Rodolfo Peña

Candies in hell: women's experiences of violence in Nicaragua

The aim of this study was to describe the characteristics of domestic violence against women in León, Nicaragua. A survey was carried out among a representative sample of 488 women between the ages of 15-49. The physical aggression sub-scale of the Conflict Tactics Scale was used to identify women suffering abuse. In-depth interviews with formerly battered women were performed and narratives from these interviews were analysed and compared with the survey data. Among ever-married women 52% reported having experienced physical partner abuse at some point in their lives. Median duration of abuse was 5 years. A considerable overlap was found between physical, emotional and sexual violence, with 21% of ever-married women reporting all three kinds of abuse. Thirty-one percent of abused women suffered physical violence during pregnancy. The latency period between the initiation of marriage or cohabitation and violence was short, with over 50% of the battered women reporting that the first act of violence act took place within the first 2 years of marriage. Significant, positive associations were found between partner abuse and problems among children, including physical abuse. Both the survey data and the narrative analysis pointed to extreme jealousy and control as constant features of the abusive relationship. Further, the data indicate that battered women frequently experience feelings of shame, isolation and entrapment which, together with a lack of family and community support, often contribute to womens difficulty in recognizing and disengaging from a violent relationship. These findings are consistent with theoretical conceptualisations of domestic violence developed in other countries, suggesting that, to a large degree, womens experiences of violence transcend specific cultural contexts.

14-day triple, 5-day concomitant, and 10-day sequential therapies for Helicobacter pylori infection in seven Latin American sites: a randomised trial

BACKGROUND Evidence from Europe, Asia, and North America suggests that standard three-drug regimens of a proton-pump inhibitor plus amoxicillin and clarithromycin are significantly less effective for eradication of Helicobacter pylori infection than are 5-day concomitant and 10-day sequential four-drug regimens that include a nitroimidazole. These four-drug regimens also entail fewer antibiotic doses than do three-drug regimens and thus could be suitable for eradication programmes in low-resource settings. Few studies in Latin America have been done, where the burden of H pylori-associated diseases is high. We therefore did a randomised trial in Latin America comparing the effectiveness of four-drug regimens given concomitantly or sequentially with that of a standard 14-day regimen of triple therapy. METHODS Between September, 2009, and June, 2010, we did a randomised trial of empiric 14-day triple, 5-day concomitant, and 10-day sequential therapies for H pylori in seven Latin American sites: Chile, Colombia, Costa Rica, Honduras, Nicaragua, and Mexico (two sites). Participants aged 21-65 years who tested positive for H pylori by a urea breath test were randomly assigned by a central computer using a dynamic balancing procedure to: 14 days of lansoprazole, amoxicillin, and clarithromycin (standard therapy); 5 days of lansoprazole, amoxicillin, clarithromycin, and metronidazole (concomitant therapy); or 5 days of lansoprazole and amoxicillin followed by 5 days of lansoprazole, clarithromycin, and metronidazole (sequential therapy). Eradication was assessed by urea breath test 6-8 weeks after randomisation. The trial was not masked. Our primary outcome was probablity of H pylori eradication. Our analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, registration number NCT01061437. FINDINGS 1463 participants aged 21-65 years were randomly allocated a treatment: 488 were treated with 14-day standard therapy, 489 with 5-day concomitant therapy, and 486 with 10-day sequential therapy. The probability of eradication with standard therapy was 82·2% (401 of 488), which was 8·6% higher (95% adjusted CI 2·6-14·5) than with concomitant therapy (73·6% [360 of 489]) and 5·6% higher (-0·04% to 11·6) than with sequential therapy (76·5% [372 of 486]). Neither four-drug regimen was significantly better than standard triple therapy in any of the seven sites. INTERPRETATION Standard 14-day triple-drug therapy is preferable to 5-day concomitant or 10-day sequential four-drug regimens as empiric therapy for H pylori infection in diverse Latin American populations. FUNDING Bill & Melinda Gates Foundation, US National Institutes of Health.

Wife abuse among women of childbearing age in Nicaragua.

OBJECTIVES This study measured the prevalence, frequency, and severity of physical wife abuse and its risk factors in León, Nicaragua. METHODS A cross-sectional survey was conducted with a representative sample of 488 women 15 to 49 years of age. RESULTS The lifetime prevalence of spousal violence was 52% among ever-married women (n = 360). Spousal violence was significantly positively associated with poverty, parity, urban residence, and history of violence in the husbands family. No significant associations were found between spousal violence and womens age, education, marital dependency, or occupation. CONCLUSIONS Wife abuse constitutes a major public health problem in Nicaragua, requiring urgent measures for prevention and treatment for victims.

Prevalence of Rheumatic Heart Disease in Children and Young Adults in Nicaragua

Rheumatic heart disease (RHD) results in morbidity and mortality that is disproportionate among individuals in developing countries compared to those living in economically developed countries. The global burden of disease is uncertain because most previous studies to determine the prevalence of RHD in children relied on clinical screening criteria that lacked the sensitivity to detect most cases. The present study was performed to determine the prevalence of RHD in children and young adults in León, Nicaragua, an area previously thought to have a high prevalence of RHD. This was an observational study of 3,150 children aged 5 to 15 years and 489 adults aged 20 to 35 years randomly selected from urban and rural areas of León. Cardiopulmonary examinations and Doppler echocardiographic studies were performed on all subjects. Doppler echocardiographic diagnosis of RHD was based on predefined consensus criteria that were developed by a working group of the World Health Organization and the National Institutes of Health. The overall prevalence of RHD in children was 48 in 1,000 (95% confidence interval 35 in 1,000 to 60 in 1,000). The prevalence in urban children was 34 in 1,000, and in rural children it was 80 in 1,000. Using more stringent Doppler echocardiographic criteria designed to diagnose definite RHD in adults, the prevalence was 22 in 1,000 (95% confidence interval 8 in 1,000 to 37 in 1,000). In conclusion, the prevalence of RHD among children and adults in this economically disadvantaged population far exceeds previously predicted rates. The findings underscore the potential health and economic burden of acute rheumatic fever and RHD and support the need for more effective measures of prevention, which may include safe, effective, and affordable vaccines to prevent the streptococcal infections that trigger the disease.

Physical partner abuse during pregnancy: a risk factor for low birth weight in Nicaragua

OBJECTIVE To assess whether being physically abused during pregnancy increases the risk of a low birth weight (LBW) infant. METHODS We conducted a hospital‐based case‐control study in León, Nicaragua. Cases consisted of 101 newborns with a birth weight under 2500 g, and for each case two controls with a birth weight over 2500 g were selected randomly from infants born the same day. Anthropometry of newborns was done immediately after birth, and background information and data on experiences of violence and potential confounders were obtained through private interviews with mothers. Crude and adjusted odds ratios (ORs) and population‐attributable proportion were calculated for exposure to partner abuse in relation to LBW. Multivariate logistic regression analysis was used to control for potential confounding. RESULTS Seventy‐five percent of LBW newborns (cases) were small for gestational age and 40% were preterm. Twenty‐two percent of the mothers of LBW infants had experienced physical abuse during pregnancy by their intimate partners compared with 5% of controls. Low birth weight was associated with physical partner abuse even after adjustment for age, parity, smoking, and socioeconomic status (OR 3.9; 95% confidence interval 1.7, 9.3). Given a causal interpretation of the association, about 16% of the LBW in the infant population could be attributed to physical abuse by a partner in pregnancy. CONCLUSION Physical abuse by a partner during pregnancy is an independent risk factor for LBW.

The effect of poverty, social inequity, and maternal education on infant mortality in Nicaragua, 1988-1993.

OBJECTIVES This study assessed the effect of poverty and social inequity on infant mortality risks in Nicaragua from 1988 to 1993 and the preventive role of maternal education. METHODS A cohort analysis of infant survival, based on reproductive histories of a representative sample of 10,867 women aged 15 to 49 years in León, Nicaragua, was conducted. A total of 7073 infants were studied; 342 deaths occurred during 6394 infant-years of follow-up. Outcome measures were infant mortality rate (IMR) and relative mortality risks for different groups. RESULTS IMR was 50 per 1000 live births. Poverty, expressed as unsatisfied basic needs (UBN) of the household, increased the risk of infant death (adjusted relative risk [RR] = 1.49; 95% confidence interval [CI] = 1.15, 1.92). Social inequity, expressed as the contrast between the household UBN and the predominant UBN of the neighborhood, further increased the risk (adjusted RR = 1.74; 95% CI = 1.12, 2.71). A protective effect of the mothers educational level was seen only in poor households. CONCLUSIONS Apart from absolute level of poverty, social inequity may be an independent risk factor for infant mortality in a low-income country. In poor households, female education may contribute to preventing infant mortality.

Women's strategic responses to violence in Nicaragua

STUDY OBJECTIVE To describe the responses of women in León, Nicaragua to partner abuse and identify contextual factors associated with the use of certain coping mechanisms and the likelihood of permanent separation. DESIGN Cross sectional population-based survey. SETTING León, Nicaragua. PARTICIPANTS 188 women 15–49 years of age who had experienced physical partner abuse, out of 488 women interviewed. MAIN RESULTS 66% of women defended themselves effectively from abuse either physically or verbally. Forty one per cent of women had left home temporarily because of violence and 20% had sought help outside the home. Women experiencing severe abuse were more likely to leave or seek help, whereas women with less severe abuse were more able to defend themselves effectively. Seventy per cent of women eventually left abusive relationships. Help seeking and temporary separations increased the likelihood of a permanent separation, whereas women who defended themselves and were able to stop the violence, at least temporarily, were more likely to remain in abusive relationships. CONCLUSIONS Women in Nicaragua use a variety of methods in order to overcome physical partner abuse. Temporary leaving and help seeking are critical steps in the process of leaving a violent relationship. However, many women indicated that they did not receive support for their situation. More interventions are needed to help women recognise and deal with violence, as well as strengthening the community support networks available to abused women.

Violence against pregnant women: prevalence and characteristics. A population-based study in Nicaragua.

Objective  This study aims to estimate the prevalence and characteristics of partner abuse during pregnancy as well as to investigate associated social factors in León, Nicaragua.

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.

Risk of recurrent Helicobacter pylori infection 1 year after initial eradication therapy in 7 Latin American communities.

IMPORTANCE The long-term effectiveness of Helicobacter pylori eradication programs for preventing gastric cancer will depend on recurrence risk and individual and community factors. OBJECTIVE To estimate risk of H. pylori recurrence and assess factors associated with successful eradication 1 year after treatment. DESIGN, SETTING, AND PARTICIPANTS Cohort analysis of 1463 randomized trial participants aged 21 to 65 years from 7 Latin American communities, who were treated for H. pylori and observed between September 2009 and July 2011. INTERVENTIONS Randomization to 1 of 3 treatment groups: 14-day lansoprazole, amoxicillin, and clarithromycin (triple therapy); 5-day lansoprazole and amoxicillin followed by 5-day lansoprazole, clarithromycin, and metronidazole (sequential); or 5-day lansoprazole, amoxicillin, clarithromycin, and metronidazole (concomitant). Participants with a positive (13)C-urea breath test (UBT) 6 to 8 weeks posttreatment were offered voluntary re-treatment with 14-day bismuth-based quadruple therapy. MEASUREMENTS Recurrent infection after a negative posttreatment UBT and factors associated with successful eradication at 1-year follow-up. RESULTS Among participants with UBT-negative results who had a 1-year follow-up UBT (n=1091), 125 tested UBT positive, a recurrence risk of 11.5% (95% CI, 9.6%-13.5%). Recurrence was significantly associated with study site (P = .03), nonadherence to initial therapy (adjusted odds ratio [AOR], 2.94; 95% CI, 1.31-6.13; P = .01), and children in the household (AOR, 1.17; 95% CI, 1.01-1.35 per child; P = .03). Of the 281 with positive posttreatment UBT results, 138 completed re-treatment, of whom 93 tested UBT negative at 1 year. Among the 1340 who had a 1-year UBT, 80.4% (95% CI, 76.4%-83.9%), 79.8% (95% CI, 75.8%-83.5%), and 77.8% (95% CI, 73.6%-81.6%) had UBT-negative results in the triple, sequential, and concomitant groups, respectively (P = .61), with 79.3% overall effectiveness (95% CI, 77.1%-81.5%). In a single-treatment course analysis that ignored the effects of re-treatment, the percentage of UBT-negative results at 1 year was 72.4% (95% CI, 69.9%-74.8%) and was significantly associated with study site (P < .001), adherence to initial therapy (AOR, 0.26; 95% CI, 0.15-0.42; P < .001), male sex (AOR, 1.63; 95% CI, 1.25-2.13; P < .001), and age (AOR, 1.14; 95% CI, 1.02-1.27 per decade; P = .02). One-year effectiveness among all 1463 enrolled participants, considering all missing UBT results as positive, was 72.7% (95% CI, 70.3%-74.9%). CONCLUSIONS AND RELEVANCE One year after treatment for H. pylori infection, recurrence occurred in 11.5% of participants who had negative posttreatment UBT results. Recurrence determinants (ie, nonadherence and demographics) may be as important as specific antibiotic regimen in determining the long-term success of H. pylori eradication interventions. Study findings are relevant to the feasibility of programs for the primary prevention of gastric cancer in high-incidence regions of Latin America. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01061437.