Displaced And Nondisplaced Colombian Patients Health And Social Care Essay
Objective: To analyze the access to medicines by displaced and non-displaced populations that reside in urban zones in Colombia.
Design: Household survey
Sample: 2,060 individuals from 514 displaced and non-displaced families who live in conditions of high social vulnerability and reside in urban reception zones for persons displaced by armed conflict in the metropolitan area of Bucaramanga, Colombia
Measurements: Analysis of access to medicines for self-reported and medically diagnosed health conditions. A multiple logistic regression model was used to determine factors associated with access to medicines.
Results: Only 29.1% (95%CI 22.04-37.08) with medical prescription and 44.3% (95%CI 40.42-48.25) of individual with a self-reported probable or highly probable need for pharmacotherapy were taking medicines. Access to medicines was greater for individuals with acute than for those with chronic diseases (46% vs 29%) and very low for those with mental disorders. Greater access was primarily associated with the perceived severity of the illness, higher income, having a health center nearby and not perceiving barriers to access to services, while social security affiliation and being displaced were not related.
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Conclusions: Coverage of social security alone does not have an effect on access to medicines for displaced families. Policies should be focused not only on displaced but also on those living in similar poverty conditions.
Word count: 209
Word count (excluding ref. and tables): 3,345
Key words: vulnerable populations, essential medicines, Colombia, access to health care
Internal displacement is a demographic process characterized by forced migration without crossing national borders. The United Nations estimated that by 2008 there were 26 million internally displaced people (IDP) (Internal Displacement Monitoring Centre, 2009). Colombia, with approximately 3.8 million, is second on the list of countries with the greatest number of IDP, surpassed only by Sudan, with more than 5 million. These two countries, along with Angola, have experienced the most prolonged and aggressive armed conflicts in recent times (United Nations. Office for the Coordination of Humanitarian Affairs, 2006). The United Nations pointed out that globally the increasing number of IDP has resulted in a continuous rise of poverty in the urban areas (Comité Internacional de la Cruz Roja, 2005). This significant increase of population in these areas has frequently overwhelmed the capacity of local authorities, a fact that is reflected in the limited availability, accessibility and coverage of social and public services (such as drinking water and sewage) and housing for residents (Banco Mundial, 2002). To nursing it is a special concern because these populations need to increase their empowerment, to improve their networks and relationships with health care system to solve health problems (Carrington & Procter, 1995).
In Colombia the patterns of displacement due to armed conflict are predominantly from rural areas to large cities (Consultoría para los Derechos Humanos y el Desplazamiento, 2005), particularly to their peripheries which have resulted in their rapid growth with little or no urban development planning (Zafra-Roldán, 2009). Resettlement zones are characterized by precarious intra-domestic and environmental sanitary conditions and lack of public services (Consultoría para los Derechos Humanos, 2006; Organización Panamericana de la Salud, 2005). The IDP are in competition of public resources with the local population with very low economic resources making them vulnerable to envy and reinforcing their status as unwanted and stigmatized (Castillejo, 2000). IDP have historically lived below the poverty line and have to face situations that limit their opportunities for human development, in addition to presenting psychosocial risks due to displacement and the socio-political context (Porter & Haslam, 2005; Cáceres, Izquierdo, Mantilla, Jara & Velandia 2002; Leus, Wallace & Loretti, 2001). Various studies have reported poor living and health conditions for persons who reside in urban reception zones for IDP (Arias, 2002; Echeverri, 2007; Mogollón, Vásquez & García, 2003; Mogollón & Vásquez, 2008; Mogollón & Vásquez, 2006; Puertas, Ríos & Del Valle, 2006) as well as low percentages of access to curative and preventive medical care (Arias, 2002; Echeverri, 2007; Ruiz-Rodriguez, Vera & López, 2008). Previous research found that around 70% of the IDP in Colombia belongs to communities of ethnic Afro-Colombian and indigenous people, with women, children and black people the most affected by displacement (Gómez, Astaiza & Minayo, 2008).
Colombia has recently implemented changes in its health system that promotes increasing health coverage for IDP due to armed conflict (Ministerio de Protección Social de la República de Colombia, 2007). These changes seek to guarantee improvements in access to health services, including all of the interventions necessary to recover good health, one of which is access to medicines. In spite of the incorporation of these changes, there is an absence of published studies about access to medicines for highly socially vulnerable populations such as those of IDP located in urban reception zones.
What is the prevalence of access to medicines access to medicines for self-reported and medically diagnosed health conditions of highly socially vulnerable populations such as those of IDP located in urban reception zones in Colombia? Hence, the objective of this study was to evaluate access to medicines by IDP, and those not displaced, that reside in urban reception zones in Colombia.
Design and sample
The analysis of data presented is based on the study, "Health diagnostic survey of populations displaced, and not displaced, in Bucaramanga and its metropolitan area," which was conducted during the second semester of 2003 and approved by the ethics committee at the Industrial University of Santander de Bucaramanga, Colombia. The study methodology has been published in an extensive report (Angulo et al., 2003). Briefly, this survey was conducted with 514 displaced and non-displaced families who live in conditions of high social vulnerability and reside in urban reception zones for persons displaced by armed conflict in Bucaramanga, Piedecuesta, Floridablanca and Giron, some of the municipalities that constitute the Bucaramanga Metropolitan Area. To select participants, a probabilistic sampling was developed that considered these municipalities as strata.
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The calculation of the sample size was based on the displaced families registry identified in each of the four settlements, produced by the Social Solidarity Network, a state entity responsible for registering IDP. Given the study's diagnostic interest, the prevalence of illness was considered to be 50%, with a precision of 6% and a 95% confidence level. Following the methods for proportional allocation among strata, the sample was determined for each stratum such that the sample maintained the same relative weight with respect to the number of families in each stratum compared to total families in the population. For the non-displaced population, an equal number of families was calculated, including in the study one family not displaced for each displaced family, thus obtaining the total number of families needed to be sampled to capture the existing differences between the two populations.
Individuals considered to be IDP were those who were forced to migrate within the national territory, abandoning their locality of residence or usual economic activities because their life, physical integrity, personal security or liberty had been violated or directly threatened, in addition to any of the following situations: internal armed conflict, internal disturbances or tensions, generalized violence, massive human rights violations, internal human rights infractions and other circumstances arising from the above situations that could alter or drastically alter the public order (República de Colombia. Ley 387 de 1997).
The data were obtained using structured interviews of each one of the family members after having given informed consent. The questionnaire was developed for said study and previously piloted; the data from the pilot study were excluded since modifications were made to the questionnaire. Information for minors under the age of 15 and individuals with some type of disability was supplied by caregivers. The interview included a section about family structure and housing conditions that was reported by the head of household, and a second section asking about information for each family member. All family members were investigated with respect to: 1) sociodemographic data, 2) self-reported health problems present during the previous two weeks, 3) health problems diagnosed by a physician and 4) use of medicines at the time of the interview, including data up to three medicines per interviewee.
Data was collected about the illness for which medicine was being taken and who had prescribed it. Household members who reported to have been taking medicines were asked to show the containers (bottles, boxes, blisters, etc) in order to copy the name of the product. In addition, for individuals 18 years of age and older, a check list was used to investigate chronic illnesses and other conditions relevant to public health. Those who answered affirmatively to having had one of the illnesses were asked if the illness was being treated by a physician and if its management included medicines. The Zung scale was also administered to detect anxiety and depression, using a version previously validated for the Colombian population (Campo, Díaz & Rueda, 2006).
Defining the need for and consequently access to medicines based on self-reports of a health problem was more complex in the absence of a medical prescription. In such event, the need to receive pharmacotherapy was classified as "probable" or "highly probable" based on the evidence that existed about the likelihood that the self-reported illness would result in health problems and subsequent complication. We took into consideration the individual and environmental conditions of IDP with scarce economic resources to manage health problems, frequent nutritional deficits and living in inadequate intra-domestic and environmental sanitary conditions (Macinko, Shi, Starfield & Wulu, 2003; Cheung & Hwang, 2004). This increases the burden caused by illness and requires the problems to be identified and treated early to avoid complications. "Highly probable" need for pharmacotherapy was classified according to health problems considered to have a high likelihood of requiring medicines due to very adverse living conditions (Table 1). Health problems assigned to the "probable" category were those that were reported as symptoms and other problems where the illness history indicated that medicine was only required depending on the stage of the illness, an aspect that is not possible to characterize in a self-report.
All categorical variables were described using percentages and continuous variables were described as measures of central tendency and dispersion, according to the distribution. Since an individual could present more than one health problem, the sum could surpass 100%. Afterwards, the characteristics of displaced persons and those not displaced were compared using the ï£2 test or the Fisher exact test, according to the observed distribution. The prevalence of need of access and access to medicines for each illness was determined using their respective 95% confidence intervals.
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Finally, using logistic regression, factors associated with of access were analyzed (the antiparsimony principle was applied for the purpose of identifying the uncertainty inherent in observational studies that lack randomness (Draper, 1995) where access to medicines was considered to be the dependent variable (yes/no). Independent variables were sex, age, being a internally displaced person or not, the municipality of the settlement, affiliation with the health system (affiliated/not affiliated), the type of health problem (acute/chronic), if there was a perceived severity of the illness and access barriers, antecedents with respect to use of health services during the previous year, distance to health services (km), economic income level (tertiles) and number of family members. Since an hypothesis was that individuals with more extreme ages had more possibility for access to medicines, it was decided to explore such behavior by including the quadratic term for age; thus, better power and validity estimation were also sought, as was a decrease in the influence of extreme values (Brenner & Blettner, 1997). All of the estimations considered the family as a conglomerate, thus correcting for a possible intra-class correlation effect among individuals in the same family. The analyses were developed using the STATA 9 statistical program (Stata Corporation, College Station, Texas).
A total of 2,060 persons from 514 families participated in the study, of which 54.6% were women. More than half of the population (61%) was younger than 20 years of age and the median age was 14 years old (Table 2). A total of 50.8% of those interviewed were displaced due to armed conflict. In comparison with the non-displaced population, the IDP interviewed had, on average, less schooling, less time residing in the settlement and more family members (p<0.05). With regard to economic situation and social security, IDP had less income and only one-third (35% vs 65%) was affiliated with the public health system (SGSSS, abbreviation in Spanish). There was no difference with respect to prevalence of principal health problems.
Access to medicines
Of the total interviewees, 20.3% (n=419) were taking some type of medicines at the time of the survey; of those, 69.9% (n=293) were taking only one medicine, 19.3% (n=81) were taking two and 10.7% (n=45) were taking three medicines (Table 2). With regard to who recommended the medicine, more than half (55.1%) of those taking medicines were doing so according to medical advice, 32.7% were taking medicines on their own (self-medication) or on the recommendation of a family member or friend, and 12.1% were advised by a pharmacy. It is notable that compared with those not displaced, IDP more often reported taking medicines based on advice given by a pharmacy (41% vs 10%, p=0.001).
A total of 26.5% of medicines were being taken by children less than five years of age and 10.9% of the medicines reported were being taken by adults over the age of 51. The principal problems for which the interviewees received a medical prescription for pharmacological treatment were arterial hypertension, diabetes mellitus, cardiac illnesses, epilepsy and hypercholesterolemy (Table 3). Only 29% of those who received a medical prescription used pharmacological treatment and patients with kidney disease had the lowest percentage of access.
Table 4 summarizes access to medicines for self-diagnosed health problems or those diagnosed by the Zung scale. In general, 44.3% of the persons had a medicine available for the indicated treatment. It is noteworthy that none of those interviewed who presented severe anxiety, according to the Zung scale, reported being treated for it. Other health problems in which the majority of cases did not use medicines included back pain, stomach pain and diarrhea.
Factors associated with access to medicines
The multiple logistic regression model enabled the identification of some of the determinants of access to medicines (Table 5). The perception of severity has the greatest impact on access to medicines, followed by higher income, the antecedent of use of medical services during the previous year, less distance from a health center and living in the municipality of Giron Piedecuesta. Persons who perceive barriers to access to health services have less access to medicines. With regard to age, the model shows an inverted J distribution, where those who are younger tend to have greater access, and at older ages there is a gradual increase in access as age increases. The other variables explored did not show an effect on access to medicines, including affiliation and being displaced.
Given the lack of quantitative information about access to medicines for IDP, the findings in this study are very relevant to health care policies for this population. Worldwide, forced displacement produces an accumulation of vulnerabilities related with the loss of political rights and social support networks, with the break-up of nuclear families and the risk of migration itself, and with adverse sanitary, infrastructure and environmental conditions experienced by displaced persons in their place of arrival (Cookson, Carballo, Nolan, Keystone & Jong, 2001; Bello, 2003; Waldman & Martone, 1999). All of these characteristics increase the risk of death and illness for this population (Murray, King, Lopez, Tomijima & Krug, 2002; Mollica et al., 2001). The absence of pharmacological treatment contributes to the deterioration in health and, in and of itself, constitutes an inequity in access, increasing the vulnerability of the individual.
In the study population, access to medicines was very low. Only 29% of those who received prescriptions for medicines were taking them, and of those who reported symptoms that were classified as indicators of illnesses that would probably or highly probably require pharmacological treatment, only half (56%) were taking medicine. Access to medicines was greater for persons with acute problems than for those with chronic problems (46% vs 29%). One likely explanation is that persons with acute problems have better access due to lower cost, since medicines for chronic problems involve a constant expense and many used to treat illnesses such as diabetes and epilepsy are more expensive than those used to treat pain, for example.
Of particular concern is the lack of use of medicine for treating mental illnesses. Different studies have shown that mental health problems for displaced and refugee populations are prevalent (Mollica et al., 2001; Alejo, Rueda, Ortega & Orozco, 2007) and in some cases can persist for long periods of time after the displacement event occurs (Mollica et al., 2001). In other populations, it has been found that psychiatric morbidity and an unfavorable health prognosis are associated with unfavorable socioeconomic conditions (Lorant et al., 2003) and, therefore, pharmacological treatment could be an alternative to improve one's health status. Puertas et al. reported that there is a greater prevalence of common mental disorders in zones where displaced and non-displaced persons live than in zones with only non-displaced persons (Puertas, Ríos, Del Valle, 2006).
One of the most important findings in this study, which was unexpected in light of the authors' hypothesis before conducting the study, is that access to medicines is not associated with the condition of being displaced due to armed conflict or with having medical insurance; thus other barriers to access to medicines exist that prevent their use. There are multiple reasons why medical insurance may be failing to provide access to medicines, among them, because medicines are not included in the health plan (Mogollón & Vásquez, 2008; Lorant & Deliège, 2003; Mogollón & Navarrete, 2003) or because there are bureaucratic problems such as long distances to the pharmacies that fill prescriptions, very limited hours, and excessive paperwork for medicines to be supplied by the insurer (Mogollón and Vásquez, 2008).
Another important result of our study is that access was associated with age and the perceived severity of the illness, indicating that families have a prioritization in which children and illnesses that are perceived to be serious take priority. There is also a direct association with income which suggests that economic variables have a strong influence on access even though the study population has precarious economic resources, demonstrating that there is unequal access due to economic capacity.
The population studied was very young, with half being less than 20 years old. Therefore, acute problems such as diarrhea were very frequent in this population. Given that the inappropriate use of medicines for gastro-intestinal illnesses in children in low-income countries is well documented (Weisstaub & Araya, 2008), it would be important to include strategies to encourage the appropriate use of medicines in programs for improving access to them. Patterns for seeking advice about medicines were distinct: more IDP used pharmacies as a source of obtaining advice about which medicine they should take. Since only one-third of IDP having health insurance, it is possible that the pharmacy was an alternative for seeking care since the consultation for the health problem is free.
Although the study was conducted in a large metropolitan area in Colombia, the characteristics of the population studied are similar to other populations that live in other reception zones for displaced persons (Organización Panamericana de la Salud, 2005), thus the findings of the investigation can serve as a guide for improving access to medicines in other displacement situations. Given the general paucity of literature about access to and use of medicines the findings are also relevant for other countries. This study is based on participant self-reports and highly probable access and probable access were defined based on the information from the interviewees and could therefore be biased due to memory and other factors. Nevertheless, our results are consistent with other studies conducted with displaced and non-displaced poor populations (Organización Panamericana de la Salud, 2005; Cáceres, Izquierdo, Mantilla, Jara & Velandia 2002; Arias, 2002; Ruiz-Rodriguez, Vera & López 2008) that indicate low rates of access to preventive and curative health services, suggesting that the existence of barriers to access to health services is systematic for this type of population living in urban areas in situations of poverty and displacement.
As far as we know, this is the first study that quantifies access to and use of medicines by IDP in Colombia. The findings in this study enable recommendations to be made for the design and/ or adjustment of pharmaceutical policies and for health programs and policies geared towards IDP in general:
1) Policies for access to pharmacological treatment should be focused not only on the displaced but also on persons who live in similar poverty conditions. In Colombia in recent years, there has been a large emphasis on programs focused on displaced persons, discriminating against non-displaced populations that live in similar conditions (Arias, 2002); as the results show that both groups have low percentages of access to medicines, policies should be similar for the two groups.
2) Coverage of social security alone does not have an effect on access to medicines if it does not include essential medicines that respond to the real health problems of this population (for example, mental health problems) and if it does not decrease administrative and organizational barriers that prevent such access.
3) Access to mental health care and care for chronic illnesses, in particular, is crucial to respond to the specific needs of the population. We found that 23% of the individuals that responded to the Zung test were highly probably in need of pharmacological treatment. Internationally, the need to offer mental health care in emergency situations, such as displacement, has been recognized (Mollica et al., 2004).
4) The pharmacy has a relevant role in providing access to medicines and giving advice about their use; therefore, health promotion and prevention programs should use the pharmacy as part of the health system and offer training to personnel to promote the appropriate use of medicines.
The role of nurses in these activities can be highly relevant. Training in nursing offers greater possibilities than other professionals (i.e. physicians, psychologists, or social workers) to understand the complex problems of IDP, and their relationships with health conditions and access to health care services, even medicines and another clinical interventions.
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