TB in Vulnerable Populations: The Case of an Indigenous Community in the Peruvian Amazon.

This article analyzes the factors associated with vulnerability of the Ashaninka, the most populous indigenous Peruvian Amazonian people, to tuberculosis (TB). By applying a human rights-based analytical framework that assesses public policy against human rights standards and principles, and by offering a step-by-step framework for a full assessment of compliance, it provides evidence of the relationship between the incidence of TB among the Ashaninka and Peru's poor level of compliance with its human rights obligations. The article argues that one of the main reasons for the historical vulnerability of the Ashaninka to diseases such as TB is a lack of political will on the part of the national government to increase public health spending, ensure that resources reach the most vulnerable population, and adopt and invest in a culturally appropriate health system.

Factors behind job preferences of Peruvian medical, nursing and midwifery students: a qualitative study focused on rural deployment.

BACKGROUND: Deployment of health workforce in rural areas is critical to reach universal health coverage. Students' perceptions towards practice in rural areas likely influence their later choice of a rural post. We aimed at exploring perceptions of students from health professions about career choice, job expectations, motivations and potential incentives to work in a rural area. METHODS: In-depth interviews and focus groups were conducted among medical, nursing and midwifery students from universities of two Peruvian cities (Ica and Ayacucho). Themes for assessment and analysis included career choice, job expectations, motivations and incentives, according to a background theory a priori built for the study purpose. RESULTS: Preference for urban jobs was already established at this undergraduate level. Solidarity, better income expectations, professional and personal recognition, early life experience and family models influenced career choice. Students also expressed altruism, willingness to choose a rural job after graduation and potential responsiveness to incentives for practising in rural areas, which emerged more frequent from the discourse of nursing and midwifery students and from all students of rural origin. Medical students expressed expectations to work in large urban hospitals offering higher salaries. They showed higher personal, professional and family welfare expectations. Participants consistently favoured both financial and non-financial incentives. CONCLUSIONS: Nursing and midwifery students showed a higher disposition to work in rural areas than medical doctors, which was more evident in students of rural origin. Our results may be useful to improve targeting and selection of undergraduate students, to stimulate the inclination of students to choose a rural job upon graduation and to reorient school programmes towards the production of socially committed health professionals. Policymakers may also consider using our results when planning and implementing interventions to improve rural deployment of health professionals.

[Traditional andean healers in the context of change: the case of Churcampa in Peru]. / Terapeutas tradicionales andinos en un contexto de cambio: el caso de Churcampa en el Perú.

OBJECTIVES: Describe the diversity of traditional healers, their links with the formal health system and changes in their therapeutic resources in two rural Andean communities in Churcampa, in the region of Huancavelica, Peru. MATERIALS AND METHODS: Qualitative study which combined three ethnographic techniques: in depth interviews, observations and accompaniments to traditional healers and health care personnel. RESULTS: 58 traditional healers, classified as healers, midwives and bonesetters were identified. Most healers interviewed learned their work while young and few had a teacher or mentor. The vast majority have objections to linking with health care facilities beyond referrals. There was no coordinated work among health personnel and traditional healers. However, when it happened, health personnel preferred those healers who have the willingness to adapt to the needs of the health services. We found that most of the healers were changing their practices due to the influence of evangelical churches. No healer had disciples to transmit their knowledge and practices. CONCLUSIONS: There is great diversity of traditional healers. This diversity is decreasing, among other factors, by the advance of the evangelical churches. Traditional healers refer some patients to the health facility; while health personnel establish hierarchical working relationships with the healers. It is necessary to work on these attitudes of the health care personnel, since the basis of an intercultural approach is to have coordinated and horizontal working relationships between both systems.

Terapeutas tradicionales andinos en un contexto de cambio: el caso de Churcampa en el Perú / Traditional andean healers in the context of change: the case of Churcampa in Peru

Describir la diversidad de terapeutas tradicionales, sus vínculos con el sistema de salud oficial y los cambios en sus recursos terapéuticos, en dos comunidades rurales de los andes en Churcampa, región de Huancavelica, Perú. Materiales y métodos. Estudio cualitativo en el que se combinan tres técnicas etnográficas: entrevistas en profundidad, observaciones y acompañamientos a terapeutas tradicionales y personal de salud. Resultados. Se identificaron 58 terapeutas, clasificados como curanderos, parteros y hueseros. La mayoría de terapeutas entrevistados aprendió su labor siendo joven y muy pocos tuvieron un maestro o mentor. La gran mayoría señaló tener reparos para vincularse con los establecimientos de salud más allá de las referencias. No había un trabajo articulado entre personal de salud y terapeutas tradicionales. Sin embargo, cuando sucedía, el personal de salud prefería a aquellos terapeutas que tuvieran la disposición para adecuarse a las necesidades de los servicios de salud. Se encontró que buena parte de los terapeutas estaban cambiando sus prácticas debido a la influencia de las iglesias evangélicas. Ningún terapeuta contaba con discípulos para transmitir sus conocimientos y prácticas. Conclusiones. Existe una gran diversidad de terapeutas tradicionales. Esta diversidad viene disminuyendo, entre otros factores, por el avance de las iglesias evangélicas. Los terapeutas tradicionales refieren a algunos pacientes al establecimiento de salud; mientras que el personal de salud establece relaciones jerárquicas de trabajo con los terapeutas. Se requiere trabajar estas actitudes del personal de salud pues la base de un enfoque intercultural es el trabajo articulado y horizontal entre ambos sistemas...

Describe the diversity of traditional healers, their links with the formal health system and changes in their therapeutic resources in two rural Andean communities in Churcampa, in the region of Huancavelica, Peru. Materials and methods. Qualitative study which combined three ethnographic techniques: in depth interviews, observations and accompaniments to traditional healers and health care personnel. Results. 58 traditional healers, classified as healers, midwives and bonesetters were identified. Most healers interviewed learned their work while young and few had a teacher or mentor. The vast majority have objections to linking with health care facilities beyond referrals. There was no coordinated work among health personnel and traditional healers. However, when it happened, health personnel preferred those healers who have the willingness to adapt to the needs of the health services. We found that most of the healers were changing their practices due to the influence of evangelical churches. No healer had disciples to transmit their knowledge and practices. Conclusions. There is great diversity of traditional healers. This diversity is decreasing, among other factors, by the advance of the evangelical churches. Traditional healers refer some patients to the health facility; while health personnel establish hierarchical working relationships with the healers. It is necessary to work on these attitudes of the health care personnel, since the basis of an intercultural approach is to have coordinated and horizontal working relationships between both systems...

Job preferences of nurses and midwives for taking up a rural job in Peru: a discrete choice experiment.

BACKGROUND: Robust evidence on interventions to improve the shortage of health workers in rural areas is needed. We assessed stated factors that would attract short-term contract nurses and midwives to work in a rural area of Peru. METHODS AND FINDINGS: A discrete choice experiment (DCE) was conducted to evaluate the job preferences of nurses and midwives currently working on a short-term contract in the public sector in Ayacucho, Peru. Job attributes, and their levels, were based on literature review, qualitative interviews and focus groups of local health personnel and policy makers. A labelled design with two choices, rural community or Ayacucho city, was used. Job attributes were tailored to these settings. Multiple conditional logistic regressions were used to assess the determinants of job preferences. Then we used the best-fitting estimated model to predict the impact of potential policy incentives on the probability of choosing a rural job or a job in Ayacucho city. We studied 205 nurses and midwives. The odds of choosing an urban post was 14.74 times than that of choosing a rural one. Salary increase, health center-type of facility and scholarship for specialization were preferred attributes for choosing a rural job. Increased number of years before securing a permanent contract acted as a disincentive for both rural and urban jobs. Policy simulations showed that the most effective attraction package to uptake a rural job included a 75% increase in salary plus scholarship for a specialization, which would increase the proportion of health workers taking a rural job from 36.4% up to 60%. CONCLUSIONS: Urban jobs were more strongly preferred than rural ones. However, combined financial and non-financial incentives could almost double rural job uptake by nurses and midwifes. These packages may provide meaningful attraction strategies to rural areas and should be considered by policy makers for implementation.

Efecto de la movilización articular sobre la amplitud del Reflejo H en personas con espasticidad / Effect of joint mobilization on the H Reflex amplitude in people with spasticity / Efeito da mobilização articular sobre a amplitude do reflexo H em pessoas com espasticidade

Objetivo: Determinar el efecto de la movilización articular del tobillo sobre la amplitud del reflejo H del músculo sóleo en personas con espasticidad. Materiales y métodos: Se realizó un cuasiexperimento con diseño cruzado y enmascaramiento simple en 24 personas voluntarias aleatorizadas para iniciar en el estudio control o experimental. Se aplicó tracción y oscilación rítmica en la articulación del tobillo durante cinco minutos. Se midieron los cambios en la amplitud de la onda H del reflejo de Hoffmann, como equivalente eléctrico del reflejo espinal monosináptico, estimulando el nervio tibial a nivel de la fosa poplítea y captando en el músculo sóleo. A cada persona se le realizaron 12 mediciones: basal, durante la movilización y después de finalizada. Se calcularon las variaciones de la amplitud de la onda H respecto a la medida basal. Para cada una de las mediciones se realizó una prueba de hipótesis (t de Student). Resultados: En los grupos de pacientes con lesión cerebral y lesión medular incompleta se encontró una diferencia significativa entre las medias de ambos estudios respecto a la variación de la amplitud de la onda H durante la aplicación de la movilización articular con disminución en el experimental y aumento en el control; en contraste, no se encontraron diferencias significativas después de finalizada la movilización. En pacientes con lesión medular completa no se observaron diferencias significativas en ninguna de las mediciones. Conclusiones: Se demuestra la eficacia de la movilización articular para la disminución de la amplitud de la onda H durante la maniobra de movilización en pacientes con lesión cerebral o lesión medular incompleta, pero sin ningún efecto residual después de finalizada. La investigación no arrojó evidencia para la disminución de la amplitud en lesión medular completa. Se sugiere replantear las intervenciones terapéuticas para disminución del tono muscular basadas en la movilización articular.

Objective: To determine the effect of ankle joint mobilization on the H reflex amplitude of the soleus muscle in people with spasticity. Materials and methods: A quasi-experimental study with crossover design and simple masking was conducted in 24 randomized subjects to initiate the control or experimental group. Traction and rhythmic oscillation were applied for five minutes to the ankle joint. H wave amplitude changes of Hoffmann reflex (electrical equivalent of the monosynaptic spinal reflex) was assessed, stimulating the tibial nerve at the level of the popliteal fossa and recording in the soleus muscle. In each subject 12 measurements were taken: basal rate, during and after mobilization. Changes in H reflex amplitude were calculated in relation to basal measurement. For each measurement a hypothesis test was performed (Student t test). Results: In groups of patients with brain injury and incomplete spinal cord injury, a significant difference was found between measurements of both studies, concerning variation in H reflex amplitude during the application of joint mobilization techniques, with a decrease in the experimental group and an increase in the control group. In contrast, no significant differences were found after mobilization therapy. Patients with complete spinal cord injury showed no significant differences in any measurements. Conclusion: We demonstrate the effectiveness of joint mobilization in the decrease of H reflex amplitude in patients with brain injury or incomplete spinal cord injury during the mobilization maneuver, but no residual effect after completion of the trial. This research showed no evidence regarding excitability reduction in complete spinal cord injury. We suggest that therapeutic interventions to decrease muscle tone based on the joint mobilization should be reconsidered.

Objetivo: Determinar o efeito da mobilização articular do tornozelo sobre a amplitude do reflexo H do músculo sóleo em pessoas com espasticidade. Materiais e métodos: se realizou um quase-experimento com desenho cruzado e mascaramento simples em 24 pessoas voluntárias aleatorizadas para iniciar o estudo controle ou experimental. Aplicou-se tração e oscilação rítmica na articulação do tornozelo durante cinco minutos. Mediram-se as mudanças na amplitude da onda H do reflexo de Hoffmann, como equivalente elétrico do reflexo espinhal monossináptico estimulando o nervo tibial no nível da fossa poplítea e captando no músculo sóleo. A cada uma das pessoas realizaram-lhes 12 medições: basal, durante a mobilização e depois de finalizada. Calcularam-se as variações da amplitude da onda H em relação à medida basal. Para cada uma das medições realizou-se uma prova de hipótese (t de Student). Resultados: Nos grupos de pacientes com lesão cerebral e lesão medular incompleta encontrou-se uma diferença significativa entres as médias de ambos os estudos com relação à variação da amplitude da onda H durante a aplicação da mobilização articular com diminuição no experimental e aumento no controle; em contraste, não se encontraram diferenças significativas depois de finalizada a mobilização. Em pacientes com lesão medular completa não se observaram diferenças significativas em nenhuma das medições. Conclusões: Se demonstra a eficácia da mobilização articular para a diminuição da amplitude da onda H durante a manobra de mobilização em pacientes com lesão cerebral ou lesão medular incompleta, mas sem nenhum efeito residual depois de finalizada. A pesquisa não produziu evidência para a diminuição da amplitude em lesão medular completa. Sugere-se reformular as intervenções terapêuticas para diminuição do tom muscular baseadas na mobilização articular. Palavras chave: Manipulações musculoesqueléticas, terapia por exercício, tom muscular, espasticidade muscular.

Lesiones medulares y discapacidad: revisión bibliográfica / Lesões medulares e discapacidade: uma revisão bibliográfica / Spinal cord injuries and disabilities: a review

La lesión medular es una entidad neurológica causante de importantes procesos de discapacidad. Su incidencia en el país puede estar cercana a los mayores estimativos mundiales debido a las condiciones actuales de violencia. El aumento de la expectativa de vida de esta población —gracias a los avances tecnológicos y científicos en prevención, atención y manejo de complicaciones— lleva a la necesidad de proveer servicios de rehabilitación integrales que trasciendan los aspectos funcionales y permitan la inclusión social. Para este propósito es necesario un abordaje integral de la situación, que en el ámbito de la evaluación debe incluir no sólo la estimación de la condición de salud, sino todo lo relacionado con el funcionamiento de las personas en su vida diaria. La clasificación internacional del funcionamiento, la discapacidad y la salud, brinda un marco conceptual para abordar la discapacidad y el funcionamiento humano relacionado con la salud desde un enfoque biopsicosocial que articula las dimensiones corporal, individual y social de las personas y su relación con los factores del ambiente. Este enfoque de abordaje, plasmado en el instrumento de evaluación denominado WHO-DAS II, se considera un referente importante para evaluar la discapacidad asociada a la lesión medular.

Spinal cord injury is a neurological event that can result in major disability. Its incidence in Colombia is possibly among the highest in the world, given the current level of violence. The increased life expectancy for this group, thanks to technological and scientific progress with respect to prevention, care and treatment of complications, has created the need for comprehensive rehabilitation services that go beyond functional aspects and enable patients to rejoin society. This demands a holistic approach to the situation, including not only an assessment of health conditions but of everything related to how persons function in their daily lives. The International Classification of Functioning, Disability and Health provides a conceptual framework to address disability and human functioning related to health, through a biopsychosocial approach that articulates the person’s physical, individual and social dimensions and their relationship with factors in the environment. This approach, incorporated into an evaluation tool known as WHO-DAS II, is considered an important benchmark for assessing disability associated with spinal medulla injury.

Lesão medular é uma entidade neurológica que causa processos graves de discapacidade. Sua incidência no país pode aproximar-se às principais estimativas globais, devido às condições atuais de violência. O aumento da expectativa de vida da população, graças aos avanços tecnológicos e científicos na prevenção, cuidados e tratamento das complicações, exige a prestação de serviços de reabilitaçãointegrais que vai além dos aspectos funcionais e permitem a inclusão social. Para este efeito, é preciso uma amplio para a situação em matéria de avaliação deve incluir não apenas a estimativa do estado de saúde, mas tudo relacionado ao funcionamento das pessoas em suasvidas diárias. A Classificação Internacional de Funcionalidade, Discapacidade e Saúde suministra um quadro conceptual para abordar adeficiência e a funcionalidade humanas relacionadas com a saúde usando uma abordagem biopsicossocial que integre o desenvolvimento físico, social e individual das pessoas e sua relação com os fatores do meio ambiente. Esta abordagem, consagrada no instrumento de avaliação chamado OMS DAS-II, é considerada um marco importante para a avaliação da discapacidade associada com lesão medular.

Calidad de vida y situación de discapacidad / Quality of life and disability status / Qualidade de vida e situação de deficiência fisica

Introducción: El estudio de la calidad de vida en personas en situación de discapacidad ha aumentado de forma importante durante las últimas décadas, siendo abordada desde áreas diversas como salud, rehabilitación, servicios sociales y educación. La tendencia frente al tema es a reconocer la naturaleza holística de la persona, la complejidad de relaciones hombre-contexto, las condiciones de vida en situación de discapacidad y sus perspectivas a futuro. Objetivo: Identificar y reflexionar sobre la calidad de vida, específicamente en el ámbito de la discapacidad, desde modelos teóricos y herramientas para la medición de este constructo. Para lograr el objetivo, se analizarán definiciones elaboradas por diferentes autores sobre calidad de vida y su reflexión en torno a la situación de discapacidad. Seguido a ello, se abordará, de manera sucinta, la medición de calidad de vida con énfasis en el modelo propuesto por Schalock. Finalmente se presentará la propuesta de utilizar el constructo Calidad de Vida como herramienta de medición para evaluar las estrategias y la calidad de resultados de los programas, servicios y tratamientos en el área de salud y rehabilitación, para determinar en qué medida estos logran impactar la situación de discapacidad. El presente artículo es fruto de la reflexión teórica de las autoras en la Maestría en Discapacidad de la Universidad Autónoma de Manizales, Colombia.

Introduction: The study of the quality of life of handicapped people has highly increased during the last decades, and addressed from diverse areas such as health, rehabilitation, social services and education. The trend in this subject tends to recognize the holistic nature of human beings, the complexity of human—context relations, the life conditions faced by people living with disability and their future perspectives. Objective: Identify and reflect on the quality of life, specifically regarding disability, based on the theoretical models and the most relevant elements the subject matter implies. In order to achieve this aim, definitions on quality of life constructed by different authors will be used; then, the quality of life in handicapped persons will be analyzed; after that, the measurement of quality of life will be approached in a concise manner emphasizing the model proposed by Schalock. Finally, the proposal using the Quality of Life construct as a measurement tool in order to evaluate the strategies and the results of the programs, services and treatments in health and rehabilitation area is presented, in order to determine to what extent these results can impact the quality of life of handicapped persons. The present paper is the result of a theoretical reflection of the authors in the Masters Program on Disability at the Universidad Autónoma y of Manizales.

Introdução: A pesquisa da qualidade de vida em pessoas que sofrem deficiência tem aumentado de maneira importante durante as ultimas décadas, sendo abordadas desde as áreas diversas como saúde, reabilitação, serviços sócias e educação. A tendência frente ao tema é reconhecer a natureza holística da pessoa, a complexidade das relações homem-contexto, às condições de vida em situação de deficiência física e suas perspectivas a futuro. Objetivo: Identificar e reflexionar sobre a qualidade de vida, especificamente no âmbito da deficiência física, desde modelos teóricos e ferramentas para a medição deste constructo. Para o objetivo, analisaram se definições elaboradas por diferentes autores sobre qualidade de vida e sua reflexão em torno à situação de deficiência física. Seguido a isto, se abordara, de maneira Sucinta, a mediação de qualidade de vida com ênfase no modelo proposto por Schalock. Finalmente apresentaram se a proposta de utilizar o constructo Qualidade de Vida como ferramenta de medição para avaliar as estratégias e a qualidade dos resultados dos programas, serviços e tratamentos na área de saúde e reabilitação, para determinar em que medida estes logram impactar a situação de deficiência física. O presente artigo é o fruto da reflexão teórica das autoras na Maestria em Deficiência física da Universidade Autônoma de Manizales, Colômbia.

Cultural adaptation of birthing services in rural Ayacucho, Peru.

PROBLEM: Maternal mortality is particularly high among poor, indigenous women in rural Peru, and the use of facility care is low, partly due to cultural insensitivities of the health care system. APPROACH: A culturally appropriate delivery care model was developed in poor and isolated rural communities, and implemented between 1999 and 2001 in cooperation with the Quechua indigenous communities and health professionals. Data on birth location and attendance in one health centre have been collected up to 2007. LOCAL SETTING: The international nongovernmental organization, Health Unlimited, and its Peruvian partner organization, Salud Sín Límites Perú, conducted the project in Santillana district in Ayacucho. RELEVANT CHANGES: The model involves features such as a rope and bench for vertical delivery position, inclusion of family and traditional birth attendants in the delivery process and use of the Quechua language. The proportion of births delivered in the health facility increased from 6% in 1999 to 83% in 2007 with high satisfaction levels. LESSONS LEARNED: Implementing a model of skilled delivery attendance that integrates modern medical and traditional Andean elements is feasible and sustainable. Indigenous women with little formal education do use delivery services if their needs are met. This contradicts common victim-blaming attitudes that ascribe high levels of home births to 'cultural preferences' or 'ignorance'.