A disparity in prosthetic access for Ecuadorians with lower-limb amputation.

BACKGROUND: Individuals with disabilities in low- and middle-income countries face barriers to rehabilitation services, including prosthetic care. Many countries, such as Ecuador, have adapted policies toward achieving universal health care coverage. For optimal functional outcomes, understanding the physical potential of prosthetic users is critical for appropriate prosthetic services. OBJECTIVE: To determine the association between the functional level of Ecuadorians with lower-limb amputations and the functional level of their prosthetic componentry. STUDY DESIGN: Retrospective study. METHODS: A data set containing functional level (K-Level) of Ecuadorians with lower-limb amputations and the K-Level of their prosthesis was analyzed. RESULTS: A diverse cohort of 164 participants with unilateral lower-limb amputation was recruited. Most participants were male (76.8%) with transfemoral amputations (56.1%) due to traumatic causes (51.2%). There was a small, positive, and statistically significant correlation between participants' functional levels and prosthetic componentry. Participants's functional levels were typically superior (median = 3) to their prostheses' functional abilities (median = 1), and 37.2% of participants did not have a prosthesis at the time of assessment. CONCLUSIONS: These data indicated that participants whose physical ability exceeded basic ambulation lacked access to prostheses to match their functional abilities. The detailed disparity between physical potential and prosthetic access derived from the study's analysis supports investment into high functioning prosthetic componentry and further investigation into where gaps in care exist.

Ultra-processed foods in a rural Ecuadorian community: associations with child anthropometry and bone maturation.

Frequent ultra-processed food (UPF) consumption is consistently associated with poor health outcomes. Little is known about UPF intake during early childhood and its effects on growth. We assessed UPF in relation to child anthropometry, bone maturation, and their nutrition profiles in a rural Ecuadorian community. Covariate-adjusted regression models estimated relationships between UPF intake from a 24-hour Food Frequency Questionnaire and three outcomes: linear growth, weight status and bone maturation. Nutrient Profiling Models (NPM) evaluated a convenience sample of UPF (n 28) consumed by children in the community. In this cohort (n 125; mean age = 33·92 (sd 1·75) months), 92·8 % consumed some form of UPF the previous day. On average, children consuming UPF four to twelve times per day (highest tertile) had lower height-for-age z-scores than those with none or a single instance of UPF intake (lowest tertile) (ß = -0·43 [se 0·18]; P = 0·02). Adjusted stunting odds were significantly higher in the highest tertile relative to the lowest tertile (OR: 3·07, 95 % CI 1·11, 9·09). Children in the highest tertile had significantly higher bone age z-scores (BAZ) on average compared with the lowest tertile (ß = 0·58 [se 0·25]; P = 0·03). Intake of savoury UPF was negatively associated with weight-for-height z-scores (ß = -0·30 [se 0·14]; P = 0·04) but positively associated with BAZ (ß = 0·77 [se 0·23]; P < 0·001). NPM indicated the availability of unhealthy UPF to children, with excessive amounts of saturated fats, free sugars and sodium. Findings suggest that frequent UPF intake during early childhood may be linked to stunted growth (after controlling for bone age and additional covariates), despite paradoxical associations with bone maturation.

Antibiotic use by backyard food animal producers in Ecuador: a qualitative study.

BACKGROUND: Antibiotics are increasingly used throughout the world in food animal production for controlling and preventing disease and for promoting growth. But this trend also has the potential for promoting antibiotic resistance, which represents a threat to human, animal, and environmental health. The use of antibiotics and the potential effects of antibiotic dependence has often been associated with large-scale food animal production. But rural households also engage in small-scale production, often operating literally in backyards. While some small-scale producers use veterinary antibiotics, many do not. This paper examines knowledge, attitudes, beliefs, and agricultural practices (KAP) that represent an alternative to dependence on antibiotics. METHODS: Qualitative field research was based on four focus group discussions (FGDs) with non-indigenous backyard food animal producers in four communities near Quito, Ecuador and two FGDs with veterinarians. FGDs were supplemented by structured observations and key informant interviews. They were recorded with digital audio devices and transcriptions were analyzed independently by two researchers using a three-stage coding procedure. Open coding identifies underlying concepts, while axial coding develops categories and properties, and selective coding integrates the information in order to identify the key dimensions of the collective qualitative data. RESULTS: Backyard food animal producers in the Ecuadorian highlands generally do not use antibiotics while rearing small batches of animals and poultry for predominantly non-commercial household consumption. Instead, they rely on low cost traditional veterinary remedies. These practices are informed by their Andean history of agriculture and a belief system whereby physical activity is a holistic lifestyle through which people maintain their health by participating in the physical and spiritual environment. CONCLUSIONS: Backyard food animal producers in the Ecuadorian highlands implement complex strategies based on both economic calculations and sociocultural underpinnings that shape perceptions, attitudes, and practices. They use traditional veterinary remedies in lieu of antibiotics in most cases because limited production of food animals in small spaces contributes to a predictable household food supply, while at the same time conforming to traditional concepts of human and environmental health.

A sex- and gender-based analysis of factors associated with linear growth in infants in Ecuadorian Andes.

Although female infants may have an early life biological advantage over males, gendered treatment can alter health outcomes. Ecuador has an unusually high ratio of male to female infant mortality, but gender norms have been reported to favor boys. This analysis of baseline data from the Lulun Project, a randomized controlled trial conducted in rural Andean communities of Ecuador, investigates the roles of sex and gender in undernutrition among infants 6 to 9 months of age. Twenty-four-hour recall frequencies were used to assess dietary intake. Food outcome models were analyzed as prevalence ratios calculated using a binomial distribution with a log link or robust Poisson regression. Linear regression was used to analyze the continuous growth outcome length-for-age z score. Socioeconomic and health history variables were comparable between male and female infants. Boys were more often fed liquids other than breastmilk within their first 3 days of life (17.1% vs. 5.2%, P = 0.026). Compared with girls, boys were less likely to be fed eggs by 33% (95% CI 0.46, 0.96), cheese, yogurt, or other milk products by 40% (95% CI 0.39, 0.92), yellow fruit by 44% (95% CI 0.33, 0.97), water by 37% (95% CI 0.45, 0.88), thin porridge by 29% (95% CI 0.56, 0.92), and tea without milk by 67% (95% CI 0.11, 0.99). Prevalence of boys with an adequate dietary diversity score (≥ 4) was reduced by 27% relative to girls (95% CI 0.54, 0.99). Males fared worse in length-for-age z scores (- 2.16 vs. - 1.56, P = 0.000), weight-for-age z scores (- 0.86 vs. - 0.33, P = 0.002), prevalence of stunting (50.6% vs. 23.4%, P = 0.000), and plasma concentrations of dimethylglycine (1.25 vs. 1.65 µg/mL, P = 0.021). After adjusting for demographic, caregiver perceptions of appetite, and biological factors, length-for-age z score for a male child was 0.62 units lower than for a female (95% CI - 0.98, - 0.26). Male infants were shown to receive lower quality complementary foods and have worse anthropometric measures than female infants.Trial registration clinicaltrials.gov, NCT02446873. Registered February 28, 2015, https://clinicaltrials.gov/ct2/show/NCT02446873 .

Caliata: An Indigenous Community in Ecuador Offers Lessons on Food Sovereignty and Sustainable Diets.

BACKGROUND: To achieve a healthy sustainable food system globally, it is imperative to understand how local food systems can provide healthy and sustainable conditions. OBJECTIVE: To explore, through the indigenous community of Caliata in the Ecuadorian highlands, the factors that support or hinder sustainable Andean food systems. METHODS: We designed a participatory mixed-methods study in Caliata (Chimborazo, Ecuador) and an inclusive and transdisciplinary research process with constant member checking. The study combined culturally validated qualitative methods (n = 49), agroecology-based site analysis, and household surveys (n = 57), including a modified 48-h recall. We used the NOVA food classification system to categorize the diet according to levels of processing and analyzed categorical and numeric data to understand the interplay of parcel size, agrodiversity, and diet diversity. RESULTS: First, the agroecological space is defined by the stewardship of Pachamama (Mother Nature), a central role in Andean cosmovision, leading to trophic interactions and cycles characterized by a diversity of heterarchical social organizations and agroecologically useful species. Second, consistency was found in dietary patterns; all respondents consume their produce, fruits being the most popular snack (in a 24-h period, 70% reported an average of 2.2 servings), and two-thirds of households' consumption represent unprocessed or minimally processed foods. Third, gendered agriculture and population aging represent demographic challenges, while chronic health problems remain relatively infrequent compared with the general population. Fourth, food sovereignty is an ecocentric concept based on production, exchanges of seeds and produce, consumption of produce, and knowledge of how agroecological space is treated. This system represents a nutrient loop tied to a system of knowledge about how to care for soil, land, and the ecological community. CONCLUSIONS: Caliata provides important perspectives on linkages between diet, biodiversity, use of agroecological space, and rural-urban dynamics. This small indigenous community offers lessons for achieving both healthy ecosystems and food security.

Fetal brain ultrasound measures and maternal nutrition: A feasibility study in Ecuador.

OBJECTIVE: Nutrition during pregnancy is an important modifiable determinant of fetal growth and development. This pilot study aimed to characterize the association between fetal anthropometry, fetal brain development, and maternal diet among women in Ecuador using portable ultrasound in resource-limited clinics, including measurements of brain structures not typically imaged in this setting. METHODS: Pregnant women (n = 47) from four resource-limited health centers were surveyed on demographic, socioeconomic, morbidity, and dietary information. Maternal height, weight, and blood pressure were taken. A sonographer took 15 images per participant, including those standardly assessed during the fetal survey and additional brain structures identified as potentially responsive to maternal nutrition, but not part of the standard fetal survey. RESULTS: Mean percentiles for all standard fetal survey measurements generated from WHO Fetal Growth Curves fell below 50%, and negative mean Z scores were found for biparietal diameter (-0.95 ± 1.11) and femur length (-0.22 ± 1.10). Generalized linear modeling adjusting for gestational age and other covariates showed frequency of seafood consumption was positively associated with fetal biparietal diameter Z score (P = 0.005), beans and legumes positively associated with femur length (P = 0.006), and a negative association was found for soda consumption and fetal head circumference (P = 0.013). CONCLUSIONS: This pilot study demonstrated the feasibility of capturing images of nutrition-relevant fetal brain structures not part of the standard fetal survey in resource-limited settings using portable ultrasound. Our study revealed associations between anthropometry, brain structure size, and maternal diet demonstrating potential for prenatal nutrition research using ultrasound in the field.

Ethnic Disparities in Nutritional Status among Older Adults: Evidence from the Survey of Health, Welfare and Aging (SABE) Ecuador.

This study aims to identify those populations that should be targeted by specific interventions. A cross-sectional design was utilized. Ordered logistic regression analysis was utilized to assess the association between ethnic identity and risk of malnutrition. Data were drawn from Ecuador's Survey of Health, Welfare and Aging (SABE). The final sample consisted of 4,572 people who were 60 years or older who were able to provide responses to the survey by themselves. Ethnic identity was categorized into four: indigenous, mestizo (Spanish and Indigenous mixed heritage), Afro-Ecuadorian/mulato, and other. Risk of malnutrition was measured using Mini Nutritional Assessment Short-Form (MNA-SF). A range of covariates were selected from three groups of factors: sociodemographic, health-related, and social network. Results revealed that the indigenous ethnicity was the only group who had significantly higher risk of malnutrition compared to mestizo even after controlling for a range of covariates including socio-economic status, health related factors, and social support. Findings suggest the existence of underlaying factors hindering the risk of malnutrition among indigenous older adults. Considering the information revealed by SABE, interventions and other strategies should be targeted and designed specifically accounting for the needs, preferences, and culture of the most vulnerable population.

Assessing Upstream Determinants of Antibiotic Use in Small-Scale Food Animal Production through a Simulated Client Method.

Small-scale food animal production has been celebrated as a means of economic mobility and improved food security but the use of veterinary antibiotics among these producers may be contributing to the spread of antibiotic resistance in animals and humans. In order to improve antibiotic stewardship in this sector, it is critical to identify the drivers of producers' antibiotic use. This study assessed the determinants of antibiotic use in small-scale food animal production through simulated client visits to veterinary supply stores and surveys with households that owned food animals (n = 117) in Ecuador. Eighty percent of households with food animals owned chickens and 78% of those with chickens owned fewer than 10 birds. Among the households with small-scale food animals, 21% reported giving antibiotics to their food animals within the last six months. Simulated client visits indicated that veterinary sales agents frequently recommended inappropriate antibiotic use, as 66% of sales agents recommended growth promoting antibiotics, and 48% of sales agents recommended an antibiotic that was an inappropriate class for disease treatment. In contrast, few sales agents (3%) were willing to sell colistin, an antibiotic banned for veterinary use in Ecuador as of January 2020, which supports the effectiveness of government regulation in antibiotic stewardship. The cumulative evidence provided by this study indicates that veterinary sales agents play an active role in promoting indiscriminate and inappropriate use of antibiotics in small-scale food animal production.

Breastfeeding practices and complementary feeding in Ecuador: implications for localized policy applications and promotion of breastfeeding: a pooled analysis.

BACKGROUND: Best practices in breastfeeding are often not followed despite appropriate levels of knowledge and positive attitudes regarding the benefits of human milk. For many reasons, some women do not initiate breastfeeding, suspend breastfeeding early, or initiate complementary feeding earlier than recommended. Usual measurement methods use large sample surveys at a national scale, which are not well suited for monitoring sub-national differences. METHODS: In order to understand how local infant feeding practices could influence policy and promotion practices, we apply data pooling methodology to analyse breastfeeding patterns in different Ecuadorian settings: Cumbayá parish, located near Quito, the Ecuadorian capital; the city of Macas and rural surroundings in the Amazon basin province of Morona Santiago; and the province of Galapagos. Surveys were conducted independently between August 2017 and August 2018; while they are representative of each respective setting, sampling designs and survey methods differ, but the same demographic information and data based on standard breastfeeding indicators established by the World Health Organization (WHO) were collected. In order to account for differences in the different settings, the design effect of each survey was considered in the analysis. RESULTS: Significant differences were found in breastfeeding practices between the suburban Cumbayá parish near Quito and Galapagos on one hand, and urban and rural parts of Morona Santiago, on the other. The rates of early breastfeeding initiation and age-appropriate breastfeeding are significantly higher in urban and rural Morona Santiago then in Cumbayá or Galapagos, while the rate of exclusive breastfeeding is highest in rural parts of Morona Santiago. No significant differences were found in complementary feeding practices between Cumbayá and Galapagos, but there are with urban and rural Morona Santiago. Initiation of breastfeeding in the first hour after birth occurs in only 36.2% of cases in Cumbayá but in 75.4% of cases in urban Morona. CONCLUSIONS: Differences among regions reflect specific opportunities and barriers to practices related to promoting optimal infant health and nutrition. Consequently, regional or local conditions that often are not apparent in national-level data should orient policies and promotion activities in specific populations.

Biosafety at Home: How to Translate Biomedical Laboratory Safety Precautions for Everyday Use in the Context of COVID-19.

Population adoption of social distancing measures during the COVID-19 pandemic is at times deficient, increasing the risk of SARS-CoV-2 transmission. Healthcare workers and those living in areas of intense transmission may benefit from implementing biosafety measures in their daily lives. A mixed-methods approach, combining components of single negotiation text and the Delphi method, was used to create a COVID-19 biosafety-at-home protocol. A consensus building coordinator liaised with 12 experts to develop the protocol over 11 iterations. Experts had more than 200 years of combined experience in epidemiology, virology, infectious disease prevention, and public health. A flyer, created from the final protocol, was professionally designed and initially distributed via social media and institutional websites/emails in Ecuador beginning on May 2, 2020. Since then, it has been distributed in other countries, reaching ∼7,000 people. Translating research laboratory biosafety measures for the home/street environment might be challenging. The biosafety-at-home flyer addresses this challenge in a user-friendly format.

Malnutrition inequalities in Ecuador: differences by wealth, education level and ethnicity.

OBJECTIVE: To describe and quantify the magnitude and distribution of stunting, wasting, anaemia, overweight and obesity by wealth, level of education and ethnicity in Ecuador. DESIGN: We used nationally representative data from the 2012 Ecuadorian National Health and Nutrition Survey. We used the Multidimensional Poverty Index (MPI) as a proxy of wealth. The MPI identifies deprivations across three dimensions (health, education and standard of living). We defined education by years of schooling and ethnicity as a social construct, based on shared social, cultural and historical experiences, using Ecuadorian census categories. SETTING: Urban and rural Ecuador, including the Amazon rainforest and the Galapagos Islands. PARTICIPANTS: Children aged <5 years (n 8580), adolescent women aged 11-19 years (n 4043) and adult women aged 20-49 years (n 15 203). RESULTS: Among children <5 years, stunting and anaemia disproportionately affected low-wealth, low-education and indigenous groups. Among adolescent and adult women, higher rates of stunting, overweight and obesity were observed in the low-education and low-wealth groups. Stunting and short stature rates were higher in indigenous women, whereas overweight and obesity rates were higher in Afro-Ecuadorian women. CONCLUSIONS: Malnutrition differs significantly across sociodemographic groups, disproportionately affecting those in the low wealth tertile and ethnic minorities. Rates of stunting remain high compared with other countries in the region with similar economic development. The effective implementation of double-duty actions with the potential to impact both sides of the double burden is urgently required.

Egg intervention effect on linear growth no longer present after two years.

The Lulun Project, a randomized controlled trial conducted in 2015, found that one egg per day for 6 months during early complementary feeding reduced stunting by 47% and increased linear growth by 0.63 length-for-age Z (LAZ). This follow-up cohort study (Lulun Project II) aimed to test whether the growth effect remained in the egg intervention group compared with the control group after approximately 2 years. Mothers or caregivers from the Lulun Project were recontacted and recruited for this study. Enumerators collected data on socio-economic and demographic factors, 24-hr frequency of dietary intakes, morbidities, and anthropometric measures of height, weight, and head circumference using World Health Organization protocols. Statistical analyses followed the same analytical plan as Lulun Project, applying generalized linear models and regression modelling to test group differences in height-for-age z (HAZ) from LAZ at Lulun Project endline, and structural equation modelling for mediation. One hundred thirty-five mother-child dyads were included in Lulun II, with 11% losses to follow-up from endline Lulun Project. Growth faltering across all children was evident with HAZ -2.07 ± 0.91 and a stunting prevelance of 50%. Regression modelling showed no difference between egg and control groups for the HAZ outcome and other anthropometric outcomes, and significant declines in HAZ from endline Lulun Project in the egg intervention are compared with control groups. Current dietary egg intake, however, was associated with reduced growth faltering in HAZ from Lulun Project endline to Lulun Project II, independent of group assignment and through mediation, explaining 8.8% of the total effect. Findings suggest the need for a longer intervention period and ongoing nutrition support to young children during early childhood.

Government Policy, Clean Fuel Access, and Persistent Fuel Stacking in Ecuador.

After more than three decades of access to low-cost liquefied petroleum gas (LPG) financed by large direct government subsidies, more than 90% of Ecuadorian households cook primarily with LPG. Due to the large fiscal burden of the LPG subsidy, increases in electricity from hydropower, and other sociopolitical factors, the Government of Ecuador launched a major induction stove program (PEC) to reduce the demand for LPG. We assess the effects of the LPG subsidies and PEC using government records, interviews, academic literature, newspaper reports, household surveys, and focus groups. Household surveys, conducted in rural, northern Ecuadorian households (n=383), characterized cooking patterns and fuel access. Focus groups (n=6) were carried out with a subset of surveyed households to better characterize survey findings. The LPG subsidy was developed as part of broad social support reforms in the early 1970s, without specific aims to reduce the health impacts of household air pollution from woodfuel or provide economic benefits as part of the transition to a clean cooking fuel. Nonetheless, the subsidy has resulted in nearly all Ecuadorian households cooking primarily with LPG. PEC has generated the sale of 740,000 induction stoves since its inception in 2014, short of the goal of 3.5 million. Among the rural households surveyed, LPG use, acceptance, and satisfaction was high, however, more than three-quarters of those surveyed reported weekly woodfuel use. Induction stove ownership (17%) and use as a primary cooking fuel (1%) was low among the rural households surveyed; furthermore, households owning induction stoves reported very low satisfaction with the stoves. Here we show that nationally-representative surveys reporting only "primary cooking fuef" use may underestimate solid fuel use as a supplemental household cooking energy, particularly in rural areas where fuel availability issues play a stronger role in decisions about what fuels to use.

The Lulun Project's social marketing strategy in a trial to introduce eggs during complementary feeding in Ecuador.

The Lulun Project incorporated a social marketing strategy that accompanied a randomized controlled trial (RCT) of a food-based intervention that introduced eggs into the complementary feeding diet of Ecuadorian infants. This strategy was designed to promote behaviour change, in this case, egg consumption, through voluntary prosocial behaviour, empowerment, and brand loyalty. A three-phase social marketing strategy (design, campaigns, and evaluation) contributed to our successful RTC by applying techniques drawn from marketing, publicity, design, and communications. To develop the strategy, we conducted (a) market research focused on culturally based norms, values, and local expectations; (b) a situational assessment based on the four Ps of social marketing (people, product, place, and price); and (c) fostered a creative process to develop the project's brand and communication plan. The strategy combined a communication plan, brand, and activities that were implemented in four campaigns: outreach, recruitment, promotion, and closing. Our evaluation showed that the social marketing strategy was instrumental in promoting the RCT's objectives and responding to unforeseen events and community concerns regarding the RCT. The strategy resulted in high compliance, low attrition, and infant feeding policy change, including Ecuador's Ministry of Public Health new complementary feeding guidelines for introducing eggs early in complementary feeding. Use of social marketing techniques, like those in our study, could be key for scaling up this food-based intervention-or others like it-in Ecuador and beyond.

Overweight, obesity, and food consumption in Galapagos, Ecuador: a window on the world.

BACKGROUND: In order to understand why rates of overweight and obesity are so high in the Ecuadorian province of Galapagos, this study analyzes changes in household food expenditures and perceptions and practices related to food consumption patterns. Galapagos is understood as an unusual but not unique case because conditions there graphically illustrate trends observed in communities and countries worldwide. A mixed methods approach was employed: a quantitative component was based on expenditures for foods classified according to the NOVA system, and a qualitative component utilized focus group discussions, key informant interviews, and structured observations. RESULTS: Galapagos residents increased consumption of processed and ultra-processed foods and decreased consumption of unprocessed and minimally processed foods. Perceived barriers to healthy diets include price, availability, and quality of fresh produce, as well as easy access to industrialized processed and ultra-processed foods. CONCLUSIONS: Changes in consumption patterns represent both local conditions and global trends; in that sense, the factors that affect Galapagos residents are not unique. Hence, these findings help elucidate processes observed in communities around the world.

The double burden of chronic malnutrition and overweight and obesity in Ecuadorian mothers and children, 1986-2012.

BACKGROUND:: The simultaneous presence of undernutrition and over-nutrition represents a paradox in global public health and is of increasing concern in Ecuador, where chronic malnutrition and overweight and obesity occur in the context of demographic and epidemiologic transitions. Two overlapping trends are present in Ecuador; while levels of stunting have decreased slowly in the past three decades, increasing proportions of children <5 years and women of reproductive age suffer from overweight and obesity. AIM:: To analyze stunting and overweight and obesity in children <5 and their mothers aged from 15 to 49 years in the context of demographic and household characteristics between 1986 and 2012. METHODS:: This study compares data from nationally-representative surveys conducted in Ecuador in 1986, 2004, and 2012, each of which collected information on children <5 and mothers aged 15-49 years. RESULTS:: The prevalence of chronic malnutrition in children <5 decreased at different rates among Ecuadorians who differ in terms of residence, socioeconomic status, and mothers' level of education, while overweight and obesity increased dramatically in the same period. CONCLUSION:: Chronic malnutrition in children <5 and overweight in children <5 and mothers 15-49 years represent a double burden of malnutrition in Ecuador. The phenomena differ in their effects, and, while the prevalence of stunting is declining in Ecuador as it is in many parts of the world, the problem of overweight and obesity has emerged in dramatic fashion, and currently represents an extraordinary challenge to public health.