The Role of Community Health Agents in Promoting Social Change in Peru.

BACKGROUND: Community health agents (CHAs) provide basic health services and increase health care access thereby improving health outcomes for peri-urban regions in Peru. Few studies analyze the effect that becoming a CHA has on women's interpersonal interactions. We aim to explore the impact CHAs may have on gender and social norms through their roles as trusted leaders in male-dominated communities. METHODS: We conducted six 90-minute group discussions with CHAs working in Huancayo and Trujillo, Peru. We designed the discussions to extract data about family and community norms that changed as a result of working as a CHA. RESULTS: A total of 53 female CHAs participated in six discussion groups. CHAs reported shifting family support (a change in how their family supported them in their role as a CHA), gaining status within their family (feeling more valued for their knowledge and experience), and shifting family gender roles (men and boys taking on more household responsibilities) as a result of their work. CHAs also reported a change in community norms and felt they were more valued and respected within their communities as women leaders. CONCLUSIONS: Working as a CHA creates an opportunity to enact social change through altering family dynamics and community perceptions. Moreover, empowering women to become CHAs not only generates tangible benefits in community health, but can help create social change that ultimately improves the lives of women and realize their human rights.

Treatment-as-Usual for Couples: Trajectories Before and After Beginning Couple Therapy.

Couple therapy has been shown to be a meaningful way to improve couples' relationships. However, less information is known about couples' functioning prior to entering treatment in community settings, as well as how their relationship functioning changes from initiating therapy onward. This study examined 87 couples who began community-based couple therapy during a longitudinal study of couples in the military. The couples were assessed six times over the course of 3 years, including time points before and after starting couple therapy. Using an interrupted-time series design, we examined trajectories across the start of couple therapy in relationship satisfaction, divorce proneness, and negative communication. The results demonstrated that couples' relationship satisfaction was declining and both divorce proneness and negative communication were increasing prior to entering couple therapy. After starting couple therapy, couples' functioning on all three variables leveled off but did not show further change, but previous experience in relationship education moderated these effects. Specifically, those who were assigned to the relationship education program (vs. control) demonstrated greater reductions in divorce proneness and greater increases marital satisfaction after starting therapy; however, they also started more distressed.

Se ha demostrado que la terapia de pareja es una manera valiosa de mejorar las relaciones de las parejas. Sin embargo, se cuenta con menos información acerca del funcionamiento de las parejas antes de comenzar un tratamiento en entornos comunitarios, así como acerca de la manera en que el funcionamiento de su relación cambia desde el inicio de la terapia en adelante. Este estudio analizó a 87 parejas que comenzaron terapia de pareja basada en la comunidad durante un estudio longitudinal de parejas en las fuerzas armadas. Se evaluó a las parejas seis veces durante el transcurso de tres años, incluidos momentos específicos antes y después de comenzar la terapia de pareja. Utilizando un diseño de series de tiempo interrumpido, analizamos las trayectorias a lo largo del comienzo de la terapia de pareja en la satisfacción con la relación, la propensión al divorcio y la comunicación negativa. Los resultados demostraron que la satisfacción con la relación de la pareja estaba disminuyendo y que tanto la propensión al divorcio como la comunicacióin negativa estaban aumentando antes de comenzar la terapia de pareja. Después de comenzar la terapia de pareja, el funcionamiento de las parejas en las tres variables se nivelaron pero no demostraron otros cambios, aunque la experiencia previa en capacitación en relaciones moderó estos efectos. Específicamente, los que fueron asignados al programa de capacitación en relaciones (frente al grupo de control) demostraron una mayor reducción de la propensión al divorcio y un mayor aumento de la satisfacción conyugal después de comenzar la terapia, sin embargo, también comenzaron la terapia más angustiados.

Associations of Army Fathers' PTSD Symptoms and Child Functioning: Within- and Between-Family Effects.

This study examined the within-family and between-family associations between fathers' military-related PTSD symptoms and parent ratings of children's behavioral and emotional problems. The sample included married couples (N = 419) with children composed of a civilian wife and an active-duty husband serving in the U.S. Army. Results indicate that changes in fathers' PTSD symptoms over time were associated with corresponding changes in both mothers' and fathers' reports of child behavioral and emotional problems. These within-family findings were independent from between-family effects, which showed that higher average PTSD symptomatology was associated with more overall behavioral and emotional problems for children. This study uses advances in statistical methodologies to increase knowledge about how PTSD symptoms and child problems are related, both across different families and over time within families.

Grandparenting and psychosocial health among older Chileans: a longitudinal analysis.

OBJECTIVES: To investigate factors associated with Chilean grandparents' provision of help to grandchildren and associations between provision of such help and grandparents' mental well-being two years later. METHODS: Data are drawn from a representative sample of 2000 people aged 66-68 resident in low- or middle-income areas of Santiago who were surveyed in 2005 and re-interviewed two years later. Multivariable analyses were used to investigate factors associated with provision of help to grandchildren at baseline and associations between providing such help and life satisfaction, SF36-Mental Component Summary scores, and depression two years later. RESULTS: 41% of grandparents lived with one or more grandchildren and over half provided four or more hours per week of help to grandchildren. Models controlling for baseline mental health, grandchild characteristics, marital and household characteristics, socio-economic status and functional health showed that grandfathers who provided four or more hours per week of help to grandchildren had better life satisfaction two years later and that those providing material help had higher SF36 MCS scores at follow-up. Grandmothers providing four or more hours of help a week had lower risks of depression. CONCLUSION: Older Chileans make important contributions to their families through the provision of help to grandchildren and these appear to have some benefits for their own psychosocial health. Gender differences in the pattern of associations may reflect differences in overall family responsibilities and merit further investigation.

Effect of a nutrition supplement and physical activity program on pneumonia and walking capacity in Chilean older people: a factorial cluster randomized trial.

BACKGROUND: Ageing is associated with increased risk of poor health and functional decline. Uncertainties about the health-related benefits of nutrition and physical activity for older people have precluded their widespread implementation. We investigated the effectiveness and cost-effectiveness of a national nutritional supplementation program and/or a physical activity intervention among older people in Chile. METHODS AND FINDINGS: We conducted a cluster randomized factorial trial among low to middle socioeconomic status adults aged 65-67.9 years living in Santiago, Chile. We randomized 28 clusters (health centers) into the study and recruited 2,799 individuals in 2005 (~100 per cluster). The interventions were a daily micronutrient-rich nutritional supplement, or two 1-hour physical activity classes per week, or both interventions, or neither, for 24 months. The primary outcomes, assessed blind to allocation, were incidence of pneumonia over 24 months, and physical function assessed by walking capacity 24 months after enrollment. Adherence was good for the nutritional supplement (~75%), and moderate for the physical activity intervention (~43%). Over 24 months the incidence rate of pneumonia did not differ between intervention and control clusters (32.5 versus 32.6 per 1,000 person years respectively; risk ratio = 1.00; 95% confidence interval 0.61-1.63; p = 0.99). In intention-to-treat analysis, after 24 months there was a significant difference in walking capacity between the intervention and control clusters (mean difference 33.8 meters; 95% confidence interval 13.9-53.8; p = 0.001). The overall cost of the physical activity intervention over 24 months was US$164/participant; equivalent to US$4.84/extra meter walked. The number of falls and fractures was balanced across physical activity intervention arms and no serious adverse events were reported for either intervention. CONCLUSIONS: Chile's nutritional supplementation program for older people is not effective in reducing the incidence of pneumonia. This trial suggests that the provision of locally accessible physical activity classes in a transition economy population can be a cost-effective means of enhancing physical function in later life. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 48153354.

Methods for economic evaluation of a factorial-design cluster randomised controlled trial of a nutrition supplement and an exercise programme among healthy older people living in Santiago, Chile: the CENEX study.

BACKGROUND: In an effort to promote healthy ageing and preserve health and function, the government of Chile has formulated a package of actions into the Programme for Complementary Food in Older People (Programa de Alimentación Complementaria para el Adulto Mayor - PACAM). The CENEX study was designed to evaluate the impact, cost and cost-effectiveness of the PACAM and a specially designed exercise programme on pneumonia incidence, walking capacity and body mass index in healthy older people living in low- to medium-socio-economic status areas of Santiago. The purpose of this paper is to describe in detail the methods that will be used to estimate the incremental costs and cost-effectiveness of the interventions. METHODS AND DESIGN: The base-case analysis will adopt a societal perspective, including the direct medical and non-medical costs borne by the government and patients. The cost of the interventions will be calculated by the ingredients approach, in which the total quantities of goods and services actually employed in applying the interventions will be estimated, and multiplied by their respective unit prices. Relevant information on costs of interventions will be obtained mainly from administrative records. The costs borne by patients will be collected via exit and telephone interviews. An annual discount rate of 8% will be used, consistent with the rate recommended by the Government of Chile. All costs will be converted from Chilean Peso to US dollars with the 2007 average period exchange rate of US$1 = 522.37 Chilean Peso. To test the robustness of model results, we will vary the assumptions over a plausible range in sensitivity analyses. DISCUSSION: The protocol described here indicates our intent to conduct an economic evaluation alongside the CENEX study. It provides a detailed and transparent statement of planned data collection methods and analyses. TRIAL REGISTRATION: ISRCTN48153354.