Being both a grandmother and a health worker: experiences of community-based health workers in addressing adolescents' sexual and reproductive health needs in rural Zambia.

INTRODUCTION: Community-based health workers (CBHWs) possess great potential to be the missing link between the community and the formal health system for improving adolescents' access to sexual and reproductive health and rights (SRHR) information and services. Yet, their role in addressing adolescents' SRHR within the context of the community-based health system has received very little attention. This paper analyses how CBHWs experience and perceive their role in addressing adolescents' SRHR needs in rural Zambia, including the possible barriers, dilemmas, and opportunities that emerge as CBHWs work with adolescents. METHODS: Between July and September 2019, we conducted 14 in-depth interviews with 14 community-based health workers recruited across 14 different communities in the central province of Zambia. The interviews were focused on eliciting their experiences and perceptions of providing sexual and reproductive health services to adolescents. Charmaz's grounded theory approach was used for the analysis. RESULTS: We present the core category "being both a grandmother and a CBHW", which builds upon four categories: being educators about sexual and reproductive health; being service providers and a link to SRHR services; being advocates for adolescents' SRHR; and reporting sexual violence. These categories show that CBHWs adopt a dual role of being part of the community (as a grandmother) and part of the health system (as a professional CBHW), in order to create/maximise opportunities and navigate challenges. CONCLUSION: Community-based health workers could be key actors providing context-specific comprehensive SRHR information and services that could span all the boundaries in the community-based health system. When addressing adolescents SRHR, playing dual roles of being both a grandmother and a professional CBHW were sometimes complimentary and at other times conflicting. Additional research is required to understand how to improve the role of CBHWs in addressing adolescents and young people's sexual and reproductive health.

Exploring cross-boundary collaboration for youth mental health in Sweden - a qualitative study using the integrative framework for collaborative governance.

BACKGROUND: Youth mental health is a major health concern in almost every country. Mental health accounts for about 13% of the global burden of disease in the 10-to-19-year age group. Still there are significant gaps between the mental health needs of young people and the quality and accessibility of available services. Collaboration between health and social service actors is a recognized way of reducing gaps in quality and access. Yet there is little scientific evidence on how these collaborations are applied, or on the challenges of cross-boundary collaboration in the youth mental health space. This study aims to explore how collaboration is understood and practiced by professionals working in the Swedish youth mental health system. METHODS: We conducted 42 interviews (November 2020 to March 2022) with health and social care professionals and managers in the youth mental health system in Sweden. Interviews explored participants' experience and understanding of the purpose, realization, and challenges of collaboration. Data were analysed under an emergent study design using reflexive thematic analysis. RESULTS: The analysis produced three themes. The first shows that collaboration is considered as essential and important, and that it serves diverse purposes and holds multiple meanings in relation to professionals' roles and responsibilities. The second addresses the different layers of collaboration, in relation to activities, relationships, and target levels, and the third captures the challenges and criticisms in collaborating across the youth mental health landscape, but also in growing possibilities for future development. CONCLUSION: We conclude that collaboration serves multiple purposes and takes many shapes in the Swedish youth mental health system. Despite the many challenges, participants saw potential in further building collaboration. Interestingly our participants also raised concerns about too much collaboration. There was scepticism about collaboration directing attention away from young people to the professionals, thereby risking the trust and confidentiality of their young clients. Collaboration is not a panacea and will not compensate for an under-resourced youth mental health system.

Widening the scope of mental health with a 'youth centred' approach: a qualitative study involving health care professionals in Sweden's youth clinics.

PURPOSE: The aim of this study was to explore how health care providers at youth clinics (YCs) in Sweden engage with, focus on, and navigate across the mental health youth space, while upholding the core bedrock principle of "youth-centeredness". METHODS: Qualitative interviews were conducted with 21 health care professionals working in three YCs located in three different regions of Sweden. Data were analysed using reflexive thematic analysis informed by the work of Braun and Clarke. RESULTS: The three themes were: 1) "youth mission-at the core of the YCs" work and challenged by a stronger involvement in mental ill health'; 2) "YCs" unique and complementary role in the youth mental health system: a holistic perspective, team work, and a focus on normalization', and 3) "Caught between a rock and a hard place: to treat at a care level that is not optimal for the young users" needs or to refer within an unreliable system'. CONCLUSION: This study reflects the individuality and key features of YCs, their widening roles within the mental health sphere, and the challenges faced in maintaining and expanding the characteristic "youth-centred" approach while expanding their work with mental health.

Why do certain primary health care teams respond better to intimate partner violence than others? A multiple case study / ¿Por qué ciertos equipos de atención primaria de salud responden mejor a la violencia de compañero íntimo? Un estudio de casos múltiples

Objective: To analyse how team level conditions influenced health care professionals' responses to intimate partner violence. Methods: We used a multiple embedded case study. The cases were four primary health care teams located in a southern region of Spain; two of them considered "good" and two s "average". The two teams considered good had scored highest in practice issues for intimate partner violence, measured via a questionnaire (PREMIS - Physicians Readiness to Respond to Intimate Partner Violence Survey) applied to professionals working in the four primary health care teams. In each case quantitative and qualitative data were collected using a social network questionnaire, interviews and observations. Results: The two "good" cases showed dynamics and structures that promoted team working and team learning on intimate partner violence, had committed social workers and an enabling environment for their work, and had put into practice explicit strategies to implement a women-centred approach. Conclusions: Better individual responses to intimate partner violence were implemented in the teams which: 1) had social workers who were knowledgeable and motivated to engage with others; 2) sustained a structure of regular meetings during which issues of violence were discussed; 3) encouraged a friendly team climate; and 4) implemented concrete actions towards women-centred care

Objetivo: Analizar cómo las condiciones del equipo influyen en las respuestas de los/las profesionales sanitarios a la violencia de compañero íntimo. Método: Se realizó un estudio de casos múltiples. Los casos fueron cuatro equipos de atención primaria de salud ubicados en una región del sur de España. Dos de ellos se calificaron como «buenos» y otros dos como «promedio». Se calificaron como «buenos» los dos equipos con puntuaciones más altas en prácticas en cuanto a violencia de compañero íntimo, medidas a través de un cuestionario (PREMIS, cuestionario que mide la capacidad de respuesta de los/las médicos) que se aplicó a profesionales de los cuatro equipos. En cada caso se recolectaron datos cuantitativos y cualitativos mediante un cuestionario de redes sociales, entrevistas y observaciones. Resultados: Los dos casos «buenos» presentaban dinámicas y estructuras que promovían el aprendizaje y el trabajo en equipo en el tema de violencia de compañero íntimo, contaban con trabajadoras sociales comprometidas con el tema y un ambiente que les permitía desarrollar su trabajo, y habían puesto en práctica de manera explícita estrategias para ofrecer una atención centrada en las mujeres. Conclusiones: Los equipos que respondieron mejor a la violencia de pareja fueron aquellos que: 1) tienen trabajadoras sociales bien informadas y motivadas para involucrar a otros/as; 2) mantienen una estructura de reuniones regulares en las que se aborda el tema de la violencia; 3) promueven un buen ambiente de trabajo; y 4) desarrollan acciones concretas para ofrecer una atención centrada en las mujeres

¿Cómo acceden las mujeres inmigrantes a los servicios sanitarios en el País Vasco? Percepciones de profesionales sanitarias / How do immigrant women access health services in the Basque Country? Perceptions of health professionals

OBJETIVO: Explorar la percepción de las profesionales sanitarias que trabajan en centros sanitarios alternativos sobre las barreras y los facilitadores en el acceso de las mujeres inmigrantes a los servicios sanitarios públicos generales y de salud sexual y reproductiva en el País Vasco. Emplazamiento: País Vasco. DISEÑO: Análisis de contenido cualitativo basado en 11 entrevistas individuales. PARTICIPANTES: Profesionales sanitarias que trabajan en centros sanitarios alternativos de atención primaria y salud sexual y reproductiva. MÉTODO: La recolección de datos se realizó entre septiembre y diciembre de 2015 en cuatro centros sanitarios alternativos. Tras su transcripción, se identificaron unidades de significado, códigos y categorías. RESULTADOS: Del análisis emergieron cuatro categorías que representan cómo las características de las mujeres inmigrantes (Dime cómo eres y te diré cómo accedes), la actitud del personal administrativo y sanitario ("Cuando ya les atienden, estupendamente. El problema está con los administrativos"), el funcionamiento del sistema sanitario (Sistema de salud inflexible, pasivo y receptor de necesidades) y las políticas sanitarias ("Si no cumples los requisitos, pues no entras. La ley es la ley") influyen en el acceso a los servicios sanitarios públicos de las mujeres inmigrantes. CONCLUSIONES: Este estudio indica que hay un considerable número de barreras y pocos facilitadores en el acceso de las mujeres inmigrantes a los servicios sanitarios públicos y de salud sexual y reproductiva en el País Vasco. Los centros sanitarios alternativos se presentaron como favorecedores en la mejora de la salud de la población inmigrante y en su acceso

OBJECTIVE: To determine the perception of health professionals working in alternative health centres on the barriers and facilitators in the access by immigrant women to general public health services and sexual and reproductive health in the Basque Country. LOCATION: Basque Country. DESIGN: Analysis of qualitative content based on 11 individual interviews. PARTICIPANTS: Health professionals working in alternative health centres of Primary Care and sexual and reproductive health. METHOD: Data collection was performed between September and December 2015 in four alternative health centres. After transcription, the units of meaning, codes and categories were identified. RESULTS: Four categories emerged from the analysis, which represented how the characteristics of immigrant women (Tell me how you are and I will tell you how to access), the attitude of the administrative and health staff ("When they are already taken care of"), the functioning of the health system (Inflexible, passive and needs-responsive health system), and health policies ("If you do not meet the requirements, you do not go in. The law is the law") influence access to health services of immigrant women. CONCLUSIONS: This study shows that there are a considerable number of barriers and few facilitators to the access by immigrant women to public health and sexual and reproductive health services in the Basque Country. The alternative health centres were presented as favouring the improvement of the health of the immigrant population and in their access

Factores asociados a la respuesta a la violencia del compañero íntimo en atención primaria de salud en España / Factors associated with primary care professionals' readiness to respond to intimate partner violence in Spain

Objetivo: Analizar la capacidad de respuesta a la violencia del compañero íntimo (VCI) de profesionales sanitarios/as españoles/as en atención primaria e identificar posibles determinantes que puedan favorecer una mejor respuesta. Método: Estudio transversal con muestreo no probabilístico y por conveniencia en profesionales sanitarios/as de 15 centros de atención primaria españoles. El instrumento Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), en su versión validada y traducida al español, permitió recolectar información sobre conocimientos, opiniones y prácticas sobre VCI. Se realizaron análisis estadísticos descriptivo y de regresión lineal bivariada y multivariada. Resultados: Se recibieron 265 cuestionarios diligenciados, con una tasa de respuesta del 80,3%. Se observó un efecto exposición-respuesta, en el que a más horas de formación, mayor puntuación en las escalas del cuestionario (p <0,05). La edad, el tipo de profesión, los años de experiencia en atención primaria, las horas de formación en VCI y la lectura del protocolo mostraron asociación positiva con conocimientos (preparación percibida, conocimiento percibido, conocimiento real), opiniones (preparación del equipo, requerimientos legales, autoeficacia, disponibilidad de recursos en el lugar de trabajo, barreras, entendimiento de la víctima) y prácticas del personal sanitario. Conclusiones: Leer el protocolo de actuación regional/nacional y recibir formación en VCI fueron las intervenciones más importantes asociadas a una mejor capacidad de respuesta a la VCI de los/las profesionales sanitarios/as en atención primaria

Objective: To analyse the Spanish primary care professionals' readiness to respond to intimate partner violence (IPV) in primary care and identify possible determinants that could facilitate a better response. Method: A cross-sectional study with a non-probabilistic sampling by convenience was performed among healthcare professionals working in 15 primary care centres in Spain. The Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), the version validated and translated into Spanish, was the instrument used to collect information about knowledge, opinions and practices regarding intimate partner violence. Descriptive analysis and, simple and multiple linear regression analysis were performed. Results: A total of 265 completed questionnaires were received, with a response rate of 80.3%. An exposure-response effect was observed, where at higher hours of training a higher score was obtained on the questionnaire sections (p <0.05). Age, type of profession, years of experience in primary care, hours of IPV training and reading the protocol showed positive association with knowledge (perceived preparation, perceived knowledge, actual knowledge), opinions (staff preparation, legal requirements, self-efficacy, workplace issues, constraints, understanding of the victim) and practice of healthcare professionals. Conclusions: Reading the regional/national protocol for action and receiving training in IPV were the most important interventions associated to a better primary care professionals' readiness to respond to IPV in Spanish primary care settings

Primary health care attributes and responses to intimate partner violence in Spain / Atributos de atención primaria y respuestas a la violencia de compañero íntimo en España

Objective: This study provides an overview of the perceptions of primary care professionals on how the current primary health care (PHC) attributes in Spain could influence health-related responses to intimate partner violence (IPV). Methods: A qualitative study was conducted using semi-structured interviews with 160 health professionals working in 16 PHC centres in Spain. Data were analysed using a qualitative content analysis. Results: Four categories emerged from the interview analysis: those committed to the PHC approach, but with difficulties implementing it; community work relying on voluntarism; multidisciplinary team work or professionals who work together?; and continuity of care hindered by heavy work load. Participants felt that person-centred care as well as other attributes of the PHC approach facilitated detecting IPV and a better response to the problem. However, they also pointed out that the current management of the health system (workload, weak supervision and little feedback, misdistribution of human and material resources, etc.) does not facilitate the sustainability of such an approach. Conclusion: There is a gap between the theoretical attributes of PHC and the ‘reality’ of how these attributes are managed in everyday work, and how this influences IPV care (AU)

Objetivo: Este estudio presenta las percepciones de profesionales de atención primaria sobre cómo los atributos de la atención primaria en España pueden influenciar las respuestas sanitarias a la violencia del compañero íntimo (VCI). Métodos: Estudio cualitativo con entrevistas semiestructuradas con 160 profesionales sanitarios de 16 centros de atención primaria en España. Los datos se analizaron con el enfoque de análisis de contenido. Resultados: Del análisis de las entrevistas emergieron cuatro categorías: Implicados/as con el enfoque de primaria, pero enfrentando dificultades para implementarlo; El trabajo comunitario depende del voluntarismo; ¿Trabajo multidisciplinario o profesionales que trabajan juntos?; y Continuidad amenazada por la sobrecarga de trabajo. Los participantes consideraron que la atención centrada en la persona y otros atributos del enfoque de atención primaria facilitaban la detección de VCI y una mejor respuesta a este problema. Sin embargo, también reconocieron que la forma en que se gestionan los servicios sanitarios (sobrecarga de trabajo, débil supervisión y escaso feed-back, distribución de los recursos humanos y materiales, etc.) no facilita la sostenibilidad de este enfoque. Conclusión: Existe una brecha entre los atributos teóricos de la atención primaria y la «realidad» de cómo estos atributos se gestionan en la actividad profesional del día a día y de qué manera esta influye en la atención a la VCI (AU)

Detección de violencia del compañero íntimo en atención primaria de salud y sus factores asociados / Detection of intimate partner violence in primary care and related factors

Objetivo: La violencia de compañero íntimo (VCI) contra las mujeres es un importante problema de salud pública y de derechos humanos. Los profesionales de atención primaria tienen un papel clave en su detección y abordaje. El objetivo de este estudio es determinar la frecuencia y los factores asociados a la realización de preguntas de detección de VCI en atención primaria, y describir las principales acciones desarrolladas en los casos identificados. Métodos: Estudio transversal en 15 centros de salud de cuatro comunidades autónomas, con 265 profesionales sanitarios. Recogida de información mediante el cuestionario PREMIS (Physician Readiness to Manage Intimate Partner Violence Survey) autocumplimentado, que incluye variables sobre realización de preguntas para detección, sociodemográficas, nivel de formación/conocimientos en VCI, percepciones y acciones. Se realizó un análisis descriptivo y analítico. Resultados: El 67,2% de los participantes señalan que preguntan sobre VCI en la consulta, siendo las acciones más frecuentes referir/derivar a otros servicios, consejo individual y entrega de información. Se asociaron a mayor probabilidad de indagar sobre VCI tener ≥21 de horas de formación, nivel formativo avanzado, conocer políticas y programas, y disponer de protocolo y recursos apropiados de referencia. La realización de preguntas aumenta a medida que los/las profesionales se sienten formados en VCI y provistos/as de un protocolo de manejo de casos. Conclusiones: Dos terceras partes de los/las profesionales sanitarios/as encuestados/as refirieron indagar sobre VCI. Dada la influencia de la formación en VCI y el conocimiento sobre los recursos para su abordaje, resulta imprescindible continuar invirtiendo en la formación en VCI del personal sanitario (AU)

Objective: Intimate partner violence (IPV) against women is a significant public health and human rights problem. Primary care professionals play a key role in detecting and addressing this issue. The aim of this study is to determine the frequency of IPV and its associated factors in primary care by means of a screening questionnaire and to describe the main actions taken in identified cases. Methods: Cross-sectional study in 15 health centers in four autonomous regions of Spain with a total of 265 health professionals. The information was collected through the self-administered PREMIS questionnaire (Physician Readiness to Manage Intimate Partner Violence Survey), which includes variables concerning screening questions, sociodemographic factors, level of training/knowledge about IPV, perceptions and actions. A descriptive and analytical study was conducted. Results: 67.2% of participants said they ask about IPV during consultations. The most frequent actions were: referring patients to other departments, individual counselling and information delivery. ≥21hours of training, an advanced training level, knowledge of policies and programmes and the implementation of an appropriate protocol and reference resources were all factors that increased the likelihood of investigating IPV. The asking of questions increases in line with professionals’ perceived level of training in IPV and the provision of a case management protocol. Conclusions: Two thirds of health professional respondents said they inquire about IPV. Given the influence of training in IPV and awareness of the resources to address the issue, it is essential to continue investing in the IPV training of healthcare personnel (AU)

Discursos profesionales sobre la violencia del compañero íntimo: implicación en la atención de las mujeres inmigrantes en España / Professional discourses on intimate partner violence: implication for care of immigrant women in Spain

Objetivo: 1) Explorar los discursos de los/las profesionales implicados/as en la atención a las mujeres que sufren violencia del compañero íntimo en cuanto a cómo describen a las mujeres inmigrantes afectadas, los agresores y su propia responsabilidad en la atención a este problema, y 2) comparar estos discursos entre los diferentes grupos profesionales implicados en la atención a dichas mujeres (servicios sociales, asociaciones y policial judicial). Métodos: Estudio cualitativo basado en entrevistas semiestructuradas a 43 profesionales de servicios sociales, asociaciones y ámbitos policial y judicial. Se realizó un análisis del discurso para identificar repertorios interpretativos sobre la violencia del compañero íntimo, las mujeres inmigrantes y sus agresores, su cultura y las prácticas profesionales. Resultados: Emergieron cuatro repertorios interpretativos en los discursos profesionales: «Prototipos culturales de mujeres afectadas por violencia del compañero íntimo», «Los agresores son similares independientemente de su cultura de origen», «¿Son las víctimas creíbles y los agresores responsables?» y «Falta de sensibilidad cultural de los/las profesionales para ayudar a las mujeres inmigrantes en situación de maltrato». Estos repertorios corresponden a los prototipos que los/las profesionales construyen de las mujeres afectadas y de sus agresores, la credibilidad y la responsabilidad que les atribuyen, y la interpretación de su propio rol profesional. Conclusiones: La presencia de mediadores culturales con formación específica sobre violencia del compañero íntimo en los servicios implicados en la atención a las mujeres que la sufren, junto a la formación en competencias culturales de los/las profesionales, contribuirían a proporcionar una atención culturalmente sensible a las mujeres inmigrantes afectadas por violencia del compañero íntimo (AU)

Objective: 1) to examine the discourses of professionals involved in the care of female victims of intimate partner violence (IPV), with emphasis on how they describe the immigrant women, the perpetrators and their own responsibility of care; and 2) to compare these discourses with the other professions involved in caring for these women (social services, associations and police and justice). Methods: Qualitative study based on semi-structured interviews with 43 professionals from social services, associations and the police and judicial systems. A discourse analysis was carried out to identify interpretive repertoires about IPV, immigrant women and their aggressors, their culture and professional practices. Results: Four interpretive repertoires emerged from professional discourses: ‘Cultural prototypes of women affected by IPV’, ‘Perpetrators are similar regardless of their culture of origin’, ‘Are victims credible and the perpetrators responsible?’ and ‘Lack of cultural sensitivity of professionals in helping immigrant women in abusive situations’. These repertoires correspond to preconceptions that professionals construct about affected women and their perpetrators, the credibility and responsibility they attribute to them and the interpretation of their professional roles. Conclusions: The employment of IPV-trained cultural mediators in the services responsible for caring for the female victims, together with cultural training for the professionals, will facilitate the provision of culturally sensitive care to immigrant female victims of intimate partner violence (AU)

¿Es posible una atención primaria «amigable para las/los jóvenes» en España? / Is youth-friendly primary care feasible in Spain?

No disponible

Validación de la versión española del cuestionario Physician readiness to manage intimate partner violence survey (PREMIS) / Validation of the Spanish version of Physician readiness to manage intimate partner violence survey (PREMIS)

Fundamentos: El Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) es uno de los cuestionarios más completos en el contexto internacional para la valoración de la capacidad de respuesta frente a la violencia del compañero íntimo por los profesionales de Atención Primaria de Salud. El objetivo de este estudio fue determinar la fiabilidad, consistencia interna y validez de constructo de la versión española de este cuestionario. Métodos: Tras la traducción, retrotraducción y valoración de la validez de contenido del cuestionario, se distribuyeron en una muestra de 200 profesionales de medicina y enfermería de 15 centros de atención primaria de 4 Comunidades Autónomas en 2013 (Comunidad Valenciana, Castilla León, Murcia y Cantabria). Se calcularon los coeficientes alfa de Cronbach, los de correlación intraclase y rho de Spearman (test-retest). Resultados: la versión española del PREMIS incluyó 64 ítems. El coeficiente α de Cronbach fue superior a 0,7 o muy cercano a ese valor en la mayoría de los índices. Se obtuvo un coeficiente de correlación intraclase de 0,87 y un coeficiente de Spearman de 0,67 que muestran una fiabilidad alta. Todas las correlaciones observadas para la escala de opiniones, la única tratada como estructura factorial en el cuestionario PREMIS, fueron superiores a 0,30. Conclusiones: el PREMIS en español obtuvo una buena validez interna, alta fiabilidad y capacidad predictiva de las prácticas auto-referidas por médicos(as) y enfermeros(as) frente a casos de violencia del compañero íntimo en centros de atención primaria (AU)

Background: At the international level PREMIS - 'Physician Readiness to Manage Intimate Partner Violence Survey'- is amongst the most comprehensive instruments to evaluate primary health care professionals’ readiness. The aim of this study is to assess the reliability, internal consistency and construct validity of the Spanish version of this questionnaire. Methods: After translation, back translation and assessment of content validity of the questionnaire, 200 questionnaires were distributed to medical doctors and nurses working in 15 primary health care centres located in 4 autonomous regions (Comunidad Valenciana, Castilla León, Murcia, Cantabria), in 2013. Cronbach’s alpha, intraclass correlation and rho Spearman coefficients were calculated. Results: the Spanish version of PREMIS encompasses 64 items. Cronbach’s alpha coefficient was greater than or close to 0.7 in most of indices. Intraclass correlation coefficient of 0.87 and Spearman coefficient of 0.67 showed a high reliability. All correlations for the scale of Opinions, which is the only one that was considered factorial structure of the questionnaire PREMIS, were higher than 0.30. Conclusions: the Spanish version of PREMIS obtained good internal validity, high reliability and predictive self-reported capacity of medical practitioners and nurses in Intimate Partner Violence cases in PHC centers (AU)

Using realist evaluation to assess primary healthcare teams' responses to intimate partner violence in Spain / Uso de la evaluación realista para evaluar las respuestas de los equipos de atención primaria a la violencia del compañero íntimo en España

Objective: Few evaluations have assessed the factors triggering an adequate health care response to intimate partner violence. This article aimed to: 1) describe a realist evaluation carried out in Spain to ascertain why, how and under what circumstances primary health care teams respond to intimate partner violence, and 2) discuss the strengths and challenges of its application. Methods: We carried out a series of case studies in four steps. First, we developed an initial programme theory (PT1), based on interviews with managers. Second, we refined PT1 into PT2 by testing it in a primary healthcare team that was actively responding to violence. Third, we tested the refined PT2 by incorporating three other cases located in the same region. Qualitative and quantitative data were collected and thick descriptions were produced and analysed using a retroduction approach. Fourth, we analysed a total of 15 cases, and identified combinations of contextual factors and mechanisms that triggered an adequate response to violence by using qualitative comparative analysis. Results: There were several key mechanisms —the teams’ self-efficacy, perceived preparation, women-centred care—, and contextual factors —an enabling team environment and managerial style, the presence of motivated professionals, the use of the protocol and accumulated experience in primary health care— that should be considered to develop adequate primary health-care responses to violence. Conclusion: The full application of this realist evaluation was demanding, but also well suited to explore a complex intervention reflecting the situation in natural settings (AU)

Objetivo: Hay pocas evaluaciones de los factores que generan una respuesta sanitaria adecuada a la violencia del compañero íntimo. Este artículo tiene como objetivo: 1) describir una evaluación realista para investigar por qué, en qué circunstancias y cómo los equipos de atención primaria en España responden a la violencia de pareja, y 2) discutir las fortalezas y los desafíos de su aplicación. Métodos: Se llevaron a cabo una serie de estudios de caso en cuatro pasos. Primero construimos una teoría del programa inicial (PT1), basada en entrevistas con profesionales del nivel gerencial. Segundo, refinamos la PT1 a PT2, a través del estudio de caso en un equipo de atención primaria que estaba respondiendo activamente a la violencia. Tercero, refinamos la PT2 incorporando al análisis otros tres casos situados en la misma región. Recogimos información cualitativa y cuantitativa, elaboramos descripciones extensas de los casos y los analizamos usando el enfoque de retroducción. Cuarto, analizamos 15 casos para identificar las combinaciones de factores contextuales y mecanismos que desencadenaban una respuesta adecuada a la violencia, utilizando análisis cualitativo comparativo. Resultados: Hubo varios mecanismos clave –autoeficacia del equipo, preparación percibida, y atención centrada en las mujeres–, así como factores contextuales –ambiente de equipo y estilo de gestión, presencia de profesionales motivados, uso del protocolo y experiencia acumulada en atención primaria–, que deben considerarse para generar respuestas sanitarias adecuadas a la violencia. Conclusión: La aplicación de esta evaluación realista requirió tiempo, pero resultó apropiada para explorar una intervención compleja tal como se desarrolla en condiciones reales (AU)

Applying the WHO recommendations on health-sector response to violence against women to assess the Spanish health system. A mixed methods approach / La aplicación de las recomendaciones de la OMS sobre la respuesta del sector salud a la violencia contra las mujeres para evaluar el sistema sanitario español

This methodological note describes the development and application of a mixed-methods protocol to assess the responsiveness of Spanish health systems to violence against women in Spain, based on the World Health Organization (WHO) recommendations. Five areas for exploration were identified based on the WHO recommendations: policy environment, protocols, training, accountability/monitoring, and prevention/promotion. Two data collection instruments were developed to assess the situation of 17 Spanish regional health systems (RHS) with respect to these areas: 1) a set of indicators to guide a systematic review of secondary sources, and 2) an interview guide to be used with 26 key informants at the regional and national levels.We found differences between RHSs in the five areas assessed. The progress of RHSs on the WHO recommendations was notable at the level of policies, moderate in terms of health service delivery, and very limited in terms of preventive actions. Using a mixed-methods approach was useful for triangulation and complementarity during instrument design, data collection and interpretation (AU)

Esta nota metodológica describe el desarrollo de un protocolo de investigación que utiliza métodos mixtos para evaluar la respuesta del sistema sanitario español a la violencia contra las mujeres, partiendo de las recomendaciones de la Organización Mundial de la Salud (OMS).A partir de estas recomendaciones, se definieron cinco áreas para su evaluación: políticas, protocolos, formación, rendición de cuentas/monitoreo, y acciones de prevención y promoción. Se desarrollaron dos instrumentos - un conjunto de indicadores para orientar la revisión sistemática de fuentes secundarias, y una guía de entrevista, que se utilizó con 26 informantes clave - y se aplicaron en los 17 sistemas sanitarios autonómicos. Se evidenciaron diferencias entre autonomías y entre las cinco áreas evaluadas: notable progreso en políticas, menos destacado en la prestación de servicios y muy limitados en acciones preventivo-promocionales. Combinar métodos permitió lograr triangulación, complementariedad y desarrollo, durante el diseño de los instrumentos, la recogida de información y su interpretación (AU)

Risk factors for pregnancy among adolescent girls in Ecuador's Amazon basin: a case-control study / Factores de riesgo de embarazo en adolescentes de la cuenca amazónica de Ecuador: estudio de casos y controles

OBJECTIVE: To examine risk factors for pregnancy among adolescent girls in the Amazon basin of Ecuador. METHODS: A matched case-control study with cases and controls identified within a community-based demographic and health survey was conducted in Orellana, Ecuador, from May to November 2006. A questionnaire focused on socioeconomic status, family structure, education, reproductive health, and childhood-adolescent trauma was applied. Conditional logistic regression was used to adjust for potential confounders. RESULTS: Respondents included 140 cases and 262 controls. Factors associated with increased risk of adolescent pregnancies through multivariate analysis were: sexual abuse during childhood-adolescence (odds ratio (OR) 3.06, 95 percent confidence interval (CI) 1.08-8.68); early sexual debut (OR 8.51, 95 percent CI 1.12-64.90); experiencing periods without mother and father (OR 10.67, 95 percent CI 2.67-42.63); and living in a very poor household (OR 15.23, 95 percent CI 1.43-162.45). Another two factors were statistically associated in the bivariate analysis: being married or in a consensual union (OR 44.34, 95 percent CI 17.85-142.16) and not being enrolled in school at the time of the interview (OR 6.31, 95 percent CI 3.70-11.27). For a subsample of sexually initiated adolescents, "non-use of contraception during first sexual intercourse" was also found to be a risk factor (OR 4.30, 95 percent CI 1.33-13.90). CONCLUSION: The study found that early sexual debut, non-use of contraception during first sexual intercourse, living in a very poor household, having suffered from sexual abuse during childhood-adolescence, and family disruption (living extended periods of life without both parents) were associated with adolescent pregnancy in Orellana.

OBJETIVO: Analizar los factores de riesgo de embarazo en adolescentes de la cuenca amazónica de Ecuador. MÉTODOS: Estudio de casos y controles pareados, identificados mediante una encuesta demográfica y de salud realizada en Orellana, Ecuador, entre mayo y noviembre de 2006. Se aplicó un cuestionario dirigido a recabar información sobre: condiciones socioeconómicas, estructura familiar, nivel educacional, salud reproductiva y traumas durante la niñez y la adolescencia. Se empleó la regresión logística condicional para ajustar por posibles factores de confusión. RESULTADOS: Entre las que respondieron la encuesta se encontraron 140 casos y se seleccionaron 262 controles. Los factores asociados mediante el análisis multifactorial con un mayor riesgo de embarazo adolescente fueron: abuso sexual durante la infancia o la adolescencia (razón de posibilidades (odds ratio, OR) = 3,06; intervalo de confianza de 95 por ciento [IC95 por ciento]: 1,08 a 8,68); inicio temprano de la vida sexual (OR = 8,51; IC95 por ciento: 1,12 a 64,90); haber vivido largos períodos sin sus padres (OR = 10,67; IC95 por ciento: 2,67 a 42,63); y vivir en un hogar muy pobre (OR = 15,23; IC95 por ciento: 1,43 a 162,45). Otros dos factores se asociaron estadísticamente en el análisis bifactorial: estar casada o vivir en unión consensual (OR = 44,34; IC95 por ciento: 17,85 a 142,16) y no estar matriculada en la escuela al momento de la entrevista (OR = 6,31; IC95 por ciento: 3,70 a 11,27). En una submuestra de adolescentes que habían iniciado su vida sexual, no haber utilizado un método anticonceptivo durante su primera relación sexual resultó también un factor de riesgo (OR = 4,30; IC95 por ciento: 1,33 a 13,90). CONCLUSIONES: El inicio temprano de las relaciones sexuales, la no utilización de un método anticonceptivo durante la primera relación sexual, vivir en un hogar muy pobre, haber sufrido abuso sexual durante la niñez o la adolescencia, y la separación familiar (haber ...

Epidemiology of malaria in the Amazon basin of Ecuador

Malaria is reemerging in most endemic countries of South America. In Ecuador, malaria is endemic on the Pacific coast, in the inter-Andean valleys, and in the Amazon River basin. In the Lower-Napo region of northeastern Ecuador, malaria was considered eliminated in the 1970s, but the disease has reemerged in recent years. Three organizations are involved in malaria related work in the area, but they are not coordinating their efforts. This study was designed to describe the epidemiology of malaria incidence in the Lower-Napo region for the period of January 1992 through December 1995, and to determine the extent of seasonality in transmission in the area. To determine malaria incidence, data were collected for that 4-year period from the records of the three malaria-related organizations: the office of the National Center for Malaria Eradication (NCME) in the town of Coca, the district hospital in Nuevo Rocafuerte (DHNR), and an association of community health workers called Sandi Yura. Data on climatic conditions for the same period were collected from the Ecuadorian Air Force and civil aviation authorities. During the 1992-1995 period, NCME diagnosed a total of 773 malaria cases, DHNR diagnosed 485, and Sandi Yura clinically diagnosed 859. For the 4-year period, an annual parasite index of 40.4 was found with the DHNR data, 35.8 with the Sandi Yura data, and 6.2 with the NCME data. The predominant parasite in the area was Plasmodium vivax (92 percent of all the cases). Twenty-eight percent of the infected persons were under 10 years old. No discernible differences between the genders were found. There was also no seasonal variation among the cases. Further research is needed in order to confirm these findings and better understand malaria transmission in the region. The study highlights the need for a closer coordination among the area's malaria-control organizations so as to have an improved understanding of malaria epidemiology and to design and implement effective control strategies

Epidemiology of malaria in the Amazon basin of Ecuador / Epidemiología de la malaria en la cuenca amazónica del Ecuador

Malaria is reemerging in most endemic countries of South America. In Ecuador, malaria is endemic on the Pacific coast, in the inter-Andean valleys, and in the Amazon River basin. In the Lower-Napo region of northeastern Ecuador, malaria was considered eliminated in the 1970s, but the disease has reemerged in recent years. Three organizations are involved in malaria related work in the area, but they are not coordinating their efforts. This study was designed to describe the epidemiology of malaria incidence in the Lower-Napo region for the period of January 1992 through December 1995, and to determine the extent of seasonality in transmission in the area. To determine malaria incidence, data were collected for that 4-year period from the records of the three malaria-related organizations: the office of the National Center for Malaria Eradication (NCME) in the town of Coca, the district hospital in Nuevo Rocafuerte (DHNR), and an association of community health workers called Sandi Yura. Data on climatic conditions for the same period were collected from the Ecuadorian Air Force and civil aviation authorities. During the 1992-1995 period, NCME diagnosed a total of 773 malaria cases, DHNR diagnosed 485, and Sandi Yura clinically diagnosed 859. For the 4-year period, an annual parasite index of 40.4 was found with the DHNR data, 35.8 with the Sandi Yura data, and 6.2 with the NCME data. The predominant parasite in the area was Plasmodium vivax (92 percent of all the cases). Twenty-eight percent of the infected persons were under 10 years old. No discernible differences between the genders were found. There was also no seasonal variation among the cases. Further research is needed in order to confirm these findings and better understand malaria transmission in the region. The study highlights the need for a closer coordination among the area's malaria-control organizations so as to have an improved understanding of malaria epidemiology and to design and implement effective control strategies

La malaria está reapareciendo en la mayoría de los países endémicos de América del Sur. En el Ecuador, la enfermedad es endémica en la costa del Pacífico, en los valles de los Andes y en la cuenca del río Amazonas. En el Bajo Napo en el nordeste del Ecuador, la malaria se consideraba eliminada en los años setenta, pero la enfermedad ha vuelto a aparecer en años recientes. Aunque en la actualidad tres organismos participan en actividades antimaláricas en esa zona, sus actividades no están coordinadas. Este estudio se efectuó con el propósito de describir la epidemiología de la incidencia de malaria en el Bajo Napo durante el período de enero de 1992 a diciembre de 1995, así como de determinar hasta qué punto existen patrones estacionales en la transmisión en ese territorio. Para determinar la incidencia de malaria, se recogieron datos para el cuadrienio 1992­1995 a partir de los registros de los tres organismos con actividades antimaláricas: la sede del Servicio Nacional de Erradicación de la Malaria (SNEM) en Coca, el hospital de distrito de Nuevo Rocafuerte (HDNR) y una asociación de trabajadores de salud comunitarios llamada Sandi Yura. La información climatológica para el mismo período se obtuvo de la Fuerza Aérea Ecuatoriana y de las autoridades de aviación civil. Durante el período de 1992 a 1995, el SNEM diagnosticó un total de 773 casos de malaria, el HDNR 485, y Sandi Yura 859. Para el mismo cuadrienio se detectó un índice parasitario anual de 40,4 con los datos del HDNR; 35,8 con los de Sandi Yura, y 6,2 con los del SNEM. Plasmodium vivax fue el parásito hallado con mayor frecuencia en el territorio (92% de todos los casos). De las personas infectadas, 28% tenían menos de 10 años de edad. No se hallaron diferencias patentes entre los sexos, ni tampoco variaciones estacionales del número de casos. Es preciso hacer más investigaciones para confirmar estos resultados y para entender más a fondo la transmisión de la malaria en la zona. El estudio subraya la necesidad de fortalecer la coordinación entre las organizaciones que participan en la lucha antimalárica en el territorio, a fin de mejorar los conocimientos sobre la epidemiología de la malaria y de diseñar y poner en marcha estrategias de control adecuadas.

Preventing and addressing intimate partner violence against migrant and ethnic minority women: the role of the health sector

Violence against women is an extreme manifestation of gender inequality in society and a seriousviolation of fundamental human rights. Intimate partner violence (IPV) is the most common typeof such violence and takes place within couples. IPV can lead to death, physical injury, functionalimpairment, mental health problems, negative health behaviour, chronic conditions and reproductivehealth problems. Institutional discrimination, lack of access to or knowledge of services, and culturaldifferences can prevent women who are not only experiencing IPV but also migrants or members ofethnic minorities from seeking help. This policy brief aims to provide input into the role of the healthsector in preventing and addressing IPV among migrant women and those of ethnic minorities. Itdescribes the scope of the problem, presenting key evidence, and makes recommendations for healthpolicy and health systems, health facilities and health service providers.

Preventing and addressing intimate partner violence against migrant and ethnic minority women: the role of the health sector: policy brief

Violence against women is an extreme manifestation of gender inequality in society and a serious violation of fundamental human rights. Intimate partner violence (IPV) is the most common type of such violence and takes place within couples. IPV can lead to death, physical injury, functional impairment, mental health problems, negative health behaviour, chronic conditions and reproductive health problems. Institutional discrimination, lack of access to or knowledge of services, and cultural differences can prevent women who are not only experiencing IPV but also migrants or members of ethnic minorities from seeking help. This policy brief aims to provide input into the role of the health sector in preventing and addressing IPV among migrant women and those of ethnic minorities. It describes the scope of the problem, presenting key evidence, and makes recommendations for health policy and health systems, health facilities and health service providers.

Informe ejecutivo del taller: Bolivia mujer indígena: salud y derechos diagnóstico participativo con CIDOB, CNAMIB y CNMCIOB-BS. Necesidades de fortalecimiento para el trabajo en salud y derechos sexuales y reproductivos en las organizaciones de mujeres indígenas, originarias y campesinas / sss

En Bolivia también se realizó un taller nacional de tres días en Cochabamba, con la participaciónde las contrapartes: Confederación Nacional de Mujeres Bartolina Sisa, CIDOB y CNAMIB. El diagnóstico participativo, se centró en el tema de cómo fortalecer la capacidad de las organizaciones indigenas para trabajar en temas de género y salud reproductiva, pero los productos fueron diferentes para cada organización debido a sus diferentes dinámicas, estructuras y experiencia en el tema...