Salud sexual y reproductiva en exguerrilleras colombianas antes del Acuerdo de Paz y después de este / Sexual and Reproductive Health of Former Colombian Female Guerrillas before and after the Peace Agreement / Saúde sexual e reprodutiva em ex-guerrilheiras colombianas antes e depois do Acordo de Paz

El objetivo de este artículo es describir las experiencias en salud sexual y reproductiva de exguerrilleras de las Fuerzas Armadas Revolucionarias de Colombia-Ejército del Pueblo (fARC-EP) durante el conflicto armado y después de la firma del Acuerdo de Paz. A lo largo de 2018 se realizó un estudio de caso interpretativo a través de observación participante, once entrevistas y dos grupos focales. En las fARC-EP no hubo un enfoque de salud sexual y reproductiva integral ni con perspectiva de género; se privilegió la prevención del embarazo con métodos y sanciones para las mujeres. Debido a su carácter de ejército clandestino, las decisiones no eran tomadas de manera individual, y la autoridad del superior implicaba las relaciones erótico-afectivas, aunque se garantizaba una atención expedita para casos de urgencias. Posterior a la firma del acuerdo, con su consiguiente inserción en el sistema de salud colombiano, se amplían las posibilidades de atención para casos no urgentes, pero persisten las barreras de atención del sistema de salud.

This study examined the sexual and reproductive health statuses of former female guerrillas of the Revolutionary Armed Forces of Colombia-People's Army (fARC-EP) during the armed conflict and after the signing of the peace agreement. During 2018, an interpretive case study was conducted through the participant observation, 11 interviews, and 2 focus groups. In the fARC-EP group, no comprehensive approach to sexual and reproductive health was noted from a gender perspective, but pregnancy prevention using methods and sanctions for women was found to be privileged. Owing to its characteristic as a clandestine army, decisions were not made individually, and the authority of the superior involved erotic-affective relationships, although expedited attention was guaranteed for emergency cases. After the signing of the agreement, with its consequent insertion into the Colombian health system, the possibilities of care for non-urgent cases have been expanded, with the barriers to healthcare being emphasized

O objetivo deste artigo é descrever as experiências em saúde sexual e reprodutiva de ex-guerrilheiras das Forças Armadas Revolucionárias da Colômbia - Exército Popular (fARC-EP) durante o conflito armado e após a assinatura do acordo de paz. Durante o ano de 2018, foi realizado um estudo de caso interpretativo através da observação participante, 11 entrevistas e dois grupos focais. Nas fARC-EP não havia abordagem integral da saúde sexual e reprodutiva ou perspectiva de gênero; privilegiou-se a prevenção da gravidez com métodos e sanções para as mulheres. Por ser um exército clandestino, as decisões não eram tomadas individualmente, e a autoridade do superior implicava relações erótico-afetivas, embora garantisse atendimento ágil em casos de emergência. Após a assinatura do convênio, com sua consequente inserção no sistema de saúde colombiano, ampliam-se as possibilidades de atendimento aos casos não urgentes, mas enfatizam-se as barreiras para o atendimento no sistema de saúde.

Experiencias en la atención en salud de mujeres con anormalidades citológicas o cáncer de cuello uterino en dos departamentos fronterizos: una lucha entre la vida y el sistema de salud colombiano / Experiences in the Health Care of Women with Cytological Abnormalities or Cervix Cancer in Two Border Departments: A Struggle between Life and the Colombian Health System / Experiências na atenção em saúde de mulheres com anormalidades citológicas ou câncer de colo de útero em dois estados da fronteira: uma luta entre a vida e o sistema de saúde colombiano

Resumen Objetivo: Describir la experiencia en la atención en salud de mujeres con anormalidades citológicas con biopsia negativa para malignidad o cáncer de cuello uterino invasor no mayor a 2 meses, en los departamentos de La Guajira y Nariño, en Colombia, entre 2016 y 2017. Metodología: Se presenta el componente cualitativo de un estudio de métodos mixtos de triangulación convergente, a través de 10 entrevistas y 3 grupos focales. Participaron 9 mujeres con cáncer y 6 con anormalidades citológicas entre los 43 y 65 años de edad, 6 de ellas indígenas y 14 pertenecientes al régimen subsidiado. Resultados: Las participantes mencionaron experiencias negativas frente a la atención en salud, pues enfrentan múltiples barreras para acceder al diagnóstico y al tratamiento, como demora en la asignación y la autorización de citas, exámenes y procedimientos; el gasto de bolsillo para traslados a ciudades capitales donde se brinda el servicio; dificultades para encontrar acompañamiento familiar fuera de sus comunidades de origen y barreras idiomáticas en mujeres de comunidades indígenas. También se presentaron dificultades de comunicación efectiva con el personal de salud, lo que llevó a algunas participantes a no entender su diagnóstico tratamiento, y a no sentirse escuchadas. La vivencia del cáncer generó sufrimiento, rechazo de personas de su entorno social y despersonalización. Conclusiones: Las barreras de diversa índole para el acceso oportuno al tratamiento se agudizan por características de base como la pobreza y la pertenencia a grupos étnicos, convirtiéndose la supervivencia en una lucha diaria, que va más allá de las características propias de la enfermedad.

Abstract Objective: To describe the health care experience of women with cytological abnormalities with negative biopsy for malignancy or invasive cervix cancer within two months after diagnosis, in La Guajira and Nariño departments, Colombia, between 2016 and 2017. Methodology: The qualitative component of a mixed methods study of convergent triangulation is presented, through ten interviews and three focus groups. Nine women with cancer and six women with cytological abnormalities between 43 and 65 years of age participated; six of them were indigenous, and fourteen are enrolled to the subsidized health regime. Results: Participants referred negative experiences in the health care system as they face numerous barriers for the diagnosis and access to treatment. Such as, delay in the assignment and authorization of medical appointments, tests, and procedures; the out-of-pocket expenses for transportation to capital cities where the health service is provided; difficulties to find family support outside their communities of origin, and language barriers among women from indigenous communities. Besides, effective communication problems with health personnel were also presented, which lead some participants to misunderstanding their diagnosis or treatment and feeling that they were not being heard. The experience of having cancer led to suffering, rejection from people in their social environment, and depersonalization. Conclusions: Barriers of various kinds for the timely access to treatment are exacerbated by baseline characteristics such as poverty and belonging to ethnic groups, turning survival into a daily struggle, which goes beyond the specific characteristics of the disease itself.

Resumo Objetivo: Descrever a experiência na atenção em saúde de mulheres com anormalidades citológicas com biopsia negativa para malignidade ou câncer de colo de útero invasivo não maior a 2 meses nos estados de La Guajira e Nariño, na Colômbia, entre 2016 e 2017. Metodologia: Foi apresentado o componente qualitativo de um estudo de métodos mistos de triangulação convergente, através de 10 entrevistas e 3 grupos de foco. Participaram 9 mulheres com câncer e 6 com anormalidades citológicas entre 43 e 65 anos da idade, 6 delas indígenas e 14 pertencentes ao sistema subsidiado. Resultados: As participantes mencionaram experiências negativas na atenção em saúde, pois enfrentaram múltiplos obstáculos para ter acesso ao diagnóstico e ao tratamento, como demora na marcação e autorização de consultas, exames e procedimentos; despesas com transporte para cidades capitais onde se oferece o serviço; dificuldades para ter acompanhamento familiar fora das suas comunidades de origem e barreiras idiomáticas para mulheres de comunidades indígenas. Apresentaram-se também, dificuldades de comunicação efetiva com o pessoal de saúde, o que levou a algumas participantes a não entender seu diagnóstico ou tratamento e a não se sentirem escutadas. A experiência do câncer gerou sofrimento, rejeição de pessoas do entorno social e despersonalização. Conclusões: As barreiras de diversas índoles para o acesso oportuno ao tratamento foram agudizadas por características de base como a pobreza e ao fato de pertencer a grupos étnicos, transformando a sobrevivência numa luta diária, que vai além das características próprias da enfermidade.

Factores asociados a la percepción de vulnerabilidad al VIH en mujeres transgénero de tres ciudades de Colombia

Objetivo: Describir la percepción de vulnerabilidad al VIH y sus factores asociados en mujeres transgénero (MT) en Bogotá, Medellín y Santiago de Cali, Colombia. Materiales y métodos: Se llevó a cabo un estudio transversal, a partir de un muestreo dirigido por encuestados (RDS), en el que participaron 620 MT. Se investigaron aspectos sociodemográficos, conductas sexuales, consumo de sustancias psicoactivas y percepción de vulnerabilidad al VIH. Se realizó un análisis descriptivo, a través de asociaciones bivariadas, utilizando chi cuadrado. También se realizó el análisis multivariado y se construyó un modelo de regresión de Poisson. Resultados: El 63% de las participantes son menores de 35 años, se desempeñan principalmente como trabajadoras sexuales, modelos web cam y estilistas, tienen bajos ingresos, iniciaron relaciones sexuales a temprana edad, y el 84,7% había recibido dinero a cambio de sexo alguna vez en la vida. La percepción de vulnerabilidad al VIH aumenta entre quienes ejercen la prostitución, antecedente de infecciones de transmisión sexual en el último año, son solteras, consumieron cocaína en los seis meses previos a la encuesta y evitan los servicios de prevención. Conclusiones: La percepción de vulnerabilidad al VIH entre las MT participantes del estudio es alta, por lo cual se requieren intervenciones efectivas que mejoren sus condiciones de vida y comportamientos sexuales.

Objective: To describe the perception of vulnerability to HIV and its associated factors among transgender women (TW) in Bogotá, Medellín and Santiago de Cali, Colombia. Materials and methods: We conducted a cross-sectional study, using respondent-driven sampling (RDS) in which 620 TW participated. Sociodemographic aspects, sexual behavior, consumption of psychoactive substances and the perception of vulnerability to HIV were studied. We carried out a descriptive analysis, in which bivariate associations were evaluated using chi-square. We also conducted a multivariate analysis and built a model using Poisson regression. Results: Of the participants, 63% were 35 years old or younger, had low income, started sexual relations at an early age and worked mainly as sex workers, webcam models and hairdressers; 84.7% of the participants had received money in exchange for sex at some point. The perception of vulnerability to HIV increased among those who were single, worked in prostitution, had sexually transmitted infections in the last year, avoided preventive health services and consumed cocaine during the six months before this survey. Conclusion: The perception of vulnerability to HIV among the TW participants in this study is high; therefore, effective interventions are required to improve the living conditions and sexual behavior of this population.

Significados que construyen mujeres afrodescendientes frente al cáncer de mama y cuello uterino, atendidas en Medellín, Colombia / Meanings that build Afro-descendant women facing breast and cervical cancer, who were attended in Medellin, Colombia

Resumen Introducción: La investigación sobre la salud de mujeres afrodescendientes es escasa en Colombia, especialmente cuando se trata de estudios que muestren relación entre etnia y cáncer. El cáncer de mama (CaMa) y cuello uterino (CaCu) requieren ser investigados desde la voz de las mujeres afrodescendientes que lo padecen. Objetivo: Comprender los significados frente al CaMa o CaCu que construyen mujeres afrodescendientes atendidas en los servicios de salud de Medellín, Colombia. Materiales y métodos: Investigación cualitativa con enfoque etnográfico. Se realizaron entrevistas semiestructuradas a mujeres con CaMa y CaCu y grupos focales con población afrodescendiente sin cáncer; observaciones en citas médicas, quimioterapia y lugares cotidianos. El análisis fue guiado por el método de comparación constante. Resultados: Emergieron tres categorías: "El señor cáncer" que da cuenta de la enfermedad concebida como fatal y peligrosa, "La enfermedad desplaza", producto de la migración de las mujeres a Medellín para recibir tratamientos; y "Parte la vida en dos" por los cambios que conlleva la enfermedad. Conclusión: La enfermedad se concibió más allá de lo biológico al experimentar una alteración de la vida social, familiar y emocional. Se requiere mayor visibilidad del proceso salud-enfermedad de las afrodescendientes, por su rol ancestral como cuidadoras y forjadoras de unidad familiar.

Abstract Introduction: Research on the health of Afro-descendant women is scarce in Colombia, especially when it comes to studies that show the relationship between ethnicity and cancer. Breast cancer and cervix need to be investigated from the voice of Afro-descendant women who suffer from it. Objective: To understand the meanings facing breast or cervix cancer that are built by Afro-descendant women in the health services of Medellin, Colombia. Materials and methods: A qualitative research with an ethnographic approach was made. Semi-structured interviews were conducted for women with breast and cervix cancer and there were focal groups with Afro-descendant population without cancer with observations in medical appointments, chemotherapy and everyday places. The analysis was guided by the Constant Comparative method. Results: Three categories emerged: "Lord Cancer" which accounts for the disease conceived as fatal and dangerous, "the disease displaces", product of the migration of women to Medellin to receive treatments; and "it parts life in two" because of the changes that the disease brings. Conclusion: The disease was conceived beyond the biological part by experiencing an alteration of social, familiar and emotional life. There is a need for greater visibility of the health-disease process of the afro-descendants, or their ancestral role as caregivers and family unit builders.

Health Beliefs Associated with the Follow-Up of Pap Smear Abnormalities Among Low-Income Women in Medellín, Colombia.

The purpose of the study was to explore variables of the health belief model in relation to the follow-up of abnormal Pap smear among low-income women in Medellín, Colombia. Eight focus groups (62 women) were conducted according to age groups (25-45 and 46-69 years). The data were analyzed using content analysis. The participants perceived themselves as vulnerable, recognized the severity of the disease in terms of both its emotional and physical consequences, perceived the benefits of the follow-up, and mentioned cues to action, such as social support and the support of health entities. Perceived self-efficacy was compromised by health system barriers and by personal barriers, such as placing the needs of their children ahead of their own, fear, neglect, and the pain caused by the diagnostic and therapeutic procedures. Health education activities aimed at increasing the follow-up of abnormal Pap smears should consider psychological factors.

Evaluation of Entertainment Education Strategies to Promote Cervical Cancer Screening and Knowledge in Colombian Women.

Cervical cancer is considered to be a major health problem for women in developing countries, but it is also problematic for more developed countries as global migration increases and health behaviors move from the countries of origin to new places of residence. We designed and produced a testimonial video and a fotonovela (printed short story) to educate women about cervical cancer and screening. The development of the materials included formative research, production, pretesting, dissemination, and evaluation. The evaluation included 100 women that completed a pretest and a posttest at eight health clinics in Medellin. The pretest and posttest were analyzed using McNemar's test for categorical variables and paired t test for continuous variables. Women in the study had a high initial Stage of Change as defined by the Transtheoretical Model and a high baseline knowledge of HPV and cervical cancer, with the caveat of specific knowledge deficiencies especially for HPV. While not statistically significant, postintervention Transtheoretical Model status in both interventions changed towards higher stages, specifically, from Precontemplation to Contemplation and Preparation. Women who participated in the study liked the educational materials and their knowledge increased, especially for HPV. However, the perception of risk did not change.

Barreras y facilitadores del sistema de salud relacionadas con el seguimiento de anormalidades citológicas, Medellín-Colombia / Barriers and Facilitators of the Health System Related to the Follow-Up of Cytological Abnormalities, Medellin-Colombia / Barreiras e facilitadores do sistema de saúde relacionadas com o monitoramento de anormalidades citológicas, Medellin-Colómbia

Objetivos: identificar barreras y facilitadores del seguimiento: diagnóstico y tratamiento de anormalidades citológicas en mujeres de bajos ingresos usuarias de la red pública de servicios de salud de la ciudad de Medellín, Colombia. Métodos: se realizaron ocho grupos focales (62 mujeres) según grupos de edad (25-45 y 46-69 años) y se hizo un análisis de contenido. Resultados: las barreras del sistema de salud reportadas fueron: a) barreras estructurales: fragmentación en la prestación del servicio, problemas con afiliaciones y características del régimen de afiliación; b) barreras administrativas: problemas y demoras en la asignación de citas, largas filas, problemas con autorizaciones y maltrato; y c) barreras económicas derivadas de las dos anteriores y relacionadas con el gasto de bolsillo. También se mencionaron facilitadores estructurales y administrativos. Conclusión: algunas características estructurales del sistema de salud y de la administración de las aseguradoras limitan el acceso de las mujeres al seguimiento de lesiones precancerosas.

Objectives: Identifying barriers and facilitators of the diagnostic monitoring and treatment of cytological abnormalities in low-income women users of the public health service network in Medellin, Colombia. Methods: We created eight focal groups (62 women) according to age groups (ages 25-45 and 46-69), and performed a content analysis. Results: The reported barriers ofthe health system were: a) structural barriers: fragmentation in the provision of the service, problems with the affiliations and characteristics of the affiliation regime; b) management barriers: problems and delays in the assignment of appointments, long queues, problems with authorizations and mistreatment; and c) economic barriers derived from the aforementioned and related with expenses. Management and structural facilitators were also mentioned. Conclusion: Some structural characteristics of the health system and the management of insurance companies limit access for women to the monitoring of pre-cancerous lesions.

Objetivos: identificar barreiras e facilitadores do seguimento: diagnóstico e tratamento de anormalidades citológicas em mulheres de baixa renda usuárias da rede pública de serviços de saúde da cidade de Medellín, Colombia. Métodos: Realizaram-se oito grupos foçais (62 mulheres) de acordo com as faixas etárias (25-45 e 46-69 anos) e se fez análise de conteúdo. Resultados: as barreiras do sistema de saúde reportadas foram: a) barreiras estruturais: fragmentacáo na prestacáo do serviço, problemas com afiliacoes e caraterísticas do régime de afiliação; b) barreiras administrativas: problemas e atrasos na alocação de citas, longas filas, problemas com autorizares e abuso; e c) barreiras económicas decorrentes das duas anteriores e relacionadas com a caixa pequena. Mesmo foram mencionados facilitadores estructuráis e administrativos. Conclusão: algumas caraterísticas estruturais do sistema de saúde e da administração das asseguradoras limitam o acesso das mulheres ao acompanhamento de lesoes précancerosas.