Identifying access barriers faced by rural and dispersed communities to better address their needs: implications and lessons learned for rural proofing for health in the Americas and beyond.

INTRODUCTION: Universal access to health services and universal health coverage are needed to achieve good health for all, yet rural communities face a variety of access barriers. As part of an effort to 'rural proof' health systems, it is therefore imperative to identify and act on the factors limiting access to health services by rural and indigenous communities. This article provides a comprehensive overview of the wide range of access barriers faced by rural and remote communities in two countries where barrier assessments were conducted. It also discusses the potential for barrier assessments to contribute evidence for rural proofing of national health policies, strategies, plans and programs. METHODS: The study applied a concurrent triangulation design to collect and analyze data obtained from narrative-style literature reviews, in-depth interviews with local health authorities, and secondary analyses of existing household data on Guyana and Peru. These two countries were selected because they have some of the largest rural and indigenous populations in Latin America and the Caribbean, and have national policies in place for providing free, essential health services for these communities. Both quantitative and qualitative data were collected separately, and results were interpreted together. The main objective was to corroborate and cross-validate findings looking for convergence between the separate data analyses. RESULTS: Seven dominant themes were identified across the two countries: use of traditional medicine and practice; decision making, gender, and family power dynamics; ethnicity and trust; knowledge and health literacy; geographic accessibility, health personnel and intercultural skills; and financial accessibility. The findings suggest that the interaction between these barriers may be as important as the singular role played by each factor, thereby highlighting the complex and multifactorial nature of accessing services in rural settings. Issues with limited availability of human resources for health were compounded by inadequate supplies and infrastructure. Financial barriers were often linked to the indirect costs of transport and geographic location, and further exacerbated by reduced socioeconomic status of rural communities, a majority of which are indigenous and have a strong preference for traditional medicines. Importantly, rural and indigenous communities experience considerable non-financial barriers related to issues of acceptability, which requires adaptation of health personnel and health service delivery models to the context-specific needs and realities of each rural community. CONCLUSION: This study presented an approach for data collection and analysis that is both feasible and effective for evaluating access barriers in rural and remote communities. While this study explored access barriers through general health services in two rural settings, the issues identified reflect the structural deficiencies of many health systems. These challenges and singularities require adaptive organizational models for the provision of health services that respond to the specific characteristics of rural and indigenous communities. This study indicates the potential relevance of conducting assessments of barriers to health services as part of a wider approach to rural proofing and supports the notion that a mixed-methods approach, linking secondary analysis of existing relevant national survey data with focused key-informant interview data, may be an effective and efficient way to transform data into the knowledge policymakers need to rural proof health policies.

Prostate cancer screening behaviors among Indo-Guyanese.

OBJECTIVE: The objective of this study was to explore prostate cancer screening behaviors among Indo-Guyanese men. METHODS: This qualitative study was conducted in the surrounding neighborhood of Queens, New York during 2018 and 2019. In-depth, one-on-one interviews were conducted using 20 Indo-Guyanese men between the ages of 45 and 75. RESULTS: The findings suggest that Indo-Guyanese men are being screened for prostate cancer at a very low rate. Only 30% (n = 6) of participants underwent prostate cancer screening. Four major themes were derived from the data, which could have contributed to the decreased level of screening. These included: (1) recommendations must come from their healthcare professional; (2) reluctance to engage in screening; (3) distrust of the medical system; and (4) screening only if symptoms are present or they know someone with prostate cancer. CONCLUSIONS: Behavioral patterns for prostate cancer screening among Indo-Guyanese men share some similarities with other Caribbean countries. Clinicians and Healthcare Professionals should be culturally competent for the patients they serve. Understanding the behavioral variations within this diverse culture could help provide the highest possible care, specifically tailored to each patient.

Malaria care-seeking and treatment ideation among gold miners in Guyana.

BACKGROUND: Although miners are a priority population in malaria elimination in Guyana, scant literature exists on the drivers of malaria-related behaviour. This study explores the relationship between gold miners' malaria-related ideation and the adoption of malaria care-seeking and treatment behaviours including prompt care-seeking, malaria testing, and self-medication. METHODS: Data are from a cross-sectional quantitative survey of 1685 adult miners between the ages of 18-59 years who live in mining camps in Regions 1, 7, and 8. The analysis focused on miners who reported an episode of fever in the past year (n = 745). Malaria care-seeking and treatment ideation was defined as a composite additive score consisting of the following variables: general malaria knowledge, perceived severity, perceived susceptibility, beliefs, perceived self-efficacy, perceived norms, interpersonal communication, and perceived response efficacy. Multivariable logistic regressions explored the relationship between ideation on care-seeking/treatment behaviours, controlling for confounding variables. RESULTS: Most miners with a recent episode of fever had perceived risk (92%), self-efficacy (67%), susceptibility (53%) and high malaria knowledge (53%). Overall, miners' care-seeking/treatment ideation score ranged from 0 to 8 with a mean of 4.1. Ideation scores were associated with higher odds of care-seeking for fever (aOR: 1.19; 95% CI 1.04-1.36), getting tested for malaria (aOR: 1.22; 95% CI 1.07-1.38) and lower odds of self-medication (aOR: 0.87; 95% CI 0.77-0.99). CONCLUSIONS: A national community case management initiative is using study findings as part of its scale-up, using volunteers to make testing and treatment services more accessible to miners. This is complemented by a multi-channel mass media campaign to improve miners' ideation. Communication messages focus on increasing miners' knowledge of malaria transmission and symptoms, encourage positive beliefs about malaria testing and volunteer testers, promote evidence about the effectiveness of testing, and reminders of how quick and easy it is to get a malaria test with the community case management initiative. Study findings also have implications for efforts to eliminate malaria across the Guiana Shield.

Osteology-focused redescription and description of the blood-feeding candirus Paracanthopoma parva and Paravandellia alleynei sp.n. (Trichomycteridae: Vandelliinae).

This study resolves a significant impediment to the taxonomy of the Neotropical endemic hematophagous candirus by providing the first high-resolution, CT-based osteological descriptions of type and nontype specimens of Paracanthopoma parva, type species of the genus. We also describe the distinctive new species Paravandellia alleynei based on specimens that were previously misidentified as Parac. parva in the only taxonomic study of that species since its 1935 description. Paracanthopoma parva is distinguished from all nominal congeners by its parietosupraoccipital and caudal skeleton morphology and by various meristics, including numbers of teeth on median premaxilla, vertebrae, and procurrent and principal caudal-fin rays. Paravandellia alleynei differs from both nominal congeners (Paravandellia oxyptera and Paravandellia phaneronema) by the unique morphology of its maxilla, mesethmoid and opercular apparatus, relative position of the pelvic- and anal-fin origins, orientation of the opercular odontodes, and various meristics, including numbers of vertebrae, median premaxillary teeth, medial teeth on premaxilla, branchiostegal rays, opercular and interopercular odontodes, distal claw-like premaxillary teeth, dorsal-fin rays and dentary teeth. This is the first species of Paravandellia recognized from Guyana and the Essequibo River basin. It is currently known only from two type specimens from the lower Essequibo River basin and 43 nontype specimens from the upper Branco River basin. By providing the first skeletal observations for type specimens of the type species Parac. parva and for topotypic specimens of all three nominal species of Paravandellia, we clarify and confirm the diagnosis of Parac. parva and establish a robust foundation for ongoing taxonomic revisions of these two small-sized and species-poor, yet trans-continentally distributed genera, both of which contain considerable unrecognized diversity.

Human-centered design process and solutions to promote malaria testing and treatment seeking behavior in Guyana hinterlands.

BACKGROUND: Malaria is a persistent public health challenge among miners and other hard-to-reach populations in Guyana's hinterland, specifically in Regions 1, 7, 8, and 9. Despite an overall decrease in malaria prevalence throughout Guyana, it remains common among mining populations whose work conditions both contribute toward malaria transmission and make it difficult to seek timely, Ministry of Health (MoH) approved malaria testing and treatment services. In an effort to develop innovative approaches to address this public health challenge, an interdisciplinary team of public health professionals, designers, and mining organizations collaborated using a human-centered design (HCD) process facilitated by the USAID-funded Breakthrough ACTION Guyana project in partnership with the MoH. METHODS: This paper describes two phases: [1] Define and [2] Design & Test. In the Define phase, following a literature review, we conducted 108 qualitative interviews with miners, camp managers, trained malaria testers, health workers, and other key stakeholders to understand experiences and challenges when seeking malaria testing and treatment services. These interviews were synthesized into 11 insights on issues such as risk perception, malaria knowledge, preventive behaviors, traditional and self-treatment, adherence to the correct treatment, testing, and coordination and communication gaps. From these insights, during the Design & Test phase, we developed 33 "How might we…?" questions which led to 792 ideas, of which eight emergent concepts were prototyped and refined in the field with 145 miners, camp managers, and stakeholders. RESULTS: The five final prototypes included: "Little Mosquito, Big Problem" social behavior change campaign; rapid counseling cards; branded malaria testing and treatment services; innovations in treatment adherence; and a participants, content, and logistics approach. CONCLUSION: When applying HCD to public health issues, there are both opportunities and challenges to reconcile gaps that may exist between the two disciplines. However, HCD provides additional tools and mindsets to generatively work with migrant and mobile mining communities to encourage malaria testing and treatment services.

Barriers to Prostate Cancer Screening Among Indo-Guyanese.

Prostate cancer is one of the most common types of cancer in many industrialized countries and is among the leading causes of death. Ranking among one of the top three forms of cancer, it is unfortunate that prostate cancer screening is not routinely recommended. This study attempts to explore the barriers to prostate cancer screening among Indo-Guyanese men. We conducted in-depth, one on one interviews among 20 Indo-Guyanese men between the ages of 45 and 75 years old, residing in the New York City neighborhood of Queens. Qualitative analysis was performed using multiple coders. Detailed analysis of the data found four major themes to be the culprit associated with a decrease in prostate cancer screening in this population: (1) lack of knowledge about the disease, (2) fear of diagnosis, (3) embarrassment and, (4) personal reservations with the rectal exam. The findings of this research suggest that Indo-Guyanese immigrants are lacking the basic understanding of prostate cancer and the importance of screening. It is possible that this deficiency is also applicable to many other disease states. By collaborating with healthcare providers and other stakeholders, such as community leaders and elected officials, we can develop culturally appropriate services specific to this population, to address these barriers to healthcare services.

[Gender equality and health equity: strategic lessons from country experiences of gender mainstreaming in healthIgualdade de gênero e equidade em saúde: lições estratégicas de experiências de país na integração do gênero na saúde]. / Igualdad de género y equidad en salud: lecciones estratégicas de las experiencias de los países en la incorporación de la perspectiva de género en la salud.

OBJECTIVES: To analyze progress in organizational structures, mechanisms, strategies, and enabling factors and barriers towards gender mainstreaming (GM) in health in Guatemala, Guyana, and Peru, given GM's role in addressing gender inequalities in health as a key structural driver of health equity. METHODS: Data was obtained through a grey literature review of laws, policies, and/or program documents and semi-structured qualitative interviews with 37 informants. Analysis was based on a theoretical framework including 7 categories considered essential to advance GM in the health sector. RESULTS: Despite significant efforts and accumulated experiences of GM in health, structural barriers include: wider societal challenges of transforming gender unequal power relations; health system complexity combined with the low technical, political, and financial capacity of institutional structures tasked with GM; and limited coordination with (often weak) National Women's Machineries (NWMs). In some contexts, barriers are compounded by limited understanding of basic concepts underlying GM (at times exacerbated by misunderstandings related to intersectionality and/or engagement with men) and the absence of indicators to measure GM's concrete results and impact. CONCLUSIONS: Successful GM requires a more strategic and transformational agenda, developed and implemented in coordination with NWMs and civil society and with reference to external bodies (e.g. Committee on the Elimination of Discrimination against Women) to go beyond process, with clearer distinction between gender sensitivity and gender transformation, and definition of expected results and indicators to measure advances. These then could be better documented and systematized, enabling GM to be more broadly understood and operationalized as a concrete instrument towards health equity.

OBJETIVOS: Analisar o progresso nas estruturas organizacionais, mecanismos, estratégias, e fatores habilitadores e barreiras para a integração do gênero (IG) na saúde na Guatemala, na Guiana e no Peru, dado o papel da IG na abordagem das desigualdades de gênero na saúde como um dos principais impulsionadores estruturais da equidade em saúde. MÉTODOS: Os dados foram obtidos por meio de uma análise das leis, políticas e/ou documentos de programa e entrevistas qualitativas semi-estruturadas junto a 37 informantes, extraídos da literatura cinza. A análise foi efetuada com base em uma estrutura teórica que incluiu 7 categorias consideradas essenciais para promover a IG no setor da saúde. RESULTADOS: Apesar dos esforços significativos e das experiências acumuladas na IG na saúde, as barreiras estruturais incluem: os desafios sociais mais amplos de transformar relacionamentos desiguais de poder; a complexidade dos sistemas de saúde associada à baixa capacidade técnica, política e financeira das instituições encarregadas pela IG; e a coordenação limitada (e muitas vezes fraca) com as Maquinarias Nacionais de Mulheres (NWM, na sigla em inglês). Em alguns contextos, as barreiras são exacerbadas pela compreensão limitada de conceitos básicos nas bases da IG (às vezes agravadas por mal entendidos relacionados à intersecção com homens e/ou o envolvimento deles); e a ausência de indicadores para medir resultados concretos da IG e seu impacto. CONCLUSÕES: Para que a IG ocorra de fato, é necessária uma pauta mais estratégica e transformadora, elaborada e implementada em coordenação com as NWM e a sociedade civil, e fazendo referência a organismos externos (por exemplo, Comitê sobre a Eliminação de todas as Formas de Discriminação contra a Mulher) para que a integração inclua não só o processo, mas que forneça, além disso, uma diferenciação mais clara entre a sensibilidade às questões de gênero e a transformação das relações de gênero, e defina os resultados esperados e os indicadores para medir os avanços. A partir de então, elas poderiam ser melhor documentadas e sistematizadas, permitindo um melhor entendimento sobre a IG e sua operacionalização como instrumento concreto rumo à equidade na saúde.

Exploring the determinants and outcomes of intimate partner violence during pregnancy for Guyanese women: Results from a nationally representative cross-sectional household survey.

OBJECTIVE: To determine predictors associated with physical violence during pregnancy, and to determine the relationship between exposure to intimate partner violence during pregnancy and women's health and suicide ideation in Guyana. METHODS: A secondary data analysis of a cross-sectional household survey. Multivariate logistic regression models were fitted to the data to estimate the association between physical violence during pregnancy, controlling partner behavior, and other predictors. Ordered logistic regression models were fitted to estimate the association between physical violence during pregnancy and women's health, and lifetime physical partner violence and overall health. Logistic regression models were fitted to estimate associations between physical violence during pregnancy and lifetime physical partner violence and overall health and suicide ideation. RESULTS: The prevalence of lifetime physical/sexual intimate partner violence was 38.8%, current physical/sexual intimate partner violence 11.1%, and violence during pregnancy 9.2%. Controlling partner behavior was significantly and positively associated with maternal experience of physical violence during pregnancy. Experiencing physical partner violence during pregnancy, but not lifetime physical partner violence, was associated with significantly increased odds of poor overall health. Physical violence during pregnancy and lifetime physical violence were both significantly associated with increased odds of suicide ideation. CONCLUSIONS: The prevalence of violence during pregnancy in Guyana is high and is associated with adverse health outcomes. These findings suggest the need for intimate partner violence prevention, and for integrating intimate partner violence screening and treatment into antenatal care, reproductive health services, and maternal and child health programs and services to identify and treat at-risk women.

Sorcery and well-being: bodily transformation at Beckeranta.

This paper examines bodily transformation and well-being within the context of a millenarian movement that emerged during the 1840s in the area surrounding Mount Roraima at the periphery of Brazil, Guyana (British Guiana at the time), and Venezuela. The site of this movement was Beckeranta - meaning 'Land of the Whites' - where up to 400 Amerindians were reportedly killed in a quest that is described in its sole historical account as centred around a goal of bodily transformation into white people. In examining this movement, the paper engages with longstanding debates in medical anthropology concerning the body, as well as conversations among Amazonianists concerning the social formation of bodies, and examines sorcery and shamanism as practices that go 'beyond the body'. Notions of bodily transformation in Amazonia, which are often activated by strong emotions, facilitate conceptual expansions of the body in medical anthropology. The paper suggests that bodily transformations tied to sorcery and shamanism are in some contexts, such as at Beckeranta, associated with desires for well-being.Supplemental data for this article is available online at https://doi.org/10.1080/13648470.2020.1807726.

The Cauxin-femme binary: Femme performativity as a response to violence in Guyana.

The Caribbean region has a long history of violence and conflict due to colonization and contemporary neocolonial policies and structures. The region's political, economic, and social climate is overshadowed by activism that centers legal repeal of homophobic laws left intact by colonial powers. These movements have created a polarization between the mainstream groups seeking legal changes, and those who are denied and erased from these discourses. This article is an examination of lesbian, bisexual, queer and gay women of mixed-race middle-class status in the city of Georgetown, Guyana as they negotiate racialized heteropatriarchal violence, a space that offers a unique place in which to understand how different queer subjects experience violence within Guyana. This article examines a set of interrelated questions: In what ways do women who love women perceive their gender performances? In what ways is femme-ness embodied to resist violence and yet is a site of violence? The analysis reveals the ways in which women embody a strategic femme-ness in a political, racial, class, and gender hierarchical society. As the country becomes increasingly incorporated into a global queer culture, divisions within the queer community are further sharpened, with racial, class, sexual, gender, and regional boundaries shifting and forging new lived realities for queer subjects.