Research

Introduction

I have been working with MEDLIFE, a non-profit organization that travels to Ecuador from New England to provide medical and dental care to the poor of Ecuador during one or two week medical missions. In addition to MEDLIFE’s short term goals, it is also working toward building a community health center in a small rural village in Ecuador called Cebadas. Cebadas is located in the province of Chimborazo, the second poorest province in the country (located beside the poorest province). Within Chimborazo, Cebadas represents the poorest canton (a sub-division of the province), Guamote. Cebadas is a village of approximately 8,000 people, made up of 30 smaller villages. These 30 smaller villages are similar in that they subsist from agriculture, dairy cows, and are indigenous (most being bilingual, Spanish and Quechua). Although these two similarities are quite representative of these people, Cebadas represents a heterogeneous society, with the poorest of the poor, a few individuals who could be considered middle class; people who have no representation politically and others who have managed to connect them to resources outside of the village. In this sense, we sought for our survey to be as representative as possible, by interviewing people from each of the 30 villages. We believe that the first stage of building a community health clinic in Cebadas is to make sure we understand the realities of people living in Cebadas. The first stage of building the community health center is to do a needs assessment/survey of Cebadas. I wrote a proposal to DIHG to be funded to do such a survey. In addition to myself, I worked with Juan Camilo Vanegas a member of MEDLIFE, Joan Heir, a fourth year medical student from DMS, Eric Ha, a second year medical student at DMS, Alia Whitehead a second year medical student at UVM, Sarah White, a second year medical student at UNE, and Angie Vidal a dentistry student from Lima, Peru. We had slightly over a month to organize and conduct the survey. With the assistance of Dr. Lance Evans, MD, an American physician practicing in Ecuador for the past 30 years and with extensive experience in designing and analyzing surveys, we designed a survey to be used in Cebadas. Dr. Peter Millard, MD, PhD, also assisted us in designing the survey. Dr. Millard is a family practice physician currently practicing out of Bangor, ME, who has experience in public health (his PhD was in public health through the CDC) and who has worked on projects throughout Latin America and Africa, in particular in the areas of Infectious Disease (mostly HIV). At Dartmouth Medical School, Dr. Virginia Lyons was my DIHG advisor.

Methods

Juan Camilo and I designed the first round of the survey and with the help of Dr. Evans and Dr. Millard revised it several times. When we had a revised edition that we were satisfied with we brought it to Cebadas, Ecuador, and worked with local people made sure our questions were understandable to the residents of Cebadas. MEDLIFE hired eight local people to conduct the survey. We spent just under one week training these interviewers on how to conduct the survey, in particular emphasizing the format and style of questioning to avoid leading the person being questioned, to ensure the most accurate information possible was being collected. In addition to native Spanish speakers from Cebadas we also made sure we had several (five) bilingual (Spanish and Quechua) persons to help us with the interviewing process. During this training period these interviewers worked on translating the questions from Spanish to Quechua. Each day the interviewers started the day by meeting with me or Juan Camilo and we practiced the survey on each other. We learned from a doctor with long time experience in Ecuador who advised us on the phrasing of certain questions in Spanish and we revised the phraseology in order to best communicate some questions to people with little educational attainment. The interviewers in Cebadas were crucial in this aspect. Each day we made revisions to the questions and format of the interview so that it was clear, simple and representative of the people we were interviewing. On the third day of training we started to ask for local volunteers for our interviewers to interview in order to practice on people who did not have previous exposure to the survey. This also proved to be valuable. We continued in this fashion for three more days until we felt that the interviewers were ready to begin the survey in the village. To finalize the survey we sent it to both Dr. Evans and Dr. Millard for their final evaluations. We planned twenty-two days of interviewing. Due to constraints in time, we chose central locations that several villages could come to and be interviewed. Per the recommendation of the hired interviewers and Dr. Evans we offered those who came to be interviewed, tea and cookies which was considered an act of respect for their collaboration. In order to inform villagers that we were planning to come to their village we contacted the village “President” (per recommendation of Dr. Evans and our interviewers) so that they would inform their constituents of our arrival. We were concerned with a potential confounding effect that this political entity could represent, but due to local custom we decided that this would be the best way to maintain good relations with villagers and their choice of organization within the community. We hired a local driver who owned a pick-up truck to drive us to the villages. We were greeted by the villagers and usually started the day by my speaking about the survey. We wanted to make sure to refer to it as a needs assessment and not refer to our desire to understand the state of health in the community, because part of the evaluation was to see to what extent health was a concern for villagers). The interviewers interviewed the villagers over the course of a month and then the surveys were collected and entered into a database.

Results

Cebadas is a village of slightly over 8000 people, represented by 30 smaller villages (all of which were represented in our survey). We interviewed 702 households. All of the smaller villages were represented in the survey. With an average of 5.44 people per household, our survey represents approximately, 3819 people. The average age of the person we interviewed was 40.2 years. Sixty-five percent (65%) of the people we interviewed were women. Per household there were .26 people older than 65, 2.42 people between the ages of 18 to 65, and 2.8 kids under the age of 18. Sixty-nine percent (69%) of people prefer to speak Quechua over Spanish, but nearly all are bilingual. When someone in the house gets sick 7% of households say they go to a local healer (curandero), 6.6% go to a private clinic, and 3.3% go to a private consultorio, 64% say they go to the local subcenter of health (run by the government), 32% say they go to a hospital in Riobamba (the closest city), 7% say they consult a pharmacy for health care advice and 4.9% say they use some “other” category when they are ill. The average household reports a monthly income of $75.40. Fifty percent (50%) of households have had someone in the house who had to migrate looking for work. Seventy-eight percent (78%) of households report that they receive a version of Ecuadorian welfare ($30/mo as reported by the interviewees). Seventeen and one-half percent (17.5%) say that someone in the house has been in a transit accident, 19.3% have had someone who had an accident while working, and 12.4% report someone in the house that has suffered from some other accident. Fifteen and one-half percent (15.5%) report someone who has had a surgery in the household. The woman of the household was an average age of 39.5 years old and had her first pregnancy at 19.9 years of age. Seven point eight percent (7.8%) of women were pregnant at the time of the interview. The average woman has had 5.2 pregnancies and 4.94 births. Of the average number of births (4.94) only .04 of them were reported as being C-sections (representing less than 1% of births being via C-section). Of the 4.94 births per household, 4.79 gave birth in their home (representing 97% of births being at home). A limited number (.008 of those 4.94 births) occurred in the subcenter of health (recall 64% say they use the subcenter when someone in the family is sick, but less than 1% of births have occurred at the subcenter of health). Of the 4.94 births, 3.11 were attended by a relative (or gave birth alone), 1.7 were attended by a midwife, and .02 and .16 were attended by a nurse and doctor, respectively. This means that only three percent (3%) of all births have occurred in the presence of a trained physician. Sixty (60) out of 100 households have lost a child to illness or accident, and of the 466 children who had died and reported at the time of this interview 90% of them were under the age of 5. Although our survey did not draw a direct link between access to pediatric healthcare and childhood mortality our data would suggest a link between these two factors exists. When asked what people felt was missing in their household and community the most common response was access to healthcare.