Comprehensive Health Insurance and access to maternal healthcare services among Peruvian women: a cross-sectional study using the 2021 national demographic survey.

BACKGROUND: The government-subsidized health insurance scheme Seguro Integral de Salud ("SIS") was introduced in Peru initially to provide coverage to uninsured and poor pregnant women and children under five years old and was later extended to cover all uninsured members of the population following the Peruvian Plan Esencial de Aseguramiento Universal - "PEAS" (Essential UHC Package). Our study aimed to analyze the extent to which the introduction of SIS has increased equity in access and quality by comparing the utilization of maternal healthcare services among women with different insurance coverages. METHODS: Relying on the 2021 round of the nationally-representative survey "ENDES" (Encuesta Nacional Demográfica y de Salud Familiar), we analyzed data for 19,181 women aged 15-49 with a history of pregnancy in the five years preceding the survey date. We used a series of logistic regressions to explore the association between health insurance coverage (defined as No Insurance, SIS, or Standard Insurance) and a series of outcome variables measuring access to and quality of all services along the available maternal healthcare continuum. RESULTS: Only 46.5% of women across all insurance schemes reported having accessed effective ANC prevention. Findings from the adjusted logistic regression confirmed that insured women were more likely to have accessed ANC services compared with uninsured women. Our findings indicate that women in the "SIS" group were more likely to have accessed six ANC visits (aOR = 1.40; 95% CI 1.14-1.73) as well as effective ANC prevention (aOR = 1.32; 95% CI 1.17-1.48), ANC education (aOR = 1.59; 95% CI 1.41-1.80) and ANC screening (aOR = 1.46; 95% CI 1.27-1.69) during pregnancy, compared with women in the "Standard Insurance" group [aOR = 1.35 (95% CI 1.13-1.62), 1.22 (95% CI 1.04-1.42), 1.34 (95% CI 1.18-1.51) and 1.31(95% CI 1.15-1.49)] respectively. In addition, women in the "Standard Insurance" group were more likely to have received skilled attendance at birth (aOR = 2.17, 95% CI 1.33-3.55) compared with the women in the "SIS" insurance group (aOR = 2.12; 95% CI 1.41-3.17). CONCLUSIONS: Our findings indicate the persistence of inequities in access to maternal healthcare services that manifest themselves not only in the reduced utilization among the uninsured, but also in the lower quality of service coverage that uninsured women received compared with women insured under "Standard Insurance" or "SIS". Further policy reforms are needed both to expand insurance coverage and to ensure that all women receive the same access to care irrespective of their specific insurance coverage.

Home birth preference, childbirth, and newborn care practices in rural Peruvian Amazon.

Home birth is very common in the Peruvian Amazon. In rural areas of the Loreto region, home to indigenous populations such as the Kukama-Kukamiria, birth takes place at home constantly. This study aims to understand the preference for home births as well as childbirth and newborn care practices among Kukama-Kukamiria women in rural Loreto. Following a case study approach, sixty semi-structured, face-to-face interviews were conducted with recent mothers who experienced childbirth within one year prior to the interview, female relatives of recent mothers who had a role in childbirth, male relatives of recent mothers, community health workers, and traditional healers. We found that for women from these communities, home birth is a courageous act and an intimate (i.e. members of the community and relatives participate in it) and inexpensive practice in comparison with institutional birth. These preferences are also linked to experiences of mistreatment at health facilities, lack of cultural adaptation of birthing services, and access barriers to them. Preparations for home births included handwashing and cleaning delivery surfaces. After birth, waiting for the godparent to arrive to cut the cord can delay drying of the newborn. Discarding of colostrum, lack of skin-to-skin contact as well as a range of responses regarding immediate breastfeeding and immediate drying of the baby were also found. These findings were used to tailor the educational content of the Mamas del Rio program, where community health workers are trained to identify pregnancy early, perform home visits to pregnant women and newborns, and promote essential newborn care practices in case institutional birth is not desired or feasible. We make recommendations to improve Peru's cultural adaptation of birthing services.

Indigenous communities' responses to the COVID-19 pandemic and consequences for maternal and neonatal health in remote Peruvian Amazon: a qualitative study based on routine programme supervision.

AIM: To explore indigenous communities' responses to the COVID-19 pandemic and its consequences for maternal and neonatal health (MNH) care in the Peruvian Amazon. METHODS: Mamás del Río is a community-based, MNH programme with comprehensive supervision covering monthly meetings with community health workers (CHW), community leaders and health facilities. With the onset of the lockdown, supervisors made telephone calls to discuss measures against COVID-19, governmental support, CHW activities in communities and provision of MNH care and COVID-19 preparedness at facilities. As part of the programme's ongoing mixed methods evaluation, we analysed written summaries of supervisor calls collected during the first 2 months of Peru's lockdown. RESULTS: Between March and May 2020, supervisors held two rounds of calls with CHWs and leaders of 68 communities and staff from 17 facilities. Most communities banned entry of foreigners, but about half tolerated residents travelling to regional towns for trade and social support. While social events were forbidden, strict home isolation was only practised in a third of communities as conflicting with daily routine. By the end of April, first clusters of suspected cases were reported in communities. COVID-19 test kits, training and medical face masks were not available in most rural facilities. Six out of seven facilities suspended routine antenatal and postnatal consultations while two-thirds of CHWs resumed home visits to pregnant women and newborns. CONCLUSIONS: Home isolation was hardly feasible in the rural Amazon context and community isolation was undermined by lack of external supplies and social support. With sustained community transmission, promotion of basic hygiene and mask use becomes essential. To avoid devastating effects on MNH, routine services at facilities need to be urgently re-established alongside COVID-19 preparedness plans. Community-based MNH programmes could offset detrimental indirect effects of the pandemic and provide an opportunity for local COVID-19 prevention and containment.

Evaluating Academic Mentorship Programs in Low- and Middle-Income Country Institutions: Proposed Framework and Metrics.

A growing number of low- and middle-income country (LMIC) institutions have developed and implemented formal programs to support mentorship. Although the individual-level benefits of mentorship are well established, such activities can also sustainably build institutional capacity, bridge inequities in health care, and catalyze scientific advancement. To date, however, evaluation of these programs remains limited, representing an important gap in our understanding about the impact of mentoring. Without rigorous and ongoing evaluation, there may be missed opportunities for identifying best practices, iteratively improving program activities, and demonstrating the returns on investment in mentorship. In this report, we propose a framework for evaluating mentorship programs in LMIC settings where resources may be constrained. We identify six domains: 1) mentor-mentee relationship, 2) career guidance, 3) academic productivity, 4) networking, 5) wellness, and 6) organizational capacity. Within each, we describe specific metrics and how they may be considered as part of evaluation plans. We emphasize the role of measurement and evaluation at the institutional level, so that programs may enhance their mentoring capacity and optimize the management of their resources. Although we advocate for a comprehensive approach to evaluation, we recognize that-depending on stage and relative maturity-some domains may be prioritized to address short- and medium-term program goals.

Nuestras Historias- Designing a novel digital story intervention through participatory methods to improve maternal and child health in the Peruvian Amazon.

BACKGROUND: In rural areas of the Loreto region within the Peruvian Amazon, maternal mortality rate is above the national average and the majority of women deliver at home without care from a trained health care provider. METHODS: To develop community-tailored videos that could be used for future interventions, we conducted Photovoice and digital storytelling workshops with community health workers (CHW) and mothers from 13 rural communities in the Parinari district. Through Photovoice we recognized local barriers to healthy pregnancies. Participants (n = 28) were trained in basic photography skills and ethics. They captured photos representing perceived pregnancy-related road-blocks and supports, and these photos identified central themes. Participants recorded personal stories and "storyboarded" to develop digital stories around these themes, and a Digital Story Curriculum called Nuestras Historias (Our Stories), was created. An acceptability survey of the digital stories was then conducted including 47 men (M) and 60 women (F). RESULTS: According to the PhotoVoice workshops, pregnancy-related problems included: lack of partner support, domestic violence, early pregnancies, difficulty attending prenatal appointments, and complications during pregnancy and delivery. Over 30 stories on these themes were recorded. Seven were selected based on clarity, thematic relevance, and narrative quality and were edited by a professional filmmaker. The acceptability survey showed that local participants found the digital stories novel (M = 89.4%, F = 83.3%), relatable (M = 89.4%, F = 93.2%), educational (M = 91.5%, F = 93.3%) and shareable (M = 100%, F = 100%). Over 90% of respondents rated the digital stories as "Excellent" or "Good", found the videos "Useful" and considered them "Relevant" to their communities. CONCLUSIONS: The digital stories address community-specific problems through narrative persuasion using local voices and photography. This combination had a high acceptability among the target population and can serve as a model for developing educational strategies in a community-tailored manner. This package of seven videos will be further evaluated through a cluster randomized trial.

The Amazon Hope: A qualitative and quantitative assessment of a mobile clinic ship in the Peruvian Amazon.

The Loreto region of the Peruvian Amazon faces many obstacles to health care delivery. The majority of the population is river-bound and lives below the poverty line, with some of the worst health indicators in Peru. To overcome these barriers and fill a gap in health services, an NGO-based provider known as the Vine Trust has been providing care since 2001 via a mobile ship clinic called the Amazon Hope. This study presents an assessment of the Amazon Hope, first reporting health indicators of the program´s catchment area, services provided, and program utilization. It then describes perceptions of the program by community members and health workers, the program's strengths and weaknesses in contributing to health service delivery, and provides recommendations addressing limitations. The qualitative analysis included 20 key informant interviews with community members and health service providers. In the quantitative analysis, 4,949 residents of the catchment area were surveyed about medical histories, experiences with the program, and suggestions for improvement. The survey showed poor indicators for reproductive health. The AH clinic was the main provider of health care among those surveyed. Community members reported satisfaction with the program's quality of care, and health workers felt the program provided a unique and necessary service. However, community members requested prior notification and additional services, while health workers described misunderstandings in community-tailored care, and difficulties with continuity of care and coordination. Data show that the program has been successful in providing quality health care to a population but has room to improve in its health service delivery. Suggested improvements are provided based on participant suggestions and relevant literature. The study sheds light on the important role of mobile clinics in Peru, and the methodology can serve as a model for assessing the role of mobile clinics in other remote settings.

What Men Who Have Sex With Men in Peru Want in Internet-Based Sexual Health Information.

We aimed to gather information among gay men regarding their preferences for online sexual health information; 1,160 Peruvian MSM, 18 years or older, completed an online survey hosted on www.tunexo.org . The mean age was 26.8 years. Around 90% had post-high school education. The self-reported HIV prevalence was 12.3%. The acceptability of sexual health content was greater in the most highly educated group. The highest rated topics and services of interest were those related to improving sexual and mental health. The least educated group was significantly more interested in "getting prevention messages on mobiles" compared to men with the highest level of education (71% vs. 52%; p < 0.001). Men's sexual health was of more interest to the 30-39-year-old group compared to the 18-24-year-old one (97% vs. 87%; p = 0.005). Future Web-based interventions related to sexual health among targeted groups of MSM in Peru can be tailored to meet their preferences.

HPV vaccine knowledge and acceptability among Peruvian men who have sex with men and transgender women: A pilot, qualitative study.

PURPOSE: Human papillomavirus (HPV) is the most common sexually transmitted infection globally and is responsible for a variety of cancers in men and women. An effective HPV vaccine licensed for use in girls and boys has been indicated for-but is not widely implemented in-men who have sex with men (MSM). Limited data are available for transgender women (TW). We explored the social and behavioral aspects related to HPV vaccine uptake and participation in HPV vaccine studies among Peruvian MSM and TW. METHODS: Focus groups and individual in-depth interviews were conducted to obtain the knowledge, thoughts, and opinions from Peruvian MSM and TW regarding HPV vaccination. Data were analyzed using systematic comparative and descriptive content analysis. RESULTS: Three focus groups and fifteen individual in-depth interviews were conducted among 36 MSM and TW. Participant mean age was 26 years (range 18-40). Though many participants were unfamiliar with HPV vaccination, most expressed positive attitudes. Participants expressed concerns about the potential for stigma when disclosing HPV vaccination. CONCLUSION: Peruvian MSM and TW felt that HPV vaccination would be acceptable to themselves and their peers. Nonetheless, vaccine intake may be impeded by potential stigma. Findings from this study may guide HPV vaccine implementation in similar populations.

The global burden of women's cancers: a grand challenge in global health.

Every year, more than 2 million women worldwide are diagnosed with breast or cervical cancer, yet where a woman lives, her socioeconomic status, and agency largely determines whether she will develop one of these cancers and will ultimately survive. In regions with scarce resources, fragile or fragmented health systems, cancer contributes to the cycle of poverty. Proven and cost-effective interventions are available for both these common cancers, yet for so many women access to these is beyond reach. These inequities highlight the urgent need in low-income and middle-income countries for sustainable investments in the entire continuum of cancer control, from prevention to palliative care, and in the development of high-quality population-based cancer registries. In this first paper of the Series on health, equity, and women's cancers, we describe the burden of breast and cervical cancer, with an emphasis on global and regional trends in incidence, mortality, and survival, and the consequences, especially in socioeconomically disadvantaged women in different settings.

High prevalence of human T-lymphotropic virus infection in indigenous women from the peruvian Amazon.

BACKGROUND: In an earlier study, we detected an association between human T-cell lymphotropic virus (HTLV) infection and cervical human papillomavirus (HPV) in indigenous Amazonian Peruvian women of the Shipibo-Konibo ethnic group. As both HTLV and HPV can be transmitted sexually, we now report a population-based study examining the prevalence and risk factors for HTLV-1 and HTLV-2 infection in this population. METHODS: Between July and December 2010, we conducted a comprehensive screening for HTLV among Shipibo-Konibo women 15 to 39 years of age living in two communities located in Lima and in 17 communities located within four hours by car or boat from the Amazonian city of Pucallpa in Peru. RESULTS: We screened 1,253 Shipibo-Konibo women for HTLV infection 74 (5.9%) tested positive for HTLV-1, 47 (3.8%) for HTLV-2 infection, and 4 (0.3%) had indeterminate results. In the multivariate analysis, factors associated with HTLV-1 infection included: older age (Prevalence Ratio (PR): 1.04, 95% CI 1.00-1.08), primary education or less (PR: 2.01, 95% CI: 1.25-3.24), younger or same age most recent sex partner (PR: 1.66, 95% CI: 1.00-2.74), and having a most recent sex partner who worked at a logging camp (PR: 1.73, 95% CI: 1.09-2.75). The only factor associated with HTLV-2 infection was older age (PR: 1.08, 95% CI: 1.03-1.12). CONCLUSION: HTLV infection is endemic among Shipibo-Konibo women. Two characteristics of the sexual partner (younger age and labor history) were associated with infection in women. These results suggest the need for implementation of both HTLV screening during the antenatal healthcare visits of Shipibo-Konibo women, and counseling about the risk of HTLV transmission through prolonged breastfeeding in infected women. We also recommend the implementation of prevention programs to reduce sexual transmission of these viruses.

Training the biomedical informatics workforce in Latin America: results of a needs assessment.

Objective To report the results of a needs assessment of research and training in Medical Informatics (MI) and Bioinformatics (BI) in Latin America. Methods and results This assessment was conducted by QUIPU: The Andean Global Health Informatics Research and Training Center. After sending email invitations to MI-BI related professionals from Latin America, 142 surveys were received from 11 Latin American countries. The following were the top four ranked MI-related courses that a training programme should include: introduction to biomedical informatics; data representation and databases; mobile health; and courses that address issues of security, confidentiality and privacy. Several new courses and topics for research were suggested by survey participants. The information collected is guiding the development of curricula and a research agenda for the MI and BI QUIPU multidisciplinary programme for the Andean Region and Latin America.

Tecnologías de información y comunicación para la prevención y control de la infección por el VIH y otras ITS / Information and communication technologies for prevention and control of HIV infection and other STI

Avances tecnológicos innovadores como Internet, computadoras personales de bolsillo, teléfonos celulares y otros equipos son un arsenal en crecimiento en el esfuerzo de impedir y controlar el VIH y otras infecciones de transmisión sexual (ITS). A pesar que existe una diversidad de tecnologías de información y comunicación en diferentes etapas de desarrollo para la prevención del VIH e ITS, la investigación en esta área se encuentra aún en crecimiento, y el impacto en la incidencia de enfermedad, las evaluaciones con diseños rigurosos y los estudios económicos todavía son muy limitados. Sin embargo, algunas de estas evidencias son prometedoras y poseen un gran potencial para su uso en nuestro medio. En este artículo hemos realizado una revisión sistemática de la literatura relacionada con el uso de la tecnología aplicada a la prevención y control del VIH e ITS. De ser usada apropiadamente, esta tecnología podría mejorar la vigilancia del VIH y otras ITS, diagnóstico, notificación de parejas, prevención, manejo clínico, y capacitación de profesionales de la salud.

Innovative tools such as the Internet, personal digital assistants, tablet computers, cell phones, and other technologies are a growing arsenal in the global effort to prevent and control HIV and other sexually transmitted infections (STIs). While a variety of information and communication technology tools are in various stages of use for HIV/STI prevention, relatively few areas have accumulated a critical mass of evidence-based data about the most effective approaches. However, some of that evidence is compelling, and the potential for future uses appears large. Application to some areas of practice and research are nascent, the impact on disease incidence and economic evaluation data are still very limited, and evaluation of these tools would benefit from rigorous study designs. In this article we review the published literature regarding the use of information and communication technology applications to HIV/STI control. Appropriately utilized technologies may improve HIV/STI screening, prevention, surveillance, and care for patients and populations in both resource-constrained and resource-rich settings.

TECNOLOGÍAS DE INFORMACIÓN Y COMUNICACIÓN PARA LA PREVENCIÓN Y CONTROL DE LA INFECCIÓN POR EL VIH Y OTRAS ITS.

Innovative tools such as the Internet, personal digital assistants, tablet computers, cell phones, and other technologies are a growing arsenal in the global effort to prevent and control HIV and other sexually transmitted infections (STIs). While a variety of information and communication technology tools are in various stages of use for HIV/STI prevention, relatively few areas have accumulated a critical mass of evidence-based data about the most effective approaches. However, some of that evidence is compelling, and the potential for future uses appears large. Application to some areas of practice and research are nascent, the impact on disease incidence and economic evaluation data are still very limited, and evaluation of these tools would benefit from rigorous study designs. In this article we review the published literature regarding the use of information and communication technology applications to HIV/STI control. Appropriately utilized technologies may improve HIV/STI screening, prevention, surveillance, and care for patients and populations in both resource-constrained and resource-rich settings.