Neck circumference as a predictor of all-cause mortality in middle-aged and older adults in rural Ecuador.

BACKGROUND: Neck circumference (NC) has been associated with mortality secondary to cardiovascular diseases and other conditions. However, information on this association in the population at large is limited. We aimed to assess this association in community dwellers living in rural Ecuador. METHODS: Individuals aged ≥40 y who were enrolled in the population-based Three Villages Study cohort were prospectively followed to estimate mortality risk according to baseline measurements of NC, after adjusting for relevant confounders. RESULTS: Analysis included 1521 individuals followed for a mean of 6.4±3.4 y. Mean NC was 36.2±3.7 cm, with 509 (33%) individuals allocated to the first (25-34 cm), 319 (21%) to the second (36-37 cm), 417 (27%) to the third (37-39 cm) and 276 (18%) to the fourth (40-50 cm) quartile. A total of 211 (14%) individuals died during the follow-up. Overall, the crude mortality rate was 2.3 per 100 person-years, which increased to 5.63 for those in the fourth NC quartile. An adjusted Cox-proportional hazards model showed that individuals in the fourth quartile of NC had higher mortality risk compared with the first quartile (HR: 2.98; 95% CI 1.77 to 5.02). CONCLUSION: Larger NC increases mortality risk in middle-aged and older adults of indigenous ancestry living in rural Ecuador.

Social determinants of health and cognitive performance of older adults living in rural communities: The Three Villages Study.

OBJECTIVES: There is limited information on factors associated with poor cognitive performance in rural settings of Low- and Middle-Income Countries. Using the Three Villages Study Cohort, we assessed whether social determinants of health (SDH) play a role in cognitive performance among older adults living in rural Ecuador. METHODS: Atahualpa, El Tambo and Prosperidad residents aged ≥60 years received measurement of SDH by means of the Gijon Scale together with a Montreal Cognitive Assessment (MoCA). The association between SDH and cognitive performance (dependent variable) was assessed by generalized linear models, adjusted for demographics, years of education, cardiovascular risk factors, symptoms of depression and biomarkers of structural brain damage. RESULTS: We included 513 individuals (mean age: 67.9 ± 7.3 years; 58% women). The mean score on the Gijon scale was 9.9 ± 2.9 points, with 237 subjects classified as having a high social risk (≥10 points). The mean MoCA score was 19.6 ± 5.4 points. Locally weighted scatterplot smoothing showed an inverse linear relationship between SDH and MoCA scores. SDH and MoCA scores were inversely associated in linear models adjusted for clinical covariates (ß: -0.17; 95% C.I.: -0.32 to -0.02; p = 0.020), neuroimaging covariates (ß: -0.17; 95% C.I.: -0.31 to -0.03; p = 0.018), as well as in the most parsimonious model (ß: -0.16; 95% C.I.: -1.30 to -0.02; p = 0.026). CONCLUSIONS: Study results provide robust evidence of an inverse association between SDH and cognitive performance. Interventions and programs aimed to reduce disparities in the social risk of older adults living in underserved rural populations may improve cognitive performance in these individuals.

Fontes de Apoio Social em contextos de pobreza: o que dizem as comunidades rurais? / Sources of Social Support in contexts of poverty: what do rural communities say?

Esse artigo tem como objetivo compreender as fontes de apoio social utilizadas pelos moradores de comunidades rurais nas regiões Nordeste, Norte e Sul do Brasil, analisadas como estratégias de enfrentamento às situações de opressão decorrentes da pobreza. Foram realizados 14 grupos focais, analisados em quatro dimensões: apoio familiar, apoio comunitário, apoio religioso e apoio institucional, com a utilização do software Atlas ti 5.2. Os resultados apontam que a família é o apoio diante de situações de angustia e privações decorrentes dos contextos de pobreza, reiterando a sua função no suporte emocional e na segurança material. O apoio comunitário se relaciona também ao apoio emocional e à partilha dos bens disponíveis, com poucas referências às lutas comunitárias. A espiritualidade, analisada como apoio religioso, é um campo de consolo existencial que se amplia a partir da precarização do apoio institucional. Esse apoio institucional, advindo das políticas públicas de saúde, educação e assistência social, apareceu na realidade dessas comunidades, no entanto com algumas dificuldades de funcionamento. Estudar o apoio social em comunidades rurais pobres busca superar os estudos que identificam a pobreza apenas como ausência, carência ou limitações, esquecendo a existência de espaços de potencialidades e enfrentamento.

This article aims to understand the sources of the social support used by residents of rural communities in the Northeast, North, and South regions of Brazil, analyzed as strategies to confront situations of oppression resulting from poverty. A total of 14 focus groups were analyzed in four dimensions: family support, community support, religious support, and institutional support using the Atlas software 5.2. The results indicate that the family is supportive of situations of distress and deprivation arising from the contexts of poverty, reiterating its role in emotional support and material security. Community support also relates to emotional support and the sharing of available assets, with few references to community struggles. Spirituality, analyzed as religious support, is a field of existential consolation that expands from the precariousness of institutional support. This institutional support, coming from the public policies of health, education, and social assistance, has appeared in the reality of these communities, but with some difficulties in functioning. Studying social support in poor rural communities seeks to overcome studies that identify poverty only as an absence, lack, or limitations, forgetting the existence of spaces of potentialities and coping

Cerebral small vessel disease in community-dwelling older adults living in remote rural settings.

PURPOSE: Cerebral small vessel disease (cSVD) has been overlooked in remote settings. In this study, we aimed to assess the burden of neuroimaging biomarkers of cSVD and its association with risk factors in community-dwelling older adults residing in rural Ecuador. METHODS: Brain MRIs were performed in 590 individuals aged ≥60 years living in three neighboring rural villages. MRI readings focused on white matter hyperintensities (WMH) of presumed vascular origin, deep cerebral microbleeds (CMB), enlarged basal ganglia-perivascular spaces (BG-PVS), and lacunes of presumed vascular origin. Mixed effects models for binary outcomes were fitted using WMH as the dependent variable. RESULTS: The mean age of participants was 71.1 ± 8.5 years (57% women). Moderate-to-severe WMH were noticed in 172 individuals (29%), deep CMB in 49 (8%), >10 enlarged BG-PVS in 183 (31%), and lacunes in 67 (11%). All biomarkers of cSVD were associated with increasing age, lower levels of education, poor physical activity, and arterial hypertension. Neuroimaging evidence of cSVD was present in almost half of older adults living in remote settings. CONCLUSIONS: Prompt recognition of cSVD biomarkers and implementation of strategic interventions may prove cost-effective for reducing its burden in underserved communities.

Cerebrovascular Correlates of Dementia in Community-Dwelling Older Adults Living in Rural Communities - The Three Villages Study. Rationale and Protocol of a Population-Based Prospective Cohort Study.

BACKGROUND: Despite the assumption that dementia is increasing in rural areas of Latin America, there is no information on the burden and risk factors leading to dementia in these settings. AIMS: To assess prevalence and incidence of dementia, and its cerebrovascular correlates in an established cohort of community-dwelling older adults living in rural Ecuador, and to explore the impact of dementia on functional disability and the role of the social determinants of health in the above-mentioned relationships. DESIGN: Population-based, cohort study with cross-sectional and longitudinal components. Baseline clinical interviews will focus on the assessment of cognitive performance and dementia by means of the clinical dementia rating scale (CDRS). Functional disability and social determinants of health will be correlated with CDRS scores. In addition, participants will undergo interviews and procedures to assess cardiovascular risk factors and signatures of brain damage, cerebral small vessel disease, and other stroke subtypes. The CDRS and the Functional Activities Questionnaire will be administered every year to assess the rate of incident dementia and the severity of functional disability. Neuroimaging studies will be repeated at the end of the study (5 years) to assess the impact of newly appeared cerebral and vascular lesions on cognitive decline. COMMENT: This study will allow determine whether cerebrovascular diseases are in the path of dementia development in these rural settings. This may prove cost-effective for the development of preventive strategies aimed to control modifiable factors and reduce disability in patients with dementia living in underserved populations.

Forms of subjectivation and precariousness of life: Contradictions in rural settings / Modos de subjetivação e precarização da vida: rebatimentos em contextos rurais / Modos de subjetivación y precarización de la vida: impactos en contextos rurales

This theoretical paper aims to examine some of the interfaces between rural settings and the field of mental health. First, living conditions in rural regions will be discussed, exploring rurality from a perspective of vulnerability and its impact on psychological health. Next, we will expand this approach by analyzing other analytical perspectives, namely Judith Butler's (2018) essay on the precariousness of life and Mbembe's (2018) necropolitics. Finally, this paper seeks to contribute to research on the living conditions and mental health of rural populations, and to promote territorial practices. Consideration will also be given to the specific lifestyles and needs of this community - without disregarding deteriorating conditions of inequality and insecurity arising from the conservative political discourse underway in our society.

O presente texto, de cunho teórico, objetiva discutir algumas interfaces entre contextos rurais e o campo da saúde mental. Inicialmente problematizamos as condições de vida no meio rural, chamando atenção para as ruralidades, e operando a partir do conceito de vulnerabilidade e seus rebatimentos na saúde mental. Em seguida, ampliamos essa discussão abrindo diálogo com outras perspectivas analíticas, a exemplo da discussão aportada por Judith Butler sobre a precarização da vida e da necropolítica de Mbembe. Por fim, pretendemos contribuir com as investigações que buscam entender as condições de vida e saúde mental das populações rurais e subsidiar práticas de cuidado territorializadas, considerando as especificidades dos modos de vida e necessidades dessas populações e atentando para o agravamento das condições de iniquidade e desproteção decorrentes de um projeto político conservador em curso em nossa sociedade.

El presente texto se propone discutir algunas interfaces entre los contextos rurales y el campo de la salud mental. Inicialmente, problematizamos las condiciones de vida en el medio rural, llamando atención sobre las diferentes ruralidades, y operando a partir del concepto de vulnerabilidad y sus impactos en la salud mental. A continuación, ampliamos esa discusión abriendo el diálogo a otras perspectivas analíticas, por ejemplo la discusión aportada por Judith Butler sobre la precarización de la vida y la necropolítica de Mbembe. Por último, pretendemos contribuir a las investigaciones que buscan entender las condiciones de vida y salud mental de las poblaciones rurales y aportar a prácticas de cuidado territorializadas, considerando las especificidades de los modos de vida y de las necesidades de esas poblaciones, y alertando sobre el agravamiento de las condiciones de inequidad y desprotección que se derivan de un proyecto político conservador en curso en nuestra sociedad.

Stroke risk factors in couples. A population-based study in community-dwelling adults living in a remote rural setting (the Atahualpa Project).

PURPOSE: By the use of a population-based design, this study aimed to evaluate the presence of similar stroke risk factors in couples living in a remote rural setting (Atahualpa). METHODS: Atahualpa residents aged ≥40 years were identified by means of door-to-door surveys, and those who signed a comprehensive consent form were enrolled in the Atahualpa Project. Baselines interviews and procedures, aimed to assess stroke risk factors, were collected at the time of admission in all participants. RESULTS: We identified 268 couples among 898 individuals aged ≥40 years enrolled in the Atahualpa Project. Traditional risk factors were defined according to the American Heart Association criteria. Generalized estimating equations, adjusted for age, showed that being married to a spouse with poor physical activity (p = 0.027) and a poor diet (p < 0.001) were associated with the presence of these risk factors in the other partner. CONCLUSIONS: Intervention strategies directed to couples are needed to improve poor healthy styles leading to stroke in underserved populations.

Clinical and neuroimaging risk factors for cognitive decline in community-dwelling older adults living in rural Ecuador. A population-based prospective cohort study.

OBJECTIVE: There is limited information on factors influencing cognitive decline in rural settings from low- and middle-income countries. Using the Atahualpa Project cohort, we aimed to assess the burden of cognitive decline in older adults living in a rural Ecuadorian village. METHODS: The study included Atahualpa residents aged greater than or equal to 60 years who had a follow-up Montreal Cognitive Assessment (MoCA) repeated at least 1 year after baseline. MoCA decline was assessed by multivariable longitudinal linear models, adjusted for demographics, days between MoCA tests, cardiovascular risk factors, and neuroimaging signatures of structural brain damage. RESULTS: We included 252 individuals who contributed 923.7 person-years of follow-up (mean: 3.7 ± 0.7 years). The mean baseline MoCA was 19.5 ± 4.5 points, and the follow-up MoCA was 18.1 ± 4.9 points (P = 0.001). Overall, 154 individuals (61%) had lower MoCA scores at follow-up. The best fitted longitudinal linear model showed a decline of follow-up MoCA from baseline (ß: 0.14; 95% CI, 0.0-0.21; P < 0.001). High glucose levels, global cortical atrophy, and white matter hyperintensities were independently and significantly associated with greater MoCA decline. CONCLUSION: This study provides evidence of cognitive decline in older adults living in a rural setting. Main targets for prevention should include glucose control and the control of factors that are deleterious for the development of cortical atrophy and white matter hyperintensities.

Ações das equipes volantes de CRAS no interior do Rio Grande do Norte / CRAS mobile team's performance in the countryside of Rio Grande do Norte / Acciones de los equipos móviles de CRAS dentro del Rio Grande do Norte

As equipes volantes de CRAS surgiram para viabilizar o acesso das famílias que vivem em regiões de difícil acesso ou grande espalhamento territorial aos serviços socioassistenciais. Investigou-se como as ações dessas equipes respondem às demandas de seus territórios no Rio Grande do Norte. Foram realizadas oito entrevistas semiestruturadas com equipes de sete municípios. Devido à falta de infraestrutura e quantidade de comunidades rurais espalhadas pelos territórios, a presença das equipes nas áreas rurais se torna esporádica, fragilizando a continuidade das ações. O conhecimento das profissionais sobre a realidade dos territórios é precário, pois a busca pelas demandas é assistemática. Entretanto, algumas equipes realizam ações que buscam romper com os limites e práticas assistencialistas, promovendo articulações com equipamentos e movimentos sociais que estão mais próximos às famílias.

The CRAS mobile teams were created to enable the access of families who live in areas which are difficult to access or have an extensive territory to the social services. We investigated how the performance of these mobile teams meets the demands of their territories in Rio Grande do Norte by making eight semi-structured interviews with teams that work in seven small towns. Given the lack of infrastructure and the number of rural communities scattered throughout the territory, the presence of the teams in rural areas becomes sporadic and ultimately the continuity of actions is undermined. The knowledge of the professionals about the reality of the territories is precarious, as the search for demands is asystematic. Nevertheless, some teams perform strategies and actions that seek to overcome the limits and the traditional assistencialism, working in partnership with social movements and equipments that are closer to the families.

Los equipos móviles del CRAS han surgido para facilitar el acceso de las familias que viven en zonas de difícil acceso o gran dispersión territorial para los servicios de asistencia social. Se investigó como las acciones de estos equipos responden a las demandas de sus territorios en el Rio Grande do Norte. Se realizaron ocho entrevistas semi-estructuradas con equipos de siete municipios. Debido a la falta de infraestructura y cantidad de comunidades rurales dispersadas por los territorios, la presencia de los equipos en las zonas rurales se vuelve esporádica, lo que debilita la continuidad de las acciones. El conocimiento de los profesionales sobre la realidad de los territorios es precaria, ya que la búsqueda de las demandas es poco sistemática. Sin embargo, algunos equipos realizan acciones que buscan romper con los límites y prácticas tradicionales, promoviendo las conexiones con los materiales y movimientos sociales que están más cerca de las familias.

Iniquidades Sociais e Saúde Mental no Meio Rural / Social Inequality and Mental Health in Rural Areas / Inequidades Sociales y Salud Mental en Contexto Rural

Esse artigo objetiva discutir casos de comorbidade de transtornos mentais comuns e uso abusivo de álcool e suas determinações entre moradores de assentamentos de reforma agrária. Trata-se de um estudo de delineamento combinado quantitativo-qualitativo, com amostra inicial de 2.012 moradores, resultando, após aplicação de questionário sociodemográfico e ferramentas de rastreamento (SRQ-20 e AUDIT) na identificação de 39 casos de comorbidade, aos quais foi aplicada entrevista semiestruturada. Para análise descritiva dos dados quantitativos utilizou-se o software SPSS for Windows, versão 20 e a construção de mapas dialógicos para os qualitativos. Aspectos envolvendo educação e trabalho, ambientes de interação/coesão social (redes e apoio social), mobilidade e transporte, acesso a equipamentos e serviços, falta de espaços de lazer, são fatores que interferem na saúde mental. Considera-se, dessa forma, a interdependência entre condições socioeconômicas, características dos territórios, padrões culturais, histórias de vida dos indivíduos e os agravos em saúde e morbidades psiquiátricas, em particular.(AU)

The vulnerable psychosocial conditions found within poverty are made worse when dealing with populations from rural areas. These groups suffer the most from a lack of basic infrastructure and the problems that arise from the lack of social development. These people are hit the hardest, but remain less visible and far out of reach of public policies, especially in the case of mental health. For this discussion, we analyze cases of comorbidity of common mental disorders and alcohol abuse and its determinations among residents of land reform settlements. It is a combined quantitative-qualitative delineated study, with na initial sample of 2,012 residents. After the administration of a sociodemographic questionnaire and screening tools (SRQ-20 e Audit), 39 cases of comorbidity were identified, to which semi-structured interviews were administered. For descriptive analysis of the quantitative data, we used SPSS for Windows version 20, and the construction of dialogic maps for qualitative data. We bserved the interdependence between socioeconomic conditions, the characteristics of territories, cultural patterns, individuallife stories and mental diseases in particular.(AU)

El objetivo de este artículo fue discutir casos de comorbilidad de trastornos mentales comunes y uso exagerado de alcohol y sus determinaciones entre vecinos de la reforma agraria.Se trata de un estudio de delineamiento combinado cuantitativo - cualitativo,con una muestra inicial de 2012 participantes, resultando después de aplicarse un cuestionario sociodemógrafico y herramientas de rastreamiento (SRQ-20 y AUDIT), la identificación de 39 casos de comorbilidad, a los cuales les fue aplicada una entrevista semiestructurada.Para el análisis descriptivo de los datos cuantitativos se utilizó el software for Windows, versión 20 y la construcción de mapas dialógicos para los datos cualitativos. Aspectos relativos a educación y trabajo, ambientes de interacción/cohesión social (redes y apoyo social) movilidad y transporte,acceso a equipamientos y servicios, falta de espacios de recreación, son factores que interfieren en la salud mental.Por lo tanto se considera la interdependencia entre condiciones socieconómicas, características de los territorios, padrones culturales, historia de vida de los individuos, y losagravios en salud y morbilidad psiquiátricas, en particular.(AU)

Atahualpa, una población rural ideal para la práctica de estudios epidemiológicos / Atahualpa, an optimal rural setting for the practice of epidemiological studies

RESUMEN Atahualpa es una población rural situada en el litoral Ecuatoriano, que cumple una serie de requisitos como para ser considerada ideal para la práctica de estudios epidemiológicos. Entre estos destacan el hecho de ser una población aislada, con muy bajos índices de migración y bastante homogénea en lo que respecta a raza, costumbres, estilos de vida y alimentación, la cual es rica en pescado oleoso. Los habitantes son nativos Ecuatorianos con escasa evidencia de mestizaje. La mayoría de los hombres son carpinteros y las mujeres cumplen quehaceres del hogar. Estas coincidencias reducen el riesgo de factores confusores que pueden comprometer la veracidad de los datos al momento del análisis. Sin embargo, esta homogeneidad podría condicionar que los datos obtenidos en este pueblo no sean extrapolables a otras comunidades de la región. Es necesario hacer réplicas del Proyecto Atahualpa en poblados vecinos (utilizando protocolos similares), con la finalidad de valorar la generalización de los datos obtenidos en esta población.

ABSTRACT Atahualpa is a rural village located in coastal Ecuador that achieves a number of requisites to be considered as an optimal setting for the practice of epidemiological studies. Atahualpa is an isolated village with a very low index of migration rate. Inhabitants are fairly homogeneous regarding race, lifestyles and diet, which is rich in oily fish. From the racial point of view, inhabitants are Ecuadorian natives with little evidence of cross-breading. Most men are artisan carpenters and most women are homemakers. These coincidences reduce the risk of the presence of unexpected confounders at the time of data analyses. However, this may also cause that data obtained might not be extrapolated to other regions. The practice of studies in neighboring villages, using similar protocols, is needed to validate generality of data obtained in Atahualpa.

Detection of drug resistant Mycobacterium tuberculosis among patients with and without HIV infection in a rural setting / Detección de Mycobacterium tubersulosis resistente a los antibióticos entre pacientes con y sin infección por VIH en un área rural

OBJECTIVE: To analyse the sensitivity of Mycobacterium tuberculosis by nitrate reductase assay (NRA) and the Hain molecular line probe assay (LPA) in sputa of tuberculosis (TB)/HIV co-infected patients in Guyana. DESIGN: Sputum samples were collected from known TB patients at Georgetown Chest Clinic and were analysed at the Reference Laboratory, Guyana, over the period April 2010 to April 2011. RESULTS: Both methods recorded greater sensitivity for rifampin (RIF) than of isoniazid (INH). Both methods detected four RIF resistant, two INH resistant and two multi-drug resistant (MDR) strains and they had greater negative agreement indices than positive agreement indices. CONCLUSION: It was established that the sensitivity of Mycobacterium tuberculosis by the NRA and Hain LPA in TB/HIV co-infected patients has acceptable correlation and that HIV infection does not affect drug susceptibility testing.

OBJETIVO: Analizar la sensibilidad de Mycobacterium tuberculosis por medio del ensayo de nitrato reductasa (NRA) y el ensayo de sonda lineal (LPA) molecular de Hain en esputos de pacientes co-infectados TB/VIH en Guyana. DISEÑO: Muestras de esputo de pacientes de la Clínica del Tórax en Georgetown diagnosticados con tuberculosis, fueron analizadas en el Laboratorio de Referencias, en Guyana, en el período de abril de 2010 a abril de 2011. RESULTADOS: Ambos métodos registraron una mayor sensibilidad a la rifampicina (RIF) que a la isoniacida (INH). Ambos métodos detectaron cuatro cepas resistentes a RIF, dos resistentes a INH, y dos resistentes a mútiples medicamentos (RMM). Asimismo, presentaban mayores índices de concordancia negativa que de concordancia positiva. CONCLUSIÓN: Se estableció que la sensibilidad de Mycobacterium tuberculosis por medio del ensayo de NRA y el LPA de Hain en pacientes co-infectados TB/VIH, guarda una correlación aceptable, y que la infección por VIH no afecta la prueba de susceptibilidad a los medicamentos.