Does Information and Communication Technology Add Value to Citizen-Led Accountability Initiatives in Health? Experiences from India and Guatemala.

Information and Communication Technology (ICT) may facilitate the collection and dissemination of citizen-generated data to enhance governmental accountability for the fulfillment of the right to health. The aim of this multiple case study research was to distill considerations related to the implementation of ICT and health accountability projects, describe the added operational value of ICT tools (as compared to similar projects that do not use ICT), and make preliminary statements regarding government responsiveness to accountability demands through ICT projects. In all three projects, the need for relationship building, continuous community engagement and technical support, and training for volunteers or service users was identified. Government responsiveness to the data varied, suggesting that political will is lacking in certain contexts. Despite these challenges, ICT initiatives provided an easy, accessible, and low-risk platform for reporting violations and demanding accountability from service providers and decision-makers. ICT-enabled citizen generated data can add significant operational value and some political value to project activities and goals, and may affect systems change when it is part of a broad-based, multi-level civil societal and governmental effort to improve health care quality.

Development and validation of a Screening Questionnaire of Family Mistreatment against Older Adults for use in primary care settings in Mexico.

The abuse of older adults is a serious public health issue that can be difficult to identify at the first level of care. Medical and nursing personnel are sometimes unable to identify older adults who suffer family mistreatment. This can occur when victims feel shame or as a result of cultural factors. In the light of this, healthcare personnel require a screening tool that can be used to identify signs of mistreatment. The aim of this study was to develop and validate a screening tool for detecting the familial mistreatment of older adults in primary care settings. A mixed method cross-sectional study was carried out in three phases between 2009 and 2012 in Mexico. The formative phase involved using a qualitative methodology to identify terms that older adults use to identify practices defined as forms of mistreatment. On this basis, the second phase involved the design of a screening tool through the formation of items in collaboration with a panel of experts. These items were tested on older adults to ensure their intelligibility. Finally, validity and reliability levels were evaluated through the application of the screening tool to a sample of older adults at a primary care facility and at a legal centre. These findings were discussed with gerontologists, and the data were analysed through an exploratory factor analysis with orthogonal rotation and Cronbach's alpha using STATA v13. From the results, we generated a screening tool that is culturally and socially tailored to older adults in Mexico. The tool has a Cronbach's alpha of 0.89, a sensitivity value of 86% (p < .05) and a specificity value of 90% (p < .05) for positive answers to the tool's 15 items. Applying this tool at the first level of care could limit damage to older adults' health and could lower the frequency of emergency room use in hospitals.

Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity.

The 400 million indigenous people worldwide represent a wealth of linguistic and cultural diversity, as well as traditional knowledge and sustainable practices that are invaluable resources for human development. However, indigenous people remain on the margins of society in high, middle and low-income countries, and they bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators in relation to the 15-year push to meet the Millennium Development Goals. As we enter the Sustainable Development Goals (SDGs) era, there is growing consensus that efforts to achieve Universal Health Coverage (UHC) and promote sustainable development should be guided by the moral imperative to improve equity. To achieve this, we need to move beyond the reductionist tendency to frame indigenous health as a problem of poor health indicators to be solved through targeted service delivery tactics and move towards holistic, integrated approaches that address the causes of inequalities both inside and outside the health sector. To meet the challenge of engaging with the conditions underlying inequalities and promoting transformational change, equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilizing networks of collective action. The application of systems thinking approaches offers a pathway for the evolution of equity-oriented research and practice in collaborative, politically informed and mutually enhancing efforts to understand and transform the systems that generate and reproduce inequities in indigenous health. These approaches hold the potential to strengthen practice through the development of more nuanced, context-sensitive strategies for redressing power imbalances, reshaping the service delivery environment and fostering the dynamics of collective action for political reform.

Looking forward to the next 15 years: innovation and new pathways for research in health equity.

Since our launch in 2002, the International Journal for Equity in Health (IJEqH) has furthered our collective understanding of equity in health and health services by providing a platform on which academics and practitioners can share their work. Today, we celebrate our fifteenth anniversary with an article collection that presents a call for new and novel research in equity in health and we invite our authors to use new approaches and methods, and to focus on emerging areas of research related to health equity in order to set the stage for the next fifteen years of health equity research.Our anniversary issue provides a platform for expanding the conceptualization, diversity of populations and study designs, and for increasing the use of novel methodologies in the field. The IJEqH has helped to support the wider group of researchers, policymakers and practitioners with a commitment to social justice and equity but there is still more to do. With the help of the highly committed editorial team and editorial board, the innovative work of researchers worldwide, and the countless of hours dedicated by hundreds of reviewers, we are confident in the IJEqH's ability to continue supporting the dissemination of health equity research for years to come.

Abuse and discrimination towards indigenous people in public health care facilities: experiences from rural Guatemala.

BACKGROUND: Health inequalities disproportionally affect indigenous people in Guatemala. Previous studies have noted that the disadvantageous situation of indigenous people is the result of complex and structural elements such as social exclusion, racism and discrimination. These elements need to be addressed in order to tackle the social determinants of health. This research was part of a larger participatory collaboration between Centro de Estudios para la Equidad y Gobernanza en los Servicios de Salud (CEGSS) and community based organizations aiming to implement social accountability in rural indigenous municipalities of Guatemala. Discrimination while seeking health care services in public facilities was ranked among the top three problems by communities and that should be addressed in the social accountability intervention. This study aimed to understand and categorize the episodes of discrimination as reported by indigenous communities. METHODS: A participatory approach was used, involving CEGSS's researchers and field staff and community leaders. One focus group in one rural village of 13 different municipalities was implemented. Focus groups were aimed at identifying instances of mistreatment in health care services and documenting the account of those who were affected or who witnessed them. All of the 132 obtained episodes were transcribed and scrutinized using a thematic analysis. RESULTS: Episodes described by participants ranged from indifference to violence (psychological, symbolic, and physical), including coercion, mockery, deception and racism. Different expressions of discrimination and mistreatment associated to poverty, language barriers, gender, ethnicity and social class were narrated by participants. CONCLUSIONS: Addressing mistreatment in public health settings will involve tackling the prevalent forms of discrimination, including racism. This will likely require profound, complex and sustained interventions at the programmatic and policy levels beyond the strict realm of public health services. Future studies should assess the magnitude of the occurrence of episodes of maltreatment and racism within indigenous areas and also explore the providers' perceptions about the problem.

Prevalence and factors associated with violence and abuse of older adults in Mexico's 2012 National Health and Nutrition Survey.

BACKGROUND: Factors associated with violence and the abuse of older adults are understudied and its prevalence in Mexico has not been reported. The aim of this study was to identify the prevalence and factors associated with violence and abuse of older adults in Mexico. METHODS: We used Mexico's 2012 National Health and Nutrition Survey, which included a sample of 8,894 individuals who are 60 years or older and who self-reported a negative health event related to robbery, aggression or violence in the previous 12 months. We used chi-squared test and Fisher's exact test to analyze the variables related to violence. Adjusted estimates were completed with multiple logistic regression models for complex surveys. RESULTS: The prevalence of violence was 1.7 % for both men and women. In 95 % of the cases, the aggression was from an unknown party. Verbal aggressions were the most prevalent (60 %). Among men, physical aggression was more common. Violence frequently occurred in the home (37.6 %); however, men were primarily assaulted in public places (42.4 %), in comparison to women (30.7 %). There were also differences in the risk factors for violence. Among men, risk was associated with younger age (60-64 years), higher education (secondary school or above) and higher socioeconomic status. Among women, risk was associated with depression, not being the head of the family, and region of the country. CONCLUSIONS: Violence against older adults presents differently for men and women, which means it is necessary to increase knowledge about the dynamics of the social determinants of violence, particularly in regards to the role of education among men. The relatively low prevalence found in this study may reflect the difficulty and fear of discussing the topic of violence. This may occur because of cultural factors, as well as by the perception of helplessness perpetuated by the scarce access to social programs that ensure protection and problem solving with regards to the complex social determinants of individual and family violence that this population group endures.

Health, equity and the post-2015 agenda: raising the voices of marginalized communities.

In September 2012 the United Nations (UN) initiated a process that would extend and enhance the unfinished agenda of the Millennium Development Goals (MDGs), integrating a new vision for sustainable development beyond the year 2015. The initial consultation phase has been completed, with the UN and partner organizations undertaking eleven thematic consultations, including one on health. It is in this context that the European Commission (EC) has tasked the research consortium Goals and Governance for Global Health (Go4Health) with providing recommendations for the post-2015 health-related development goals and including voices that are routinely excluded from health-related decision-making processes. This has not been an easy task. It has led us to question how to define marginalization, how to access marginalized communities, as well as how community members could provide informed consent. The context of the communities we worked with was far removed from the reality of the post-2015 debates, where the MDGs and the new goals are remote and abstract, and where the promise of immediate benefit from participation could not be assured. Given the social, historical, cultural, ethnic and geographical diversity of our chosen community partners, and the diversity of their lived experiences, could their unique situations be generalized in ways that could influence the global debate? In this special issue, we have tried to explore the uniqueness and the commonalities of the issues and barriers that marginalized communities face all over the globe, and present them in individual papers that, together, provide a nuanced and complex picture of the challenges that face the post-2015 health-related agenda setting-process.

Making the post-MDG global health goals relevant for highly inequitable societies: findings from a consultation with marginalized populations in Guatemala.

INTRODUCTION: The United Nations presented a set of Millennium Development Goals that aimed to improve social and economic development and eradicate poverty by 2015. Most low and middle-income countries will not meet these goals and today there is a need to set new development agenda, especially when it comes to health. The paper presents the findings from a community consultation process carried out within the Goals and Governance for Global Health (GO4Health) research consortium in Guatemala, which aims to identify community needs and expectations around public policies and health services. METHODS: Through a participative and open consultation process with experts, civil society organizations and members of the research team, the municipalities of Tectitan and Santa Maria Nebaj were selected. A community consultation process was undertaken with community members and community leaders. Group discussions and in-depth interviews were conducted and later analyzed using thematic analysis, a qualitative method that can be used to analyze data in a way that allows for the identification of recurrent patterns that can be grouped into categories and themes, was used. FINDINGS: Following the Go4Health framework's domains for understanding health-related needs, the five themes identified were health, social determinants of health, essential health needs and their provision, roles and responsibilities of relevant stakeholders and community participation in decision-making. Participants reported high levels of discrimination related to ethnicity, to being poor and to living in rural areas. Ethnicity played a major role in how community members feel they are cared for in the health system. CONCLUSION: Achieving health goals in a context of deep-rooted inequality and marginalization requires going beyond the simple expansion of health services and working with developing trusting relationships between health service providers and community members. Involving community members in decision-making processes that shape policies will contribute to a larger process of community empowerment and democratization. Still, findings from the region show that tackling these issues may prove complicated and require going beyond the health system, as this lack of trust and discrimination has permeated to all public policies that deal with indigenous and rural populations.

The role of social participation in municipal-level health systems: the case of Palencia, Guatemala.

BACKGROUND: Social participation has been recognized as an important public health policy since the declaration of Alma-Ata presented it as one of the pillars of primary health care in 1978. Since then, there have been many adaptations to the original policy but participation in health is still seen as a means to make the health system more responsive to local health needs and as a way to bring the health sector and the community closer together. OBJECTIVE: To explore the role that social participation has in a municipal-level health system in Guatemala in order to inform future policies and programs. DESIGN: Documentary analysis was used to study the context of participation in Guatemala. To do this, written records and accounts of Guatemalan history during the 20th century were reviewed. The fieldwork was carried out over 8 months and three field visits were conducted between early January of 2009 and late March of 2010. A total of 38 in-depth interviews with regional health authorities, district health authorities, community representatives, and community health workers (CHWs) were conducted. Data were analyzed using thematic analysis. RESULTS: Guatemala's armed civil struggle was framed in the cold war and the fight against communism. Locally, the war was fed by the growing social, political, and ethnic inequalities that existed in the country. The process of reconstructing the country's social fabric started with the signing of the peace agreements of 1996, and continued with the passing of the 2002 legal framework designed to promote decentralization through social participation. Today, Guatemala is a post-war society that is trying to foster participation in a context full of challenges for the population and for the institutions that promote it. In the municipality of Palencia, there are three different spaces for participation in health: the municipal-level health commission, in community-level social development councils, and in the CHW program. Each of these spaces has participants with specific roles and processes. CONCLUSIONS: True participation and collaboration among can only be attained through the promotion and creation of meaningful partnerships between institutional stakeholders and community leaders, as well as with other stakeholders working at the community level. For this to happen, more structured support for the participation process in the form of clear policies, funding and capacity building is needed.

'It's the sense of responsibility that keeps you going': stories and experiences of participation from rural community health workers in Guatemala.

BACKGROUND: In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world's health issues required more than just hospital-based and physician-centered policies. The declaration called for a paradigm change that would allow governments to provide essential care to their population in a universally acceptable manner. The figure of the community health worker (CHW) remains a central feature of participation within the PHC approach, and being a CHW is still considered to be an important way of participation within the health system. METHODS: This study explores how the values and personal motivation of community health workers influences their experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, we used an ethnographic approach and collected data in January-March of 2009 and 2010 by using participant observation and in-depth interviews. RESULTS: We found that the CHWs in the municipality had a close working relationship with the mobile health team and with the community, and that their positions allowed them to develop leadership and teamwork skills that may prove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is a key value in Palencia, but there is a lack of infrastructure and growth opportunities. CONCLUSION: Attention should be paid to keeping the high levels of commitment and integration within the health team as well as keeping up supervision and economic funds for the program.

Social participation within a context of political violence: implications for the promotion and exercise of the right to health in Guatemala.

Social participation has been understood in many different ways, and there are even typologies classifying participation by the degree of a population's control in decision making. Participation can vary from a symbolic act, which does not involve decision making, to processes in which it constitutes the principal tool for redistributing power within a population. This article argues that analyzing social participation from a perspective of power relations requires knowledge of the historical, social, and economic processes that have characterized the social relations in a specific context. Applying such an analysis to Guatemala reveals asymmetrical power relations characterized by a long history of repression and political violence. The armed conflict during the second half of the 20th century had devastating consequences for a large portion of the population as well as the country's social leadership. The ongoing violence resulted in negative psychosocial effects among the population, including mistrust toward institutions and low levels of social and political participation. Although Guatemala made progress in creating spaces for social participation in public policy after signing the Peace Accords in 1996, the country still faces after-effects of the conflict. One important task for the organizations that work in the field of health and the right to health is to help regenerate the social fabric and to rebuild trust between the state and its citizens. Such regeneration involves helping the population gain the skills, knowledge, and information needed in order to participate in and affect formal political processes that are decided and promoted by various public entities, such as the legislative and executive branches, municipal governments, and political parties. This process also applies to other groups that build citizenship through participation, such as neighborhood organizations and school and health committees.