“Children's growth up to age five is influenced by
nutrition, environment and health care,
rather than by
genetics or ethn...
Factors affecting Health
Diseases



In 2002, nearly 11 million children died before reaching their
fifth birthday – 98% ...
Leading Causes of Death in Children
Under 5 years of age
Perinatal (22%)

Pneumonia
(20%)
Malnutrition
underlying factor
(...
Factors affecting Health
Poverty and Environment



Poverty, social exclusion, poor housing and poor health
systems are a...
1.1 BILLION PEOPLE
TRY TO LIVE ON
LESS THAN $1 PER
DAY (WORLD BANK)

Zimbabwe
mother and
child

(The Associated Press File...
Gross National Income (GNI) per capita, 2003

(World Bank group http://www.worldbank.org/data/maps/images/GNIpercapita.jpg...
Nicaragua
Country profile
Nicaragua, Nicaraguita
MANAGUA

Home for the only Children’s Hospital of the Nation

La Plaza de la Republica. This is where we can find the
old ...
LEON


Colonial City, where The cathedral is located



…Legends, traditions…



Full of Wonderful, hard working, simpl...
Major Traumas that affect
Children’s Health





POVERTY
WAR
MALNUTRITION
NATURAL DISASTERS
1524

Sandinistas 1979-1990

History
1821

1990-1996

Somoza 1936-1979

XIX century

Arnoldo Aleman’s
embezzlement

Enriqu...
General Situation






Area: 130,244 km2 (smaller than the state of FL)
Population: 5,710,670, 56.4% urban
Life expe...
Economy overview
One of the hemisphere’s poorest countries
 118th in the Human Development Index
 50.3% of citizens belo...
Natural Disasters
1972 Managua Earthquake

Last earthquake: Masaya, July of 2000.
Hurricane Mitch, 1998
200,000 inhabitants afflicted,
10,000 people lost their homes,
1,000 people were buried when
an enti...
Natural
Disasters

Political
instability

Structural Crisis

Post - War

Economic
Adjustment
Measures
THE EFFECT OF TRAUMA
Hurricane Mitch effect on
Nicaraguan adolescents


Adolescents with extreme objective and subjective hurricane-related tr...
Effects of Civil War on Mental
Health




Civil war during 1980s lasted about ten years, causing terror.
Military servi...
Malnutrition, a Global Trauma
Child with Spina Bifida and Hydrocephalus
(Folic acid deficiency during pregnancy)

Child wi...
Nutrition and Mental Health


Evidence from observational studies suggests that there is an
association between n-3 long-...
Malnutrition and Mental Health


In most societies, mothers are the primary providers of nutrition
and care to young chil...
Conclusions
1.

The post-trauma recovery of the severely affected Nicaraguan
children is vital to the social and economic ...
Health Situation in Nicaragua


Major problems include:
Inappropriate services for adolescents, elderly,
disabled, and ad...
Health Situation in Nicaragua
Life expectancy (years)
Fertility rate (births per woman)

68.8
3.4

Infant mortality rate (...
Specific Health Trends


Children 0-4: IMR has decreased from 45 to 30
(1997-2003)




Causes: Pneumonia, diarrhea, gas...
Specific Health Trends


Adolescents (10-19y):
FR 152/1000, 3:10 births involved teenage mothers.
 Deaths: natural disas...
Specific Health Trends
Elderly: 4.7% of the population
 Disabled: 12.1%


Visual 63.9%, hearing 9.2%
 Birth 10%, diseas...
Specific Health Problems












Mental Health
Vector borne diseases: malaria, dengue, Chagas’
Diseases pre...
Response of the
Health System
Health System
“The deterioration in the country’s health, education and nutrition
status is directly related to the unequa...
Structure of the system






National Health Policy: modernizing the health
sector and social security system, streng...
Structure of the system






Ministry of Health, with 996 health care
facilities (48.3% in the Pacific coast area).
Pr...
Organization of the system
Ministry of Health
Public (60%)

Hospitals

Private (20%)

SSI (10%)

Hospitals (8)
Medical and...
Human Resources


23,285 health care workers (32% Gov, 47.4%
primary, 52% secondary care)
5,656 general practitioners, 95...
Health expenditure and financing









Resources: public sector 41.5%, private 44.8%, external
cooperation 13.7%.
...
Public Health System


Potable water: urban 89%, and rural 33%





Samples collected: 4% 50 coliform/100ml

Inadequat...
International policies and its impact
IMF

External debt
100.3 of GDP

Multilateral
Debt Relief
Initiative 2005

Restricti...
Health care system from the perspective
of core values and social justice
“That the country counts with an institutional
e...
Inequities in health


Incidence of diseases and accidents higher among:








Low income level.
Women of all grou...
Inequities in health


Women declare more illness and receive more care than men.
Among younger than 20, men receive more...
Inequities in health


1990 to 2005:





Rural areas:







Expenditure on education from 3.4 to 3.1 of GDP
Expe...
Inequities in health
Survey
year

One-year-olds fully
immunized

Children under
height
For age (% under
age 5)

IMR
(per 1...
Core Values of the Government
Health System







Tendency of locating the development in the capital.
Preferential ...
Core Values of the Government
Health System


Focus in Treatment rather than Prevention. Preventive medicine
is underdeve...
What has to be done:
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








Improve social conditions of the poorest.
Eliminate health care inequality
Preven...
WHAT CAN WE DO?


Make a difference…



One child at a time
Then, millions at a time…

Discover, Educate, Care, Lead
“A small group of thoughtful, committed
citizens can change
the world.
Indeed, it’s the only thing that ever has.”
Margare...
By Imelda Medina, M.D.
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References
AAP. (2006). Rec...
References (cont.)
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Goenjian AK, Molina L, Steinberg AM, Fairbanks LA, Alvarez ML, Goenjian HA, Pyn...
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Nicaragua identifying factors that affect childrens health

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  • Historical background and the creation of the current crisis
    Nicaragua is the largest country in Central America, and counts with splendid natural resources, despite of the vast exploitation that has taken place during the last 500 years. In 1524, the Spanish conquerors started to explore and take possession of the land beginning a process of oppression and social division, with the establishment of the economical and cultural patterns of domination, as well as the formation and consolidation of our nationality of mestizos. The basic human services nowadays continue to be unreachable for the most part of the population.
    Since its independence in 1821, Nicaragua has been characterized by political instability due to civil wars. From 1936 to 1979, the Liberal Somoza’s dynasty established a regimen of power and injustice, increasing the gap between social classes and income level. However, the stability of the government created conditions for a growing economy to the extent that Nicaragua became one of the richest countries in Central America. The Somozas owned most of the businesses and had the political and military power. There was no Democracy. During this period, the environment started to suffer the consequences of the government's corruption and its favor to international companies. For example, the Nicaraguan Long Leaf Pine Company was exempted of having to reforest clear cut areas. The expansion of cotton plantations forced hundreds of peasant families to leave their lands and homes. The importation of banned pesticides, such as DDT, Endrin, Dieldrin and Lindane caused many health problems that still remain. The resulting chemical pollution from lakeside factories and the untreated sewage of the city of Managua caused the lost of the natural resources of Managua’s Lake "Xolotlan." In 1972, the capital was devastated by an earthquake, worsening the living conditions. Environmental pollution and natural disasters have continuously stoned Nicaragua during the last four decades.
    Violent opposition to the government's corruption and manipulation came from all sectors and classes, and ended in a revolution brought by Sandinistas guerrillas in 1979, marking the end of Somoza’s dynasty. Nicaraguans attitude toward the revolution was hopeful and dreamed about the creation of a system free of the political, social, and economic inequalities.
    After elections in 1984, the new called Sandinista Government became extremely Marxist-communist, and subsequently free elections were not allowed. Another civil war started among Nicaraguans, and continued through the 80’s. More than 50,000 Nicaraguans died, 120,000 were exiles, and 600,000 became homeless during this civil war. The economy went down due to the war and International trade blockage resulting in the devaluation of the currency to 1 dollar per 1 million Cordobas. In spite of this, the government created effective community organization, worker unions, alphabetization campaigns, and campaign of erradication of diseases such as Malaria.
    Free elections ocurred in 1990, after extensive international pressure, and Violeta Barrios became the first female president in the country and in Central America. The triumph for Democracy and social justice was partial since Sandinistas kept its power on institutions and economy. Since then, the country has kept its polarization between Sandinistas and Anti-Sandinistas making it difficult to reach agreements and country development. In 1996, the Liberal Arnoldo Aleman won the elections and continued the liberation of the economy, and creation of infrastructure until the country was devastated by the Hurricane Mitch in October 1998.
    The next president, Enrique Bolaños, started a national campaign against corruption, especially against Aleman’s administration. He charged Aleman with corruption crimes and resulted in a trial that placed him in jail. Bolaños' government was characterized by having good international relations and strict adherence to international policies such as the International Monetary Fund (IMF). Two major achievements of Bolaños' administration were the forgiveness of the external debt and the signature of CAFTA. Both achievements also bring positive and negative consequences on social determinants and therefore, in health determinants. The IMF imposes restriction such as structural adjustment, and no increase salary above the projected inflation rate. Non-compliance with IMF would jeopardize ongoing aid negotiations and help. This has resulted in a national health strike protesting against the low salaries of health care workers, which are 40% less than their counterparts in Central America, and are currently the lowest in Central America.
    The country has slowly rebuilt its economy and showed some progress in human development and health indicators after 1990, but the post war effect, natural disasters and corruption has made difficult its development. The disorganization and country's political instability led Daniel Ortega to win the last elections with less than 40% votes. We are currently striving to maintain Democracy as well as the economical development that was steadily achieved during the past decade.
  • Nicaragua is one of the hemisphere’s poorest countries, being in the third place on poverty after Haiti and Guatemala. It ranks 112th in the Human Development Index. More than half of their citizens (50.3%) fall below poverty line, and one quarter live in extreme poverty. The GDP growth is 3.5%, and the public debt constitutes 100.3% of the GDP.
  • Nicaragua identifying factors that affect childrens health

    1. 1. “Children's growth up to age five is influenced by nutrition, environment and health care, rather than by genetics or ethnicity.”
    2. 2. Factors affecting Health Diseases  In 2002, nearly 11 million children died before reaching their fifth birthday – 98% of these deaths were in developing countries. 2006 World Health Organization
    3. 3. Leading Causes of Death in Children Under 5 years of age Perinatal (22%) Pneumonia (20%) Malnutrition underlying factor (60%) All other causes (29%) Malaria (8%) Measles (5%) Diarrhea (12%) HIV / AIDS (4%) World Health Organization data 2001 (from Global Health Council http://www.globalhealth.org)
    4. 4. Factors affecting Health Poverty and Environment  Poverty, social exclusion, poor housing and poor health systems are among the main social causes of ill health. 2006 World Health Organization- Commission on Social Determinants of Health
    5. 5. 1.1 BILLION PEOPLE TRY TO LIVE ON LESS THAN $1 PER DAY (WORLD BANK) Zimbabwe mother and child (The Associated Press File photograph; article by B. Willis, Books and Authors, Edmonton Journal May 1, 2005)
    6. 6. Gross National Income (GNI) per capita, 2003 (World Bank group http://www.worldbank.org/data/maps/images/GNIpercapita.jpg)
    7. 7. Nicaragua Country profile
    8. 8. Nicaragua, Nicaraguita
    9. 9. MANAGUA Home for the only Children’s Hospital of the Nation La Plaza de la Republica. This is where we can find the old cathedral, Nicaragua’s National Museum, Managua’s cultural center and other interesting sites. Hi! The Tyscapa Lagoon
    10. 10. LEON  Colonial City, where The cathedral is located  …Legends, traditions…  Full of Wonderful, hard working, simple people… ...and Beauty.
    11. 11. Major Traumas that affect Children’s Health     POVERTY WAR MALNUTRITION NATURAL DISASTERS
    12. 12. 1524 Sandinistas 1979-1990 History 1821 1990-1996 Somoza 1936-1979 XIX century Arnoldo Aleman’s embezzlement Enrique Bolaños 2001 - 2006
    13. 13. General Situation      Area: 130,244 km2 (smaller than the state of FL) Population: 5,710,670, 56.4% urban Life expectancy at birth: 68.4 Birth rate: 35.3/1000 Literacy: 67.5%
    14. 14. Economy overview One of the hemisphere’s poorest countries  118th in the Human Development Index  50.3% of citizens below poverty line, 25% extreme poverty  20% of Nicaragua’s children malnourished  GDP growth: 3.5% (Public debt 100.3%GDP)  Employment/underemployment: 54% unemployed  56% urban gainfully employed less than $9.20/month (basic basket US$13.3)
    15. 15. Natural Disasters 1972 Managua Earthquake Last earthquake: Masaya, July of 2000.
    16. 16. Hurricane Mitch, 1998 200,000 inhabitants afflicted, 10,000 people lost their homes, 1,000 people were buried when an entire slope of a volcano crashed down on 14 villages, 2,823 people died, 885 reported missing, 49 municipalities severely damaged
    17. 17. Natural Disasters Political instability Structural Crisis Post - War Economic Adjustment Measures
    18. 18. THE EFFECT OF TRAUMA
    19. 19. Hurricane Mitch effect on Nicaraguan adolescents  Adolescents with extreme objective and subjective hurricane-related traumatic features of exposure experience severe and chronic posttraumatic stress and comorbid depressive reactions (Am J Psychiatry 2001; 158: 788-794).  PTSD represents a serious mental health problem after a disaster. Higher vulnerability is found among illiterate persons, females and those with previous mental health problems (Soc Psychiatry Psychiatr Epidemiol (2001) 36: 108-114).
    20. 20. Effects of Civil War on Mental Health    Civil war during 1980s lasted about ten years, causing terror. Military service used to be obligatory starting at later teens. PTSD found in war wounded ex-combatants (Med War. 1994 Jan-Mar;10(1):425).  In a study done in 1991, 62% of men and 91% of women exrefugees still living in the war zone reported as cases of psychological disturbance on the General Health Questionnaire. Somatization was central to the subjective experience and communication of the distress. Anxiety-based symptomatology common. 25% of men and 50% of women merited a diagnosis of PTSD (Med War. 1991 Apr-Jun;7(2):84-99).
    21. 21. Malnutrition, a Global Trauma Child with Spina Bifida and Hydrocephalus (Folic acid deficiency during pregnancy) Child with Myelomeningocele (Folic acid deficiency during pregnancy) High Prevalence of Prematurity Protein, Calories, Vitamins deficiencies
    22. 22. Nutrition and Mental Health  Evidence from observational studies suggests that there is an association between n-3 long-chain polyunsaturated fatty acids and depression (Am J Clin Nutr. 2007 Nov;86(5):1278-85).  There is a strong and consistent association between eicosapentaenoic acid in serum phospholipids and self-reported physical well-being (Am J Clin Nutr. 2007 Nov;86(5):1278-85).  A history of attempted suicide is associated with low levels of antioxidant vitamins and carotenoids (Nutr Neurosci. 2007 FebApr;10(1-2):51-8).
    23. 23. Malnutrition and Mental Health  In most societies, mothers are the primary providers of nutrition and care to young children. This is a demanding task, and poor physical or mental health in mothers might be expected to have adverse consequences on their children's health, nutrition and psychological well-being.  What is the relationship between Maternal Mental Health and Children Malnutrition and Mental Health? Is this a cycle?  Mothers who report stress, depression, or anxiety symptoms are at risk for nonresponsive feeding styles (J Nutr. 2008 Apr;138(4):799-805).
    24. 24. Conclusions 1. The post-trauma recovery of the severely affected Nicaraguan children is vital to the social and economic recovery of a country ravaged by years of political violence and poverty. 2. Maternal mental health can affect children’s ultimate nutritional status. 3. These are worldwide problems, currently not adequately addressed in developing countries.
    25. 25. Health Situation in Nicaragua  Major problems include: Inappropriate services for adolescents, elderly, disabled, and adults.  Focus in health treatment rather than prevention. Preventive medicine is underdeveloped.  Child psychiatry healthcare services are very limited nationwide. 
    26. 26. Health Situation in Nicaragua Life expectancy (years) Fertility rate (births per woman) 68.8 3.4 Infant mortality rate (per 1,000 live births) 30.0 Under 5 mortality rate (per 1,000 children) 38.0 Child immunization, measles (% of under 12 mos) 93.0 Incidence of tuberculosis (per 100,000 people) 62.7 Tuberculosis cases detected under DOTS (%) 91.2 Prevalence of HIV, total (% of population aged 15-49) Source: World Development Indicators database, April 2004 0.2
    27. 27. Specific Health Trends  Children 0-4: IMR has decreased from 45 to 30 (1997-2003)   Causes: Pneumonia, diarrhea, gastroenteritis, and transport accidents. Schoolchildren (5-9): accidents, pneumonia, drowning, exposure to unknown factors
    28. 28. Specific Health Trends  Adolescents (10-19y): FR 152/1000, 3:10 births involved teenage mothers.  Deaths: natural disasters, pesticide poisoning (30%), accidents.   Maternal Mortality: 102-133/100,000   Hemorrhages by placenta retention, pregnancy induced hypertension, sepsis, rupture of the uterus, and abortions. Family planning service coverage: 21%
    29. 29. Specific Health Trends Elderly: 4.7% of the population  Disabled: 12.1%  Visual 63.9%, hearing 9.2%  Birth 10%, disease 29%, war 3%, and accidents 12%.   Workers: 24,000 children 10-14 informal sector, 6000 formal sector.  90-100% farmers exposed to some type of pesticide. 
    30. 30. Specific Health Problems            Mental Health Vector borne diseases: malaria, dengue, Chagas’ Diseases preventable by immunization (Pneumococcal, Meningococcal, Varicella nor Hep. A vaccines are available) Intestinal infectious diseases Chronic communicable diseases Acute respiratory infections Zoonoses: rabies Nutritional and metabolic diseases Circulatory system Accidents and violence Oral health
    31. 31. Response of the Health System
    32. 32. Health System “The deterioration in the country’s health, education and nutrition status is directly related to the unequal distribution of resources, lack of access to basic services, and the economic crisis” (Human Development Report 2002)
    33. 33. Structure of the system     National Health Policy: modernizing the health sector and social security system, strengthening the Ministry of Health, improving hospital care, and formulating new strategies. Potential coverage of 3 million people. Primary and secondary care. MINSA is the regulatory institution.
    34. 34. Structure of the system    Ministry of Health, with 996 health care facilities (48.3% in the Pacific coast area). Private: 8 hospitals each with 400 beds; 200 outpatients clinics. Insurance Managed Companies have begun prepaid plans to expand their service.
    35. 35. Organization of the system Ministry of Health Public (60%) Hospitals Private (20%) SSI (10%) Hospitals (8) Medical and dental Clinics, Labs, imaging centers Insurance Management Companies Health centers Health posts Community Promotor NGO (10%)
    36. 36. Human Resources  23,285 health care workers (32% Gov, 47.4% primary, 52% secondary care) 5,656 general practitioners, 950 specialist, 323 professional nurses, 974 dentist, 1042 pharmacists, 56 lab tech, 21 radiologist.  Nursing personnel 1538 (62% secondary, 1/3 in Managua). Primary care with 52% auxiliary personnel. 
    37. 37. Health expenditure and financing      Resources: public sector 41.5%, private 44.8%, external cooperation 13.7%. Per capita health spending: US$45.1 Government allocation is 3.2% of GDP (9.5% general budget). The smallest in Central America. International assistance 1.3% GDP (25.6% total budget) Household on health: 2.5- 2.8% of GDP
    38. 38. Public Health System  Potable water: urban 89%, and rural 33%    Samples collected: 4% 50 coliform/100ml Inadequate excreta disposal: 21% (rural) Urban: 65% solid waste not subject to proper disposal.
    39. 39. International policies and its impact IMF External debt 100.3 of GDP Multilateral Debt Relief Initiative 2005 Restrictions: Structural adjustment, no increase salary above the projected inflation rate -Non-compliance with IMF would jeopardize ongoing aid negotiations Health budget has been declining Doctors per 10,000: 6 to 3.8. Overwork. US$300 monthly salary (40% less than the rest of Central America) Insufficient funds for provision of basic medical supplies, repairs for dilapidated hospitals, subsidies for essential medicines, and other 20,000 public health care workers declared an indefinite nationwide strike in since November, 2005
    40. 40. Health care system from the perspective of core values and social justice “That the country counts with an institutional environment that assures justice, transparency in public affairs and democracy.” (PNUD Survey, July 2002)
    41. 41. Inequities in health  Incidence of diseases and accidents higher among:      Low income level. Women of all groups of age and income (50 years old highly vulnerable). High maternal mortality. Rural areas, related to income level. Respiratory diseases first cause of death children under 5 years old (preventable diseases). Related to income level. Diarrheic diseases among children under 5 are higher in rural areas. (National Household Survey about levels of life, 1998.)
    42. 42. Inequities in health  Women declare more illness and receive more care than men. Among younger than 20, men receive more care.  Care coverage positively correlated to the income level.  Distance and time from the house to health center are markedly higher in rural areas.  Institutional delivery lower in rural areas, and related to the income level. (National Household Survey about levels of life, 1998.)
    43. 43. Inequities in health  1990 to 2005:    Rural areas:     Expenditure on education from 3.4 to 3.1 of GDP Expenditure on health 3.9 to 3.2 Poverty (50.3%), extreme poverty (25%), children malnourished (20%), unemployment. Deforestation, water pollution. Children under weight 10%, under height 20%. (1:3) LBW 12%. (Human development report, 2005)
    44. 44. Inequities in health Survey year One-year-olds fully immunized Children under height For age (% under age 5) IMR (per 1000 live births) Under-five mortality rate Poorest 20% 2001 Births attended by skilled personnel Richest 20% Poorest 20% Richest 20% Poorest 20% Richest 20% Poorest 20% Richest 20% Poorest 20% Richest 20% 77.5 99.3 63.6 71 22.4 4.1 49.6 16.3 64.3 19.2 (Human development report 2005)
    45. 45. Core Values of the Government Health System      Tendency of locating the development in the capital. Preferential decision according to external policies. Healthcare services focus on mothers and children under age 5. Inappropriate services for adolescents, elderly, disabled, and adults. Inappropriate mental health services.
    46. 46. Core Values of the Government Health System  Focus in Treatment rather than Prevention. Preventive medicine is underdeveloped.  No appreciation for the healthcare workforce and the importance of education.  Corruption is still a major threat.
    47. 47. What has to be done:          Improve social conditions of the poorest. Eliminate health care inequality Preventive Medicine Improvement Improve Mental Health Services for Children and adults. Incorporate public mental health approaches including systematic screening and trauma/grief-focused interventions within a comprehensive disaster recovery program. Programs of reduction of illiteracy Sustainable use of natural resources Increase Employment and salaries National infrastructure development
    48. 48. WHAT CAN WE DO?  Make a difference…  One child at a time
    49. 49. Then, millions at a time… Discover, Educate, Care, Lead
    50. 50. “A small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.” Margaret Mead
    51. 51. By Imelda Medina, M.D.
    52. 52.                                                References AAP. (2006). Recommended Childhood and Adolescent Immunization Schedule United States. from http://www.cispimmunize.org/IZSchedule_2006.pdf BBC. (2001, 30 July 2001). Timeline: Nicaragua. Retrieved 30 July 2001, 2001, from http://www.hartford-hwp.com/archives/47/397.html Beachy, B. (2006, 01/30/2006). The IMF debt relief sham: swindling the sick. The counterpunch. sick. counterpunch. Blakely, T., Hales, S., Kieft, C., Wilson, N., & Woodward, A. (2005). The global distribution of risk factors by poverty level. Bull World Health Organ, 83(2), 118-126. 83(2), Boelen, C. (2003). [World Health Organization strategies "Towards Unity for Health" and the social responsibility of medical schools]. Sante Publique, 15 Spec No, 137-145. No, Bower, H. (1998). Sackings and strikes paralyse Nicaraguan health care. Bmj, 316(7138), 1115. 316(7138), Braveman, P. (2006). Health disparities and equity: concepts and measurement. Annu Rev Public Health, 27, 167-194. 27, Braveman, P., & Gruskin, S. (2003). Poverty, equity, human rights and health. Bull World Health Organ, 81(7), 539-545. 81(7), Caldera , N. (2005). General debate of the 60th session of the united nations general assembly: Ministry of Foreign Affairs of the Republic of Nicaragua. assembly: CIA. (2006). The World Factbook-Nicaragua. from http://www.cia.gov/cia/publications/factbook/geos/nu.html http://www.cia.gov/cia/publications/factbook/geos/nu.html CISAS. (2003). Nicaragua health in the poverty reduction strategy., from http://www.cisas.org.ni/pdf/ercerp%20english%20trans%20con%20anexos.pdf Goyder, E. C., Blank, L., Ellis, E., Furber, A., Peters, J., Sartain, K., et al. (2005). Reducing inequalities in access to health care: developing a toolkit through action research. Qual Saf Health Care, 14(5), 336-339. 14(5), Maclure, R. S., M. (2004). 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