Trends and factors related to adolescent pregnancies: an incidence trend and conditional inference trees analysis of northern Nicaragua demographic surveillance data

Background We aimed to identify the 2001-2013 incidence trend, and characteristics associated with adolescent pregnancies reported by 20-24-year-old women. Methods A retrospective analysis of the Cuatro Santos Northern Nicaragua Health and Demographic Surveillance 2004-2014 data on women aged 15-19 and 20-24. To calculate adolescent birth and pregnancy rates, we used the first live birth at ages 10-14 and 15-19 years reported by women aged 15-19 and 20-24 years, respectively, along with estimates of annual incidence rates reported by women aged 20-24 years. We conducted conditional inference tree analyses using 52 variables to identify characteristics associated with adolescent pregnancies. Results The number of first live births reported by women aged 20-24 years was 361 during the study period. Adolescent pregnancies and live births decreased from 2004 to 2009 and thereafter increased up to 2014. The adolescent pregnancy incidence (persons-years) trend dropped from 2001 (75.1 per 1000) to 2007 (27.2 per 1000), followed by a steep upward trend from 2007 to 2008 (19.1 per 1000) that increased in 2013 (26.5 per 1000). Associated factors with adolescent pregnancy were living in low-education households, where most adults in the household were working, and high proportion of adolescent pregnancies in the local community. Wealth was not linked to teenage pregnancies. Conclusions Interventions to prevent adolescent pregnancy are imperative and must bear into account the context that influences the culture of early motherhood and lead to socioeconomic and health gains in resource-poor settings

Влијание на кинеската традиционална медицина за лекување на болки во грбот

Болките во грбот претставуваат еден од почестите проблеми со кој се соочуваат луѓето во нивниот секојдневен живот и се најчеста причина за значајни загуби на работните денови. Хроничните болки во грбот станаа една од најчестите причини за боледување кај вработените на возраст под 45 години. Кога луѓето остануваат дома заради повреда во грбот, само 65% се враќаат на работа по една недела и речиси 14% се сеуште отсутни по еден месец. И ако некој е на боледување подолго од шест месеци, има само 50% шанси да се врати на работа. Поголемиот дел од болките во грбот се должат на иритација на зглобовите, или притисок врз лигаментите и мускулите од заболени дискови или шилци. Притисокот врз нервните завршетоци исто така може, да доведе до болки во грбот и нозете. Многу фактори можат да ги влошат болките во грбот. Доживеаниот стрес, преголемата тежина, неправилното држење на телото и лошата кондиција можат да ги влошат или продолжат болките во грбот. Постојат огромен број причини за појава на болки во грбот, но најчесто се работи за една од следниве: механички проблеми, повреди, стекнати болести, инфекции и тумори и емоционален стрес. Кинеската традиционална медицина се развивала во денешна Кина, потоа била пренесена во Јапонија, Кореа, Монголија, Виетнам, Филипините и др. Од физиолошка гледна точка, древните лекари го разгледувале човечкиот организам како сложен систем, во кој елементите се функционално поврзани. Тие си го претставиле телото како “монада“, поделено на два еднакви дела Jин и Јан. Јан го претставува машкиот дел или татковото потекло, кој се изразува во секое светло, активно, суво, топло, творечко, постојано. Jин е од мајчинско потекло кое се изразува како влажно, ладно, темно, сокриено, пасивно. Здравото тело олицетворение на хармонијата помеѓу Јан и Jин. Дисбалансот помеѓу нив доведува до болест. Друга претстава од страна на старата источна медицина е взаемното дејство помеѓу петте елементи – симболи на физичката состојба на природата: дрвото – црн дроб, оган – срце, земја – панкреас, метал – бели дробови, вода – бубрези. Древните научници откриле точки кои ги нарекле космички точки. Боцкањето со игли, загревањето со мокса, притисокот и масажата во тие точки доведува до подобрување на состојбата. Исто така била откриена и т.н. космичка енергија или Чи која што се движи по невидливите канали - меридијаните. Меридијаните се 12 парни кои се расположени по двете страни на телото и два непарни, кои на краевите се поврзани со внатрешните клонови еден со друг и така енергијата Чи циркулира низ телото во еден затворен систем. Секој меридијан има најголема активност по 2 часа дневно. Кај болков синдром меридијаните со нивните билошко – активни точки (БАТ) се место на надворешна симптоматика и перку нив може да се дијагностицира. Точките стануваат болни, со покачена температура и тврди. Треба да се знае дека точките не се поставени во близина на болниот орган, туку тие се наоѓаат по меридијаните. Акупресурата како метода има предност затоа што е безболна и безкрвна процедура, не е потребна специјална техника и лесно се применува. Таа се употребува за покачување на заштитните сили на организмот, за тонизирање, за подобрување и одржување на општата состојба, се употребува и како профилактички метод. Може да се употреби и со други терапевтски методи: класична или сегментарна масажа, климато терапија, балнео терапија. Клучни зборови Акупресура – метод на лекување со притискање. Јин – вид на енергија во телото кое го претставува женскиот пол Јан – вид на енергија во телото кое го претставува машкиот по

Adolescent pregnancies in Nicaragua. The importance of education

Early adolescent pregnancy implies increased social and medical risks. There is lack of understanding of the mechanisms behind early sexual debut and pregnancy. This contributes to the difficulties to meet the educational and health care needs of adolescents. In Nicaragua, few reproductive health interventions target adolescents and even fewer studies focus on sexual and reproductive health in this age group. Therefore, the aim of this thesis is to analyze the background of adolescent pregnancy in Nicaragua, for future interventions. Focus group discussions and in-depth interviews were carried out with young and adult women and men from different social backgrounds in the city of León. Results were used in the planning of a cross-sectional household study carried out in 1993, covering a population of 43,765 in 50 randomly selected clusters in rural and urban León. Reproductive histories were obtained from all women aged 15 to 49 years (n= 10,867), corresponding to 176281 person years of reproductive life. Random sub-samples of men (n=388) and women (n=413) were interviewed in privacy about their age at sexual debut, contraceptive use and reproductive history. The background to early adolescent pregnancy was further analyzed in a matched case-referent study of girls who got their first pregnancy before 17 years of age (146 cases, 242 randomly selected age-matched referents). Economic deprivation and disturbed family relations with an unsatisfied craving for parental affection influence adolescent sexual behavior. Girls' romanticism, belief in virginity until marriage and the contrasting male machismo culture contribute to a lack of empowerment of adolescents. At 15 years of age, 25% of boys and girls had had their sexual debut, and at 18 years this was the case for 85% of boys and 53% of girls. Among girls, the latency period from sexual debut to the end of first pregnancy was only 22 months, indicating very limited access to contraceptive counseling and services. At 17 years of age, one fourth had become pregnant. Contraceptive use was 54% among sexually active adolescents, aged 15-19 years, pills being the most common method. Among adults, female sterilization was the most common method, followed by Intra Uterine Device (IUD) and pilL Condom use was low as well as the use of traditional methods. Low educational attainment was a strong determinant for lack of contraception. Age at sexual debut and age at first pregnancy had been increasing, and fertility rate had declined in Nicaragua from the 1970s to the 1990s. The increase in women’s education was found to be the strongest explanatory factor behind this transition in fertility. Girls who had successfully completed at least 5 years of schooling had lower risk for early pregnancy. This protective effect of education was found for groups with high as well as low socioeconomic status. The background of adolescent pregnancy consists of a complex interaction of socio­economic, familial and cultural factors. Lack of political will to challenge current values, religious influence in sexual and educational issues, romanticism and lack of empowerment, especially among adolescent women, are also influencing elements. Contraceptive use is still low among sexually active teenagers in Nicaragua, and pregnancy follows soon after first intercourse. There is a strong need for family life education at schools and health services geared to adolescents. Non-use of contraception is associated with poverty and lack of education. The association between education and fertility decline, and the protective effect of education in preventing early pregnancies, even among poor families, indicates that education is a powerful tool in breaking the vicious cycles of poverty and early pregnancy.digitalisering@um

Breaking the cycles of poverty : Strategies, achievements, and lessons learned in Los Cuatro Santos, Nicaragua, 1990-2014

Background: In a post-war frontier area in north-western Nicaragua that was severely hit by Hurricane Mitch in 1998, local stakeholders embarked on and facilitated multi-dimensional development initiatives to break the cycles of poverty. Objective: The aim of this paper is to describe the process of priority-setting, and the strategies, guiding principles, activities, achievements, and lessons learned in these local development efforts from 1990 to 2014 in the Cuatro Santos area, Nicaragua. Methods: Data were derived from project records and a Health and Demographic Surveillance System that was initiated in 2004. The area had 25,893 inhabitants living in 5,966 households in 2014. Results: A participatory process with local stakeholders and community representatives resulted in a long-term strategic plan. Guiding principles were local ownership, political reconciliation, consensus decision-making, social and gender equity, an environmental and public health perspective, and sustainability. Local data were used in workshops with communities to re-prioritise and formulate new goals. The interventions included water and sanitation, house construction, microcredits, environmental protection, school breakfasts, technical training, university scholarships, home gardening, breastfeeding promotion, and maternity waiting homes. During the last decade, the proportion of individuals living in poverty was reduced from 79 to 47%. Primary school enrolment increased from 70 to 98% after the start of the school breakfast program. Under-five mortality was around 50 per 1,000 live births in 1990 and again peaked after Hurricane Mitch and was approaching 20 per 1,000 in 2014. Several of the interventions have been scaled up as national programs. Conclusions: The lessons learned from the Cuatro Santos initiative underline the importance of a bottom- up approach and local ownership of the development process, the value of local data for monitoring and evaluation, and the need for multi-dimensional local interventions to break the cycles of poverty and gain better health and welfare

Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings

Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs

Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings

Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs