Access to medicines for acute illness in middle income countries in Central America

OBJECTIVE

To analyze the main predictors of access to medicines for persons who experienced acute health conditions.

METHODS

This was a cross-sectional analytic study, based on data from household surveys. We examined the predictors of: (1) seeking care for acute illness in the formal health care system and (2) obtaining all medicines sought for the acute condition.

RESULTS

The significant predictors of seeking health care for acute illnesses were urban geographic location, head of household with secondary school education or above, age under 15, severity of illness perceived by the respondent, and having health insurance. The most important predictor of obtaining full access to medicines was seeking care in the formal health care system. People who sought care in the formal system were three times more likely to receive all the medicines sought (OR 3.0, 95%CI 2.3;4.0). For those who sought care in the formal health system, the strongest predictors of full access to medicines were seeking care in the private sector, having secondary school education or above, and positive perceptions of quality of health care and medicines in public sector health facilities. For patients who did not seek care in the formal health system, full access to medicines was more likely in Honduras or Nicaragua than in Guatemala. Urban geographic location, higher economic status, and male gender were also significant predictors.

CONCLUSIONS

A substantial part of the population in these three countries sought and obtained medicines outside of the formal health care system, which may compromise quality of care and pose a risk to patients. Determinants of full access to medicines inside and outside the formal health care system differ, and thus may require different strategies to improve access to medicines. 

Nicaraguan migration and the prevalence of adolescent childbearing in Costa Rica

This study describes the dynamics of adolescent childbearing of Nicaraguan-born and Costa Rican-born adolescents in Costa Rica and examines the association between socio-demographic factors and adolescent childbearing in the country. We studied Nicaraguan-born and Costa Rican adolescents using the data of the 2000 Census. Multivariate logistic regression was used to analyze the association between country of origin and adolescent childbearing, while controlling for socio-demographic factors (age, education, union, urbanization and poverty). 26% of Nicaraguan-born migrants and 9.5% of Costa Ricans had given birth during adolescence. The migrants' increased odds of pregnancy decreased from 3.34 (CI 3.21, 3.48) to 1.88 (CI 1.79, 1.97) when controlling for socio-demographic factors. Age, low educational attainment, urban residence, poverty and union were all significant predictors of adolescent pregnancy. Nicaraguan-born status is associated with adolescent childbearing in Costa Rica. Further research is needed to understand what factors, other than socio-demographic indicators, contribute to the differing prevalence of adolescent childbearing in Costa Rica.

Abortion law reforms in Colombia and Nicaragua: issue networks and opportunity contexts

This article analyses two instances of abortion law reform in Latin America. In 2006, after a decades-long impasse, the highly controversial issue of abortion came to dominate the political agenda when Colombia liberalized its abortion law and Nicaragua adopted a total ban on abortion. The article analyses the central actors in the reform processes, their strategies and the opportunity contexts. Drawing on Htun's (2003) framework, it examines why these processes concluded with opposing legislative outcomes. The authors argue for the need to understand the state as a non-unitary site of politics and policy, and for judicial processes to be seen as a key variable in facilitating gender policy reforms in Latin America. In addition, they argue that ‘windows of opportunity’ such as the timing of elections can be critically important in legislative change processes.

Who cares in Nicaragua? A care regime in an exclusionary social policy context

In Latin American countries with historically strong social policy regimes (such as those in the Southern Cone), neoliberal policies are usually blamed for the increased burden of female unpaid work. However, studying the Nicaraguan care regime in two clearly defined periods — the Sandinista and the neoliberal eras — suggests that this argument may not hold in the case of countries with highly familialist social policy regimes. Despite major economic, political and policy shifts, the role of female unpaid work, both within the family and in the community, remains persistent and pivotal, and was significant long before the onset of neoliberal policies. Nicaragua's care regime has been highly dependent on the ‘community’ or ‘voluntary’ work of mostly women. This has also been, and continues to be, vital for the viability of many public social programmes.

Cross-cultural beliefs, ceremonies, and rituals surrounding death of a loved one

The purpose of this qualitative study was to describe practices surrounding death of a loved one by European, Asian, Caribbean, Central American, and South American families living in the United States. A focus group with 14 masters nursing students from a wide variety of cultural and religious backgrounds was conducted to gain a better understanding of the beliefs, ceremonies, and rituals surrounding death. Many commonalties were found across cultures and religions. A pervasive theme was that beliefs about the soul of the deceased lead families to perform rituals and ceremonies that foster passage to God, the "light," or another life. The stronger their beliefs, the more dedicated the family is in completing the rituals and ceremonies in the way dictated by their religion or culture. Participants had difficulty separating the influence of culture and religion on these practices.

Perceived social status, language and identified dental home among Hispanics in Florida

BACKGROUND

The authors conducted a study to examine the extent to which perceived social status in communities and in U.S. society in general and primary language are associated with having a dental home among four Hispanic groups.

METHODS

The authors used random-digit-dialing technology to select a probability sample of Hispanic adults in Miami-Dade County, Fla., for a telephone-based survey. Trained interviewers administered the pretested survey instrument in Spanish or English. The authors used bivariate contingency tables and multiple logistic regression modeling to analyze the data.

RESULTS

Eight hundred ten adults participated, and their nationality groups were as follows: Cuba (n = 450), Nicaragua (n = 139), Colombia (n = 132) and Puerto Rico (n = 89). After controlling for nationality group, the authors found that respondents who perceived themselves to be at a higher social status in the United States than in their own community were significantly more likely to have a dental home; those who reported having a higher community status were significantly less likely to have a dental home compared with respondents who perceived their national and community social status to be equal. Respondents who primarily spoke a language other than English at home were less likely than those who primarily spoke English to have a dental home. Female respondents were more likely than male respondents to have a dental home. Respondents with dental insurance were more likely to have a dental home than were those without dental insurance.

CONCLUSIONS

Perceived social status and acculturation may influence whether Hispanics have a dental home. However, because of the sample design, the findings may not be generalizable to all Hispanic populations in Florida or the United States.

CLINICAL IMPLICATIONS

Reducing disparities in oral health status and in use of dental services among Hispanics relative to non-Hispanic whites may require attention to cultural factors such as language, community structure and immigrants' degree of acculturation.

[Diagnostic image (174). A Nicaraguan man with an epileptic seizure. Neurocysticercosis]

A 56-year-old Nicaraguan man was referred because of a generalised seizure. CT revealed neurocysticercosis.

Nicaraguan population data on LDLR, GYPA, D7S8, HBGG, GC and HLA-DQA1 loci

Nicaraguans have become the most numerous and fastest increasing minority in Costa Rica: at present they represent around 6% of the total population of the country. We have analyzed the allele and genotype frequencies of six PCR-based genetic markers (LDLR, GYPA, HBGG, D7S8, GC, and HLA-DQA1) in 100 unrelated Nicaraguans living in Costa Rica. All loci studied were in Hardy-Weinberg equilibrium. Some statistical parameters of forensic interest were also calculated (h, PD and CE). Allele frequencies of the markers HLA-DQA1 and GYPA were found to be significantly different between the populations of Nicaragua and Costa Rica. Nevertheless, genetic distances showed that Nicaragua is close to other Hispanic-admixed populations like those from Argentina, Chile, Colombia, Costa Rica, and USA Hispanics. The loci set was assessed to be useful for paternity testing and individual identification in the Nicaraguan population residing in Costa Rica.

Sexual abuse during childhood and adolescence among Nicaraguan men and women: a population-based anonymous survey

AIMS

The objective was to describe experiences of sexual abuse occurring before 19 years of age among men and women in León, Nicaragua and to explore the possible association to later sexual risk behavior.

METHOD

A sub-sample of literate urban men and women 25-44 years of age was selected from a representative sample of households in León. After an invitation to a public health event, 154 men (53% of the invited) and 213 women (66% of those invited) participated in giving written answers to an anonymous questionnaire.

RESULTS

Twenty percent of men and 26% of women reported that they had experienced sexual abuse. Women had been victims of attempted or completed rape twice as often as men, 15% as compared to 7%. Thirty-three percent of the abuse towards boys and 66% of the abuse towards girls was committed by family members. Women who had experienced attempted or completed rape were more likely to later have had a higher number of sexual partners compared to non-abused or moderately abused women.

CONCLUSIONS

Sexual abuse of children and adolescents of both sexes is common in Nicaragua. The results underscore the urgent need to address this serious problem more openly, and to make more resources available for the prevention of sexual abuse and for support to victims.

Herbal knowledge on Nicaragua's Atlantic Coast: consensus within diversity

This article examines knowledge of medicinal plants, both among the people of Nicaragua's Atlantic Coast and among the scientific community. Data collected during an 809-household, five-community survey in 1990 and a ten-community botanical collection in 1991 are used to estimate the distribution of medicinal plant knowledge among the region's six ethnic groups. The list of 162 plants identified during this project is compared with other research results to provide the reader with a framework for understanding the distribution of medicinal plant knowledge. While a few plants are widely thought to have medicinal properties, the majority of identifications come from only one or two informants, demonstrating a pattern of consensus within diversity. Discussion focuses on the impact of methodology on the gathering of data, on the distribution and durability of medicinal plant knowledge, and on the proprietary nature of such knowledge.

Ethnomedical interactions: health and identity on Nicaragua's Atlantic coast

This paper describes contemporary and historical interactions of medical belief and practice among the six ethnic groups of Nicaragua's Atlantic Coast--Mestizo, Creole, Miskitu, Sumu, Garifuna and Rama. The expansion of preventive medicine and primary care under the Sandanista-led government during the 1980s is presented, along with brief descriptions of counter-revolutionary attacks on the health care system. Traditional uses of medicinal plants and various forms of spiritual healing are then juxtaposed with the sporadic introduction of European and North American biomedicine throughout history. Next, the results of a health care survey carried out in 1990 are used to: (1) demonstrate the widespread use of the official health care system; and (2) show that traditional practices--use of herbal medicine, visits to spiritual healers, and home birth--are more prevalent among specific ethnic and socioeconomic strata of Nicaraguan Atlantic Coast society. Finally, I use these descriptions and survey results to argue for an understanding of health care behavior based on personal identity. I argue that a number of identities--ethnic, historical, political, socioeconomic and spatial (village, city, region or nation)--both situate and influence health care behavior, and thus mediate between the psychological and spiritual realms of illness and healing. Each individual chooses, variably and often subconsciously, to identify with any of a number these 'imagined communities' as he or she makes health care choices. These identity-influenced decisions are then manifested as specific health-related behaviors, forming the real-world data on which this argument is premised.

Pattern of malaria imported by foreign residents under active survey

An active of imported malaria was carried out on 1432 foreign residents entering Czechoslovakia between 1986-1989. The survey group consisted of adult aged 18-35 years who arrived from malaria endemic regions. Of 660 people surveyed who were from regions of Africa south of the Sahara, 10% were positive for Plasmodium falciparum. Whereas, those arriving from South East Asia had a relatively low prevalence of malaria (2.6%), predominantly P. vivax. Of the 10% of cases testing positive for P. falciparum, 85% had less than 10,000 asexual stages/microliters of blood and 75% were asymptomatic carriers. By contrast, 93.8% of P. vivax/ovale infections were diagnosed because of the onset of symptoms. Both the frequency of seropositivity and the geometrical mean reciprocal titre (IgG), using P. falciparum antigen, were higher in those people arriving from Africa (79% and 1,307) compared with those arriving from S.E. Asia (44.4% and 628). Malaria was confirmed, by blood smear examination, in only 23.8% of the seropositive cohort. There was a positive correlation between the percentage of P. falciparum-positive blood smears and the level of antibody titre. There was no correlation between serum reactivity and level of parasitaemia.

Mortality trends among refugees in Honduras, 1984-1987

Mortality data collected from 1984 to 1987 through a routine standardized health information system in the five main refugee populations of Honduras were reviewed. The direct standardized mean annual death rate for all refugees was 5.5 per 1000 population (Honduras population as reference; Honduras mortality rate: 10.1 per 1000). Mortality decreased or remained stable among Salvadoran refugees from 1984 to 1987, but increased among Nicaraguan refugees after 1985. The highest neonatal (56.1 per 1000 livebirths), infant (126.1 per 1000 livebirths) and under-five-year-olds (35.7 per 1000 child less than five years of age) mortality rates were observed in the two Nicaraguan camps. These two camps had the highest rate of newly arriving refugees. Deaths in infants and under-five-year-olds accounted for 42 and 54.1% of all deaths respectively. Of all deaths under five years of age, respiratory infections, diarrhoeal diseases and measles accounted for 21.4%, 22.1% and 4.7%, respectively. Mortality rates, particularly among under-five-year-olds and infants increased when the rate of newly arriving refugees was higher. The importance of adapted health surveillance in refugee settlements is discussed.

[Prevalence of Trypanosoma cruzi infection in Nicaraguan students. Isle of Youth Special Municipality. February, 1987]

A seroepidemiologic study on American trypanosomiasis was performed to a group of Nicaraguan students in Isle of the Youth Special Municipality, during February 1987, using indirect hemagglutination and indirect immunoflorescence techniques. The prevalence obtained with both tests and the percentage of the most frequent titer of indirect immunofluorescence are pointed out. The youth living in rural zones presented higher risk of acquiring the infection than those living in urban zones. The students coming from the Atlantic Coast, Rio San Juan and Masaya, presented the highest positive rates. Of those who were interviewed, 59% identified the Triatoma, and 13% of them manifested to have seen it inside homes. The background of being bitten by the Tritoma was present in 16.2% of those with positive results.

[Serologic study of the diagnosis of Chagas disease in Nicaraguan students in the Juventud island]

The results obtained during the serologic study for the diagnosis of Chagas' disease in 868 Nicaraguan students in the Isle of Youth are reported. Qualitative hemagglutination and indirect immunofluorescence were used. It was found that 8.5% of these students showed antibodies specific to Trypanosoma cruzi by means of this diagnostic test.

Infectious diseases in a Nicaraguan refugee camp in Costa Rica

Some Nicaraguans living in Costa Rica are in refugee camps. The types and rates of infectious diseases in the Pueblo Nuevo refugee camp were measured by examining medical records for 1985 and performing stool and blood testing. The incidence of infections was 320 episodes per 1000 persons per year. Respiratory infections represented 63% of all illnesses and pulmonary tuberculosis was high. Malaria was not found in blood samples and no childhood illnesses preventable by immunizations were recorded in the records. Intestinal parasites were found in 56% of the persons examined, considerably higher than the 15% prevalence noted in surveys of Costa Rica as a whole. Trichuris trichiura was found in 40% of the positive stool samples. The deficient hygienic conditions and overcrowding in the camp are responsible for the high rates of infections and the continued presence of infections many of which probably were acquired in Nicaragua. Improvement of hygienic conditions can be accomplished by involving the refugees in education, cleaning and identifying problem areas. Adequate sanitation and improved water supply, and reducing overcrowding are also recommended.

American trypanosomiasis (Chagas' disease) in Central American immigrants

A survey was conducted to determine the prevalence of infection with Trypanosoma cruzi, the protozoan etiologic agent of American trypanosomiasis (Chagas' disease), among Nicaraguan and Salvadoran immigrants living in the Washington, D.C., area. The serum samples of study subjects were tested for reactivity with T. cruzi antigens in an enzyme-linked immunosorbent assay, and also tested for antibody specific for the 72 and 90 kilodalton (kDa) surface glycoproteins of the parasite in an immunoprecipitation and electrophoresis procedure. Xenodiagnosis using reduviid bugs to detect parasites, and clinical evaluations for cardiac and gastrointestinal disease were performed in patients in whom results of both serologic tests were positive. Of 205 subjects studied, 4.9 percent were infected with T. cruzi, and parasites were isolated from 50 percent of those in whom xenodiagnosis was attempted. No significant cardiac or gastrointestinal abnormalities were detected in the six infected patients who were evaluated clinically. These findings suggest that a sizable proportion of persons in this immigrant group are infected with this organism. Thus, routine serologic testing for antibody to T. cruzi may be warranted in immigrants from these countries, especially in view of the potentially serious consequences of infection with this parasite, and also because of the risk of transmission of T. cruzi by blood transfusion.