Adolescents' perceived barriers to accessing sexual and reproductive health services in California: a cross-sectional survey.

BACKGROUND: Adolescents may forego needed sexual and reproductive health (SRH) services due to a variety of concerns and barriers. The purpose of this study is to compare adolescents' perceptions of these barriers by participant characteristics including race/ethnicity, gender, sexual orientation, housing situation, and sexual experience. METHODS: Adolescents in a California-wide sexual health education program completed an anonymous survey at baseline (N = 10,015) about perceived barriers to using SRH services. Logistic regression analyses that accounted for the clustered data structure assessed differences by gender, age, sexual orientation, race/ethnicity, living situation, and sexual experience. RESULTS: The majority of participants were Hispanic/Latino (76.4%) with an average age of 14.9 years, and 28.8% had sexual experience. Half of the youth reported concerns about test results (52.7%), cost of services (52.0%), and confidentiality of services (49.8%). When controlling for other characteristics, youth identifying as transgender/non-binary/multiple genders had the highest odds of perceiving cost (odds ratio (OR) 1.89) and confidentiality (OR 1.51) as barriers. Increasing age was associated with decreasing odds of all barriers. Sexual orientation was a consistent predictor, with LGBQ+ youth having higher odds of perceiving test results (OR 1.21), cost (OR 1.36), and confidentiality (OR 1.24) as barriers. Asian or Pacific Islander/Native Hawaiian youth had higher odds of perceiving test results (OR 1.68) and cost (OR 1.37) as barriers. In contrast, Black youth had lower odds of reporting cost (OR 0.65) and confidentiality (OR 0.77) as barriers. Younger respondents and youth who identified as female, transgender/non-binary/multiple genders, LGBQ+, and Asian or Pacific Islander/Native Hawaiian had higher odds of reporting five or more barriers compared to reference groups. CONCLUSIONS: The majority of adolescents face barriers to accessing appropriate SRH services, with females, gender-minority youth, younger adolescents, LGBQ+ youth, and Asian and Pacific Islander/Native Hawaiian youth more likely than others to report barriers. Access to SRH services can be improved through strengthening linkages between clinics and SRH education programs, providing youth-friendly clinical services, and ensuring youth have sufficient information, skills, and support to access care. TRIAL REGISTRATION: Approved by California Health and Human Services Agency's Committee for the Protection of Human Subjects [12-08-0658, 11/30/2017].

Developing an SMS text message intervention on sexual and reproductive health with adolescents and youth in Peru.

BACKGROUND: Improved access to sexual and reproductive health (SRH) services and information is essential for supporting adolescents and youth in making informed decisions and optimizing each young person's outcomes related to their SRH, health and well-being and countries' current and future social and economic development. Mobile phones offer opportunities for young people to privately access SRH content and to be linked to SRH services. The objective of this study was to develop the content for an SMS (short message service or "text message") platform jointly with adolescents and youth in three regions in Peru (Lima, Ayacucho and Loreto) as part of the ARMADILLO (Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes) Study. METHODS: Content development was done in three stages. During Stage 1, we held community consultations with 13-17 year old adolescents, 18-24 year old youth and professionals who work with young people through the education and health sectors ("adult advisers") to identify and rate SRH topics of interest through group free- and guided-brainstorming activities and an individual written sharing activity. During Stage 2, the team developed the preliminary domains, sub-domains and content for the SMS platform. During Stage 3, we held focus groups with adolescents to validate the SMS content, including both individual scoring of and group feedback for each SMS. Group feedback asked about their general impressions and understanding and their thoughts about the language and usefulness of the SMS. RESULTS: A total of 172 adolescents and youth ages 13-24 and 20 adult advisers participated. Adolescents and youth brainstormed and rated SRH topics and sub-topics that led to the initial structure for the SMS platform, with 9 domains, 25 sub-domains and 146 draft SMS. Adolescents provided high scores for the SMS, with all sub-domains receiving average scores of 3.0 or higher (out of 4.0) for the SMS included. Adolescents also provided suggestions to optimize content, including improvements to unclear messages, resulting in SMS with adolescent-friendly content in simple, straightforward language. This process also revealed that adolescents lacked knowledge and had misconceptions related to contraceptive methods. CONCLUSION: This study details the systematic process used to develop relevant and accessible SRH information through a participatory approach. We document critical information about what young people know and how they think, enabling us to understand their perspective and literally speak their language. Results also provide future directions for programmatic, research and policy efforts with young people, in particular around gender norms, interpersonal violence, and access to SRH information and services, in similar settings.

Exploring the Literacy Habits of Caregivers with Young Children Ages 11-25 Months Old in Lima, Peru: A Pilot Study for the LIBRE Project.

Peruvian children's sub-optimal results on international and national assessments underscore the need for enhanced investments in early childhood development (ECD) such as shared reading between caregivers and young children. We conducted a qualitative study with 13 mothers of young children ages 11-25 months old that: used focus groups to explore caregivers' perspectives and experiences related to their daily activities, including reading and other ECD activities, with their young children; and used focus groups and video recordings to describe caregivers' experiences reading with these children during an at-home opportunity for shared reading. The mothers described daily schedules that focused on taking care of their daily chores and making sure that their young children were busy as they carried out those tasks. The mothers reported that they did not designate dedicated times to spend with their children and children were often without adult attention for lengthy periods of time. We found that after the one-month at-home opportunity for shared reading, there was a definite positive shift in both mothers' engagement with their children and their perspectives on reading. The caregivers improved their daily interactions with their children and observed important changes in their children thanks to reading. This study is encouraging and justifies a follow up randomized control trial to implement and evaluate the LIBRE shared reading program in Lima, Peru.

Information = equity? How increased access to information can enhance equity and improve health outcomes for pregnant women in Peru.

Background: The Peruvian health system provides care through numerous, disconnected health establishments and information systems. Our objective was to explore information use and needs of pregnant women to improve quality of care. Methods: We carried out a mixed methods study in the Lima capital metropolitan area in 15 health centers. This included four focus groups with 34 pregnant women and surveys with 403 pregnant women. Results: Pregnant women's information needs depend on their age, number of pregnancies and environment. Women relied on their social networks for pregnancy-related advice and valued high-quality, timely and targeted information from the health system. Participants' information needs include access to reliable information and responses to their questions in a warm, caring and safe environment. These needs can be met during prenatal check-ups and in group settings through informational talks and visual displays in waiting areas, as well as through appropriate digital technologies such as SMS messages and electronic health records. Conclusions: Pregnant women need individualized health information in an understandable, secure and friendly manner to maximize their understanding of their pregnancy, follow recommendations and optimize health outcomes. Customizing e-Health programs that reach many pregnant women has greater potential for more equitable health outcomes. Keywords: electronic health records, health information systems, healthcare disparities, maternal health services, pregnant women, text messaging.

Mental health impact of social capital interventions: a systematic review.

PURPOSE: Mental disorders are a major contributor to the global burden of disease and disability, and can be extremely costly at both individual and community level. Social capital, (SC) defined as an individual's social relationships and participation in community networks, may lower the risk of mental disorders while increasing resilience capacity, adaptation and recovery. SC interventions may be a cost-effective way of preventing and ameliorating these conditions. However, the impact of these SC interventions on mental health still needs research. METHODS: We conducted a systematic review of SC-based interventions to investigate their effect on mental health outcomes from controlled, quasi-experimental studies or pilot trials. We searched twelve academic databases, three clinical trials registries, hand-searched references and contacted field experts. Studies' quality was assessed with the Cochrane Risk of Bias tools for randomized and non-randomized studies. RESULTS: Seven studies were included in the review, published between 2006 and 2016. There was substantial heterogeneity in the definitions of both SC and mental disorders among the studies, preventing us from calculating pooled effect sizes. The interventions included community engagement and educative programs, cognitive processing therapy and sociotherapy for trauma survivors, and neighbourhood projects. CONCLUSIONS: There are paucity of SC interventions investigating the effect on mental health outcomes. This study showed that both SC scores and mental health outcomes improved over time but there was little evidence of benefit compared to control groups in the long term. Further high-quality trials are needed, especially among adverse populations to assess sustainability of effect.

Knowledge, attitudes, and practices regarding cystic echinococcosis and sheep herding in Peru: a mixed-methods approach.

BACKGROUND: The parasitic disease, cystic echinococcosis (CE), is prevalent in low-income, livestock-raising communities and 2000 new people will be diagnosed this year in South America alone. The disease usually passes from livestock to dogs to humans, making it a zoonotic disease and part of the One Health Initiative. Control of CE has been infamously difficult; no endemic areas of South America have succeeded in maintaining sustainable eradication of the parasite. For the current study, we aimed to gain a better understanding of the knowledge, attitudes, and practices of rural sheep farmers and other community leaders regarding their sheep herding practices and perspectives about a control program for CE. We also hope to identify potential barriers and opportunities that could occur in a control program. The authors conducted Knowledge, Attitude and Practices (KAP) surveys and semi-structured interviews in rural communities in the highlands of Peru. The KAP surveys were administered to 51 local shepherds, and the semi-structured interviews were administered to 40 individuals, including shepherds, community leaders, and health care providers. RESULTS: We found that the shepherds already deworm their sheep at a median of 2 times per year (N = 49, range 2-4) and have a mean willingness-to-pay of U.S. $ 0.60 for dog dewormer medication (N = 20, range = 0.00- $2.00 USD). We were not able to learn the deworming agent or agents that were being used, for neither sheep nor dogs. Additionally, 90% of shepherds slaughter their own sheep (N = 49). We also learned that the main barriers to an effective control program include: lack of education about the cause and control options for CE, accessibility to the distant communities and sparse grazing pastures, and a lack of economic incentive. CONCLUSIONS: Findings suggest it may be feasible to develop an effective CE control program which can be used to create an improved protocol to control CE in the region.

Plagiarism, Cheating and Research Integrity: Case Studies from a Masters Program in Peru.

Plagiarism is a serious, yet widespread type of research misconduct, and is often neglected in developing countries. Despite its far-reaching implications, plagiarism is poorly acknowledged and discussed in the academic setting, and insufficient evidence exists in Latin America and developing countries to inform the development of preventive strategies. In this context, we present a longitudinal case study of seven instances of plagiarism and cheating arising in four consecutive classes (2011-2014) of an Epidemiology Masters program in Lima, Peru, and describes the implementation and outcomes of a multifaceted, "zero-tolerance" policy aimed at introducing research integrity. Two cases involved cheating in graded assignments, and five cases correspond to plagiarism in the thesis protocol. Cases revealed poor awareness of high tolerance to plagiarism, poor academic performance, and widespread writing deficiencies, compensated with patchwriting and copy-pasting. Depending on the events' severity, penalties included course failure (6/7) and separation from the program (3/7). Students at fault did not engage in further plagiarism. Between 2011 and 2013, the Masters program sequentially introduced a preventive policy consisting of: (i) intensified research integrity and scientific writing education, (ii) a stepwise, cumulative writing process; (iii) honor codes; (iv) active search for plagiarism in all academic products; and (v) a "zero-tolerance" policy in response to documented cases. No cases were detected in 2014. In conclusion, plagiarism seems to be widespread in resource-limited settings and a greater response with educational and zero-tolerance components is needed to prevent it.

Is Intimate Partner and Client Violence Associated with Condomless Anal Intercourse and HIV Among Male Sex Workers in Lima, Peru?

Violence experience can increase HIV risk behaviors; however, literature is scarce on violence among male sex workers (MSWs) globally. In 2014, 210 Peruvian MSWs (median age 24.9) were interviewed about their experience of physical, emotional, and sexual violence and condom use with non-paying intimate partners and clients and were tested for HIV. Multivariable models examined relationships between violence in the past 6 months, condomless anal intercourse (CLAI) in the past 3 months and HIV infection. HIV infection (24 %), CLAI (43 %), being a violence victim (42 %) and perpetrator (39 %) were common. In separate multivariable models, being a violence victim [adjusted prevalence ratio aPR = 1.49 (95 % CI 1.09-2.03)] and perpetrator [aPR = 1.39 (1.03-1.87)] were associated with CLAI. Further, being a victim [aPR = 1.65 (1.04-2.62)] was associated with HIV infection. Violence, which was significantly associated with CLAI and HIV infection, is common among Peruvian MSWs, reinforcing the importance of violence awareness and prevention as HIV risk-reduction strategies.

'Just getting by': a cross-sectional study of male sex workers as a key population for HIV/STIs among men who have sex with men in Peru.

OBJECTIVES: To describe the sociodemographic and sex work characteristics, recent sexual practices, HIV risk perception and testing history, and HIV and syphilis prevalence of Cercado (downtown) and non-Cercado (close urban) male sex workers (MSWs) in Lima, Peru. METHODS: Eighty-nine MSWs completed a self-administered survey and participated in HIV and syphilis testing. RESULTS: Cercado MSWs had significantly lower median weekly earnings than non-Cercado MSWs (US$43 vs US$72, p=0.04). Most non-Cercado MSWs (81%) reported only insertive anal intercourse with male/transgender partners, while Cercado MSWs primarily reported only insertive (52%) or insertive and receptive (45%) anal intercourse (p=0.03). Consistent condom use was low with insertive and receptive anal intercourse in both subgroups. Among MSWs with recent female partners, condom use with the last partner was lower among Cercado versus non-Cercado MSWs for vaginal sex (37% vs 65%, p=0.04) and anal sex (27% vs 80%, p=0.01). More Cercado than non-Cercado MSWs (57% vs 42%) perceived high HIV risk (p=0.05) and Cercado MSWs had a much higher prevalence than non-Cercado MSWs of HIV (23% vs 4%, p=0.04) and syphilis (22% vs 0%, p=0.02) infections. CONCLUSIONS: MSWs in Lima are diverse and Cercado MSWs are 'just getting by,' engaging in more risk behaviours, and more likely to have HIV/STIs. Future research should identify, describe and carry out HIV/STI testing with broader groups of MSWs and their client and non-client partners. Prevention efforts should provide HIV/STI risk reduction education for MSWs and related subgroups who are currently not targeted such as female partners.

Potential point of care tests (POCTs) for maternal health in Peru, perspectives of pregnant women and their partners.

BACKGROUND: Globally, no qualitative studies have explored the perspectives of women and their partners about the integration of technology - and specifically diagnostic testing technologies - into antenatal care. The study objective was to describe the demand side for pregnancy-related diagnostic tests from the perspective of Peruvian consumers, including female and male community members, by engaging participants about their awareness of and care-seeking for pregnancy-related diagnostic tests and their preferred characteristics and testing conditions for pregnancy-related point-of-care diagnostic tests (POCTs). METHODS: Sixty-seven mothers and fathers of children under one from the peri-urban coast and the peri-urban and rural highlands and jungle of Peru participated in ten focus groups. RESULTS: Participants think that pregnancy-related diagnostic tests are important and they and their fellow community members are committed to ensuring that pregnant women receive the tests they need. Participants expressed clear demands for pregnancy-related POCTs, including important characteristics for the tests themselves (certification, rapid, reliable results) and for test implementation (well-trained, personable good communicators as test administrators at well-equipped, convenient testing sites). Participants emphasized the importance of short waiting times and explained that many people have some ability to pay for POCTs, particularly if they are innovative, rapid or multiplex. CONCLUSIONS: Engaging future POCT users as consumers who are able to make key decisions about the development and implementation of pregnancy-related POCTs is valuable and informative.

Family and peer support matter for precoital and coital behaviors among adolescents in Lima.

We analyzed the association between sub-scales developed with adolescents and the outcomes of precoital behaviors and vaginal sex in Lima, Peru. Adolescent participants in key informant sessions operationalized concepts identified during qualitative concept mapping into several sub-scales. Face and content validity testing and pilot application with respondent debriefing were used to refine the sub-scales. Three hundred 15-17 year olds were surveyed about the sub-scales, socio-demographics and sexual behaviors. Exploratory factor analysis confirmed six sub-scales, self-image, goals and decision-making, family education, parental rules/control, school support and peer support, which we regressed on the outcomes. Twice as many males as females reported more than three precoital behaviors and vaginal sex. Higher peer support reduced the likelihood of vaginal sex and precoital behaviors and higher family education reduced precoital behaviors. Results affirm the importance of including adolescents in the entire research process and of sex education with family- and peer-based strategies.

An unforgettable event: a qualitative study of the 1997-98 El Niño in northern Peru.

During the 1997-98 El Niño, Tumbes, Peru received 16 times the annual average rainfall. This study explores how Tumbes residents perceived the impact of the El Niño event on basic necessities, transport, health care, jobs and migration. Forty-five individuals from five rural communities, some of which were isolated from the rest of Tumbes during the event, participated in five focus groups; six of these individuals constructed nutrition diaries. When asked about events in the past 20 years, participants identified the 1997-98 El Niño as a major negative event. The El Niño disaster situation induced a decrease in access to transport and health care and the rise in infectious diseases was swiftly contained. Residents needed more time to rebuild housing; recover agriculture, livestock and income stability; and return to eating sufficient animal protein. Although large-scale assistance minimized effects of the disaster, residents needed more support. Residents' perspectives on their risk of flooding should be considered in generating effective assistance policies and programmes.

Our world through our eyes: adolescents use photovoice to speak their mind on adolescent health, well-being, and sexuality in Lima, Peru.

Peru's approach to its 5.7 million 10- to 19-year-olds has shifted toward positive youth development. Following that trend, our objective was to facilitate Peruvian adolescents' use of photovoice to better understand the factors affecting their health, well-being, and sexuality and to work with adolescents to present policy and programmatic recommendations. Photovoice sessions were carried out with low-income 12- to 16-year-olds (n = 13) from Lima. Sessions included basic photography and ethics, photo taking, and descriptions and discussions using the SHOWeD (What do you See here? What is really Happening? How does this relate to Our lives? Why does this problem or strength exist? What can we Do about it?) method. Participants grouped their photos into a "photo story." Each section of the story consisted of a message and 4 to 10 photos. Each photo had a caption that answered the SHOWeD questions. Messages were (a) "health and well-being in danger of extinction," (b) "with some signs of hope," (c) "innocence in spite of everything," (d) "what we as adolescents have," and (e) "but we lack opportunities to live a better life and a responsible sexuality." Participants presented the photo story to program planners, policy makers, and community members. Results underscore the value of including adolescents in program and policy planning and affirm that photovoice can achieve such inclusion. Photovoice provides a concrete method for adolescents to speak their mind through image and word.

Interspecies interactions and potential Influenza A virus risk in small swine farms in Peru.

BACKGROUND: The recent avian influenza epidemic in Asia and the H1N1 pandemic demonstrated that influenza A viruses pose a threat to global public health. The animal origins of the viruses confirmed the potential for interspecies transmission. Swine are hypothesized to be prime "mixing vessels" due to the dual receptivity of their trachea to human and avian strains. Additionally, avian and human influenza viruses have previously been isolated in swine. Therefore, understanding interspecies contact on smallholder swine farms and its potential role in the transmission of pathogens such as influenza virus is very important. METHODS: This qualitative study aimed to determine swine-associated interspecies contacts in two coastal areas of Peru. Direct observations were conducted at both small-scale confined and low-investment swine farms (n = 36) and in open areas where swine freely range during the day (n = 4). Interviews were also conducted with key stakeholders in swine farming. RESULTS: In both locations, the intermingling of swine and domestic birds was common. An unexpected contact with avian species was that swine were fed poultry mortality in 6/20 of the farms in Chancay. Human-swine contacts were common, with a higher frequency on the confined farms. Mixed farming of swine with chickens or ducks was observed in 36% of all farms. Human-avian interactions were less frequent overall. Use of adequate biosecurity and hygiene practices by farmers was suboptimal at both locations. CONCLUSIONS: Close human-animal interaction, frequent interspecies contacts and suboptimal biosecurity and hygiene practices pose significant risks of interspecies influenza virus transmission. Farmers in small-scale swine production systems constitute a high-risk population and need to be recognized as key in preventing interspecies pathogen transfer. A two-pronged prevention approach, which offers educational activities for swine farmers about sound hygiene and biosecurity practices and guidelines and education for poultry farmers about alternative approaches for processing poultry mortality, is recommended. Virological and serological surveillance for influenza viruses will also be critical for these human and animal populations.

Structural barriers to screening for and treatment of cervical cancer in Peru.

Through in-depth interviews with 30 key informants from 19 institutions in the health care system in four regions of Peru, this study identifies multiple barriers to obtaining cervical cancer screening, follow-up, and treatment. Some facilities outside Lima do not have the capacity to take Pap smear samples; others cannot do so on a continuing basis. Variation in procedures used by facilities and between regions, differences in women's ability to pay, as well as varying levels of training of laboratory personnel, all affect the quality and timing of service delivery and outcomes. In some settings, perverse incentives to accrue overtime payments increase the lag time between sample collection and reporting back of results. Some patients with abnormal results are lost to follow-up; others find needed treatment to be out of their financial or geographic reach. To increase coverage for cervical cancer screening and follow-up, interventions are needed at all levels, including an institutional overhaul to ensure that referral mechanisms are appropriate and that treatment is accessible and affordable. Training for midwives and gynaecologists is needed in good sample collection and fixing, and quality control of samples. Training of additional cytotechnologists, especially in the provinces, and incentives for processing Pap smears in an appropriate, timely manner is also required.

The ARMADILLO text message intervention to improve the sexual and reproductive health knowledge of adolescents in Peru: Results of a randomized controlled trial.

BACKGROUND: The ARMADILLO Study determined whether adolescents able to access SRH information on-demand via SMS were better able to reject contraception-related myths and misconceptions as compared with adolescents receiving pushed SMS or no intervention. TRIAL DESIGN: This trial was an unblinded, three-arm, parallel-group, individual RCT with a 1:1:1 allocation. Trial registration: ISRCTN85156148. METHODS: This study was conducted in Lima, Peru among participants ages 13-17 years. Eligible participants were randomized into one of three arms: Arm 1: access to ARMADILLO's SMS information on-demand; Arm 2 access to ARMADILLO SMS information pushed to their phone; Arm 3 control (no SMS). The intervention period lasted seven weeks. At baseline, endline, and follow-up (eight weeks following endline), participants were assessed on a variety of contraception-related myths and misconceptions. An index of myths-believed was generated. The primary outcome assessed the subject-specific change in the mean score between baseline and endline. Knowledge retention from endline to follow-up was also assessed, as was a 'content exposure' outcome, which assessed change in participants' knowledge based on relevant SMS received. RESULTS: In total, 712 participants were randomized to the three arms: 659 completed an endline assessment and were included in the primary analysis. Arm 2 participants believed fewer myths at endline compared with control arm participants (estimated subject-specific mean difference of -3.69% [-6.17%, -1.21%], p = 0.004). There was no significant difference between participants in Arm 1 vs. the control Arm, or between participants in Arm 1 vs. Arm 2. A further decrease in myths believed between endline and follow-up (knowledge retention) was observed in all arms; however, there was no difference between arms. The content exposure analysis saw significant reductions in myths believed for Arm 1 (estimated subject-specific mean difference of -9.47% [-14.83%, -4.11%], p = .001) and Arm 2 (-5.93% [-8.57%, -3.29%], p < .001) as compared with the control arm; however Arm 1's reduced sample size (n = 28) is a severe limitation. DISCUSSION: The ARMADILLO SMS content has a significant (but small) effect on participants' contraception-related knowledge. Standalone, adolescent SRH digital health interventions may affect only modest change. Instead, digital is probably best used a complementary channel to expand the reach of existing validated SRH information and service programs.

Gender-related factors influencing tuberculosis control in shantytowns: a qualitative study.

BACKGROUND: There is evidence that female gender is associated with reduced likelihood of tuberculosis diagnosis and successful treatment. This study aimed to characterize gender-related barriers to tuberculosis control in Peruvian shantytowns. METHODS: We investigated attitudes and experiences relating gender to tuberculosis using the grounded theory approach to describe beliefs amongst key tuberculosis control stakeholders. These issues were explored in 22 semi-structured interviews and in four focus group discussions with 26 tuberculosis patients and 17 healthcare workers. RESULTS: We found that the tuberculosis program was perceived not to be gender discriminatory and provided equal tuberculosis diagnostic and treatment care to men and women. This contrasted with stereotypical gender roles in the broader community context and a commonly expressed belief amongst patients and healthcare workers that female health inherently has a lower priority than male health. This belief was principally associated with men's predominant role in the household economy and limited employment for women in this setting. Women were also generally reported to experience the adverse psychosocial and economic consequences of tuberculosis diagnosis more than men. CONCLUSIONS: There was a common perception that women's tuberculosis care was of secondary importance to that of men. This reflected societal gender values and occurred despite apparent gender equality in care provision. The greatest opportunities for improving women's access to tuberculosis care appear to be in improving social, political and economic structures, more than tuberculosis program modification.

Constrained choices: adolescents speak on sexuality in Peru.

While numerous studies have explored young people's sexual behaviour in Peru, to date few have explored how adolescents situate sexuality within the context of their broader lives. This information is needed to inform policies and programmes. Life history interviews were conducted with 20 12-17-year-old young women and men from a low-income settlement near Lima, Peru. Data were analysed using holistic content analysis and grounded theory. Sexuality had a strong presence in respondents' lives. However, interviewees viewed the full expression of their sexuality as a constrained choice. Particular constraints derive from the belief that sexual intercourse always results in pregnancy; the nature of sex education; the provision of proscriptive advice; and the family tensions, economic problems, racism and violence present in young people's lives. The results of this study can inform policies and programmes to support young people as they make sexuality-related decisions.

What is adolescence?: Adolescents narrate their lives in Lima, Peru.

This study explores the lives of Peruvian adolescents in a low-income human settlement outside of Lima. Twenty 12-17 year olds were asked to narrate their own life stories using the life history narrative research method. Holistic content analysis was coupled with a grounded-theory approach to explore these data. Intergenerational responsibility, family tensions, economic pressures, racism and violence emerged without prompting and dominated the narrators' life stories, underscoring the degree to which these adolescents lack access to the supportive individuals and structures that are key to positive adolescent development. The challenges faced by these and the other 5.8 million 10-19 year olds in Peru require increased attention to the role of families, peers and communities in ensuring that adolescents are able to maintain their well-being and achieve their future expectations.

"The flu is a little more complicated than a cold": Knowledge, beliefs, and practices related to influenza and influenza vaccination among at-risk populations and health professionals in Peru.

BACKGROUND: Influenza is a major source of morbidity and mortality with an annual global attack rate estimated at 5-10% in adults and 20-30% in children. Influenza vaccination is the main strategy for reducing influenza-related morbidity and mortality. Like several other countries, Peru has low vaccination coverage, estimated at 25-50% among young children and older adults. Therefore, the study objective was to explore the knowledge, beliefs, attitudes, and practices related to influenza vaccination among populations at higher risk for infection and/or complications and health professionals in Peru, and their perspectives on health communication channels. METHODS: This qualitative study was carried out in three cities. We held nine focus groups with pregnant and postpartum women, parents of young children, and older adults. We carried out 25 in-depth interviews with health professionals (HPs) working in, leading or advising immunization-related programs. RESULTS: HPs correctly identified the causes of influenza and HPs and at risk community members identified major symptoms. Community members had poor awareness of the potential severity of influenza and were generally unaware of influenza-related mortality. Both HPs and community members greatly underestimated the prevalence of influenza in Peru. HPs in our study overestimated major side effects of the influenza vaccine and community members perceived that the vaccine caused illness. HPs missed important opportunities to promote vaccination in patients with minor illness (runny nose, allergies, colds) and community members did not understand that the vaccine should be received annually. CONCLUSIONS: There is no single strategy that will increase influenza vaccination rates to World Health Organization recommended levels. Instead, it requires multi-faceted commitment from HPs, other healthcare authorities and the government. Addressing important knowledge barriers, specifically negative views regarding the influenza vaccine and the severe morbidity and mortality associated with influenza illness, both in the community and especially among HPs, could have significant impacts.