Delays in seeking and receiving health care services for pneumonia in children under five in the Peruvian Amazon: a mixed-methods study on caregivers' perceptions.

BACKGROUND: Delays in receiving adequate care for children suffering from pneumonia can be life threatening and have been described associated with parents' limited education and their difficulties in recognizing the severity of the illness. The "three delays" was a model originally proposed to describe the most common determinants of maternal mortality, but has been adapted to describe delays in the health seeking process for caregivers of children under five. This study aims to explore the caregivers' perceived barriers for seeking and receiving health care services in children under five years old admitted to a referral hospital for community-acquired pneumonia in the Peruvian Amazon Region using the three-delays model framework. METHODS: There were two parts to this mixed-method, cross-sectional, hospital-based study. First, medical charts of 61 children (1 to 60 months old) admitted for pneumonia were reviewed, and clinical characteristics were noted. Second, to examine health care-seeking decisions and actions, as well as associated delays in the process of obtaining health care services, we interviewed 10 of the children's caregivers. RESULTS: Half of the children in our study were 9 months old or less. Main reasons for seeking care at the hospital were cough (93%) and fever (92%). Difficulty breathing and fast breathing were also reported in more than 60% of cases. In the interviews, caregivers reported delays of 1 to 14 days to go to the closest health facility. Factors perceived as causes for delays in deciding to seek care were apparent lack of skills to recognize signs and symptoms and of confidence in the health system, and practicing self-medication. No delays in reaching a health facility were reported. Once the caregivers reached a health facility, they perceived lack of competence of medical staff and inadequate treatment provided by the primary care physicians. CONCLUSION: According to caregivers, the main delays to get health care services for pneumonia among young children were identified in the initial decision of caregivers to seek healthcare and in the health system to provide it. Specific interventions targeted to main barriers may be useful for reducing delays in providing appropriate health care for children with pneumonia.

Diagnostics barriers and innovations in rural areas: insights from junior medical doctors on the frontlines of rural care in Peru.

BACKGROUND: Worldwide, rural communities face barriers when accessing health services. In response, numerous initiatives have focused on fostering technological innovations, new management approaches and health policies. Research suggests that the most successful innovations are those involving stakeholders at all levels. However, there is little evidence exploring the opinions of local health providers that could contribute with further innovation development and research. The aims of this study were to explore the perspectives of medical doctors (MDs) working in rural areas of Peru, regarding the barriers impacting the diagnostic process, and ideas for diagnostic innovations that could assist them. METHODS: Data gathered through three focus group discussions (FGG) and 18 individual semi-structured interviews (SSI) with MDs who had completed their medical service in rural areas of Peru in the last two years were analyzed using thematic analysis. RESULTS: Three types of barriers emerged. The first barrier was the limited access to point of care (POC) diagnostic tools. Tests were needed for: i) the differential diagnosis of malaria vs. pneumonia, ii) dengue vs. leptospirosis, iii) tuberculosis, iv) vaginal infections and cervical cancer, v) neurocysticercosis, and vi) heavy metal toxicity. Ultrasound was needed for the diagnosis of obstetric and intra-abdominal conditions. There were also health system-related barriers such as limited funding for diagnostic services, shortage of specialists, limited laboratory services and access to telecommunications, and lack of institutional support. Finally, the third type of barriers included patient related-barriers to follow through with diagnostic referrals. Ideas for innovations proposed included POC equipment and tests, and telemedicine. CONCLUSIONS: MDs at primary health facilities in rural Peru face diagnostic challenges that are difficult to overcome due to a limited access to diagnostic tools. Referrals to specialized facilities are constrained by deficiencies in the organization of health services and by barriers that impede the patients' travel to distant health facilities. Technological innovations suggested by the participants such as POC diagnostic tools and mobile-health (m-health) applications could help address part of the problem. However, other types of innovation to address social, adaptation and policy issues should not be dismissed.

Gastos de atención odontológica de niños con caries de infancia temprana, ocasionados a la familia y al Estado Peruano, representado por el Instituto Nacional de Salud del Niño / Costs of dental care of children with Early Childhood Caries, caused to the family and the Peruvian government, represented by the Child Heath National Institute

Determinar los gastos de atención odontológica de niños con Caries de la Infancia Temprana (CIT) que ocasionan a sus familias y al Estado Peruano, representado por el Instituto Nacional de Salud del Nino (INSN) Lima-Perú. Material y Métodos: Estudio de tipo descriptivo, observacional y transversal. La muestra escogida aleatoriamente estuvo formada por 629 niños menores de 71 meses de edad atendidos en el Servicio de Atención del Infante del INSN, en el año 2009, dicha muestra fue estratificada según condición clínica (sanos o con CIT) y procedimiento realizado (tratamiento preventivo y tratamiento restaurador: con manejo de conducta, sedación, o anestesia general). Para determinar los gastos ocasionados a las familias se entrevistaron a las madres de los niños, y los gastos del hospital fueron calculados según el reporte económico del mismo. Para el análisis estadístico se utilizó el software Stata v12, aplicando las pruebas U. Mann-Whitney y Kruskal-Wallis para comparar y encontrar las diferencias en las variables estudiadas. Resultados: La frecuencia de CIT en la muestra evaluada fue de 82.19%. Según mediana: las familias de pacientes sanos gastan por encima de S/.30.00 (min=12, max=84) en procedimientos de prevención y las familias de los pacientes enfermos gastan por encima de S/.113.00 (min=26, max=761) en tratamientos restaurativos ocasionados por CIT, (Relación de 1:4). De acuerdo al tipo de tratamiento realizado, según la mediana, lo más resaltante se encontró en el rubro de anestesia general, donde las familias gastan por encima de S/.639.00 (min=440, max=761); es decir, 20 veces más que en procedimientos de prevención. Del gasto total, la mayor parte es asumida o subvencionada por el INSN, siendo estos gastos aún mayores. Conclusiones: La CIT, ocasiona importantes gastos directos e indirectos a las familias y al Estado representado por el INSN. Las medidas preventivas son altamente costo efectivas...

Objective: To determine the cost of dental care for children with Early Childhood Caries (ECC) that causes to their families and the Peruvian State, represented by the National Institute of Child Health (INSN) LimaPeru. Methods: A descriptive, observation and transversal study. The randomly selected sample consisted of 629 children under 71 months of age, treated at the Infant Care Service of the INSN in 2009, the sample was stratified according to clinical condition (healthy or Early Childhood Caries) and procedure performed (preventive and restorative treatment: with behavior management, sedation or general anesthesia). To determine the costs incurred by families, mothers of children were asked and hospital costs were calculated according to the economic report. For statistical analysis software was used Stata v12, applying the Mann-Whitney U test and Kruskal-Wallis test to compare and find the differences in the studied variables. Results: The frequency of ECC in the evaluated sample was 82.19%. According to the median, families of healthy patients spend over to S / .30.00 (min = 12, max = 84) in methods of prevention and families of sick patients spend over to S / .113.00 (min = 26, max = 761) in restorative treatments caused by CIT, (ratio 1: 4). According the type of treatment performed, as reported by the median, most interesting observation was found under general anesthesia; families spend over to S / .639.00 (min = 440, max = 761), ie 20 times more than in methods of prevention. The biggest part of total spending is taken or subsidized by the hospital, and these costs are even higher. Conclusions: ECC, cause significant direct and indirect costs to families and the State, represented by the hospital. Preventive measures are highly cost effective...