RESUMO
Starting in 2017, Ecuador gradually expanded its primary healthcare access program nationwide using mobile traveling healthcare teams through the Estrategia Médico del Barrio (EMB) [or Neighborhood Doctor Strategy]. EMB teams, composed of a primary care physician, a nurse, and a community health worker, made home visits in marginalized areas. We estimate the impact of the EMB on health and utilization outcomes using nationally representative household surveys for 2006 (N=55,666), 2012-13 (N=92,500) and 2018-19 (N=168,747). The treatment variable at the extensive margin is any exposure to EMB at the canton level. At the intensive margin, we use exposure in terms of weeks covered by EMB and the number and composition of EMB personnel per 1000 population. We identify outcomes of treated vs. non- or partially-treated cantons based on the random combination of the timing of the start of the program's implementation and the timing of the survey interview, which varied across cantons. We use difference-in-difference (DD) and difference-in-difference-in-difference (DDD) frameworks, the latter for cantons with high indigenous concentration. We find significant effects on the reported health problem and preventive care, but mixed results in terms of curative healthcare. The DDD specification shows that EMB improved health problem diagnoses and preventive healthcare utilization, including in highly indigenous cantons, yet it seemed to have had mixed results in terms of curative care use in Ecuador. Various alternative specifications and robustness tests do not qualitatively alter the main findings.
RESUMO
BACKGROUND: A vast literature has demonstrated that several mother-related variables are positively associated with their daughters' sexual and reproductive outcomes. One underexplored variable is sexual empowerment--a subdimension of empowerment. In this study, we explore if maternal sexual empowerment is predictive of adolescent daughters' outcomes like early sexual initiation, teenage pregnancy, and contraception use. METHODS: This study uses data from the 2018 National Health and Nutrition Survey of Ecuador (Ensanut), a cross-sectional survey in Ecuador that measures health and nutrition. We examine whether mothers' sexual empowerment--measured as a woman's autonomy in sexual relationships and her ability to turn down sex and demand contraception use from her partner--is predictive of sexual and reproductive outcomes among female adolescent children. Logistic regression was performed to test this association. RESULTS: Results showed that having a mother who lacked sexual empowerment increased the odds of early sexual initiation. Girls who had a mother who had a teenage birth were more likely to experience teenage pregnancy themselves. CONCLUSIONS: Mothers may influence daughters' attitudes towards sex through their own demonstration of sexual empowerment. This research demonstrates that a lack of maternal sexual empowerment can be a risk factor of early sexual initiation, teenage pregnancy, and lack of contraception use among female adolescents. More research is needed to confirm the robustness of these results and analyze other forms of sexual empowerment. LIMITATIONS: Other variables not present in the data, like domestic violence, can be used to understand the sexual activity of young females and maternal sexual empowerment. Social desirability and recall bias are also common forms of bias in surveys regarding sexual activity among adolescents.
