic use and knowledge between adolescent and adult mothers in Ecuador.

OBJECTIVES:  To investigate the differences in antibiotic use and knowledge between adolescent and adult mothers of children under the age of 5 years in Ecuador. METHODS:  A cross sectional study was performed in four health centers and hospitals. Mothers of children under five years, seeking medical attention their child's upper respiratory tract infection (URI), were included. The data was collected through interviews, using a structured questionnaire. The questionnaire covered the topics knowledge of antibiotic treatment, risk and resistance.  RESULTS:  777 mothers were included in the study, of which 15.8% were adolescent and 84.1% adult mothers. There were significant differences in the social and economic characteristics of the mothers (p ≤ 0.05), with adolescent mothers being more likely to have an incomplete high school education and lack of basic services in their home. Significant differences between these groups were found in adherence to treatment, knowledge about risks associated with antibiotic use, and having heard of antibiotic resistance. Among the adult mothers, 83.5% reported correct adherence, 28.5% were knowledgeable about risks associated with antibiotic use, and 29.3% had heard of antibiotic resistance. Among the adolescent mothers, these numbers were 75.4%, 15.0%, and 19.8%, respectively. CONCLUSIONS:  To develop successful interventions, it is crucial to understand the factors causing differences in antibiotic use and knowledge between mothers.

Rights, knowledge, and governance for improved health equity in urban settings.

All three of the interacting aspects of daily urban life (physical environment, social conditions, and the added pressure of climate change) that affect health inequities are nested within the concept of urban governance, which has the task of understanding and managing the interactions among these different factors so that all three can be improved together and coherently. Governance is defined as: "the process of collective decision making and processes by which decisions are implemented or not implemented": it is concerned with the distribution, exercise, and consequences of power. Although there appears to be general agreement that the quality of governance is important for development, much less agreement appears to exist on what the concept really implies and how it should be used. Our review of the literature confirmed significant variation in meaning as well as in the practice of urban governance arrangements. The review found that the linkage between governance practices and health equity is under-researched and/or has been neglected. Reconnecting the fields of urban planning, social sciences, and public health are essential "not only for improving local governance, but also for understanding and addressing global political change" for enhanced urban health equity. Social mobilization, empowering governance, and improved knowledge for sustainable and equitable development in urban settings is urgently needed. A set of strategic research questions are suggested.

[Governance and health: meaning and implications in Latin America]. / Gobernanza y salud: significado y aplicaciones en América Latina.

The term governance is used more and more often in the formulation, implementation, and evaluation of public policies. The purpose of this paper is twofold: to shed light on its meaning, and to study its applicability for the study of recent public health policies in Latin America. After discussing the differences between governance and the close concepts of management, governability and government, we propose the adoption of the notion of Giddens' duality of social structure for better understanding of the governance processes. Then we use this theoretical framework for reviewing the conceptual and empirical implications of the set of papers about governance and health in Latin America included in the present special issue of the Journal of Public Health. Recognizing that the debate on governance is not closed, we end the paper highlighting the main contributions of the revised works, namely: the importance of equity in decision-making processes, the appreciation of the political nature of governance, and the advantages and limitations of the clan mechanism of governance for regulating interactions among actors involved in the health policy decision-making processes.

Gobernanza y salud: significado y aplicaciones en América Latina / Governance and health: meaning and implications in Latin America

El término gobernanza es cada vez mas utilizado en la formulación, implementación y evaluación de políticas públicas. El propósito de este artículo es de clarificar su significado y de estudiar su utilidad en el estudio de las recientes políticas de salud de la América Latina. Después de discutir de las diferencias existentes entre gobernanza y los conceptos conexos de gestión, gobernabilidad y gobierno, proponemos la noción de la dualidad de la estructura social de Giddens para una mejor comprensión de los procesos de gobernanza. Utilizamos después este marco teórico para discutir de las implicaciones conceptuales y empíricas del grupo de trabajos sobre la gobernanza en salud en América Latina incluidos en el presente número de la Revista de Salud Pública. Reconociendo que el debate sobre gobernanza aun no está cerrado, terminamos nuestro texto subrayando las contribuciones más importantes de los trabajos revisados, a saber la importancia de la equidad en el proceso de toma de decisiones, el reconocimiento de la naturaleza política de la gobernanza, y las ventajas y limitaciones del modelo de clan en la regulación de las interacciones entre los actores implicados en la toma de decisiones políticas en salud.

The term governance is used more and more often in the formulation, implementation, and evaluation of public policies. The purpose of this paper is twofold: to shed light on its meaning, and to study its applicability for the study of recent public health policies in Latin America. After discussing the differences between governance and the close concepts of management, governability and government, we propose the adoption of the notion of Giddens' duality of social structure for better understanding of the governance processes. Then we use this theoretical framework for reviewing the conceptual and empirical implications of the set of papers about governance and health in Latin America included in the present special issue of the Journal of Public Health. Recognizing that the debate on governance is not closed, we end the paper highlighting the main contributions of the revised works, namely: the importance of equity in decision-making processes, the appreciation of the political nature of governance, and the advantages and limitations of the clan mechanism of governance for regulating interactions among actors involved in the health policy decision-making processes.

Task shifting: the answer to the human resources crisis in Africa?

Ever since the 2006 World Health Report advocated increased community participation and the systematic delegation of tasks to less-specialized cadres, there has been a great deal of debate about the expediency, efficacy and modalities of task shifting. The delegation of tasks from one cadre to another, previously often called substitution, is not a new concept. It has been used in many countries and for many decades, either as a response to emergency needs or as a method to provide adequate care at primary and secondary levels, especially in understaffed rural facilities, to enhance quality and reduce costs. However, rapidly increasing care needs generated by the HIV/AIDS epidemic and accelerating human resource crises in many African countries have given the concept and practice of task shifting new prominence and urgency. Furthermore, the question arises as to whether task shifting and increased community participation can be more than a short-term solution to address the HIV/AIDS crisis and can contribute to a revival of the primary health care approach as an answer to health systems crises. In this commentary we argue that, while task shifting holds great promise, any long-term success of task shifting hinges on serious political and financial commitments. We reason that it requires a comprehensive and integrated reconfiguration of health teams, changed scopes of practice and regulatory frameworks and enhanced training infrastructure, as well as availability of reliable medium- to long-term funding, with time frames of 20 to 30 years instead of three to five years. The concept and practice of community participation needs to be revisited. Most importantly, task shifting strategies require leadership from national governments to ensure an enabling regulatory framework; drive the implementation of relevant policies; guide and support training institutions and ensure adequate resources; and harness the support of the multiple stakeholders. With such leadership and a willingness to learn from those with relevant experience (for example, Brazil, Ethiopia, Malawi, Mozambique and Zambia), task shifting can indeed make a vital contribution to building sustainable, cost-effective and equitable health care systems. Without it, task shifting runs the risk of being yet another unsuccessful health sector reform initiative.

Prevention and management of chronic obstructive pulmonary disease (COPD) in primary care: position paper of the European Forum for Primary Care.

Chronic obstructive pulmonary disease (COPD) is a smoking-related, progressive lung disease that represents a substantial individual, societal and economic burden. Primary care professionals have an important role in healthcare provision for patients with COPD. In this position paper we summarise the current knowledge about, and management of patients with COPD. Next, we describe the role general practitioners and other primary care disciplines (should) have to prevent, diagnose and treat COPD. Finally, we explore differences in the way particular aspects of primary care COPD disease management are available or organised in a number of European countries, in order to identify barriers and provide examples of 'best practices' for optimal primary care management of patients with COPD.

La inequidad en la salud: hacia un abordaje integral

Contenido: La urbanización y la problemática de las inequidades en salud: necesidad de enfoques integrales. Sistema de salud en Argentina. Gestión del espacio urbano con un enfoque de equidad. Refelxiones en torno a los problemas y potencialidades del sector público de salud. Comentarios sobre el sector informal y la salud en la pobreza. Asimetrías de poder como principal barrera para una efectiva participación social en política pública: experiencias de Guatemala. Sistema Integral de Gestión Ambiental: una herramienta para la gestión integral del territorio. Consolidadndo los derechos de los niños. Programa Rosario Hábitat. Un abordaje integral en el mejoramiento de asentamientos irregulares. Presentación del Municipio de San Fernando. Reflexiones de los participantes. Entornos urbanos y salud: comentario desde el campo de los estudios urbanos. Construyendo puentes...

Integrated approaches to address the social determinants of health for reducing health inequity.

The social and physical environments have long since been recognized as important determinants of health. People in urban settings are exposed to a variety of health hazards that are interconnected with their health effects. The Millennium Development Goals (MDGs) have underlined the multidimensional nature of poverty and the connections between health and social conditions and present an opportunity to move beyond narrow sectoral interventions and to develop comprehensive social responses and participatory processes that address the root causes of health inequity. Considering the complexity and magnitude of health, poverty, and environmental issues in cities, it is clear that improvements in health and health equity demand not only changes in the physical and social environment of cities, but also an integrated approach that takes into account the wider socioeconomic and contextual factors affecting health. Integrated or multilevel approaches should address not only the immediate, but also the underlying and particularly the fundamental causes at societal level of related health issues. The political and legal organization of the policy-making process has been identified as a major determinant of urban and global health, as a result of the role it plays in creating possibilities for participation, empowerment, and its influence on the content of public policies and the distribution of scarce resources. This paper argues that it is essential to adopt a long-term multisectoral approach to address the social determinants of health in urban settings. For comprehensive approaches to address the social determinants of health effectively and at multiple levels, they need explicitly to tackle issues of participation, governance, and the politics of power, decision making, and empowerment.

Exposure to wood dust and endotoxin in small-scale wood industries in Tanzania.

Workers in small-scale wood industries (SSWI) have increased risks of developing asthma and other respiratory diseases. Wood dust and microbial agents have both been suggested to play a role, but few studies have measured endotoxin exposure in SSWI in Africa. We assessed inhalable dust levels in 281 samples from 115 workers and bacterial endotoxins levels in 157 samples from 136 workers from SSWI in Dar es Salaam, Tanzania. The overall geometric mean of personal exposure was 3.3 mg/m(3); geometric standard deviation (GSD) 2.5; range 0.45-67.0 mg/m(3)) and 91 EU/m(3) (GSD 3.7; range 9-4914.8 EU/m(3)) for wood dust and endotoxins, respectively. Dust and endotoxin levels were weakly correlated (r = 0.44, n = 157, P < 0.0001). Between- and within-worker variances and percentages explained by the differences among job titles and seasons were 0.31 (9%) and 0.35 (30%), respectively, for wood dust exposure, and 0.35 (0%) and 0.35 (38%) for endotoxin exposure. Higher dust and endotoxin exposure levels were observed in the dry compared to the wet season, after correcting for differences in exposure between jobs. Carving and manual cleaning were associated with the highest dust exposures. Sewing seat covers and manual cleaning were associated with the highest endotoxin exposures. Dust and endotoxin exposure levels in SSWI are high and appropriate control measures are necessary.