This is a quasi-experimental study in which we have used mixed methods. By incorporating quantitative and qualitative strategies, it aims to combine the strengths of both research approaches to obtain complementary results, gain a comprehensive understanding of the phenomenon, contrast and synthesize the results [22], and address common concerns such as the meaning and interpretation of the results and the identification of trends and variations in the phenomenon under study [23]. We designed an intervention proposal to implement the RIAS for Health Promotion and Maintenance and the RIAS for Maternal-Perinatal Health to contribute to peacebuilding in a challenging scenario. Therefore, we conducted a mixed-methods study in four phases. We focused on people living in the urban area of Vista Hermosa and in Santo Domingo, one of the rural settlements with the highest population concentration in the municipality. In addition, there are no ongoing health promotion programs in Santo Domingo, nor is there a presence of national and international organizations working on peacebuilding health interventions.
Phase 1. Territorial Recognition And Bases
In this phase, we consulted and obtained a bibliography to characterize the territory, based on the following four aspects: a) the geographical and administrative description of Vista Hermosa and Santo Domingo, as well as the evolution of the armed conflict in the region and its impact on rural health; b) demography and health, for which we reviewed topics such as natality, mortality, morbidity, disability and infections through COVID-19; c) resources for developing healthy lifestyles, such as physical activity and exercise, nutrition and beneficial habits, and recreational activities to be carried out at the community level; and d) the current status of the implementation of the Peace Agreement in the municipality. We also studied the normative framework for the implementation of the RIAS in Vista Hermosa, specifically, the RIAS for Health Promotion and Maintenance and the RIAS for Maternal-Perinatal Health. In addition, we analyzed the territory based on the model of social determinants of health [24] in the municipality, so we identified the structural determinants (stratification or social position, living conditions, and population with a differential approach) and the intermediary and the personal determinants (geography and access, social actors/cohesion, demography and health, and health system).
As a result, we drew up a map of the actors, organizations, and institutions working in the field of health in the urban area of Vista Hermosa and Santo Domingo, as well as an inventory of the capacity of the local authorities to implement the RIAS in the municipality. In addition, we assessed the coverage of the social security system and identified the administrative, economic, and cultural barriers to determine the quality and delivery of services that affect the implementation of the RIAS.
Phase 2. Community-based Research And Identification Of Assets And Needs
After characterizing the community, we assessed the health situation, in particular the interventions related to the implementation of the RIAS for Health Promotion and Maintenance and the RIAS for Maternal-Perinatal Health. We evaluated the impact of these interventions on the people living in the urban area of Vista Hermosa and Santo Domingo.
At the quantitative level, we formulated a quasi-experimental design with a before and after evaluation. We calculated the sample size by comparing the medians in matched groups using Epidat 4.2, an epidemiological data analysis program. Due to a lack of statistics, we do not have data on the implementation of the RIAS in the PDETs municipalities. Therefore, we calculated the sample size by assuming a statistically significant median difference of 0.2 to detect the effects of the intervention on the variables of interest (self-perceived level of health). We defined a reliability of 95%, a potency of 80%, and a standard deviation for the differences between pairs of observations of 1.0. Thus, the initial sample to establish the baseline and final line of the study for the statistical and additional populations was 219 people (199 = statistical population, 11 = pregnant women, and 9 = postpartum women). We described the variables according to their nature, using frequencies and percentages for categorical variables. For the continuous variables, we reported the mean and standard or median deviation, and the interquartile range according to the results of the Shapiro-Wilk test to assess normality [25]. Four months later, we used the Wilcoxon signed-rank test [26] to assess any change in the distribution of the assigned health thermometer score and body mass index (BMI) after the intervention. We performed a sub analysis according to the quartile distribution of the assigned health thermometer score at baseline. We assessed the change in frequency of self-perceived health and satisfaction with health services reported by informants after the intervention. For this, we used the McNemar test [26]. We evaluated all hypothesis tests at a 5% level of significance.
Initially, we faced significant obstacles. The COVID-19 pandemic delayed the timetable for this study. We had to contact people directly, but we could not go to Vista Hermosa because of the social distance measures and the movement restrictions. In addition, the national social uprisings that began in April 2021 made access difficult. Finally, the winter season caused disturbances on the roads and hindered the transit of people. Despite these challenges, we carried out three surveys: the first collected personal and socio-demographic data, housing conditions, and the relationship of the people as users of the health system. We used the National Survey on the Evaluation of Services Delivered by the Health Promoting Entities (EPS, by its Spanish acronym) [27]. The second assessed the statistical population to determine their clinical characteristics and verify the development of tasks to implement the RIAS for the promotion and maintenance of health in adults. The third reviewed the tasks for implementing the RIAS for Maternal-Perinatal Health, considering the stages of pregnancy, the postnatal period, and neonatal care. We applied the same instruments to the original informants after four months to assess any changes in the variables of interest. We stored the data in the web-based Research Electronic Data Capture (REDCap) platform, which we adjusted and analyzed in Microsoft Excel.
We based our qualitative research on the social determinants of health model [24], the social-ecological model of health [28], and the health belief model [29]. To select the sample, we used the convenience sampling strategy [30] because it turns to places, contexts, or people in direct contact with the phenomenon. This type of sampling provided relevant data to build or adapt the thematic clusters or constructs and the question guide we followed when facilitating the focus groups and the social cartography, allowing us to know and frame a comprehensive knowledge of the territories and the bodies on health [31]. We then conducted semi-structured interviews with relevant actors who played an active role at the institutional and community level. We asked them about the implementation of the RIAS, their beliefs and values regarding health, and the links between health and peacebuilding. In summary, we undertook the following actions: a) recognition of the geographical conditions and first-hand access to the community; b) a diagnosis of the local health context; c) a compendium of the informants' values and beliefs about health; d) recognition of the barriers and enablers to the implementation of the RIAS, as well as the health needs and risks; e) a map of resources to ensure the internet connectivity throughout the municipality; and f) selection of working methods to adapt the RIAS to respond to the local context.
Phase 3. Intersectoral Articulation And Health Interventions
The community-based research and bases allowed us to identify the historical, social, economic, and cultural conditions and the quality and coverage of health care in the municipality. A fundamental action in the design of the intervention methodology to implement the RIAS was to promote collaboration between authorities and agencies at the local and national levels, international organizations, and inter-agency initiatives that were leading significant and ongoing processes in the field of health. Strengthening these relationships was strategic to ensure the continuity of projects that were effective and positive at the grassroots level, and to formulate interventions that could address the structural causes that affect people's health and well-being. A clear example was the Health for Peace: Strengthening Communities, which aimed to build local capacity to improve access to comprehensive PHC services in priority areas of the country severely affected by the armed conflict.
The identification of health needs and risks allowed us to propose six health interventions: a) training on PHC issues for the HCT of the Vista Hermosa Health Care Center to strengthen their decision-making capacity and assertiveness, as well as the quality of patient care and compliance with current health policies. Professors from the Hospital Universitario San Ignacio (HUSI, by its Spanish acronym) and the Pontificia Universidad Javeriana (PUJ, by its Spanish acronym) conducted eighteen virtual and face-to-face training sessions; b) training sessions for the staff of the Plan of Territorial Health (PTH) and the Plan of Collective Interventions (PCI) on the implementation of the RIAS, with a focus on the community level. In addition, we formed working groups to design tools to facilitate the implementation of the RIAS at the community level, and the audit to evaluate the medical records and the clinics of the Health Provider Institution (HPI); c) health training for grassroots health leaders on the General System of Social Security Health, the PAIS, the RIAS, pre-hospital care, and pediatrics. The trainers were members of the project field team and the HUSI; d) health training for the community on health promotion and maintenance and sexual and reproductive health with a focus on the RIAS. In addition, we trained a group of actors from the commercial and tourism sector on health prevention and promotion (P&P), nutrition, and environmental hazards; e) development of an educational primer for the training of the HCT on rural health by some staff of the PUJ and the Fundación Saldarriaga Concha (FSC).
These include the health regulations of the Ministry of Health and Social Security, a set of clinical practice guidelines used at the national level, and some HUSI care guidelines; and f) strengthening the municipal health network by characterizing the real health needs of the population, providing tools to strengthen the decision-making process and the decision-making capacity of the Vista Hermosa Health Care Center, strengthening community health networks, and drafting a series of recommendations on peacebuilding health interventions for the design of the future Municipal Health Plan. These actions aim to promote a re-encounter between institutions and users to improve their relationship and to generate mechanisms and actions that guarantee peacebuilding and the health rights of the population.
Phase 4. Transfer Of The Constructed Knowledge To The Local Community
This study aims to ensure the social appropriation of the knowledge built cooperatively. To this end, we will present the results and the following products to the community and local authorities: a) a prototype intervention methodology for the implementation of the RIAS for Health Promotion and Maintenance and the RIAS for Maternal-Perinatal Health in the urban area of Vista Hermosa and Santo Domingo; b) an infographic presenting the intervention methodology in eight steps; c) a strategy for the continuous training of human talent; and, d) an educational primer for the training of the HCT in rural health.
Ethical Considerations
The Research and Institutional Ethics Committee of the Faculty of Medicine of the Pontificia Universidad Javeriana evaluated and approved this study in an ordinary meeting on 09/05/2022 under minute number 08/2019. The committee concluded that the members of the team were suitable to develop the study, that the project was relevant, and that it met the methodological rigor and ethical standards required for its conduct, with a favorable risk-benefit ratio for the participants. We conducted the study in accordance with Resolution 8430 of 1993, which regulates health research in Colombia.
The study followed the ethical principles presented in the Declaration of Helsinki to protect the freedom of the eligible informants to decide to participate or not continue in the study, so we informed them of all the risks and benefits of their participation in clear and simple language. A team member who had no hierarchical or subordinate relationship with the subjects provided the information voluntarily. All participants signed a consent form before the use of their data, explaining the nature of the study and the use of the information obtained from their participation. Confidentiality was always maintained. We will only use the information obtained for dissemination purposes. Therefore, we will maintain the anonymity of the data and the impossibility of identifying the participants in any report derived from the research results. We will use personal data in accordance with the Personal Data Protection Act and the Personal Data Protection Policy of the Fundación Saldarriaga Concha and the Pontificia Universidad Javeriana, available on the organization's website and at the request of the interested party through any means of contact.
We have taken all the measures to minimize potential risks during the development of the study. This is a low-risk study because we collected data using non-invasive equipment and methods, we did not take samples and we did not extract biological material. This intervention did not pose any psychosocial risk to the participants.