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PubMed2002

Public health infrastructure and equity in the utilization of outpatient health care services in Peru.

This article analyzes the magnitude and nature of socioeconomic differences in the utilization of outpatient health care services in Peru. In particular, it explores the potential equity-enhancing effect of the expansion and improvements in the network of health centres during the 1990s. The Peruvian health reform made relatively little progress in terms of the reform agenda promoted internationally during the 1990s. Nevertheless, the expansion of the public network of health centres and the improvements in their equipment has been noteworthy during the same period. Using the 1997 survey of the Peruvian Living Standards Measurement Study (PLSMS), we find large differences in the utilization of outpatient health care services. The richest to poorest quintile ratio is 1.9, and even larger in rural areas. Estimating a probit model with random effects at the district level to control for the systematic geographic bias associated with the optimal public allocation of such infrastructure, we find the income effect to be very large, even after controlling for other socioeconomic characteristics. Finally, we also find that the expansion of the public network of health centres has indeed an equity-enhancing effect, but this is rather small. These results indicate that although the expansion of the public network of health facilities may be necessary, it is not sufficient to promote equity in the utilization of health care services by Peruvian adults, especially in rural areas. It is important to look deeper into the costs of consultations and drugs as economic barriers to the utilization of health services by the poor. In particular, the expansion of health insurance mechanisms for the poor should be carefully monitored and evaluated.

Ambulatory Care↗

PubMed1994

An operational evaluation of the Community Oral Rehydration Units in Peru.

Since 1984, in Latin America donor agencies and national governments have extensively supported the implementation of the Community Oral Rehydration Units (CORUs) in an attempt to increase the access to oral rehydration therapy and improve the case management of diarrhoea at the community level. This study surveyed 40 CORUs in two regions of Peru to assess their operation, the number of patients with diarrhoea attended, and the knowledge of volunteers in charge. The results show that CORUs were mainly implemented close to existing health centres; the median of case load was 2.0 patients in the preceding month; and the volunteers' knowledge of case management was principally deficient in the diagnosis of hydration status, dietary management and in preventive measures. This lack of knowledge was replicated by professionals at the supervising health centres. Despite the fact that CORUs have been functioning for around four years, they exhibit numerous deficiencies which prevent them from fulfilling their objectives. A global review of the whole CORU strategy is called for.

Community Health Services↗

PubMed2006

The cost-effectiveness of a child nutrition education programme in Peru.

This article reports impact and cost results from a health facility-based nutrition education programme targeting children less than 2 years of age in Trujillo, Peru. Key elements of the programme included participative complementary feeding demonstrations, growth monitoring sessions and an accreditation process. Data were collected from six intervention and six control health facilities to measure utilization and costs associated with the intervention. To calculate the unit costs of services, these costs are allocated using activity-based costing. To measure the effects of the intervention, 338 children were followed through household surveys at regular intervals from birth until the age of 18 months. The intervention had a clear positive impact both on the use of nutrition-related services and on children's growth outcomes. Children in the intervention areas made 17.6 visits to health facilities in the first 18 months of life, compared with 14.1 visits for children in the control areas (P < 0.001). This pattern holds true for all socioeconomic groups. The intervention prevented 11.1 cases of stunting per 100 children. In multivariate logistic regression analysis, children in the intervention were 0.33 times as likely to be stunted as the controls (P = 0.002). The marginal cost of the intervention - including external costs, training, health education materials and extra travel and equipment - is 6.12 US dollars per child reached and 55.16 US dollars per case of stunting prevented. The estimated marginal cost of the intervention per death averted is 1952 US dollars.

Adult↗

PubMed2006

When training is insufficient: reflections on capacity development in health promotion in Peru.

The international development community has lately recognized the programatic importance of capacity development. Despite growing attention, a consensus is still lacking on appropriate strategies and interventions to strengthen local capacity for development programs. The CHANGE Project designed and implemented a program to contribute to capacity development in health promotion in Peru between 2002 and 2005. This article discusses key lessons learned in the program. Successful capacity development requires the strengthening of institutional networks. Training activities alone are insufficient. Educational opportunities need to be integrated into strategies that aim to institutionalize competencies in specific work contexts and promote the inter-institutional linkages. The experience suggests that capacity development programs need to start by assessing challenges to make competencies effective in job performance. Projects should neither be donor-driven nor depend on individuals. Instead, they should focus on institution building, find creative ways to promote long-term sustainability of capacity development, and require long-term commitment to promote ownership and sustainability. What is needed is an approach that maximizes the impact of programs through collaboration among institutions committed to supporting and absorbing capacity, and to having mechanisms to monitor and change job performance according to the needs of staff, supervisors and other stakeholders.

Health Promotion↗

PubMed2002

An intervention for the promotion of hygienic feces disposal behaviors in a shanty town of Lima, Peru.

This paper describes the design, implementation and evaluation of an intervention to promote improved hygiene practices in a shanty town area of Lima, Peru. Following formative research, the intervention focused on behaviors associated with the hygienic use of potties by children aged 15-47 months and keeping the home environment free from feces. A health communications strategy was developed involving delivery through routine health services, and using video presentations, leaflets and counseling by health staff during consultations. Intervention activities occurred during a 6-month period in health centers and posts of four intervention communities; four other communities acted as a comparison group. Process and impact indicators were measured through questionnaires and 4-h structured observations conducted in over 600 households both pre- and post-intervention implementation, and through intervention monitoring activities. The intervention materials and approach were well received by the study community; however, in the time-frame of the project only limited coverage of the target audience was achieved, which was insufficient to result in an impact on behaviors. Nevertheless sufficient positive features existed to suggest that with higher coverage, an impact on target behaviors might have been achieved. Reasons for the intervention's shortcomings are discussed and suggestions made for more effective implementation.

Feces↗

PubMed2006

Implementation examined in a health center-delivered, educational intervention that improved infant growth in Trujillo, Peru: successes and challenges.

Process evaluation was used to examine the implementation of a randomized, controlled trial of an education intervention that improved infant growth in Trujillo, Peru. Health personnel delivered the multi-component intervention as part of usual care in the government health centers. Quantitative and qualitative methods were used to examine process indicators, which included the extent of delivery (dose), fidelity to intervention protocol, barriers to implementation and context. Results demonstrated that most intervention components were delivered at a level of 50-90% of expectations. Fidelity to intervention protocol, where measured, was lower (28-70% of expectations). However, when compared with existing nutrition education, as represented by the control centers, significant improvements were demonstrated. This included both improved delivery of existing educational activities as well as delivery of new intervention components to strengthen overall nutrition education. Barriers to, and facilitators of, implementation were explored with health personnel and helped to explain results. This study demonstrates the importance of examining actual versus planned implementation in order to improve our understanding of how interventions succeed. The information gained from this study will inform future evaluation designs, and lead to the development and implementation of more effective intervention programs for child health.

Caregivers↗

PubMed2007

Women's participation in a cervical cancer screening program in northern Peru.

Cervical cancer is often the most common cancer among women in developing countries, yet current screening efforts have not been effective in reducing incidence and mortality rates in these settings. In an effort to increase knowledge about screening participation in low-resource settings, this study sought to identify key factors affecting women's participation in a cervical screening program in north central Peru. We studied women who were exposed to various health promotion educational activities and compared a total of 156 women who sought screening between July 2001 and October 2003 with 155 women who did not. Results from logistic regression identified four significant predictors of screening: higher relative wealth, knowing other screened women, seeking care from a health facility when sick and satisfaction with services at the health facility. When we restricted our analysis to women who had experienced screening in the past, two additional predictors emerged: having a husband who was supportive of screening participation and attending an awareness-raising session. These results have important programmatic value for tailoring outreach efforts for women and indicate that different strategies may be required to best reach women who have never been screened.

Adult↗

PubMed1990

Identifying the malnourished within Peru: regional variation in the performance of a nutrition indicator.

Malnourished children may also have siblings at increased risk of poor health. Early identification of siblings at risk could lead to timely intervention to prevent the development of malnutrition or other potentially life-threatening events. In a nationwide survey conducted in Peru in 1984, stunting in an older sibling (defined as height/age less than or equal to 3.00 SD of the NCHS/CDC reference median) was evaluated as an indicator for stunting in a target sibling (next youngest) sibling) (n = 3284). The prevalence of stunting was much higher in target siblings who had an older sibling with stunting compared to those whose older sibling was not stunted, with prevalence ratios of 8.5 in Lima, 4.7 in urban areas, and 2.5 in rural areas. Screening indices (sensitivity, specificity, and predictive value positive) also showed marked variation across regions. The variation in this indicator's performance across regions demonstrates the importance of evaluating screening tools within the populations where they will be applied. Regional variations in the performance of malnutrition indicators should be anticipated because malnutrition is the result of a complex, multifactorial process.

Anthropometry↗

PubMed1992

Cholera in Piura, Peru: a modern urban epidemic.

In late January 1991, epidemic cholera appeared in Peru. Within 2 months, 7922 cases and 17 deaths occurred in Piura, a Peruvian city of 361,868. A hospital-based culture survey showed that 79%-86% of diarrhea cases were cholera. High vibriocidal antibody titers were detected in 34% of the asymptomatic population. A study of 50 case-patients and 100 matched controls demonstrated that cholera was associated with drinking unboiled water (odds ratio [OR], 3.9; 95% confidence interval [CI], 1.7-8.9), drinking beverages from street vendors (OR, 14.6; CI, 4.2-51.2), and eating food from street vendors (OR, 24.0; CI, 3.0-191). In a second study, patients were more likely than controls to consume beverages with ice (OR, 4.0; CI, 1.1-18.3). Ice was produced from municipal water. Municipal water samples revealed no or insufficient chlorination, and fecal coliform bacteria were detected in samples from 6 of 10 wells tested. With epidemic cholera spreading throughout Latin America, these findings emphasize the importance of safe municipal drinking water.

Adolescent↗

PubMed1994

Human T cell lymphotropic virus type I infection among female sex workers in Peru.

Four hundred female sex workers attending a sexually transmitted disease clinic in Lima, Peru, were interviewed for demographic information and medical, contraceptive, and sexual practice histories. Cervical cultures were done for Neisseria gonorrhoeae and Chlamydia trachomatis, and serum was tested for antibodies to human immunodeficiency virus, human T cell lymphotropic virus type I (HTLV-I), Treponema pallidum, C. trachomatis, herpes simplex virus type 2 (HSV-2), and Haemophilus ducreyi. The prevalence of HTLV-I increased with duration of prostitution from 3.6% (< 3 years) to 9.3% (3-6 years) to 15.9% (> 6 years; P < .01). After adjustment for duration of prostitution, reduced risk of HTLV-I was significantly correlated with condom use for more than half of all sexual exposures for > 3 years (odds ratio [OR], 0.34; 95% confidence interval [CI], 0.13-0.89). Further adjusting for condom use, HTLV-I seropositivity was associated with C. trachomatis (OR, 3.7; 95% CI, 1.4-13.2) and with antibody to HSV-2 (OR, 3.7; 95% CI, 0.5-29.6). Thus, duration of prostitution, lack of consistent condom use, and past infection with C. trachomatis were significantly associated with HTLV-I seropositivity.

Adult↗

PubMed1994

Severe life-threatening cholera associated with blood group O in Peru: implications for the Latin American epidemic.

A household survey in 1991, at the onset of the Latin American cholera epidemic, investigated high attack rates in Trujillo, Peru, and determined the association between blood group O and severe cholera. Of 463 persons in 69 households, 173 (37%) reported diarrhea, 21% required rehydration therapy, and 4% were hospitalized; these treatment requirements greatly exceeded estimates based on other populations. Elevated vibriocidal or antitoxic antibody titers were present in 52% of 321 from whom serum was obtained; 73% were blood group O. Blood group O was strongly associated with severe cholera: Infected persons had more diarrheal stools per day than persons of other blood groups, were more likely to report vomiting and muscle cramps, and were almost eight times more likely to require hospital treatment. Since prevalence of blood group O in Latin America may be the world's highest, estimates of treatment requirements should be increased to prevent unnecessary deaths.

ABO Blood-Group System↗

PubMed1996

Safety, immunogenicity, and protective efficacy of one and three doses of the tetravalent rhesus rotavirus vaccine in infants in Lima, Peru.

An oral rhesus-human rotavirus tetravalent (RRV-TV) vaccine (10(4) pfu of rhesus rotavirus [type G3] and of 3 human-rhesus reassortants [G1, G2, and G4]) was evaluated in a field trial in Lima, Peru. At 2, 3, and 4 months of age, infants received either a dose of RRV-TV, an initial dose of vaccine followed by a dose of placebo at 3 and 4 months, or a dose of placebo. Rotavirus-specific IgA responses were detected by ELISA in 75% of the three-dose vaccine group, 59% of the one-dose vaccine group (P = .05), and 24% of the placebo group (P < .001): 64%, 48%, and 12% of each group, respectively, had a neutralizing antibody response to at least 1 serotype. Both one and three doses of vaccine failed to induce a significant level of protection against rotavirus diarrhea; however, they did provide some protection (range, 35%-66%) against more severe rotavirus diarrhea, especially for episodes caused by type G1.

Animals↗

PubMed1993

Plasmodium vivax VK247 and VK210 circumsporozoite proteins in Anopheles mosquitoes from Andoas, Peru.

Anopheles mosquitoes captured in Andoas, Peru, a Plasmodium vivax-endemic area in the Peruvian Amazon region, contained both VK210 and VK247 P. vivax circumsporozoite (CS) proteins. Approximately 0.9% of the 4,403 mosquitoes tested by enzyme-linked immunosorbent assay were positive; 28% and 72% of the positive mosquitoes contained VK210 and VK247 CS proteins, respectively. These findings correlate strongly with a recent report of the presence of antibodies in residents of this area that recognize the VK210 and VK247 repeats, clearly indicating that both P. vivax CS protein polymorphs are common in the region.

Animals↗

PubMed2005

Transmission of a Venezuelan equine encephalitis complex Alphavirus by Culex (Melanoconion) gnomatos (Diptera: Culicidae) in northeastern Peru.

Venezuelan equine encephalitis (VEE) complex alphaviruses are serious health threats in the Americas and regularly infect humans living in or near Amazonian rain forests. As part of a larger surveillance program, we placed six hamster-baited mosquito traps in a disturbed white sand forest of northeastern Peru for 3 d. Virus isolations from hamster serum and trapped mosquito pools demonstrated that a VEE subtype IIIC alphavirus was transmitted to a hamster by the mosquito Culex (Melanoconion) gnomatos Sallum, Hutchings & Ferreira. This species, like the other seven proven VEE complex alphavirus vectors, is a member of the Spissipes section of this subgenus. The composition of mosquitoes collected at the site over the sampling period was typical for the region.

Animals↗

PubMed2005

Changes in relative species compositions of biting midges (Diptera: Ceratopogonidae) and an outbreak of Oropouche virus in Iquitos, Peru.

Species compositions of Culicoides paraensis (Goeldi) (Diptera: Ceratopogonidae), the major vector of Oropouche virus to humans in Central and South American urban cycles, and Culicoides insinuatus Ortiz & Leon differed along a northeast-to-southwest transect across Iquitos, Department of Loreto, Peru. The relative distributions of the species were consistent with patterns of human outbreaks along the Amazon River. We resumed collection of biting midges between May 2000 and January 2004 at three sites previously sampled (1996 -1997) to determine whether the known vector was expanding its range relative to the earlier survey. C. paraensis did not replace C. insinuatus across the region surveyed. Instead, C. insinuatus dominated the more southern sites and significantly increased its relative proportion at all three sites. Apparently, microhabitat differences and not range expansion by C. paraensis were responsible for differences in species compositions across the sample sites.

Animals↗

PubMed1999

Maternal zinc supplementation does not affect size at birth or pregnancy duration in Peru.

To estimate the effect of maternal zinc deficiency on pregnancy outcomes, we conducted a zinc supplementation trial in an urban shantytown in Lima, Peru, a population with habitual low zinc intakes. Beginning at 10-24 wk gestation, 1295 mothers were randomly assigned to receive prenatal supplements containing 60 mg iron and 250 (g folate, with or without 15 mg zinc. Women were followed up monthly during pregnancy. At birth, newborn weight was recorded, and crownheel length, head circumference and other circumferences and skinfold thicknesses were assessed on d 1. At delivery, 1016 remained in the study; duration of pregnancy was known for all women, and birth weight information was available for 957 newborns. No differences were noted in duration of pregnancy (39.4 +/- 2.2 vs. 39. 5 +/- 2.0 wk) or birth weight (3267 +/- 461 vs. 3300 +/- 498 g) by prenatal supplement type (iron + folate + zinc vs. iron + folate; P > 0.05), and there were no differences in the rates of preterm (<37 wk) or post-term (>42 wk) delivery, low birth weight (<2500 g) or high birth weight (>4000 g). Finally, there were no differences by prenatal supplement type in newborn head circumference, crownheel length, chest circumference, mid-upper arm circumference, calf circumference or skinfold thickness at any of three sites. Adjustment for covariates and confounding factors did not alter these results. Adding zinc to prenatal iron and folate tablets did not affect duration of pregnancy or size at birth in this population.

Adult↗

PubMed2000

Efficacy and acceptability of two iron supplementation schedules in adolescent school girls in Lima, Peru.

To assess the efficacy and acceptability of a daily and intermittent iron supplementation, a double-blind, placebo-controlled trial was conducted in a public school located in periurban Lima, Peru. Adolescent girls (n = 312), 12-18 y old, were randomly assigned to one of the following three groups: 1) 60 mg iron as ferrous sulfate daily from Monday to Friday; 2) 60 mg iron as ferrous sulfate 2 d/wk and 3 d placebo (intermittent); 3) placebo, from Monday to Friday. Field workers gave the girls supplements during school hours for 17 wk; 296 girls completed the trial. Girls took 94% of the expected dose of 85 pills. Few side effects were reported. Postintervention, hemoglobin (Hb), serum ferritin (SF) and free erythrocyte protoporphyrin (FEP) were improved significantly in the iron-supplemented groups compared with placebo (P<0.05). Daily supplements led to higher Hb increases than intermittent supplements (P<0.05), but SF and FEP were similar between the two groups. Thus, both iron supplementation schedules were efficacious in preventing iron deficiency in adolescent girls through the school system, and the daily schedule was better than the intermittent schedule at increasing Hb values and reducing anemia.

Adolescent↗

PubMed2005

Conducting research in developing countries: experiences of the informed consent process from community studies in Peru.

This article discusses the process for obtaining genuine informed consent for the participation of human subjects in research in developing countries. We discuss the consent process in the light of recently published guidelines, the experience of nutrition and health research projects, and the ethics review process of the Instituto de Investigacion Nutricional with peri-urban and rural populations in Peru. We discuss the cultural context in relation to (i) who should be involved in the decision for participation, especially for research in children and in community settings; (ii) when to use written or verbal consent; (iii) the format and presentation of the consent form to ensure understanding by the target population; and (iv) the process of how and by whom information is given and consent is obtained. Common concerns of participants with regard to their involvement in research studies are presented, as well as aspects that participants find difficult to understand. Some specific concerns of conducting research with Indigenous Peoples are discussed. We recommend future research to further understand and implement informed consent processes to assure genuine and voluntary consent in different developing country contexts.

Biomedical Research↗