Catalina A. Denman

An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study

Summary Background Cardiovascular disease contributes substantially to the non-communicable disease (NCD) burden in low-income and middle-income countries, which also often have substantial health personnel shortages. In this observational study we investigated whether community health workers could do community-based screenings to predict cardiovascular disease risk as effectively as could physicians or nurses, with a simple, non-invasive risk prediction indicator in low-income and middle-income countries. Methods This observation study was done in Bangladesh, Guatemala, Mexico, and South Africa. Each site recruited at least ten to 15 community health workers based on usual site-specific norms for required levels of education and language competency. Community health workers had to reside in the community where the screenings were done and had to be fluent in that community’s predominant language. These workers were trained to calculate an absolute cardiovascular disease risk score with a previously validated simple, non-invasive screening indicator. Community health workers who successfully finished the training screened community residents aged 35–74 years without a previous diagnosis of hypertension, diabetes, or heart disease. Health professionals independently generated a second risk score with the same instrument and the two sets of scores were compared for agreement. The primary endpoint of this study was the level of direct agreement between risk scores assigned by the community health workers and the health professionals. Findings Of 68 community health worker trainees recruited between June 4, 2012, and Feb 8, 2013, 42 were deemed qualified to do fieldwork (15 in Bangladesh, eight in Guatemala, nine in Mexico, and ten in South Africa). Across all sites, 4383 community members were approached for participation and 4049 completed screening. The mean level of agreement between the two sets of risk scores was 96 8% (weighted κ =0 948, 95% CI 0 936–0 961) and community health workers showed that 263 (6%) of 4049 people had a 5-year cardiovascular disease risk of greater than 20%. Interpretation Health workers without formal professional training can be adequately trained to effectively screen for, and identify, people at high risk of cardiovascular disease. Using community health workers for this screening would free up trained health professionals in low-resource settings to do tasks that need high levels of formal, professional training. Funding US National Heart, Lung, and Blood Institute and National Institutes of Health, UnitedHealth Chronic Disease Initiative.

Risk factors for squamous intraepithelial lesions (SIL) of the cervix among women residing at the US-Mexico border

It is now well established that cervical cancer is caused by oncogenic human papillomavirus (HPV) infections that commonly infect women worldwide. What remains to be understood are the factors that contribute to cervical cancer in the presence of HPV infection. We conducted a case‐control analysis of women recruited at the US‐Mexico border to simultaneously evaluate factors associated with 3 cytologic outcomes: atypical squamous cells of undetermined significance or atypical glandular cells of undetermined significance (ASCUS/AGUS), low grade squamous intraepithelial lesions (LSIL) and high grade squamous intraepithelial lesions (HSIL). A cross‐sectional binational study of 2,059 women ages 15–79 years was conducted between 1997 and 1998. A significant difference in the distribution of cytologic categories by country was observed (3.0% vs. 0.7% HSIL among Mexican vs. US women, respectively). The only factors independently associated with all 3 cytologic outcomes were HPV infection and viral load. A linear increase in risk with increasing viral load was observed for each of the 3 outcome variables, with the strength of this association increasing with cytology abnormality. In addition to HPV infection, parity and Mexico as a country of residence appear to be associated with LSIL and HSIL, respectively. Factors associated with cytologic outcomes in analyses limited to women with HPV infection were similar to results obtained in models where HPV infection was included as a covariate. Future work is needed to evaluate the predictive value of HPV viral load utilizing more specific and quantitative measures.

Design and results of the USA-Mexico border human papillomavirus (HPV), cervical dysplasia, and Chlamydia trachomatis study

OBJECTIVE Mexico has one of the highest mortality rates of invasive cervical cancer in the world. This is particularly true for the states in northern Mexico that border on the United States of America. In addition, Hispanics in the United States have higher rates than do non-Hispanics in the country. Therefore, a binational team was formed to focus on this problem and to determine the risk factors and prevalence of cervical dysplasia and human papillomavirus (HPV) infection, the sexually transmitted disease (STD) known to cause cervical cancer. Chlamydia trachomatis infection, a common STD and potential HPV cofactor, was also assessed. METHODS Research was conducted in 1997 and 1998 in the border region of two states, Arizona in the United States and Sonora in Mexico, applying a cross-sectional study of women attending clinics for routine gynecologic care. Clinical measurements included Pap smears, HPV infection by both polymerase chain reaction (PCR) and Hybrid Capture (HC), and C. trachomatis status by HC and enzyme-linked immunoassay (EIA). A total of 2,436 women were enrolled (mean age 33.3 years +/- 10.3 years). RESULTS The overall prevalence of abnormal cytology was 9.3%, with a significant difference in the prevalence in Mexico (11.4%) vs. the United States (6.6%). Of the participants, 14.5% of them tested positive for HPV by PCR, with no significant difference between the two countries, in spite of a lower behavioral risk profile for the Mexican women. Overall prevalence of C. trachomatis was found to be greater by HC than by EIA (8.2% vs. 3.0%), and in Mexico higher by both methods. CONCLUSIONS An important accomplishment of the project was the implementation of a quality control program for Pap smear collection, which resulted in a significant reduction in inadequate smears in Mexico. Despite numerous potential logistical barriers, the binational team successfully conducted a large-scale study in the border area and developed an infrastructure for future research.

Human papillomavirus prevalence at the USA-Mexico border among women 40 years of age and older.

The incidence of cervical cancer increases with age among USA Hispanics and women living in Latin America starting in the fourth decade of life. We conducted a study of women ≥40 living at the USA–Mexico border to determine the prevalence and risk factors for human papillomavirus (HPV) infection detected by polymerase chain reaction. In all, 9.2% of participants tested HPV positive. Compared with women aged 50–59, odds ratios of 8.82 and 6.67 were observed for women ≥60 and 40–49, respectively. Among women aged 40–49, both oncogenic and non-oncogenic HPV infections were detected; however, women ≥ 60 were positive for predominantly oncogenic genotypes. HPV risk significantly increased with ≥2 lifetime sexual partners in adjusted models. These data suggest that the prevalence of HPV infection may have a second peak among post-menopausal Hispanic women.

HEALTHCARE ACCESS AND UTILIZATION AMONG WOMEN 40 AND OLDER AT THE U.S.-MEXICO BORDER: PREDICTORS OF A ROUTINE CHECK-UP

Mexican Americans are more likely to experience barriers to access and utilization of healthcare services than any other U.S. Hispanic group. In Mexico, where the majority of the population has access to care, the pressing issue is the underutilization of preventive services among adults. This study was conducted to assess access and utilization barriers among a U.S.-Mexico border population. A cross-sectional, population-based survey was conducted during 1999–2000 in a pair of contiguous U.S.-Mexico border communities. Household surveys were administered to U.S. and Mexican women, 40 years of age and older, to assess healthcare access and utilization, participation in chronic disease screenings, orientation toward prevention and personal history of chronic disease. Analysis indicates few statistically significant differences (p < 0.05) among access and utilization variables by country. Mexican participants were more likely to have a regular source of care and to have had a blood sugar test within the past 12 months. U.S. participants more often reported having had a Pap smear and mammogram during the previous year. Factors independently positively associated with having had a routine check-up during the past 12 months included age and having a regular provider or place to go when sick. Only going to the doctor when ill was independently inversely associated with routine check-ups in the past 12 months. Findings suggest that U.S. and Mexican border populations are similar with regard to healthcare access and utilization characteristics. Efforts to increase utilization of preventive health screenings among women are needed at the U.S.-Mexico border.

Cardiovascular Disease Screening By Community Health Workers Can Be Cost-Effective In Low-Resource Countries

In low-resource settings, a physician is not always available. We recently demonstrated that community health workers-instead of physicians or nurses-can efficiently screen adults for cardiovascular disease in South Africa, Mexico, and Guatemala. In this analysis we sought to determine the health and economic impacts of shifting this screening to community health workers equipped with either a paper-based or a mobile phone-based screening tool. We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening. The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost. Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care. Policy makers should promote greater acceptance of community health workers by both national populations and health professionals and should increase their commitment to treating cardiovascular disease and making medications available.

The Training and Fieldwork Experiences of Community Health Workers Conducting Population-Based, Noninvasive Screening for CVD in LMIC

BACKGROUND Cardiovascular disease (CVD) is on the rise in low- and middle-income countries and is proving difficult to combat due to the emphasis on improving outcomes in maternal and child health and infectious diseases against a backdrop of severe human resource and infrastructure constraints. Effective task-sharing from physicians or nurses to community health workers (CHW) to conduct population-based screening for persons at risk has the potential to mitigate the impact of CVD on vulnerable populations. CHW in Bangladesh, Guatemala, Mexico, and South Africa were trained to conduct noninvasive population-based screening for persons at high risk for CVD. OBJECTIVES This study sought to quantitatively assess the performance of CHW during training and to qualitatively capture their training and fieldwork experiences while conducting noninvasive screening for CVD risk in their communities. METHODS Written tests were used to assess CHWs acquisition of content knowledge during training, and focus group discussions were conducted to capture their training and fieldwork experiences. RESULTS Training was effective at increasing the CHWs content knowledge of CVD, and this knowledge was largely retained up to 6 months after the completion of fieldwork. Common themes that need to be addressed when designing task-sharing with CHW in chronic diseases are identified, including language, respect, and compensation. The importance of having intimate knowledge of the community receiving services from design to implementation is underscored. CONCLUSIONS Effective training for screening for CVD in community settings should have a strong didactic core that is supplemented with culture-specific adaptations in the delivery of instruction. The incorporation of expert and intimate knowledge of the communities themselves is critical, from the design to implementation phases of training. Challenges such as role definition, defining career paths, and providing adequate remuneration must be addressed.

Mortalidad infantil y marginación urbana: análisis espacial de su relación en una ciudad de tamaño medio del noroeste mexicano

OBJECTIVE To identify areas with high risk of infant mortality and any possible correlation with the populations socioeconomic status through the use of a geographic information system and spacial analysis techniques. METHODS An exploratory ecologic study was conducted in Hermosillo, the capital of Sonora, Mexico, in 2000-2003. The urban marginalization index (UMI) and the infant mortality rate (IMR) were determined for each of the citys basic geostatistical areas (BGA). The UMI and IMR were statistically calculated to identify geographic areas in which they were concentrated and to determine the degree of spatial correlation between these indicators. To determine the general spatial autocorrelation and spatial clustering of UMIs and IMRs within the city and the BGAs, Morans I index, Ipop statistics, and Besag and Newells method were employed. RESULTS The mean IMR was 14.3 per 1,000 live births, higher in the BGAs with greater social marginalization (16.2 per 1,000) and lower in those with less (11.7 per 1,000). The UMI range was -3.1-6.6 (maximum: 4.3; minimum: -2.7). Autocorrelation was found among the UMI (Moran I = 0.62), with significant clustering in the citys northwest, northeast, and southeast parts. Local clustering of high IMRs was found in Hermosillos central and western areas, albeit without autocorrelation (Moran I = -0.007). High risk areas (high IMR and high UMI) were found in the citys northwestern section. CONCLUSIONS Spatial clusters with high IMR were found in socially marginalized areas in the northwestern part of Hermosillo, a city of medium size located in northwestern Mexico. These results, reached through a combination of spatial analysis techniques and geographic information tools can help guide interventions specifically designed for these high risk residential areas.

Factors Associated with Work-Related Accidents and Sickness among Maquiladora Workers: The Case of Nogales, Sonora, Mexico

The health problems of maquiladora workers were explored in a sample of 497 workers of Nogales, Sonora, Mexico. The workers were interviewed using a structured questionnaire containing four sections: a sociodemographic profile, occupational history, working conditions, and a health profile. Overall, 12.6 percent of the workers reported having an accident while working in the maquila, more than 40 percent of these requiring at least one day of disability, and 18.3 percent of workers reported having an episode of sickness/disease. More than 60 percent perceived health-related risks associated with working conditions. The presence of a doctor or nurse in the plant (odds ratio = 0.30), a perception of risk associated with working conditions (odds ratio = 1.85), and the plant offering information about work-related risks (odds ratio = 0.39) were among the significant predictors of work-related accidents and disease/sickness. The authors discuss the implications of these results for programs and policies to improve safety conditions in the maquiladora industry.

Pap Smear Screening Among Women ≥40 years Residing at the United States–Mexico Border

Invasive cervical cancer is a preventable disease due to screening for precursor lesions using the Papanicolaou cytological testing (Pap smear). Participants were assessed regarding their access to and utilization of health care services, prevention orientation, history of chronic disease screening, and reproductive health history. Factors independently positively associated with Pap smear screening were age, clinical breast exam (CBE) in the last year, doctor recommendation of a Pap test, living in the United States, and checkup in the past year. Having a regular source of health care, as well as a doctors recommendation for a Pap smear, appears to have a positive effect on womens Pap smear screening rates in U.S.–Mexico border communities.