Independent Study Project (ISP)

Background

As told by the Ancient Footprints of Acahualinca discovered in now-Managua, it is known that Nicaragua was populated at least 10,000 years ago (“Historia,” n.d.). The country shares a similar thread of history with many other countries of the Caribbean, that is the influence, exploration, and colonization by the Spanish Empire and its conquistadores. Also like many countries of Central and South America, Nicaragua eventually established its independence from Spain in the early 19th century and has since been transformed by waves of powerful political figures, regimes, revolutions, and economic crises (“Historia,” n.d.). One of the most significant and still current political periods for Nicaragua is marked by the socialist-oriented Sandinista National Liberation Front. This Nicaraguan group overthrew the Somoza family dictatorship and still maintains political power and influence as current chairperson Daniel Ortega was reelected as president in 2006, 2011, and 2016 (“Sandinista,” 2016).

Nicaragua is a warm country with warm people and a warm culture. Communities are small and intimate. Families are usually large in comparison to the average family size in the United States. It’s not uncommon for the nuclear and extended family to live in the same house or close by. Family members live and interact dependently with each other, and physical and emotional closeness is essential to the Nicaraguan culture. Due to the significance of community and relationships, the accepted interpersonal distance across all relationships is much smaller. For example, Nicaraguans will “kiss once on the cheek” during introductions and when seeing friends and family (“CIU PDP 2016,” 2016). Furthermore, the daily pace and lifestyle are also distinct from the United States. Time and punctuality are relaxed and slower.

Nicaragua has no official religion, and religious freedom and tolerance are guaranteed and promoted (Library of Congress. Federal Research Division & Merrill, 1994). Many Nicaraguans are Catholic, but there is a growing population of various Christian denominations. This religious variety and expansion are referred to as “evangelismo” in Nicaragua (“CIU PDP 2016,” 2016). Religion is integrated into all aspects of daily life and communication. For example, phrases like “gracias a Dios” and “si Dios quiere” are frequently embellished throughout a conversation (“CIU PDP 2016,” 2016). Religion also touches the education system as well. Many “private institutions that serve most upper and middle-class students” are controlled by “Roman Catholic bodies” (Library of Congress. Federal Research Division & Merrill, 1994).

 Now, most public education has been or is still currently heavily influenced by the Sandinistas’ efforts to improve and expand the education system. Their efforts were successful and notable with many education and literacy campaigns and a hallmark “ideological orientation of the curriculum” (Library of Congress. Federal Research Division & Merrill, 1994). However, it ranks fifth in literacy among the seven total Central American Countries (Bernard Nietschmann, Franklin D. Parker, Manuel S. Orozco, Rosendo Arguello, & Thomas W. Walker, 2016). The majority of Nicaraguan children only complete primary school, and in 2003, a little over half of children failed to finish the 2003 school year (“Youth Education & Development Issues in Nicaragua,” n.d.). Like the aforementioned education reforms, the Sandinista regime initiated other land and economic reforms. However, there was a shift and decrease in government spending when it “became embroiled in guerrilla warfare with a U.S.-backed insurgency beginning in the early 1980s” ((Bernard Nietschmann et al., 2016). This shift has consequentially left Nicaragua developing and progressing in education, health, and other social services.

 

Policy Analysis

My internship in Masaya, Nicaragua, will be in public health. Centro de Salud Monimbo (CS Monimbo), the community partner, provides “general medical services and health education” (n.d.-b) to address the health concerns of Nicaragua. As stated by FSD, the World Health Organization (WHO) has identified Nicaragua’s most urgent health issues to include: inequities in access to health services, infant mortality, maternal mortality, child nutrition, communicable diseases, non-communicable diseases, and growing environmental degradation (n.d.-a). According to FSD, these health concerns have derived from “poverty, geographical positioning, and a disorganized healthcare system.”

How did this “disorganized healthcare system” come to be? As described in the previous “Background” section, the Sandinista government initiated and supported many reforms, most notably education reform. Health care was also a top priority. The health reform consisted of restructuring the whole healthcare system. The medical responsibilities of the” Ministry of Health, the Nicaraguan Social Security Institute, and some twenty other quasi-autonomous health care agencies from the Somoza era” were combined into one system (Library of Congress. Federal Research Division & Merrill, 1994).

The national health care budget increased, access expanded, and the reform promoted equity and emphasized primary and preventive medicine. By the end of the “Sandinista decade,” the reform was praised for the progress and success of vaccination campaigns, oral rehydration centers that treated severe childhood diarrhea, and the Ministry of Health’s thousands of trained health brigadistas (community health volunteers) (Library of Congress. Federal Research Division & Merrill, 1994). These brigadistas ushered in a new culture of mobile health access and community participation in health education and promotion, an occupation still practiced and valued by CS Monimbo.

Like many great systems of a nation, financial resources are vital. By 1991, government spending on health went from “$58 per head per year (in 1988) to $17 per head per year” (n.d.-a). Furthermore, when an era of more liberal government began in the 1990s under Violeta Barrios Torres de Chamorro, health care shifted to be more of a private market (Kathryne Dieter, 2012). This private sector fostered health inequities across all dividing lines: the rural/urban, poor/wealthy, indigenous, female/male, children, and the elderly. The reduced budgets have significantly affected these vulnerable groups and the public health resources they utilize. No longer are personnel, supplies, and costs comfortably accessible. There now exist “out-of-pocket health expenditures” that delay or fully inhibit access for the “majority of Nicaraguans.” (n.d.)

Health centers like CS Monimbo help diminish the health disparity gap by providing free or low-cost services. To better serve their target population, vulnerable groups, CS Monimbo hosts daily educational workshops and tasks their health brigadistas to travel to puestos de salud (rural outposts). The brigadistas work with the community on health education and fulfilling vaccination campaigns. These health centers and puestos de salud are the “main health providers among the poor” (Rafael Cortez, Diego Angel-Urdinola, & Kimie Tanabe, 2008).

Regarding health policy and systems, the National Human Development Plan began in 2010. Based on 12 guidelines which combine “policy continuity with new priorities,” the strategy intends to transform the human development of the Nicaraguan population. Through the Family and Community Health Model, the government is working to prevent diseases and offer all Nicaraguans “comprehensive and integrated, free, high-quality services.” This model is central to the health policy and the goal of creating a “systematic and comprehensive” response to endemic and epidemic health concerns. The Ministry of Health has also augmented its network of services through an additional 21 primary health care facilities between 2010 and 2013. According to 2013 WHO data, Nicaragua has 1230 health facilities total. The emphasis on community participation and health care can be seen through the approval of the Civic Participation Act. This act encourages coordination and communication between the Nicaraguan citizens and the government through new and supported “institutional mechanisms” (“Nicaragua Country Cooperation Strategy,” 2016).

 

Breaking News

According to a recently published article titled “Elaboran mapa de padecimientos de salud,” specialists of the Ministry of Health (el Ministerio de Salud (Minsa)) will make a map of the most frequent illnesses and chronic diseases and where in the country they are concentrated. The map will be available April 2018. The project will also include information and many numbers regarding hospitalization, deaths, hospital quantities, health centers, patient capacity according to a site’s number of beds, and services provided to the respective population. Most importantly, the document will display the Minsa community and family health model and development of the health system by the Nicaraguan government.

I think this map by the Ministry of Health is a valuable project. Not only will it require the government to fully discover and synthesize the information listed above, but it will also result in a useful document for the health system and health professionals. I see the map serving as a visual “report card” on the various benchmarks of public health and health resources in Nicaragua. As discussed earlier in the paper, Minsa supports policies and programs that encourage collaboration and coordination between the government, health institutions, and communities. This map would be another positive, comprehensive addition to Nicaragua’s health model.

http://www.elnuevodiario.com.ni/nacionales/422023-elaboran-mapa-padecimientos-salud/#

 

“Nicaragua searches to reduce maternal deaths” states a La Prensa article. Minsa plans to accomplish a reduction from the 56 maternal death recorded in 2016 through the training of 700 new “parteras” (midwives). According to Enrique Beteta, the Vice Minister of Health, Minsa’s priorities for 2017 will be creating maternity homes in rural areas, constant midwife training, and organizing 20,000 “brigadistas de salud” (health brigaders). Furthermore, another 2017 goal of Minsa is to become a country free from mother-to-child transmission of HIV and syphilis. The Caribbean Coast of Nicaragua has its own challenges and goals regarding maternal and child health. Minsa hopes to improve the attention and care for pregnant women of the Caribbean Coast who prove to be difficult to access due to the “immense territory,” “difficulty [mobilizing]” and reaching the interior areas (Ivette Munguía Argeñal, 2017).

 I know this news article and the reported goals regarding maternal and child health and mortality are important because this article is tagged with “minsa,” “muertas maternas,” and “salud”. If these topics weren’t of frequency and importance to the country, and thus its national newspaper, they wouldn’t be a tag to reference and organize. This is an important area for CS Monimbo as well as they have an entire program in the health center called “Integral Health Care for Women, Children, and Adolescents” that provides services that align with what Minsa has outlined above: pregnancy monitoring and “workshops on health and development topics specific to pregnant and nursing women” (Foundation for Sustainable Development, 2017). However, CS Monimbo doesn’t have any mention of parteras. This is interesting because according to the heavy investment of time and training by Minsa, I would think these women and their services are important to the culture and care of pregnancy and maternal health.

http://www.laprensa.com.ni/2017/01/28/nacionales/2173155-nicaragua-busca-reducir-muertes-maternas

 

 In a 2016 year wrap-up article, BBC Mundo listed “5 important things that happened during 2016 in Central America when the world wasn’t looking.” Nicaragua and its “problems of democracy” were listed as the first of the five. This article is all the expert opinion and commentary of Carlos Dada, the founder and director of El Faro, a digital Salvadoran magazine. The crux of this statement is based on the November 6 reelection of Daniel Ortega and the “[even] more shameless nomination of his wife as the vice president”(Redacción, 2016). Beyond this great political spectacle, Dada insists that there was an affront to democracy that wasn’t covered by international media. Dada states that not only was it “an election without citizen participation, but an election without candidates as well.” In short, a great political corruption and setup for a “family dynasty” (Redacción, 2016).

I think this article and Dada’s opinion are significant to the political background and present of Nicaragua. Like all political institutions, there’s a lot behind the scenes, and I believe this article gives a strong opinion on the politics of Nicaragua. Central America is comprised of seven countries with a lot going on individually and as a whole (“Central America Map,” 2016). For the political situation of Nicaragua to be identified as not only one, but the one to “open with” of the few and five significant events of the geographic region is undeniably significant (Redacción, 2016). I also believe there is more freedom in this opinion as it was published by an external news source and from a knowledgeable, outside expert.

http://www.bbc.com/mundo/noticias-america-latina-38393028

 

What do a bishop, rural leader, boxer, and professor all have in common? Why being one of the four selected Nicaraguans to be voted by the people as “personality of the year” of course. The Auxiliary Bishop of Managua, Monsignor Silvio José Báez, was nominated due to his strong political opinions and actions, such as not voting in the November presidential elections and declaring that Nicaragua has a “corrupt, unconstitutional, authoritarian, and antidemocratic system”. Francisca Ramírez, the rural leader, coordinated a march against the Canal Interoceánico project and leads the National Council for the Defense of the Land, Lake, and Sovereignty. She too has also expressed strong, negative statements regarding the government and President Daniel Ortega. Nicaraguan boxer, Roman “Chocolatito” Gonzalez, received a nomination due to his status as a four-time world champion and third consecutive year as Nicaraguan Athlete of the Year. Professor Nilamar Alemán Mora is titled as “the teacher of solidarity” due to her trying to “help an African migrant and her baby reach the border to Honduras.” Her brave act cost her three years in prison on account of “reckless trafficking of migrants” because since November 2015 Nicaragua has closed its borders to migrants.

One of my favorite songs is “Human of the Year” by Regina Spektor. When I saw La Prensa’s article titled “¿Quién es el personaje del año en Nicaragua? Participá en la votación (Who is the personality of the year in Nicaragua? Participate in the vote),” I was not only reminded of the song and consequently drawn to the article, but I was also interested in seeing who these four principal figures of 2016 Nicaragua were and why they were in the consideration to be Nicaragua’s “Human of the Year.” These individuals were must have been significant in some sphere or aspect of Nicaragua, and after reading their short blurbs, it’s not difficult to see why they were selected. Not only were they notable and brave, but the people of Nicaragua noticed and appreciated them and their actions as well. In selecting articles from La Prensa to include in this section, I didn’t come across any articles that had comments left by the readers. This article was the exception. Not only were there comments, but there were also passionate reasons why an individual reader believed Monsignor Silvio Báez, Francisca Ramírez, Chocolatito, or Nilamar Alemán Mora should receive the title and honor. The impact areas of these individuals ranged from religion, politics, land rights, sports, and human rights. I believe it’s important to note that three of the four individuals were driven to act due to the politics and government of Nicaragua.

http://www.laprensa.com.ni/2016/12/28/nacionales/2156512-quien-es-el-personaje-del-ano

 

Faculty Connection

To further learn about Nicaragua and its public health system, I reached out to Dr. Cymene Howe, an Associate Anthropology Professor at Rice. Dr. Howe spent over a decade in Nicaragua conducting field research and writing her first book, Intimate Activism: The Struggle for Sexual Rights in Postrevolutionary Nicaragua (Duke University Press 2013). From the walking meeting we had, Dr. Howe shared many cultural and practical tips and resources pre-departure and in-country.

Beyond the practical: try not to walk alone, don’t go out late at night by myself, don’t be flashy or overtly foreign, she also shared pearls of advice substantiated by her personal experience and study of Nicaraguan society, culture, and social evolution (and at times stagnation and regression, according to her academic and personal opinion). Regarding the culture of Nicaragua, she explained that like many Latin American and Hispanic countries, machismo influences communication, social dynamics, and behaviors. Dr. Howe also recommended showing and expressing my genuine interest and gratitude would only benefit me socially with my host family and among my supervisors and colleagues and professionally at my internship site.

Regarding consejos (advice) for my internship, her academic interest and expertise is in gender and sexuality so she was only able to strongly recommended that I’m intellectually prepared and well-versed in Nicaragua’s health system, its intended goals and functions and its reality, and its pros and cons. All though this was “all” she could offer, I still recognize the value and truth in her advice. She also suggested I keep up to date with in-country news before and during my trip as I will be working with and among the people and this will be the news on their minds and in their conversations. She suggested La Prensa, which I’m already familiar with from a few of my “Breaking News” articles, Bolsa de Noticias, Confidencial, and El Nuevo Diario (also a source of one of my “Breaking News” articles) as several options. Many of these resources can also be accessed online before I’m in-country.

I would be remiss if I didn’t mention my original “un-official” faculty connection, Ms. Lucia Hurtado. Ms. Hurtado was my mentor and supervisor at my Smith Clinic internship last fall through Rice’s Spanish medical apprenticeship course. During our time together translating between the patients and health professionals of Smith Clinic, we talked a lot about Nicaragua as Ms. Hurtado is from Nicaragua. She was the first person whom I told about my fellowship and public health internship in Masaya. If I thought she had already told me a lot about Nicaragua before that day, I was wrong. She lit up with excitement and joy that I would share in her country and immediately began offering pieces of advice that I, of course, wrote down in my little observer notebook. “Don’t eat fruit that you can’t peel, but you have to try níspero, jocote, and zapote.” “The people are so friendly and warm because they’re island, tropical people. People of the Caribbean.” “Solo un beso, not dos como en España” and so many more pearls. I fell in love with Nicaragua many months ago. Ms. Hurtado also connected me with her sister and family who live and Managua, and we’re planning on meeting and connecting during a weekend this summer.

Without a doubt, I will compile and heed all the advice given to me by these amazing women of Nicaragua. The main themes I’ve identified are pre-departure knowledge acquirement, prudence, openness, and a willingness to socialize, work, and try new things. The SMART goal I published earlier this Spring (read one book on Nicaragua biweekly) can also be modified to include the news sources Dr. Howe suggested, and I believe that’s practical way to track and incorporate that piece of advice I’ve been given thus far.

 

Local Community Organization

Last year, I participated in an ASB that focused on health disparities in Houston. One of the community organizations we worked with was Legacy Community Health. I decided to return to Legacy for my community connection. It’s satisfying to know that a past LEARN opportunity of mine can and will connect to this ACT opportunity.

Legacy is a “full-service, Federally Qualified Health Center.” Legacy currently provides the following: “adult primary care, pediatrics, dental care, vision services, behavioral health services, OB/GYN and maternity, vaccinations and immunizations, health promotion and community outreach, wellness and nutrition, and comprehensive HIV/AIDS care” (Legacy Community Health, n.d.-a). The services offered at Legacy in Houston are very similar to those offered by CS Monimbo in Masaya. They both offer primary care and health services for adults, pediatric checkups, dentistry, OB/GYN and maternity services, vaccinations and immunizations, health promotion, community outreach, HIV/AIDS testing and counseling, and information on nutrition. There’s a lot of overall between the services and scope of the two health centers. CS Monimbo doesn’t offer vision services or HIV/AIDS care. CS Monimbo only offers referrals because there’s only one agency in Nicaragua that offers care and services for HIV/AIDS patients, and it’s located forty minutes away from the center in Managua (Foundation for Sustainable Development, 2017).

An aspect that I’m sure isn’t paralleled at Legacy, but is a reality for CS Monimbo is that “[CS Monimbo] routinely runs out of basic supplies and depends on the ingenuity of its staff” (Foundation for Sustainable Development, 2017). In fact, according to Legacy’s published timeline, the organization seems to be doing very well with expansion, new branches, funding, and extensive partnerships across Houston organizations and institutions (Legacy Community Health, n.d.-a). I think the services and material at CS Monimbo will be a lot more essential and simple. This year, Legacy will “break ground… on [a] new 40,000 square foot state of the art clinic” (Legacy Community Health, n.d.-a). I don’t believe “state of the art” is a level CS Monimbo has in their facility or equipment. However, both CS Monimbo and Legacy aspire to provide “state of the art” level services for their patients and communities. I also believe both organizations prioritize vulnerable groups.

I believe the need for quality health services is a globally need, from Houston to Nicaragua and every city and country on the map. However, Nicaragua has focused public health issues within their needs that are as strong in the US. For example, in Nicaragua’s public health system, there is a strong priority given to women’s and children’s health. This is evidenced not only from the services and information of CS Monimbo, but also by the national policy and initiatives proposed and carried out by Minsa and the government (see “Policy Analysis” and “Breaking News”). Nicaragua also faces specific public health issues that are not of great prevalence in the US, such as malaria, dengue, chikungunya, and Zika. In Nicaragua, these diseases are always on threat to become “regular epidemic outbreaks” and occasionally even do (“Nicaragua Country Cooperation Strategy,” 2016).

Reconnecting with Legacy Community Health through this fellowship and pre-departure research has provided me with such a great opportunity to connect the abroad with my home through this common interest and issue of public health. Legacy does have internships and externships, and this could be a future internship site for me in the future. They also accept and appreciate volunteers in various areas such as: campus hospitality, outreach, and facilities assistant. Outreach would be in the most direct link to serving and staying engaged in  public health (Legacy Community Health, n.d.-b).

 

Reflection

From that start of my time at Rice, I’ve been collecting pieces of interest. Pieces that sparked me, gave me pause, or inspired me to be better in order to be a part of something greater. Some of these pieces include: global health sustainability, global health education, chronic/acute diseases and treatment in developing countries, and childhood education. My interest in health education and community health promotion has been growing for months now. I’ve decided to dedicate my undergraduate education to the Health Sciences, and I’ve begun looking at MPH programs in Texas and across the country to further my education when I graduate. I’m interested in a future and career where I design and deliver accessible, relevant, and personalized health information and education.

I have a fierce intellectual investment and curiosity in Latin American. Nicaragua and this service offer an opportunity to connect and further explore these intellectual interests through physical action and time – linking my head, heart, and hands. Furthermore, my parents are both from developing countries, and when we visit, we go where the people live and work, where my parents grew up. I fell in love with my mom’s motherland, Jamaica, for its culture and people, not the beautiful, tropical tourism. Like my love and appreciation for Jamaica, I too fell in love with Nicaragua because of its culture, the people, and their infectious and genuine love for their home. I have found that I’m discovering a lot about myself through my learning of Spanish and Latin America.

I believe in accessible health education and care fits a major need of our immediate and future world. Health is good, and I do believe health to be a human right. I believe the purpose of health education and promotion is to allow the patient or individual to make the good, true decision for themselves regarding their health. I believe that empowerment follows education. Health education is sustainable, it can be low-cost, even free, and it can encourage further self-development and progress within a community.

Through the process of research, interviews, and conversations, I’m still left unsatisfied on the following topics: cultural competency in Nicaraguan health care, the most and least effective public health initiatives confirmed through qualitative and quantitative evaluations, partnerships with foreign individuals and/or organizations, and the tertiary levels of healthcare. I’m confident that the time and conversations I will have in Masaya will allow me to supplement and further develop my current understanding and knowledge.

 



Appendix

Works Cited

Bernard Nietschmann, Franklin D. Parker, Manuel S. Orozco, Rosendo Arguello, & Thomas W. Walker. (2016, December 14). Nicaragua. Retrieved February 16, 2017, from https://www.britannica.com/place/Nicaragua

Central America Map. (2016, September 19). Retrieved March 18, 2017, from http://www.worldatlas.com/webimage/countrys/camerica.htm

Ciudad Sandino: Pre-departure Packet. (2016). fsd.

Country Cooperation Strategy at a glance. (2016, May). Retrieved from http://apps.who.int/iris/bitstream/10665/250648/1/ccsbrief_nic_en.pdf

Foundation for Sustainable Development. (2017, March 2). Centro de Salud Monimbo. Foundation for Sustainable Development.

foundation for sustainable development. (n.d.). Child and Maternal Health Issues in Nicaragua. Retrieved February 18, 2017, from http://www.fsdinternational.org/country/nicaragua/healthissues

foundation for sustainable development. (n.d.). Ciudad Sandino Opportunities 2016. Retrieved from http://www.fsdinternational.org/sites/default/files/public/Ciudad%20Sandino%20Opportunities%202016.pdf

foundation for sustainable development. (n.d.). NicaraguaCountryOverviewFinal. fsd. Retrieved from http://www.fsdinternational.org/sites/default/files/public/NicaraguaCountryOverviewFinal.pdf

Historia. (n.d.). Retrieved February 16, 2017, from http://espanica.org/nicaragua/historia/

Ivette Munguía Argeñal. (2017, January 28). Nicaragua busca reducir muertes maternas. Retrieved March 19, 2017, from http://www.laprensa.com.ni/2017/01/28/nacionales/2173155-nicaragua-busca-reducir-muertes-maternas

Kathryne Dieter. (2012, August 20). History of Health Systems in Nicaragua. Retrieved from http://endtheneglect.org/2012/08/history-of-health-systems-in-nicaragua/

Legacy Community Health. (n.d.-a). About Us. Retrieved March 19, 2017, from http://www.legacycommunityhealth.org/about-us/

Legacy Community Health. (n.d.-b). Volunteer. Retrieved March 19, 2017, from http://www.legacycommunityhealth.org/development/volunteer/

Library of Congress. Federal Research Division, & Merrill, T. (1994). Nicaragua : a country study. Federal Research Division, Library of Congress. Retrieved from https://www.loc.gov/item/94021664/

Rafael Cortez, Diego Angel-Urdinola, & Kimie Tanabe. (2008). Equity, access to health care services and expenditures on health in Nicaragua. Washington, DC: World Bank. Retrieved from http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/CortezNicaraguaHealth.pdf

Redacción. (2016, December 27). 5 cosas importantes que pasaron durante 2016 en Centroamérica “cuando el mundo no estaba viendo.” BBC Mundo. Retrieved from http://www.bbc.com/mundo/noticias-america-latina-38393028

Sandinista. (2016, November 8). Retrieved February 16, 2017, from https://www.britannica.com/topic/Sandinista

Youth Education & Development Issues in Nicaragua. (n.d.). Retrieved February 16, 2017, from http://www.fsdinternational.org/country/nicaragua/yeissues

Breaking News Articles

“Elaboran mapa de padecimientos de salud.” El Nuevo Diario. N.p., 17 Mar. 2017. http://www.elnuevodiario.com.ni/nacionales/422023-elaboran-mapa-padecimientos-salud/#

 

Ivette Munguía Argeñal. “Nicaragua Busca Reducir Muertes Maternas.” La Prensa. N.p., 28 Jan. 2017.

http://www.laprensa.com.ni/2017/01/28/nacionales/2173155-nicaragua-busca-reducir-muertes-maternas

 

Redacción. “5 Cosas Importantes Que Pasaron Durante 2016 En Centroamérica ‘cuando El Mundo No Estaba Viendo.’” BBC Mundo 27 Dec. 2016. www.bbc.com.

http://www.bbc.com/mundo/noticias-america-latina-38393028

 

“¿Quién Es El Personaje Del Año En Nicaragua?” La Prensa. N.p., 28 Dec. 2016.

http://www.laprensa.com.ni/2016/12/28/nacionales/2156512-quien-es-el-personaje-del-ano