Assessing community health among indigenous populations in Ecuador with a participatory approach: implications for health reform

A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses

BACKGROUND

Community health needs and assets assessment is a means of identifying and describing community health needs and resources, serving as a mechanism to gain the necessary information to make informed choices about community health. The current review of the literature was performed in order to shed more light on concepts, rationale, tools and uses of community health needs and assets assessment.

METHODS

We conducted a scoping review of the literature published in English using PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library databases until March 2021.

RESULTS

A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. Relevant concepts were examined guided by a conceptual framework. The empirical papers were dominantly conducted in the  United States. Qualitative, quantitative and mixed-method approaches were used to collect data on community health needs and assets, with an increasing trend of using mixed-method approaches. Almost half of the included empirical studies used participatory approaches to incorporate community inputs into the process.

CONCLUSION

Our findings highlight the need for having holistic approaches to assess community's health needs focusing on physical, mental and social wellbeing, along with considering the broader systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize assessing community health assets as an integral component of the process, beginning foremost with community capabilities and knowledge. There has been a trend toward using mixed-methods approaches to conduct the assessment in recent years that led to the inclusion of the voices of all community members, particularly vulnerable and disadvantaged groups. A notable gap in the existing literature is the lack of long-term or longitudinal-assessment of the community health needs assessment impacts.

Ethnic inequalities in reproductive, maternal, newborn and child health interventions in Ecuador: A study of the 2004 and 2012 national surveys

BACKGROUND

Analysis of health inequalities by ethnicity is critical to achieving the Sustainable Development Goals. In Ecuador, similar to other Latin American countries, indigenous and afro-descendant populations have long been subject to racism, discrimination, and inequitable treatment. Although in recent years, Ecuador has made progress in health indicators, particularly those related to the coverage of Reproductive, Maternal, Neonatal and Child Health (RMNCH) interventions, little is known as to whether inequalities by ethnicity persist.

METHODS

Analysis was based on two nationally representative health surveys (2004 and 2012). Ethnicity was self-reported and classified into three categories (Indigenous/Afro-Ecuadorian/Mixed ancestry). Coverage data for six RMNCH health interventions were stratified for each ethnic group by level of education, area of residence and wealth quintiles. Absolute inequality measures were computed and multivariate analysis using Poisson regression was undertaken.

FINDINGS

In 2012, 74.4% of women self-identifying as indigenous did not achieve the secondary level of education and 50.7% were in the poorest quintile (Q1); this profile was relatively unchanged since 2004. From 2004 to 2012, the coverage of RMNCH interventions increased for all ethnic groups, and absolute inequality decreased. However, in 2012, regardless of education level, area of residence and wealth quintiles, ethnic inequalities remained for almost all RMNCH interventions. Indigenous women had 24% lower prevalence of modern contraceptive use (Prevalence ratio [PR] = 0.76; 95% IC: 0.7-0.8); 28% lower prevalence of antenatal care (PR = 0.72; 95% IC: 0.6-0.8); and 35% lower prevalence of skilled birth attendance and institutional delivery (PR = 0.65; 95% IC: 0.6-0.7 and PR = 0.65; 95% IC: 0.6-0.7 respectively), compared with the majority ethnic group in the country.

INTERPRETATION

While the gaps have narrowed, indigenous people in Ecuador continue in a situation of structural racism and are left behind in terms of access to RMNCH interventions. Strategies to reduce ethnic inequalities in the coverage services need to be collaboratively redesigned/co-designed.

FUNDING

This paper was made possible with funds from the Bill & Melinda Gates Foundation [Grant Number: INV-007,594/OPP1148933].

A framework for explaining the role of values in health policy decision-making in Latin America: a critical interpretive synthesis

BACKGROUND

Although values underpin the goals pursued in health systems, including how health systems benefit the population, it is often not clear how values are incorporated into policy decision-making about health systems. The challenge is to encompass social/citizen values, health system goals, and financial realities and to incorporate them into the policy-making process. This is a challenge for all health systems and of particular importance for Latin American (LA) countries. Our objective was to understand how and under what conditions societal values inform decisions about health system financing in LA countries.

METHODS

A critical interpretive synthesis approach was utilised for this work. We searched 17 databases in December 2016 to identify articles written in English, Spanish or Portuguese that focus on values that inform the policy process for health system financing in LA countries at the macro and meso levels. Two reviewers independently screened records and assessed them for inclusion. One researcher conceptually mapped the included articles, created structured summaries of key findings from each, and selected a purposive sample of articles to thematically synthesise the results across the domains of agenda-setting/prioritisation, policy development and implementation.

RESULTS

We identified 5925 references, included 199 papers, and synthesised 68 papers. We identified 116 values and developed a framework to explain how values have been used to inform policy decisions about financing in LA countries. This framework has four categories - (1) goal-related values (i.e. guiding principles of the health system); (2) technical values (those incorporated into the instruments adopted by policy-makers to ensure a sustainable and efficient health system); (3) governance values (those applied in the policy process to ensure a transparent and accountable process of decision-making); and (4) situational values (a broad category of values that represent competing strategies to make decisions in the health systems, their influence varying according to the four factors).

CONCLUSIONS

It is an effort to consolidate and explain how different social values are considered and how they support policy decision-making about health system financing. This can help policy-makers to explicitly incorporate values into the policy process and understand how values are supporting the achievement of policy goals in health system financing.

TRIAL REGISTRATION

The protocol was registered with PROSPERO, ID=CRD42017057049 .

Community factors associated with stunting, overweight and food insecurity: a community-based mixed-method study in four Andean indigenous communities in Ecuador

OBJECTIVES

We aimed to implement participatory research to answer a question posed by four Kichwa indigenous communities in Andean Ecuador about what actionable factors are associated with childhood stunting, overweight and food insecurity among their people.

DESIGN

We used mixed methods including household questionnaires, discussion groups with respondents of the questionnaires and anthropometric measurement of children (6 months to 12 years) from surveyed households.

SETTING

The study involved four Andean indigenous communities transitioning from traditional to Western lifestyles. They subsist mainly on small-scale agriculture and have a rich cultural heritage including their traditional language.

PARTICIPANTS

Anthropometric data were collected from 298 children from 139 households in four communities; all households completed the questionnaire. We held five discussion groups (6-10 participants each): three composed of mothers and two of farmers.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were stunting, overweight, food insecurity and their relationship with demographics, dietary habits and agricultural habits.

RESULTS

Of 298 children, 48.6% were stunted and 43.3% overweight for age. Stunted children were more likely to live in households that sold livestock (ORa 1.77, 95% CIa 1.06 to 2.95) and with illiterate primary caretakers (ORa 1.81, 95% CIa 1.07 to 3.06), but were less likely to live in households with irrigation (ORa 0.47, 95% CIa 0.27 to 0.81). Overweight children were more likely to be male (ORa 1.87, 95% CIa 1.02 to 3.43) and live in a household that sold livestock (ORa 2.14, 95% CIa 1.14 to 4.02). Some 67.8% of children lived in a household with food insecurity, more frequently in those earning below minimum wage (ORa 2.90, 95% CIa 1.56 to 5.41) and less frequently in those that ate quinoa in the past 24 hours (ORa 0.17, 95% CIa 0.06 to 0.48). Discussion groups identified irrigation and loss of agricultural and dietary traditions as important causes of poor childhood nutrition.

CONCLUSION

Many indigenous communities face tumultuous cultural, nutritional and epidemiological transitions. Community-based interventions on factors identified here could mitigate negative health outcomes.

Reemergence of Measles in the Americas: The Genotype B3 2011-2012 Outbreak in Ecuador

This study characterizes a measles outbreak which occurred in Ecuador in 2011–2012, analyzing data from 3700 suspected cases of measles reported to Ecuador’s Ministry of Public Health. The study population had a large age range and included 333 confirmed cases of measles. The greatest number of cases were found in the <1 year (32.43%, n = 108) and 1–4 year (30.03%, n = 100) age-groups. Compared to Mestizos, indigenous people had the highest number of cases (68.2%, n = 227), as well as a higher risk of infection (OR 7.278 (CI 5.251–10.087)). The greatest protection from measles was observed in individuals who received two doses of the measles vaccine. Residents of Pastaza (OR 6.645 CI (3.183–13.873)) and Tungurahua (OR 8.346 CI (5.570–12.507)) had a higher risk of infection than the other provinces. Of the 17 laboratory confirmed cases, all were identified as genotype B3. Age-group, ethnicity, measles vaccinations, and residence in Tungurahua and Pastaza were correlated with rates of measles infection in the outbreak. Tungurahua and Pastaza, where the outbreak originated, have large indigenous populations. Indigenous children <1 year of age showed the highest incidence. It is likely that indigenous women do not have immunity to the virus, and so are unable to confer measles resistance to their newborns.

Multifactor Analysis on the Income of Primary Health Care Institutions Implementing EMS in Hubei Province, China: A Cross-sectional Study

The objectives of this study are to measure the level of income of primary health care institutions during essential medicines system (EMS) implementation and to identify its main influencing factors for finding the evidence to promote the EMS in China’s deepening health care reform.

The field investigation with a stratified sampling method contained primary health institutions from Hubei province, based on the different economic levels. Government-run institutions which implemented EMS were all collected; they were a total of 402. A structured questionnaire survey was carried out at all institutions involving indicators such as income of primary health care institutions, government subsidy, institution staff salaries, institution indebtedness, number of health personnel, drug price cut (per cent) and number of drug use. The Statistical Package for the Social Sciences (SPSS) 12.0 was used for independent variables selection and to perform multiple linear regressions.

Government subsidy (X1), institution staff salaries (X2), institution indebtedness (X3) and number of health personnel (X4) are factors chosen into the regression model, the square root of the income of primary health institutions (Y). The model Y = 3.827 + 0.030X1 + 0.045X2 + 0.002X3 + 0.033X4 (F = 164.663, P < 0.001), where coefficient of determination R2 = 0.656. The biggest influence on income of primary health institutions is institution staff salaries (standardized coefficients = 0.398), followed by number of health personnel (standardized coefficients = 0.318) and government subsidy (standardized coefficients = 0.264).

To protect the income of primary health care institutions, more attention should be paid to the agency staffing reform, individual performance appraisal and government subsidies. For best outcomes of EMS, the subsequent implementation should be a more completed set of supporting measures besides the design of system itself.

Comprehensive primary health care in South America: contexts, achievements and policy implications

This article summarizes an extensive review of South American experiences with primary health care since the Declaration of Alma-Ata. It aims to address the following specific questions: What are the enabling and constraining historical and structural conditions for primary health care policies and practices? How has health care reform supported or undermined primary health care? What evidence exists on the effectiveness of primary health care? What strategies are common to best practices? What evidence exists on the roles of citizen participation and intersectoral action? And finally, what are the policy lessons to be learned from these experiences? Narrative synthesis was used to identify and examine patterns in the data consistent with these questions. Conditions that were found to promote successful implementation of primary health care are outlined, together with features of effective primary health care systems that help create more equitable health services and health outcomes.

[The knowledge, attitude and practice of blood pressure management from the patient's viewpoint: a qualitative study]

OBJECTIVES

This study adopted a qualitative method to explore the layman's beliefs and experience concerning high blood pressure and its management in order to develop a strategy to increase adherence to proper medical treatment.

METHODS

Semi-structured interviews that focused on personal experiences with hypertension and its management were conducted with 26 hypertensive patients. The participants were selected according to a BP above 140/90 mmHg (hypertension stage 1), based on the seventh report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure (JNC-VII). The interviews lasted for approximately 30 minutes (range: 20-60 minutes). The resulting questions were formulated into open-ended questions. The interview questionnaire was composed 17 items to examine non-adherence to treatment and 19 items to examine adherence to treatment.

RESULTS

Most participants recognized that the direct cause of high blood pressure was unhealthy behavior rather than inheritance. Thus, the hypertensive patient believed they could recover their blood pressure to a normal level through removing the direct cause of hypertension (weight reduction, diet, exercise) instead of taking drugs. The reasons for these statements were that the drugs for controlling hypertension are not natural or they are artificial, and they may have side effects, and drugs are not treatment for the root cause of hypertension. Most of the hypertensive patients chose to manage their behaviors as soon as they knew their blood pressure was high. Therefore, we should not divide the subjects into two groups according to their taking drugs or not, but they should be divided into two groups according to their willingness or not to manage their condition.

CONCLUSIONS

For developing a strategy for an individual approach to hypertension management, we need to develop a client-centered attitude and strategy. That is, we need to tailor our approach to individual cases to avoid generalizations and stereotyping when developing an adherence increasing strategy.

Best practices in intercultural health: five case studies in Latin America

The practice of integrating western and traditional indigenous medicine is fast becoming an accepted and more widely used approach in health care systems throughout the world. However, debates about intercultural health approaches have raised significant concerns. This paper reports findings of five case studies on intercultural health in Chile, Colombia, Ecuador, Guatemala, and Suriname. It presents summary information on each case study, comparatively analyzes the initiatives following four main analytical themes, and examines the case studies against a series of the best practice criteria.

Disappearing, displaced, and undervalued: a call to action for Indigenous health worldwide

"What sets worlds in motion is the interplay of differences, their attractions and repulsions. Life is plurality, death is uniformity. By suppressing differences and peculiarities, by eliminating different civilisations and cultures, progress weakens life and favours death. The ideal of a single civilisation for everyone implicit in the cult of progress and technique, impoverishes and mutilates us. Every view of the world that becomes extinct, every culture that disappears, diminishes a possibility of life!"

Globalization and local response to epidemiological overlap in 21st century Ecuador

Background

Third World countries are confronted by a complex overlay of two sets of health problems. Traditional maladies, including communicable diseases, malnutrition, and environmental health hazards coexist with emerging health challenges, including cardiovascular disease, cancer, and increasing levels of obesity. Using Ecuador as an example, this paper proposes a conceptual framework for linking epidemiologic overlap to emerging social structures and processes at the national and global levels.

Discussion

Epidemiologic trends can be seen as part of broader processes related to globalization, but this does not imply that globalization is a monolithic force that inevitably and uniformly affects nations, communities, and households in the same manner. Rather, characteristics and forms of social organization at the subnational level can shape the way that globalization takes place. Thus, globalization has affected Ecuador in specific ways and is, at the same time, intimately related to the form in which the epidemiologic transition has transpired in that country.

Summary

Ecuador is among neither the poorest nor the wealthiest countries and its situation may illuminate trends in other parts of the world.

As in other countries, insertion into the global economy has not taken place in a vacuum; rather, Ecuador has experienced unprecedented social and demographic change in the past several decades, producing profound transformation in its social structure. Examples of local represent alternatives to centralized health systems that do not effectively address the complex overlay of traditional and emerging health problems.

Breast Cancer in Limited-Resource Countries: Health Care Systems and Public Policy

As the largest cancer killer of women around the globe, breast cancer adversely impacts countries at all levels of economic development. Despite major advances in the early detection, diagnosis, and treatment of breast cancer, health care ministries face multitiered challenges to create and support health care programs that can improve breast cancer outcomes. In addition to the financial and organizational problems inherent in any health care system, breast health programs are hindered by a lack of recognition of cancer as a public health priority, trained health care personnel shortages and migration, public and health care provider educational deficits, and social barriers that impede patient entry into early detection and cancer treatment programs. No perfect health care system exists, even in the wealthiest countries. Based on inevitable economic and practical constraints, all health care systems are compelled to make trade-offs among four factors: access to care, scope of service, quality of care, and cost containment. Given these trade-offs, guidelines can define stratified approaches by which economically realistic incremental improvements can be sequentially implemented within the context of resource constraints to improve breast health care. Disease-specific "vertical" programs warrant "horizontal" integration with existing health care systems in limited-resource countries. The Breast Health Global Initiative (BHGI) Health Care Systems and Public Policy Panel defined a stratified framework outlining recommended breast health care interventions for each of four incremental levels of resources (basic, limited, enhanced, and maximal). Reallocation of existing resources and integration of a breast health care program with existing programs and infrastructure can potentially improve outcomes in a cost-sensitive manner. This adaptable framework can be used as a tool by policymakers for program planning and research design to make best use of available resources to improve breast health care in a given limited-resource setting.

Balancing empiricism and local cultural knowledge in the design of prevention research

Prevention research aims to address health and social problems via systematic strategies for affecting and documenting change. To produce meaningful and lasting results at the level of the community, prevention research frequently requires investigators to reevaluate the boundaries that have traditionally separated them from the subjects of their investigations. New tools and techniques are required to facilitate collaboration between researchers and communities while maintaining scientific rigor. This article describes the tribal participatory research approach, which was developed to facilitate culturally centered prevention research in American Indian and Alaska Native communities. This approach is discussed within the broader context of community-based participatory research, an increasingly prevalent paradigm in the prevention field. Strengths and limitations of the approach used in the study are presented.