IMPLEMENTATION OF A CULTURALLY TAILORED DECENTRALIZATION PROGRAMME FOR SNAKEBITE TREATMENT IN INDIGENOUS COMMUNITIES IN THE BRAZILIAN AMAZONIA

蛇咬伤（SBE）是一种紧急的健康状况，免费提供有效的治疗。土著居民的这种疾病负担是完全可以预防的。如上所述，在改善SBE患者的治疗结果方面需要克服的主要障碍是患者需要寻求更高级别的护理，从而离开土著村庄，同时缺乏资源，扼杀了整个土著保健。巴西亚马逊地区目前的社区保健中心护理缺乏培训和能力，无法为性剥削提供专门护理。虽然系统性挑战是复杂和多方面的，但将抗蛇毒血清从医院分散到当地社区卫生中心是可行的，可能具有成本效益，并解决了这些核心障碍。巴西亚马逊地区的土著人民被夹在被低估和瓦解的传统文化和难以接近的西方制度之间。在巴西，抗蛇毒血清由公共制造商生产，免费提供给病人，但只在城市地区有限的医院提供。当地社区卫生中心缺乏抗蛇毒血清，限制了那些村庄的病人及时获得SBE护理。我们对土著居民的初步工作表明，他们不愿意离开社区接受护理，这是造成延误的原因之一，而该地区的文化和地理障碍又加剧了延误。一个短期、安全和有效的解决办法是将抗蛇毒血清治疗小规模脑炎的工作下放到土著社区卫生中心一级。AJURI的干预措施帮助历史上受压迫和服务不足的人群开发，实施和评估一种综合护理模式，为他们的人民提供优质，以患者为中心的治疗。如果成功的话，这种干预措施可以大大减轻小规模BE的负担，并防止对土著人口造成重大的人口健康和经济负担。这项实施研究将提供基于证据的知识，以制定一种新的战略，抗蛇毒血清交付，可以实施其他弱势群体。该提案将为必要的工作提供条件，从而向UKRI医学研究理事会（MRC）提出提案，以（a）评估优化抗蛇毒血清分配的最具成本效益的方案，（B）分析实施该战略的可行性、障碍和促进因素，以及（c）评估该SBE护理提供战略的成本效益。该提案专门响应英国研究和创新应用全球卫生研究，呼吁对实施科学进行研究，旨在确保巴西亚马逊地区的土著人口以可获得和公平的方式实施基于证据的SBE治疗，这是一个很难获得卫生系统的弱势群体。我们建议开发和试点实施一种创新的多模式干预措施，以改善巴西亚马逊地区的SBE治疗。这种干预模式有可能推广到其他土著地区和其他疾病。该提案也响应了世卫组织的战略目标，即通过“增强社区权能和参与，确保安全有效的治疗，加强卫生系统，增加伙伴关系，协调和资源”的举措，在2030年之前将SBE造成的死亡和残疾人数减少50%。

Snakebite envenomations (SBE) is an emergency health condition with freely available efficacious treatment. This disease burden on the indigenous population is entirely preventable. As described, the central obstacles to overcome in improving SBE patient outcomes are the patient's need to seek higher-level care and, thus, leave the indigenous village, alongside the lack of resources that strangle indigenous health care as a whole. Current community health centres (CHC) care in the Brazilian Amazon region lacks the training and capacity to offer specialized care for SBE. Though systemic challenges are complex and multifaceted, decentralizing antivenom from hospitals to the local CHC is feasible, likely cost-effective, and addresses these central obstacles. Indigenous peoples in the Brazilian Amazon are caught between an undervalued and disintegrating traditional culture and an inaccessible western system. In Brazil, antivenom is produced by public manufacturers and provided to patients free of charge but is only available at limited hospitals in the urban areas. Absence of antivenom in indigenous CHCs limits timely access to SBE care for patients in the villages. Our preliminary work with indigenous populations has shown a resistance to leaving the community to receive care contributing to the delays, exacerbated by cultural and geographical barriers in the region. A short-term, safe and efficacious solution is to decentralize SBE treatment with antivenoms to the level of indigenous CHCs. The AJURI intervention assists a historically oppressed and underserved population to develop, implement, and evaluate an integrative model of care that delivers quality, patient-centered treatment to their peoples. If successful, this intervention could drastically reduce the burden of SBE and prevent a significant population health and economic burden among the indigenous population. This implementation study will provide evidence-based knowledge to develop a novel strategy for antivenom delivery that could be implemented for other vulnerable populations. This proposal will provide conditions for the necessary work leading to a proposal to the UKRI Medical Research Council (MRC) to (a) evaluate the most cost-effective scenario to optimize distribution of antivenom, (b) analyze the feasibility, barriers and facilitators of implementing this strategy, and (c) evaluate the cost-effectiveness of this SBE care delivery strategy. This proposal specifically responds to UK Research and Innovation-Applied global health research, calling for studies on Implementation Science, aimed to ensure that evidence-based SBE treatment is implemented in an accessible and fair way for indigenous population in the Brazilian Amazonia, a vulnerable population with great difficulty in accessing the health system. We propose the development and pilot implementation of an innovative multi-modal intervention to improve SBE treatment in the Brazilian Amazonia. This intervention model will be potentially generalizable to other indigenous areas and to other diseases. This proposal responds also to the WHO strategic aims, which advocates that the numbers of deaths and cases of disability from SBEs be reduced by 50% before 2030 through initiatives that "empower and engage communities, ensure safe and effective treatment, strengthen health systems, and increase partnerships, coordination and resources".