Impact of the armed conflict in Colombia: consequences in the health system, response and challenges.

INTRODUCTION: In Colombia, research on health and conflict has focused on mental health, psychosocial care, displacement, morbidity, and mortality. Few scientific studies have assessed health system functioning during armed conflicts. In a new period characterized by the implementation of the peace agreement with the Revolutionary Armed Forces of Colombia (FARC) armed group, understanding the effects of armed conflict on the health system, the functions, and institutions shaped by the conflict is an opportunity to understand the pathways and scope of post-conflict health policy reforms. Therefore, this study was conducted to assess the effects of armed conflict on the health system, response, and mechanisms developed to protect medical missions during armed conflict in Colombia. METHODS: This research was conducted using a qualitative approach with semi-structured interviews and focus group discussions. The qualitative guide collected information in four sections: (1) conflict and health system, effects and barriers in health service provision, (2) actions and coordination to cope with those barriers, (3) health policies and armed conflict, and (4) post-accord and current situation. Twenty-two people participated in the interviews, including eight policymakers at the national level and seven at the local level, including two NGOs and five members of international organizations. An academic project event in December 2019 and four focus groups were developed (World Cafe technique) to discuss with national and local stakeholders the effects of armed conflict on the health system and an analytical framework to analyze its consequences. RESULTS: The conflict affected the health-seeking behavior of the population, limited access to healthcare provision, and affected health professionals, and was associated with inadequate medical supplies in conflict areas. The health system implemented mechanisms to protect the medical mission, regulate healthcare provision in conflict areas, and commit to healthcare provision (mental and physical health services) for the population displaced by conflict. CONCLUSION: The state's presence, trust, and legitimacy have significantly reduced in recent years. However, it is crucial to restore them by ensuring that state and health services are physically present in all territories, including remote and rural areas.

Taking innovative vector control interventions in urban Latin America to scale: lessons learnt from multi-country implementation research.

Prior to the current public health emergency following the emergence of chikungunya and Zika Virus Disease in the Americas during 2014 and 2015, multi-country research investigated between 2011 and 2013 the efficacy of novel Aedes aegypti intervention packages through cluster randomised controlled trials in four Latin-American cities: Fortaleza (Brazil); Girardot (Colombia), Acapulco (Mexico) and Salto (Uruguay). Results from the trials led to a scaling up effort of the interventions at city levels. Scaling up refers to deliberate efforts to increase the impact of successfully tested health interventions to benefit more people and foster policy and program development in a sustainable way. The different scenarios represent examples for  a 'vertical approach' and a 'horizontal approach'. This paper presents the analysis of a preliminary process evaluation of the scaling up efforts in the mentioned cites, with a focus on challenges and enabling factors encountered by the research teams, analysing the main social, political, administrative, financial and acceptance factors.

[Operation of government policies for the prevention and control of dengue: The cases of Arauca and Armenia]. / Funcionamiento de las políticas gubernamentales para la prevención y el control del dengue: el caso de Arauca y Armenia en Colombia.

INTRODUCTION: Dengue is a growing public health problem in urban areas, given that its transmission is associated with the environment, as well as with the behaviour of individuals and communities. The model proposed by Ecohealth to study this problem includes the operation of government policies. OBJECTIVE: To describe the operation of policies to prevent and control dengue in two Colombian cities. MATERIALS AND METHODS: A qualitative study was conducted. Data was collected through interviews with officials who worked in the health and education sectors. The contents were processed with the Ethnograph software, using the proposals of the bottom-up model of implementation as analytical categories. RESULTS: A lack of coordination was identified between department and municipal offices, with few developments of the protocol for dengue and severe dengue in terms of community participation, communication strategies and studies of inhabitants´ knowledge, attitudes and practices. The integrated management strategy was limited by the instability of human resources, limited intra-institutional and cross-sectorial coordination and little emphasis on promotion interventions, both at the individual and population levels. CONCLUSIONS: Coordination between the departament and the municipality needs to be strengthened in the city of Arauca. Both here and in Armenia administration of human resources and interinstitutional coordination should be improved. Promotion of preventative measures should be strengthened to impact on the determinants of dengue.

Understanding Water Storage Practices of Urban Residents of an Endemic Dengue Area in Colombia: Perceptions, Rationale and Socio-Demographic Characteristics.

INTRODUCTION: The main preventive measure against dengue virus transmission is often based on actions to control Ae. Aegypti reproduction by targeting water containers of clean and stagnant water. Household water storage has received special attention in prevention strategies but the evidence about the rationale of this human practice is limited. The objective was to identify and describe water storage practices among residents of an urban area in Colombia (Girardot) and its association with reported perceptions, rationales and socio-demographic characteristics with a mixed methods approach. METHODS: Knowledge, attitudes and practices and entomological surveys from 1,721 households and 26 semi-structured interviews were conducted among residents of Girardot and technicians of the local vector borne disease program. A multivariate analysis was performed to identify associations between a water storage practice and socio-demographic characteristics, and knowledge, attitudes and practices about dengue and immature forms of the vector, which were then triangulated with qualitative information. RESULTS: Water storage is a cultural practice in Girardot. There are two main reasons for storage: The scarcity concern based on a long history of shortages of water in the region and the perception of high prices in water rates, contrary to what was reported by the local water company. The practice of water storage was associated with being a housewife (Inverse OR: 2.6, 95% CI 1.5 -4.3). The use of stored water depends on the type of container used, while water stored in alberca (Intra household cement basins) is mainly used for domestic cleaning chores, water in plastic containers is used for cooking. CONCLUSIONS: It is essential to understand social practices that can increase or reduce the number of breeding sites of Ae. Aegypti. Identification of individuals who store water and the rationale of such storage allow a better understanding of the social dynamics that lead to water accumulation.

Funcionamiento de las políticas gubernamentales para la prevención y el control del dengue: el caso de Arauca y Armenia en Colombia / Operation of government policies for the prevention and control of dengue: The cases of Arauca and Armenia

Introducción. El dengue es un problema de salud pública en aumento en las zonas urbanas, debido a que su transmisión está asociada con el ambiente y el comportamiento de las personas y las comunidades. El modelo propuesto por Ecosalud para su estudio, incluye el análisis del funcionamiento de las políticas gubernamentales. Objetivo. Describir el funcionamiento de las políticas para prevenir y controlar el dengue en dos ciudades colombianas. Materiales y métodos. Se adelantó un estudio cualitativo, para lo cual se recopiló información mediante entrevistas a funcionarios del sector de la salud y la educación, cuyos contenidos se procesaron en Ethnograph con base en las categorías de análisis propuestas en el modelo de ´implementación desde la base´. Resultados. Se encontró que había desarticulación entre el departamento y el municipio, así como un desarrollo escaso del protocolo de dengue y dengue hemorrágico en cuanto a la participación comunitaria, las estrategias de comunicación y los estudios de conocimientos, actitudes y prácticas de los pobladores. La estrategia de gestión integrada se ve limitada por la inestabilidad del recurso humano, la escasa coordinación entre instituciones y sectores, y la falta de énfasis en las intervenciones de promoción tanto a nivel individual como de la población. Conclusiones. En Arauca es necesario fortalecer la coordinación entre el departamento y el municipio. Tanto en Arauca como en Armenia se requiere mejorar la administración de los recursos humanos y la coordinación interinstitucional, así como fortalecer la promoción y la prevención, para lograr el efecto esperado sobre los factores determinantes del dengue.

Introduction: Dengue is a growing public health problem in urban areas, given that its transmission is associated with the environment, as well as with the behaviour of individuals and communities. The model proposed by Ecohealth to study this problem includes the operation of government policies. Objective: To describe the operation of policies to prevent and control dengue in two Colombian cities. Materials and methods: A qualitative study was conducted. Data was collected through interviews with officials who worked in the health and education sectors. The contents were processed with the Ethnograph software, using the proposals of the bottom-up model of implementation as analytical categories. Results: A lack of coordination was identified between department and municipal offices, with few developments of the protocol for dengue and severe dengue in terms of community participation, communication strategies and studies of inhabitants´ knowledge, attitudes and practices. The integrated management strategy was limited by the instability of human resources, limited intra-institutional and cross-sectorial coordination and little emphasis on promotion interventions, both at the individual and population levels. Conclusions: Coordination between the departament and the municipality needs to be strengthened in the city of Arauca. Both here and in Armenia administration of human resources and interinstitutional coordination should be improved. Promotion of preventative measures should be strengthened to impact on the determinants of dengue.

Territorial analysis of Aedes aegypti distribution in two Colombian cities: a chorematic and ecosystem approach.

A territorial analysis of Aedes aegypti density was conducted in two Colombian cities using an ecosystem and chorematic approach. Entomological and behavioral data (by cluster) and information on the urban context were used to analyze the relationship between territorial structures and dynamics and vector density. The results were represented in graphic (chorematic) models. Arauca showed higher vector density than Armenia. Higher density was related to unplanned urbanization, flood-prone areas, low socioeconomic strata, household water tanks, higher temperature, and recall of control measures for adult mosquitos. Zones with low density indices coincided with diverse socioeconomic, ecological, and behavioral conditions. The study found a relationship between territorial structures and dynamics and vector density in both Arauca and Armenia, where the interaction between ecological and social systems shape areas with high and low A. aegypti density.

Territorial analysis of Aedes aegypti distribution in two Colombian cities: a chorematic and ecosystem approach / Análise territorial da distribuição do Aedes aegypti em duas cidades da Colômbia: aproximação desde a coremática e a abordagem ecossistêmica / Análisis territorial de la distribución de Aedes aegypti en dos ciudades de Colombia: aproximación desde la coremática y el enfoque ecosistémico

A territorial analysis of Aedes aegypti density was conducted in two Colombian cities using an ecosystem and chorematic approach. Entomological and behavioral data (by cluster) and information on the urban context were used to analyze the relationship between territorial structures and dynamics and vector density. The results were represented in graphic (chorematic) models. Arauca showed higher vector density than Armenia. Higher density was related to unplanned urbanization, flood-prone areas, low socioeconomic strata, household water tanks, higher temperature, and recall of control measures for adult mosquitos. Zones with low density indices coincided with diverse socioeconomic, ecological, and behavioral conditions. The study found a relationship between territorial structures and dynamics and vector density in both Arauca and Armenia, where the interaction between ecological and social systems shape areas with high and low A. aegypti density.

Foi realizada uma análise territorial da densidade do Aedes aegypti em duas cidades da Colômbia, desde um enfoque ecossistêmico e da coremática. Com base em informação entomológica e comportamental (por conglomerados) e informação do contexto urbano, foi indagada a relação de estruturas dinâmicas do território com a densidade vetorial. Foram apresentados os resultados com modelos gráficos (coremática). Identificou-se maior densidade vetorial em Arauca do que na Armênia. Maiores densidades foram relacionadas à urbanização não planejada, zonas de alagamento, estratos socioeconômicos baixos, tanques baixos (reservatórios), maior temperatura e relatório de ações contra os mosquitos adultos. Zonas de densidades baixas coincidiram com diversas condições socioeconômicas, ecológicas e comportamentais. Foi encontrada uma relação das estruturas e dinâmicas do território com a densidade vetorial para Arauca e Armênia, onde a interação entre sistemas ecológicos e sociais configura zonas particulares de alta e baixa densidades de A. aegypti.

Se realizó un análisis territorial de la densidad de Aedes aegypti en dos ciudades de Colombia desde un enfoque ecosistémico y la coremática. A partir de información entomológica y comportamental (por conglomerados) e información del contexto urbano, se indagó la relación de estructuras y dinámicas del territorio con la densidad vectorial. Se representaron los resultados con modelos gráficos (coremática). Se identificó mayor densidad vectorial en Arauca que en Armenia. Mayores densidades se relacionaron con urbanización no planeada, zonas de inundación, estratos socioeconómicos bajos, tanques bajos (alberca), mayor temperatura y reporte de acciones hacia los mosquitos adultos. Zonas de densidades bajas coincidieron con diversas condiciones socioeconómicas, ecológicas y comportamentales. Se encontró relación de las estructuras y dinámicas del territorio con la densidad vectorial para Arauca y Armenia, donde la interacción entre sistemas ecológicos y sociales configuran zonas particulares de alta y baja densidad de A. aegypti.

Effectiveness and feasibility of long-lasting insecticide-treated curtains and water container covers for dengue vector control in Colombia: a cluster randomised trial.

BACKGROUND: Long-lasting insecticide-treated net (LLIN) window and door curtains alone or in combination with LLIN water container covers were analysed regarding effectiveness in reducing dengue vector density, and feasibility of the intervention. METHODS: A cluster randomised trial was conducted in an urban area of Colombia comparing 10 randomly selected control and 10 intervention clusters. In control clusters, routine vector control activities were performed. The intervention delivered first, LLIN curtains (from July to August 2013) and secondly, water container covers (from October to March 2014). Cross-sectional entomological surveys were carried out at baseline (February 2013 to June 2013), 9 weeks after the first intervention (August to October 2013), and 4-6 weeks after the second intervention (March to April 2014). RESULTS: Curtains were installed in 922 households and water container covers in 303 households. The Breteau index (BI) fell from 14 to 6 in the intervention group and from 8 to 5 in the control group. The additional intervention with LLIN covers for water containers showed a significant reduction in pupae per person index (PPI) (p=0.01). In the intervention group, the PPI index showed a clear decline of 71% compared with 25% in the control group. Costs were high but options for cost savings were identified. CONCLUSIONS: Short term impact evaluation indicates that the intervention package can reduce dengue vector density but sustained effect will depend on multiple factors.