Comprehensive primary health care and non-communicable diseases management: a case study of El Salvador.

BACKGROUND: One of today's greatest challenges in public health worldwide - and especially its key management from Primary Health Care (PHC) - is the growing burden of non-communicable diseases (NCDs). In El Salvador, since 2009 the Minister of Health (MoH) has scaled up a national public health system based on a comprehensive PHC approach. A national multi-sectorial strategic plan for a comprehensive approach to NCDs has also been developed. This analysis explores stakeholders' perceptions related to the management of NCDs in PHC and, in particular, the role of social participation. METHODS: A case-study was developed consisting of semi structured interviews and official document reviews. Semi-structured interviews were developed with chronic patients (14) and PHC professionals working in different levels within PHC (12). Purposive sampling was used to recruit participants. A non-pure, deductive approach was implemented for coding. After grouping codes into potential themes, a thematic framework was elaborated through a reflexive approach and the triangulation of the data. The research was conducted between March and August of 2018 in three different departments of El Salvador. RESULTS: The structure and the functioning of the Salvadoran PHC system and its intersectoral approach is firstly described. The interdisciplinary PHC-team brings holistic health care closer to the communities in which health promoters play a key role. The findings reflect the generally positive perception of the PHC system in terms of accessibility, quality and continuity of care by chronic patients. Community engagement and the National Health Forum are ensuring accountability through social controllership mechanisms. However, certain challenges were also noted during the interviews related to the shortage of medication and workforce; coordination between the levels of care and the importance of prevention and health promotion programmes for NCDs. CONCLUSIONS: The Salvadoran PHC and its comprehensive approach to NCDs with an emphasis on intersectoral participation has been positively perceived by the range of stakeholders interviewed. Social engagement and the NHF works as a driving force to ensure accountability as well as in the promotion of a preventive culture. The challenges identified provide keys to amplify knowledge for addressing inequalities in health by strengthening PHC and its NCDs management.

Costs associated with acute respiratory illness and select virus infections in hospitalized children, El Salvador and Panama, 2012-2013.

BACKGROUND AND OBJECTIVES: Although acute respiratory illness (ARI) is a leading cause of hospitalization among young children, few data are available about cost of hospitalization in middle-income countries. We estimated direct and indirect costs associated with severe ARI resulting in hospitalization among children aged <10 years in El Salvador and Panama through the societal perspective. METHODS: During 2012 and 2013, we surveyed caregivers of children hospitalized with ARI about their direct medical (i.e., outpatient consultation, medications, hospital fees), non-medical (transportation, childcare), and indirect costs (lost wages) at discharge and 7 days after discharge. We multiplied subsidized hospital bed costs derived from administrative data by hospitalization days to estimate provider costs. RESULTS: Overall, 638 children were enrolled with a median age of 12 months (IQR 6-23). Their median length of hospitalization was 4 days (IQR 3-6). In El Salvador, caregivers incurred a median of US$38 (IQR 22-72) in direct and indirect costs per illness episode, while the median government-paid hospitalization cost was US$118 (IQR 59-384) generating an overall societal cost of US$219 (IQR 101-416) per severe ARI episode. In Panama, caregivers incurred a median of US$75 (IQR 39-135) in direct and indirect costs, and the health-care system paid US$280 (IQR 150-420) per hospitalization producing an overall societal cost of US$393 (IQR 258-552). CONCLUSIONS: The cost of severe ARI to caregivers and the health care system was substantive. Our estimates will inform models to estimate national costs of severe ARI and cost-benefit of prevention and treatment strategies.

A social systems analysis of implementation of El Salvador's national HIV combination prevention: a research agenda for evaluating Global Health Initiatives.

BACKGROUND: Global Health Initiatives (GHIs) have been instrumental in the rapid acceleration of HIV prevention, treatment access, and availability of care and support services for people living with HIV (PLH) in low and middle income countries (LMIC). These efforts have increasingly used combination prevention approaches that include biomedical, behavioral, social and structural interventions to reduce HIV incidence. However, little research has evaluated their implementation. We report results of qualitative research to examine the implementation of a national HIV combination prevention strategy in El Salvador funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. METHODS: We conducted in-depth interviews with principal recipients of the funding, members of the Country Coordinating Mechanism (CCM) and front line peer outreach workers and their clients. We analyzed the data using a dynamic systems framework. RESULTS: El Salvador's national HIV combination prevention strategy had three main goals: 1) to decrease the sexual risk behaviors of men who have sex with men (MSM), commercial sex workers (CSW) and transgender women (TW); 2) to increase HIV testing rates among members of these populations and the proportion of PLH who know their status; and 3) to improve linkage to HIV treatment and adherence to antiretroviral therapy (ART). Intervention components to achieve these goals included peer outreach, community prevention centers and specialized STI/HIV clinics, and new adherence and retention protocols for PLH. In each intervention component, we identified several factors which reinforced or diminished intervention efforts. Factors that negatively affected all intervention activities were an increase in violence in El Salvador during implementation of the strategy, resistance to decentralization, and budget constraints. Factors that affected peer outreach and sexual risk reduction were the human resource capacity of grassroots organizations and conflicts of the national HIV strategy with other organizational missions. CONCLUSIONS: Overall, the national strategy improved access to HIV prevention and care through efforts to improve capacity building of grass roots organizations, reduced stigma, and improved coordination among organizations. However, failure to respond to environmental and organizational factors limited the intervention's potential impact.

Advising a woman with suspected Zika virus infection.

The Zika virus (ZIKV) epidemic is spreading: 67 countries are now reporting transmission, and over 2,000 cases of congenital Zika syndrome (CZS) have been confirmed. The heaviest burden has been borne by those living where poverty, poor infrastructure, and lack of access to health services are common and the penetration of Aedes aegypti is high. Because most cases are asymptomatic, the most dramatic signs of the disease appear through the CZS cases. In spite of the need for disaggregated epidemiological data to understand transmission patterns and evaluate interventions in vulnerable populations, there is no reliable count of ZIKV cases by sex and ethnicity (1).

Prevalence of chronic kidney disease of non-traditional causes in patients on hemodialysis in southwest Guatemala.

Objective To document the prevalence of patients on hemodialysis in southwestern Guatemala who have chronic kidney disease (CKD) of non-traditional causes (CKDnt). Methods This cross-sectional descriptive study interviewed patients on hemodialysis at the Instituto Guatemalteco de Seguridad Social on their health and occupational history. Laboratory serum, urine and vital sign data at the initiation of hemodialysis were obtained from chart reviews. Patients were classified according to whether they had hypertension or obesity or neither. The proportion of patients with and without these traditional CKD risk factors was recorded and the association between demographic and occupational factors and a lack of traditional CKD risk factors analyzed using multivariate logistic regression. Results Of 242 total patients (including 171 non-diabetics) enrolled in hemodialysis in southwestern Guatemala, 45 (18.6% of total patients and 26.3% of non-diabetics) lacked traditional CKD risk factors. While agricultural work history was common, only travel time greater than 30 minutes and age less than 50 years old were significantly associated with CKD in the absence of traditional risk factors. Individuals without such risk factors lived throughout southwestern Guatemala's five departments. Conclusions The prevalence of CKDnT appears to be much lower in this sample of patients receiving hemodialysis in Southwestern Guatemala than in hospitalized patients in El Salvador. It has yet to be determined whether the prevalence is higher in the general population and in patients on peritoneal dialysis.

Prevalence of patients receiving renal replacement therapy in El Salvador in 2014. / Prevalencia de pacientes con tratamiento sustitutivo renal en El Salvador en 2014.

El Salvador has the highest renal failure mortality rate in the Americas. Five healthcare providers offer renal replacement therapy (RRT) in the country. The national RRT prevalence has never been reported. AIMS: To determine the RRT prevalence in El Salvador and some basic characteristics. METHODS: The association of nephrology coordinated a nationwide cross-sectional survey during the third quarter of 2014. 31 renal centres participated in the survey, covering 99.5% of patients. RESULTS: National RRT prevalence: 595 per million population (pmp), N=3807, average age 50.4 years, 67.5% male. By modality: peritoneal dialysis (PD) 289 pmp, haemodialysis (HD) 233 pmp, with functioning kidney transplantation 74 pmp (living donor only). Social security covers 25% of the population but treats 49.7% of RRT patients. Generally, higher prevalence was observed in municipalities with renal centres or located on the coast or lowlands. Ninety-five percent of HD patients receive fewer than 3 weekly sessions. Of PD patients, 59% do not belong to a continuous outpatient or automated programme, and 25% still use rigid catheter. Aetiology of chronic kidney disease: unavailable/undetermined 50%, hypertension 21.1%, diabetes 18.9%, glomerulonephritis 6.7%, obstructive causes 1.2%, tubulointerstitial 0.9%, polycystic 0.4% and other 0.7%. DISCUSSION: Despite the increase in RRT services, the prevalence is lower than the Latin American average (660 pmp). Three quarters of HD and PD patients are under-dialysed. Obsolete RRT techniques are still used. The presence of Mesoamerican nephropathy influences the demographic characteristics (many young patients, two-thirds male, high prevalence in lowlands and coastlands).

Incidence, mortality, and prevalence of end-stage chronic renal disease in the Bajo Lempa region of El Salvador: A ten-year community registry. / Incidencia, mortalidad y prevalencia de enfermedad renal crónica terminal en la región del Bajo Lempa, El Salvador: 10 años de registro comunitario.

The Bajo Lempa is an impoverished rural coastal region of El Salvador affected by the chronic kidney disease (CKD) epidemic known as Mesoamerican nephropathy. The local community organisation Fondo Social de Emergencia para la Salud (FSES) (Emergency social fund for health) is helping to fight the epidemic in 42 communities of the region (19,223 inhabitants; average age 26.7 years; 48.5% male; 40.2% <18 years). OBJECTIVES: To report annual rates of end-stage renal disease (ESRD) incidence and patient mortality in these communities during a 10-year period (2004-2013), and the prevalence of patients receiving renal replacement therapy (RRT) as of 31 December 2013. METHODS: The FSES recorded new ESRD cases, basic patient history, form of RRT if received and patient deaths. RESULTS: We registered 271 new ESRD cases (annual average 27.1; 89% male; average age 55.6 years, four <18 years). Average annual ESRD incidence rate: 1409.8 per million population (pmp). Two-thirds did not report diabetes or hypertension. 94 patients (34.7%) received RRT: 58 in the Ministry of health, 26 in private services, 9 in social security and 1 in the military health system. 246 patients died (annual average 24.6 deaths; 89.4% male; average age 56.1 years; 92.3% at home). Average annual mortality rate: 128/100,000 population. Prevalence of patients receiving RRT in 2013: 1300.5 pmp (N=25; 84% male; average age 51 years). CONCLUSIONS: This region has a high incidence of ESRD. Few receive RRT. Patient mortality is high even with RRT. Most patients are male (9:1). Social determinants influence the high mortality.

Community-based assessment and intervention for early childhood caries in rural El Salvador.

OBJECTIVE: The objectives were to assess early childhood caries (ECC) in rural areas of El Salvador and to investigate the changes in caries and mouth pain in the presence of community-based interventions. METHODS: This study was a retrospective analysis of de-identified and anonymous data obtained from baseline and four annual follow-up visits that focused on the preventive oral health intervention and nutrition in a convenience sample of children 0-6 years of age. The decayed, missing and filled teeth (dmft) index for primary teeth was used as the survey tool. Caries was defined as a cavitated lesion. Descriptive statistics were used to describe the prevalence of ECC in the sample in relation to age and dmft score. Linear mixed model analysis of variance (ANOVA) and generalised linear mixed effects models were used to compare the pre-intervention and post-intervention outcomes. RESULTS: The prevalence of caries was 58%. Incorporation of a community oral health education and fluoride supplementation programme contributed to significant reductions in caries experience (from 74% to 61%) and mouth pain (from 58% to 39%), in children 3-6 years of age. CONCLUSIONS: ECC is a common public health problem in rural El Salvador. In an established community-based maternal-child health programme in El Salvador, there appears to be an association between the incorporation of preventive oral health intervention and improvement in children's oral health and quality of life over time.

Prevalence of Trypanosoma cruzi infection in blood donors in El Salvador between 2001 and 2011.

INTRODUCTION: El Salvador is regarded as a highly endemic country for Chagas disease, as evidenced by the relatively high estimated positive serology rate for Trypanosoma cruzi among blood donors. This study aimed to identify the factors contributing to this high rate by analyzing changes in T. cruzi seroprevalence. METHODOLOGY: Secondary data were collected from 31 blood banks operated by the Ministry of Health, the Red Cross, the Institute of Salvadoran Social Security, and the Military Hospital. The data were analyzed to determine the number of cases of T. cruzi seropositivity, and the average prevalence of seropositivity by province. Simple linear regression was performed to identify trends in T. cruzi seropositivity. RESULTS: Analysis of the 885,187 blood samples collected between 2001 and 2011 revealed 21,693 cases of transfusion-related infections, with a significant reduction of T. cruzi seropositivity from 3.7% in 2001 to 1.7% in 2011, reflecting a 54% decrease over the course of a decade (R(2) = 89.6%, p > 0.001). T. cruzi seroprevalence decreased in San Salvador, Santa Ana, Sonsonate, and Cuscatlán. In contrast, seroprevalence remained high with no decrease in Ahuachapán and San Vicente, and consistently low in the remainder of the country. CONCLUSIONS: Although the national prevalence of T. cruzi among blood donors has decreased, it remains high in the provinces of Ahuachapán and San Vicente. Strengthening vector control activities and developing an approach for the systematic follow-up of prospective blood donors with positive serology for T. cruzi are required, especially in areas with high seropositivity.

Prevalence of visual impairment in El Salvador: inequalities in educational level and occupational status.

OBJECTIVE: To examine the prevalence of blindness, visual impairment, and related eye diseases and conditions among adults in El Salvador, and to explore socioeconomic inequalities in their prevalence by education level and occupational status, stratified by sex. METHODS: Based upon the Rapid Assessment of Avoidable Blindness (RAAB) methodology, this nationwide sample comprised 3 800 participants (3 399 examined) ≥ 50 years old from 76 randomly selected clusters of 50 persons each. The prevalence of blindness, visual impairment and related eye diseases and conditions, including uncorrected refractive error (URE), was calculated for categories of education level and occupational status. Multiple logistic regression models were fitted to calculate odds ratios (ORs) and 95% confidence intervals (CIs) and stratified by sex. RESULTS: Age-adjusted prevalence was 2.4% (95% CI: 2.2-2.6) for blindness (men: 2.8% (95% CI: 2.5-3.1); women: 2.2% (95% CI: 1.9-2.5)) and 11.8% (95% CI: 11.6-12.0) for moderate visual impairment (men: 10.8% (95% CI: 10.5-11.1); women: 12.6% (95% CI: 12.4-12.8)). The proportion of visual impairment due to cataract was 43.8% in men and 33.5% in women. Inverse gradients of socioeconomic inequalities were observed in the prevalence of visual impairment. For example, the age-adjusted OR (AOR) was 3.4 (95% CI: 2.0-6.4) for visual impairment and 4.3 (95% CI: 2.1-10.4) for related URE in illiterate women compared to those with secondary education, and 1.9 (95% CI: 1.1-3.1) in cataract in unemployed men. CONCLUSIONS: Blindness and visual impairment prevalence is high in the El Salvador adult population. The main associated conditions are cataract and URE, two treatable conditions. As socioeconomic and gender inequalities in ocular health may herald discrimination and important barriers to accessing affordable, good-quality, and timely health care services, prioritization of public eye health care and disability policies should be put in place, particularly among women, the unemployed, and uneducated people.

Household-level dietary quality indicator for countries in nutritional transition: application to vulnerable communities in El Salvador.

OBJECTIVE: To develop a household-level diet quality indicator (HDQI) using the Salvadorian dietary guidelines to assess the dietary quality of households in vulnerable communities in El Salvador. DESIGN: The Salvadorian dietary guidelines were reviewed and eighteen HDQI components were identified (nine foods and nine nutrients). The components were evaluated using a proportional scoring system from 0 to 1, penalizing over- and under-consumption, where appropriate. The HDQI was validated in consultations with experts in El Salvador and by statistical analyses of the study sample data. Dietary variety and energy, nutrient and food intakes were compared among households above and below the median HDQI score using Student's t test. SETTING: Vulnerable, border communities in El Salvador. SUBJECTS: Households (n 140) provided food consumption information using an FFQ and sociodemographic data. RESULTS: The mean HDQI score was 63·5, ranging from 43·6 to 90·0. The indicator showed a positive, significant association with the dietary variety components. The statistical associations of the indicator with the energy and nutrient components were as expected. CONCLUSIONS: Based on the indicator's demonstrated face validity and the results of the expert consultations, the indicator is suggested as a good measure of diet quality for households in El Salvador.

First person: a mental health mission to post-earthquake El Salvador.

In this article the author excerpts and discusses salient quotes or moments from the journal he compiled while visiting El Salvador in February 2001 as head of Disaster Psychiatry Outreach (DPO) to assist survivors of a major earthquake. This case discussion of a single disaster mental health response exemplifies key issues related to both short and long term mental health service delivery to disaster affected communities.

Perceived access and actual intake of healthy diets among households in vulnerable Salvadoran communities.

OBJECTIVE: This study aimed to examine the dietary intake of Salvadoran households according to perceived access to healthy meals (PAHD), and to identify household characteristics associated with diet quality and PAHD. METHODS: Secondary data analysis with a sample of 139 Salvadoran households from resource-poor communities in El Salvador. Chi-square tests and ANOVA were used to assess differences in dietary intake across households classified according to PAHD. RESULTS: High-PAHD households had higher women's education, household food security levels, overall diet quality, and variety, and higher intakes of animal products, fats, cholesterol, vitamin C, and sodium (P < .05). Diet quality was not associated with the household characteristics studied. CONCLUSIONS AND IMPLICATIONS: Overall diet quality was associated with higher levels of PAHD, but some differences in intakes were not as expected, such as higher intakes in foods and nutrients associated with low-quality diets, among high PAHD households.

Temporal trends in diarrhea-related hospitalizations and deaths in children under age 5 before and after the introduction of the rotavirus vaccine in four Latin American countries.

INTRODUCTION: Rotavirus infection mainly affects children under 5 years of age and causes 453,000 deaths annually throughout the world. Several countries in Latin America have introduced the rotavirus vaccine and the majority have epidemiological data to measure impact following vaccine introduction. OBJECTIVE: To assess the impact of rotavirus immunization on the number of all-cause diarrhea-related deaths and hospitalizations in children under 1 and 5 years of age in Bolivia, El Salvador, Honduras and Venezuela. METHODS: Interrupted time-series analyzed with the integral method and the projection method to evaluate the pre and post-vaccine introduction trend in diarrheal disease compared to Argentina as the control country. The analysis period was from 2002 to 2010, including 2 to 4 post-vaccine years depending on the country. Information sources included records from PAHO, the Ministry of Health, public hospitals, social security, the private health system, the Expanded Programme on Immunization and UNPop 2008. RESULTS: Over the period studied, reductions were observed in trends of diarrhea-related deaths and hospitalizations in children under five. In diarrhea-related deaths, under the integral method, the range of reduction was between 15.7% (13.5-17.9) and 56.8% (56.0-57.5) while with the projection method was between 19.9% (4.9-34.8) and 63.7%(56.1-71.4). In diarrhea-related hospitalizations, under the integral method was 5.6% (4.1-6.7) and 17.9% (16.7-19.1)) while with the projection method was between 5.1%(1.7-8.7) and 11.1% (5.8-16.3) CONCLUSIONS: A decrease was observed in the number of diarrhea related deaths and hospitalizations in all countries under study following introduction of the rotavirus vaccine as opposed to the control country. The impact on reduction of deaths was greater than hospitalization.

Low socioeconomic status is associated with prolonged times to assessment and treatment, sepsis and infectious death in pediatric fever in El Salvador.

BACKGROUND: Infection remains the most common cause of death from toxicity in children with cancer in low- and middle-income countries. Rapid administration of antibiotics when fever develops can prevent progression to sepsis and shock, and serves as an important indicator of the quality of care in children with acute lymphoblastic leukemia and acute myeloid leukemia. We analyzed factors associated with (1) Longer times from fever onset to hospital presentation/antibiotic treatment and (2) Sepsis and infection-related mortality. METHOD: This prospective cohort study included children aged 0-16 years with newly diagnosed acute leukemia treated at Benjamin Bloom Hospital, San Salvador. We interviewed parents/caregivers within one month of diagnosis and at the onset of each new febrile episode. Times from initial fever to first antibiotic administration and occurrence of sepsis and infection-related mortality were documented. FINDINGS: Of 251 children enrolled, 215 had acute lymphoblastic leukemia (85.7%). Among 269 outpatient febrile episodes, median times from fever to deciding to seek medical care was 10.0 hours (interquartile range [IQR] 5.0-20.0), and from decision to seek care to first hospital visit was 1.8 hours (IQR 1.0-3.0). Forty-seven (17.5%) patients developed sepsis and 7 (2.6%) died of infection. Maternal illiteracy was associated with longer time from fever to decision to seek care (P = 0.029) and sepsis (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.09-8.63; P = 0.034). More infectious deaths occurred in those with longer travel time to hospital (OR 1.36, 95% CI 1.03-1.81; P = 0.031) and in families with an annual household income

Adolescent sexual behavior and reproductive outcomes in Central America: trends over the past two decades.

CONTEXT: Compared with the Latin American average, adolescent fertility is high in El Salvador, Guatemala, Honduras and Nicaragua, countries that also have high poverty levels and poor access to reproductive health care. METHODS: For each country, data were drawn from four national health surveys conducted between 1987 and 2007, and analysis focused on trends in sexual and reproductive behavior among adolescent females aged 15-19. Event history analysis examined transitions to first sexual intercourse, first union and first live birth across survey years; Cox hazard and logistic regression analyses assessed associations between selected demographic characteristics and these outcomes, as well as ever-use of a modern contraceptive method. RESULTS: The likelihood that adolescent females have initiated sexual intercourse has increased over time in El Salvador, Honduras and Nicaragua, and has remained stable in Guatemala. Meanwhile, the odds of having entered their first union have declined in Nicaragua and risen in El Salvador, but have not changed in Honduras or Guatemala. Notably, the likelihood that adolescents have ever used a modern contraceptive method has increased in all four countries over the survey years. Nicaraguan adolescents became significantly less likely to have had their first live birth over the study period. Finally, urban residence, education level and socioeconomic status were important predictors of adolescents' sexual and reproductive outcomes. CONCLUSIONS: Programmatic and policy initiatives should focus on improving adolescents' education and socio- economic prospects, and efforts are especially needed to help adolescents delay the age at which they become sexually active and enter their first union.

Reconsidering childhood undernutrition: can birth spacing make a difference? An analysis of the 2002-2003 El Salvador National Family Health Survey.

It is well understood that undernutrition underpins much of child morbidity and mortality in less developed countries, but the causes of undernutrition are complex and interrelated, requiring a multipronged approach for intervention. This paper uses a subsample of 3853 children under age 5 from the most recent family health survey in El Salvador to examine the relationship between birth spacing and childhood undernutrition (stunting and underweight). While recent research and guidance suggest that birth spacing of three to five years contributes to lower levels of infant and childhood mortality, little attention has been given to the possibility that short birth intervals have longer-term effects on childhood nutrition status. The analysis controls for clustering effects arising from siblings being included in the subsample, as well as variables that are associated with household resources, household structure, reproductive history and outcomes, and household social environment. The results of the multiple regression analyses find that in comparison to intervals of 36-59 months, birth intervals of less than 24 months and intervals of 24-35 months significantly increase the odds of stunting (<24 months Odds Ratio (OR) = 1.52; 95% confidence interval (CI): 1.21-1.92; 25-36 months OR = 1.30; 95% CI: 1.05-1.64). Other factors related to stunting and underweight include standard of living index quintile, child's age, mother's education, low birthweight, use of prenatal care, and region of the country where the child lives. Policy and program implications include more effective use of health services and outreach programs to counsel mothers on family planning, breastfeeding, and well child care.