Health system barriers to hypertension care in Peru: Rapid assessment to inform organizational-level change.

Traditional patient- and provider-level hypertension interventions have proven insufficient to halt hypertension as the leading cause of morbidity and mortality globally. Systems-level interventions are required to address factors challenging hypertension control across a social ecological framework, an under-studied topic particularly salient in low- and middle-income countries (LMICs) such as Peru. To inform such interventions, we sought to identify key health systems barriers to hypertension care in Puno, Peru. A participatory stakeholder workshop (October 2021) and 21 in-depth interviews (October 2021-March 2022) were conducted with 55 healthcare professionals (i.e., doctors, nurses, midwives, dentists, nutritionists), followed by a deductive qualitative analysis of transcripts and notes. Participating healthcare providers indicated that low prioritization and lack of national policies for hypertension care have resulted in limited funding and lack of societal-level prevention efforts. Additionally, limited cultural consideration, both in national guidelines as well as by some providers in Puno, results in inadequate care that may not align with local traditions. Providers highlighted that patient care is also hampered by inadequate distribution and occasional shortages of medications and equipment, as well as a lack of personnel and limited opportunities for training in hypertension. Multiple incompatible health information systems, complicated referral systems, and geographic barriers additionally hinder continuity of care and care seeking. Insights gained from health providers on the healthcare system in Puno provide essential contextual information to inform development of organizational-level strategies necessary to improve provider and patient behaviors to achieve better hypertension care outcomes.

Co-creation process of an intervention to implement a multiparameter point-of-care testing device in a primary healthcare setting for non-communicable diseases in Peru.

BACKGROUND: Point-of-care testing (POCT) devices are diagnostic tools that can provide quick and accurate results within minutes, making them suitable for diagnosing non-communicable diseases (NCDs). However, these devices are not widely implemented in healthcare systems and for this reason is relevant to understand the implementation process. AIM: To describe the process and define a strategy to implement a multiparameter POCT device for diagnosing and managing NCDs in one region of Peru. METHODS: A descriptive and non-experimental study, using the participatory methodologies of co-creation process. It was conducted in one region of Peru (Tumbes) to design an intervention for implementing a multiparameter POCT device. Two co-creation sessions were conducted involving five groups: community members, primary healthcare workers, these groups in both rural and urban settings, and regional decision-makers. These sessions included activities to understand patient journeys in receiving care for NCDs, identify facilitators and barriers to POCT devices usage, and define an implementation strategy for POCT devices in both rural and urban settings of Tumbes. The research team analysed the data and summarized key topics for discussion after each session. RESULTS: A total of 78 participants were enrolled across the five groups. Among community members: 22.2% had only diabetes, 24.1% had only hypertension, and 18.5% had both diagnoses. In the patient journey, community members mentioned that it took at least three days to receive a diagnosis and treatment for an NCD. Most of the participants agreed that the POCT devices would be beneficial for their communities, but they also identified some concerns. The strategy for POCT devices implementation included healthcare workers training, POCT devices must be placed in the laboratory area and must be able to perform tests for glucose, glycated haemoglobin, cholesterol, and creatinine. Advertising about POCT devices should be displayed at the healthcare centres and the municipality using billboards and flyers. CONCLUSIONS: The co-creation process was useful to develop strategies for the implementation of multiparameter POCT devices for NCDs, involving the participation of different groups of stakeholders guided by moderators in both, rural and urban, settings in Peru.

Facilitators and barriers of the implementation of point-of-care devices for cardiometabolic diseases: a scoping review.

BACKGROUND: Point-of-care testing (POCT) devices may facilitate the delivery of rapid and timely results, providing a clinically important advantage in patient management. The challenges and constraints in the implementation process, considering different levels of actors have not been much explored. This scoping review aimed to assess literature pertaining to implementation facilitators and barriers of POCT devices for the diagnosis or monitoring of cardiometabolic diseases. METHODS: A scoping review of the literature was conducted. The inclusion criteria were studies on the inception, planning, or implementation of interventions with POCT devices for the diagnosis or monitoring of cardiometabolic diseases defined as dyslipidemia, cardiovascular diseases, type 2 diabetes, and chronic kidney disease. We searched MEDLINE, Embase, and Global Health databases using the OVID searching engine until May 2022. The Consolidated Framework of Implementation Research (CFIR) was used to classify implementation barriers and facilitators in five constructs. Also, patient, healthcare professional (HCP), and organization level was used. RESULTS: Twenty studies met the eligibility criteria for data extraction. All studies except two were conducted in high-income countries. Some findings are: 1) Intervention: the most widely recognized facilitator was the quick turnaround time with which results are obtained. 2) Outer setting: at the organizational level, the lack of clear regulatory and accreditation mechanisms has hindered the adoption and sustainability of the use of POCT. 3) Inner setting: for HCP, performing POCT during the consultation was both a facilitator and a barrier in terms of time, personnel, and service delivery. 4) Individuals: the implementation of POCT may generate stress and discomfort in some HCP in terms of training and new responsibilities. 5) Process: for patients, it is highly appreciated that obtaining the sample was simple and more comfortable if venipuncture was not used. CONCLUSION: This scoping review has described the facilitators and barriers of implementing a POCT device for cardiometabolic conditions using the CFIR. The information can be used to design better strategies to implement these devices and benefit more populations that have low access to cardiometabolic tests.

Perceptions of acceptance and reluctance to COVID-19 vaccination in Peru. / Percepciones de aceptabilidad y reticencia a las vacunas contra la COVID-19 en el Perú.

OBJECTIVES.: To explore factors that influence the acceptance or reluctance to COVID-19 vaccination using qualitative methods. MATERIALS AND METHODS.: Descriptive qualitative study conducted between April and June 2021. A semi-structured interview guide was used to explore the perceptions of participants from different regions of Peru regarding COVID-19 vaccination. The Health Belief Model was used as theoretical framework and its dimensions are: susceptibility, severity, benefits, barriers, and cues to action. RESULTS.: We interviewed 30 people, mostly were women. For the participants, the efficacy of vaccines is related to the country of origin of the vaccines; in addition, they consider that it is important to know the long-term effects on health after vaccination. The information received by governmental and health authorities can be a decisive factor for vaccination. People with the intention of not being vaccinated feel that vaccination promotion strategies violate their human rights. CONCLUSIONS.: There is a group of people undecided or unsure about receiving COVID-19 vaccines who need to be encouraged according to their concerns and needs. Governmental and health authorities should work together to improve the confidence of the population and provide messages to clarify doubts about the efficacy and adverse reactions of vaccines.

OBJETIVOS.: Explorar los factores que predisponen la aceptabilidad o reticencia a la vacunación contra la COVID-19 utilizando métodos cualitativos. MATERIALES Y MÉTODOS.: Estudio cualitativo descriptivo realizado entre abril y junio del 2021. Se utilizó una guía de entrevista semiestructurada que exploró las percepciones de los participantes de diferentes regiones del Perú con relación a la aplicación de la vacuna para la COVID-19, tomando como marco teórico el modelo de creencias en salud, cuyas dimensiones son: susceptibilidad, severidad, beneficios, barreras y estímulos asociados para ejecutar la acción. RESULTADOS.: Se entrevistó a treinta personas, en su mayoría mujeres. Para los participantes la eficacia de las vacunas se relaciona con el país de procedencia, además, consideran que es importante conocer los efectos a largo plazo en la salud luego de la aplicación de la vacuna. La información recibida por las autoridades gubernamentales y sanitarias puede ser un factor decisivo para la aplicación de la vacuna. Las personas con la intención de no vacunarse sienten que las estrategias de promoción de la vacunación vulneran sus derechos humanos. CONCLUSIONES.: Existe un grupo de personas indecisas o inseguras de recibir las vacunas contra la COVID-19 en quienes es necesario fomentar estímulos de acuerdo con sus preocupaciones y necesidades. Las autoridades gubernamentales y sanitarias deben trabajar conjuntamente para mejorar la confianza de la población y brindar mensajes que despejen las principales dudas sobre la eficacia y las reacciones adversas de las vacunas.

Using government data to understand the use and availability of medicines for hypertension and diabetes: lessons from Peru.

BACKGROUND: Regular measurement of the availability and use of key medicines for non-communicable diseases allows the tracking of progress to achieve equitable access to medicines. Using a country-level public sector monitoring system for medicine supply, we aim to evaluate the availability and use of losartan 50 mg tablets and metformin 850 mg tablets between 2015 and 2020 investigating the impact of different policy changes and the COVID-19 pandemic. METHODS: Data from the Peruvian National System of Medicine Supply were analyzed using an interrupted time series analysis with known and unknown structural breaks. The outcomes assessed were medicine use (monthly doses dispensed at facilities over time) and medicine availability (proportion of facilities that reported having the medicine available). RESULTS: The use of losartan and metformin at the primary level of care had a linear increasing trend over the period of analysis. In secondary and tertiary levels of care, there were no increases but some significant level and trend changes of doses dispensed at different times between 2017 to 2019, but none were related to the change of procurement procedures. At all levels of care, the COVID-19 onset in April 2020 caused an abrupt drop in doses dispensed especially at the primary level. Regarding availability, we found an increasing linear trend in the primary level of care for both medicines. In secondary and tertiary levels of care, the availability fluctuated between 40 and 95%. The onset of the COVID-19 pandemic did not significantly impact medicine availability, except for losartan in the tertiary level of care. CONCLUSION: The availability and proper dispensing of first-line medicines for hypertension and diabetes is an essential factor for sustainable and equitable treatment. Health care systems need to be prepared for forecasting the increasing demand of medicines for chronic diseases, but also to maintain effective medicine supply chains during humanitarian crisis like pandemics.

Pilot Feasibility Assessment of a Tailored Physical Activity Prescription in Overweight and Obese People in a Public Hospital.

We aimed to evaluate the feasibility of a tailored physical activity (PA) prescription in overweight and obese people in a tertiary hospital in Lima, Peru. A feasibility pre-post-pilot study was conducted using mixed methods. Participants received a tailored prescription scheme for PA that lasted twelve weeks. It included two prescription sessions, three follow-up phone calls, and three evaluations. Primary feasibility outcomes were recruitment, visits, and phone call adherence. Primary intervention outcomes were self-reported PA levels and the 6 min walk test. Out of 228 people invited to participate, 30 were enrolled and received the first session of prescription, 11 went to the second session, and 21 went to the final evaluation; phone call participation decreased progressively during follow-up. There were no differences in the 6th week and the 12th week compared to the baseline for all the measures, except in the 6 min walk test. The participants considered the intervention was well designed, but they suggested complementing it with dietary instructions. The prescription of PA in overweight and obese people is feasible for promoting PA, but its implementation requires refinements to anticipate possible barriers to changing behavior.

Percepciones de aceptabilidad y reticencia a las vacunas contra la COVID-19 en el Perú / Perceptions of acceptance and reluctance to COVID-19 vaccination in Peru

RESUMEN Objetivos. Explorar los factores que predisponen la aceptabilidad o reticencia a la vacunación contra la COVID-19 utilizando métodos cualitativos. Materiales y métodos. Estudio cualitativo descriptivo realizado entre abril y junio del 2021. Se utilizó una guía de entrevista semiestructurada que exploró las percepciones de los participantes de diferentes regiones del Perú con relación a la aplicación de la vacuna para la COVID-19, tomando como marco teórico el modelo de creencias en salud, cuyas dimensiones son: susceptibilidad, severidad, beneficios, barreras y estímulos asociados para ejecutar la acción. Resultados. Se entrevistó a treinta personas, en su mayoría mujeres. Para los participantes la eficacia de las vacunas se relaciona con el país de procedencia, además, consideran que es importante conocer los efectos a largo plazo en la salud luego de la aplicación de la vacuna. La información recibida por las autoridades gubernamentales y sanitarias puede ser un factor decisivo para la aplicación de la vacuna. Las personas con la intención de no vacunarse sienten que las estrategias de promoción de la vacunación vulneran sus derechos humanos. Conclusiones. Existe un grupo de personas indecisas o inseguras de recibir las vacunas contra la COVID-19 en quienes es necesario fomentar estímulos de acuerdo con sus preocupaciones y necesidades. Las autoridades gubernamentales y sanitarias deben trabajar conjuntamente para mejorar la confianza de la población y brindar mensajes que despejen las principales dudas sobre la eficacia y las reacciones adversas de las vacunas.

ABSTRACT Objectives. To explore factors that influence the acceptance or reluctance to COVID-19 vaccination using qualitative methods. Materials and methods. Descriptive qualitative study conducted between April and June 2021. A semi-structured interview guide was used to explore the perceptions of participants from different regions of Peru regarding COVID-19 vaccination. The Health Belief Model was used as theoretical framework and its dimensions are: susceptibility, severity, benefits, barriers, and cues to action. Results. We interviewed 30 people, mostly were women. For the participants, the efficacy of vaccines is related to the country of origin of the vaccines; in addition, they consider that it is important to know the long-term effects on health after vaccination. The information received by governmental and health authorities can be a decisive factor for vaccination. People with the intention of not being vaccinated feel that vaccination promotion strategies violate their human rights. Conclusions. There is a group of people undecided or unsure about receiving COVID-19 vaccines who need to be encouraged according to their concerns and needs. Governmental and health authorities should work together to improve the confidence of the population and provide messages to clarify doubts about the efficacy and adverse reactions of vaccines.

COVID-19's impact on type 1 diabetes management: A mixed-methods study exploring the Peruvian experience.

INTRODUCTION: The COVID-19 pandemic has negatively impacted health services, especially in low-and-middle-income countries, where care for chronic conditions such as diabetes was disrupted. Our study aims to describe the challenges faced by people living with Type 1 diabetes mellitus (T1DM) to access care during the COVID-19 pandemic in Peru. METHODS: A sequential explanatory mixed-method study was conducted between May and September 2020 including health professionals involved in T1DM care, people with T1DM and their caregivers. The study consisted of a quantitative strand to gather general information through electronic surveys and a qualitative strand that involved in-depth interviews. RESULTS: For the quantitative study, we included 105 people with T1DM, 50 caregivers and 76 health professionals. The qualitative study included a total of 31 interviews; 16 people with T1DM, 14 health care professionals, and one representative from the Peruvian Ministry of Health (MoH). People with T1DM faced difficulties accessing consultations, insulin, monitoring devices and laboratory testing during the pandemic. Different phases of the Peruvian health system response were found. Firstly, an initial informal response to addressing T1DM care during the pandemic characterised by local initiatives to ensure continuity of care for people with T1DM. Following from this, a formal response was implemented by the MoH which focussed on reinforcing the primary level of care. Measures included teleconsultations and delivery of medicines, although these were not implemented in all health care establishments. Throughout the pandemic patient associations played an important role in organising and helping to counteract the impact of COVID-19 on people with T1DM. CONCLUSIONS: The Peruvian health care system slowly adapted to the COVID-19 pandemic to provide care for people with T1DM. However, people with T1DM had difficulties to access care. Thus, reinforcement of interventions such as communication between levels of care, teleconsultations and delivery of medicines was urgently needed. Patient associations' capacity to respond should be considered by local authorities and civil society should be part of the health system response.

Psychosocial telemonitoring and teleorientation for older adults in the Social Security (EsSalud) during the first six months of the COVID-19 pandemic in Peru

Introduction: The Peruvian Social Security during the COVID-19 pandemic implemented a psychosocial remote care program for older adults in order to improve their quality of life and prevent the development of mental problems. The study: Analysis of secondary data from records generated by teams from the Senior Centers at the national level between May and October 2020, with the aim to describe the experience of implementing Psychosocial telemonitoring and teleorientation for elderly patients during COVID-19 pandemic. Findings: A total of 154 280 follow-ups and 36 492 remote care services were provided to older adults. The main interventions provided were emotional support (75.5%) and social counseling (53.8%). The most recorded moods were calmness and worry. Feelings of worry, stress, sadness, and fear are higher in the reports with COVID-19 compared to those without COVID-19. Conclusion: Psychosocial telemonitoring and teleorientation for older adults can be used as another way to provide comprehensive care in elderly population.

Introducción: La Seguridad Social Peruana durante la pandemia por COVID-19 implementó un programa de cuidado psicosocial remoto para personas adultas mayores con el fin de mejorar su calidad de vida y evitar el desarrollo de problemas mentales. El estudio: Análisis de datos secundarios de registros generados por equipos de los Centros del Adulto Mayor a nivel nacional entre mayo y octubre de 2020, con objetivo de describir la experiencia de implementación de telemonitoreo y teleorientación psicosocial a distancia para pacientes adultos mayores durante la pandemia por COVID-19. Hallazgos: En total se brindaron 154 280 seguimientos y 36 492 atenciones a distancia a personas adultas mayores. Las principales intervenciones brindadas fueron apoyo emocional (75,5%) y consejería social (53,8%). Los estados de ánimo más registrados fueron calma y preocupación. Los sentimientos de preocupación, tales como estrés, tristeza y miedo fueron altos en pacientes con COVID-19 en comparación con los que no tienen COVID-19. Si bien el servicio brindado en los Centros del Adulto Mayor no fue etiquetado como "prescripción social", la mayoría de los componentes abordan beneficios similares a los modelos de prescripción social en otros países. Conclusión: El telemonitoreo y la teleorientación psicosocial pueden ser usados como otro medio para proveer cuidado integral a la población adulta mayor.

Management of type 1 diabetes in low- and middle-income countries: Comparative health system assessments in Kyrgyzstan, Mali, Peru and Tanzania.

AIMS: To describe and compare the health system responses for type 1 diabetes in Kyrgyzstan, Mali, Peru and Tanzania. METHODS: The Rapid Assessment Protocol for Insulin Access, a multi-level assessment of the health system, was implemented in Kyrgyzstan, Mali, Peru and Tanzania using document reviews, site visits and interviews to assess the delivery of care and access to insulin. RESULTS: Despite the existence of noncommunicable or diabetes strategies and Universal Health Coverage policies including diabetes-related supplies, this has not necessarily translated into access to insulin or diabetes care for all. Insulin and related supplies were often unavailable and unaffordable. Across the four countries test strips and insulin, when paid for by the individual, represented respectively 48-82% and 25-36% of total costs. Care was mainly delivered at tertiary-level hospitals by specialists. Only Kyrgyzstan had data collection systems integrated into the Ministry of Health structure. In addition, issues with healthcare worker training and education and empowerment of people with diabetes were present in these health systems. CONCLUSIONS: People with type 1 diabetes in these countries face different barriers, including the cost of insulin and care. Given the renewed attention to diabetes on the global health agenda tailored health system responses for type 1 diabetes are needed. Insulin should be prioritized as it is the foundation of type 1 diabetes care, but other elements of care and support need to be fostered by different actors.

Calidad de vida de adultos mayores de la Seguridad Social peruana durante la pandemia por COVID-19 / Quality of life of older adults in Peruvian Social Security during the COVID-19 pandemic

Introducción: Evaluar la calidad de vida de adultos mayores que pertenecen a los Centros del Adulto Mayor (CAM) de la Seguridad Social durante la pandemia por COVID-19. Material y métodos: Se recolectó información mediante llamadas telefónicas a adultos mayores de 60 años de los CAM. La calidad de vida fue evaluada con el cuestionario EQ-5D-3L, que considera las dimensiones de movilidad, cuidado personal, actividades cotidianas, dolor/malestar y ansiedad/depresión y una escala analógica de 0 a 100. Se midió la presencia de depresión, ansiedad, comorbilidades y el estado funcional. Se realizó un análisis bivariado con pruebas no paramétricas para evaluar la asociación entre covariables y la escala analógica de calidad de vida. Además, se realizó un análisis de regresión simple usando modelos lineales generalizados de la familia de Poisson para evaluar variables asociadas a la presencia de problemas en las dimensiones de calidad de vida. Resultados: Participaron 99 adultos mayores, en su mayoría mujeres (84,9%) la edad promedio fue 73,1 años, 83,3% tenían un nivel educativo superior y 86,7% vivían acompañados. Los adultos mayores con obesidad, enfermedades pulmonares, imposibilidad de manejar su propio dinero, fatiga y problemas de audición reportaron un puntaje menor al promedio (<78,9) en la escala de calidad de vida. Las enfermedades osteoarticulares y la sensación de fatiga incrementan la probabilidad de sufrir problemas de movilidad, de realizar actividades cotidianas y de dolor/malestar. Conclusiones: La calidad de vida de los adultos mayores es influida por multiples factores que se deben abordar para mejorar su bienestar físico y mental.

Introduction: To evaluate the quality of life of older adults belonging to the Centros del Adulto Mayor (CAM) of the Social Security during the COVID-19 pandemic. Material and methods: Information was collected through telephone calls to older adults over 60 years of age in the CAMs. Quality of life was assessed with the EQ-5D-3L questionnaire, which considers the dimensions of mobility, self-care, activities of daily living, pain/discomfort and anxiety/depression and an analog scale from 0 to 100. A bivariate analysis with nonparametric tests was performed to assess the association between covariates and the quality of life analog scale. In addition, a simple regression analysis was performed using generalized linear models of the Poisson family to evaluate variables associated with the presence of problems in the quality of life dimensions. Results: Ninety-nine older adults participated, most of them women (84.9%), the average age was 73.1 years, 83.3% had a higher education level and 86.7% were living with someone else. Older adults with obesity, lung disease, inability to manage their own money, fatigue and hearing problems reported a lower than average score (<78.9) on the quality of life scale. Osteoarticular diseases and feelings of fatigue increase the likelihood of problems with mobility, performing daily activities, and pain/discomfort. Conclusions: The quality of life of older adults is influenced by multiple factors that must be addressed to improve their physical and mental well-being.

Proceso de definición de prioridades institucionales de investigación en el Seguro Social de Salud del Perú, 2020-2022 / Process of defining institutional priorities for research in the Peruvian Social Health Insurance, 2020-2022

Introducción: La definición de prioridades de investigación en salud dirige los esfuerzos de investigación para promover ciencia, tecnología e innovación en salud. Material y Métodos: La definición de estas en el Seguro Social de Salud peruano para el periodo 2020-2022 se realizó en cuatro etapas y de forma sistemática, estructurada, participativa y secuencial. Resultados: Primero, se evaluó el avance de investigación en las prioridades del periodo 2017-2019. En la segunda etapa, se consultó diversas fuentes y se identificó necesidades de investigación orientadas a enfermedades y se estableció el marco para prioridades orientadas a sistemas de salud e intervenciones sanitarias. La tercera etapa consistió en una consulta ampliada para seleccionar los temas prioritarios orientados a enfermedades. Finalmente, se desarrolló un taller participativo y multidisciplinario para seleccionar temas, subtemas y áreas prioritarias de investigación. Conclusión: El producto final fue la definición de 11 temas prioritarios, siete para enfermedades y cuatro para sistemas de salud e intervenciones sanitarias.

Introduction: Health research priorities definition address research efforts to the promotion of health science, technology, and innovation. Material and Methods: Health research priorities in the Peruvian Social Security for the period 2020-2022 was carried out in four stages using a systematic, structured, participatory and sequential process. Results: First, the progress of the research in the priorities of the period 2017-2019 was evaluated. In the second stage, various sources were consulted to identify disease-oriented research needs and the framework for priorities oriented to health systems and health interventions. The third stage consisted of an expanded consultation to select priority disease-oriented topics. Finally, a participatory and multidisciplinary workshop was developed to select themes, subtopics, and priority areas for research. Conclusion: The final product was the definition of 11 priority themes, seven for diseases and four for health systems and health interventions

Precios de medicamentos esenciales para el manejo y tratamiento de la COVID-19 en establecimientos farmacéuticos peruanos públicos y privados / Prices of essential drugs for management and treatment of COVID-19 in public and private Peruvian pharmacies

RESUMEN Objetivo: comparar los precios de venta de medicamentos esenciales para el manejo y tratamiento de la COVID-19 en establecimientos farmacéuticos peruanos públicos y privados. Además, estimar el costo por persona del tratamiento farmacológico para casos leves y severos. Materiales y métodos: estudio transversal con información reportada por establecimientos farmacéuticos públicos y privados. El precio de los medicamentos se presenta en medianas y se compararon usando la prueba no paramétrica de Kruskal-Wallis. Además, se estimó el costo por persona y asequibilidad para el tratamiento de casos leves y severos. Resultados: medicamentos para casos leves como azitromicina, hidroxicloquina, ivermectina y paracetamol tienen medianas de precios entre S/ 0,04 (US$ 0,011) y S/ 23,81 (US$ 6,71) en establecimientos públicos, mientras que los mismos medicamentos en establecimientos privados fluctúan entre S/ 1,00 y S/ 36,00. En promedio, los precios de los medicamentos en el sector privado son 11 veces los precios en el sector público. Los costos de tratamiento por persona en establecimientos públicos son más asequibles que en los privados, especialmente para los medicamentos para casos más severos. Los esquemas de tratamiento para casos leves requieren la inversión de entre uno a cuatro días de salario mínimo. Mientras que los tratamientos de casos severos pueden requerir, hasta 64 días de salario mínimo en establecimientos privados. Conclusiones: el tratamiento farmacológico para COVID-19 supone un gasto importante para el sistema de salud público y para las familias a través de gastos de bolsillo. Urge diseñar e implementar medidas regulatorias para mejorar el acceso a medicamentos a precios asequibles.

ABSTRACT Objective: to compare the sale price of essential drugs used in the management and therapy of COVID-19 in public and private pharmacies in Peru. Also, to assess the cost per person of drug therapy for both mild and severe cases. Materials and methods: this is a cross-sectional study using data reported by public and private pharmacies in Peru. Drug prices are presented as median values and they were compared using the non-parametric Kruskal-Wallis test. Also, costs per person and drug accessibility for treating mild and moderate cases were estimated. Results: drugs used when treating mild cases of COVID-19, such as azythromycin, hydroxichloroquine, ivermectin, and paracetamol had median prices between S/ 0.04 (US$ 0.011) and S/ 23.81 (US$ 6.71) in public pharmacies, while the same compounds cost between S/ 1.00 (US$ 0.28) and S/ 36.00 (US$ 10.15) in private pharmacies. On average, drug prices in private pharmacies are 11 times higher compared to those in public pharmacies. Costs for (COVID-19) therapy in public pharmacies are more accessible compared to those found in private pharmacies, particularly for drugs used for more severely affected patients. Therapy regimens for mild cases require spending 1 to 4 days of the minimum daily wages, while therapy for severe cases (of COVID-19) may require up to 64 days of the minimum daily wages in private pharmacies. Conclusions: pharmacological treatment for COVID-19 represents an important expense for the public health system and for families through out-of-pocket expenses. It is urgent to design and implement regulatory measures aiming to improve the access to drug therapy (for Covid-19) in order to have drugs sold at accessible prices.

Revisión sobre obesidad como factor de riesgo para mortalidad por COVID-19 / A review on obesity as a risk factor for mortality in COVID-19 disease

RESUMEN Esta revisión presenta la evidencia disponible hasta el mes de junio del 2020 y trata sobre el efecto que tiene la obesidad como posible factor que aumenta la mortalidad en pacientes con diagnóstico por infección por COVID-19. La calidad de la mayoría de los estudios fue buena según la escala de Newcastle Ottawa (mayor o igual a 7/9). Los estudios reportaron seguimientos entre el 6 de febrero hasta el 17 de mayo del 2020. En pacientes con COVID-19, la obesidad fue un factor de riesgo para progresar a mortalidad. Las personas con obesidad deberían ser tratadas como una población de alto riesgo y se deben intensificar las medidas de prevención de contagio antes de la infección y proveer asistencia especializada en casos de confirmados de COVID-19.

ABSTRACT This review presents evidence available up to June 2020 dealing with the effects from obesity as a possible factor increasing mortality in patients diagnosed with COVID-19 infection. Quality for most of the studies was good according to the Newcastle Ottawa scale (7/9 or higher). Studies reported follow-up periods between February 6th up to May 17th, 2020. In patients with COVID-19, obesity was a risk factor for mortality. Obese persons should be treated as a high- risk population, and preventive measures against transmission of the aforementioned infection must be intensified, and specialized assistance must be given to confirmed COVID-19 cases.

Asociación entre índice de ruralidad y satisfacción laboral en médicos y enfermeros de Perú / Association between the rurality index and work satisfaction in Peruvian physicians and nurses

Introducción: La satisfacción laboral en el contexto de la salud es importante porque su ausencia se asocia a trastornos mentales o psicosociales e influye de forma negativa en los servicios prestados, en el bienestar del paciente y disminuyen el rendimiento del sistema de salud. Objetivo: Evaluar la asociación entre el índice de ruralidad del distrito donde se ubica el establecimiento de salud y la satisfacción laboral en médicos y enfermeros que laboran en estos establecimientos en Perú. Métodos: Se realizó un análisis secundario de la Encuesta Nacional de Satisfacción de Usuarios en Salud, 2016. Esta encuesta se realizó a 5098 profesionales de la salud, el 43,5 por ciento eran médicos La ruralidad fue medida como la densidad poblacional (habitantes/km2) del distrito donde se ubica el establecimiento de salud. Para evaluar la asociación de interés, se utilizó un modelo lineal generalizado de la familia de Poisson para estimar razones de prevalencia crudas y ajustadas. Resultados: El porcentaje de médicos y enfermeros con satisfacción laboral fue de 75,1 por ciento y 76,7 por ciento, respectivamente. Entre los médicos no se encontró asociación entre el índice de ruralidad y satisfacción laboral en el modelo crudo (1,01 IC 95 por ciento: 0,96 a 1,05) ni ajustado (1,01 IC 95 por ciento: 0,97 a 1,05). En enfermeros tampoco se encontró asociación en el modelo crudo (98 IC 95 por ciento: 0,95 a 1,00) ni ajustado (0,97 IC 95 por ciento: 0,93 a 1,00). Se encontró asociación entre la satisfacción con ciertas características laborales y el índice de ruralidad. Conclusiones: Se evidencia que no existe asociación entre la satisfacción laboral del personal de salud y el índice de ruralidad del distrito donde se ubica el establecimiento de salud(AU)

ABSTRACT Introduction: Work satisfaction in the health context is important because its absence is associated with mental or psychosocial disorders and adversely affects the services provided, the well-being of the patient and also decrease the performance of the health system. Objective: To assess the association between the rurality index of the district where it is located the health institution and the work satisfaction in doctors and nurses working in these institutions in Peru. Methods: It was made a secondary analysis of the National Survey of Health Users Satisfaction, 2016. This survey was conducted to 5098 health professionals, 43.5 percent of them were physicians. Rurality was measured as population density (inhabitants/km2) of the district where the health facility is. To evaluate the association of interest, it was used a Poisson´s generalized linear model of the family to estimate crude and adjusted prevalence ratios. Results: The percentage of doctors and nurses with work satisfaction was 75.1 percent and 76.7 percent, respectively. Among the physicians no association was found between the rurality index and job satisfaction in the crude model (1.01 CI 95 percent: 0.96 1.05 to 1.05) nor the adjusted one (1,01 IC 95 percent: 0.97 to 1.05). In nurses association was not found in the crude model (98 CI 95 percent: 0.95 to 1.00) nor in the adjusted one (0.97 IC 95 percent: 0.93 to 1.00). An association was found between satisfaction with certain characteristics and the rurality index. Conclusions: There is evidence that there is no association between work satisfaction of health personnel and the rurality index of the district where the health facility is(AU)

Cancer-related mortality in Peru: Trends from 2003 to 2016.

OBJECTIVES: In the last decade, Latin American (LA) countries, like Peru, have undergone an epidemiological transition that has changed the pattern of oncological cases. Given that Peru's oncological pattern could illustrate those of other LA countries, we aimed at determining trends and changes in cancer-related mortality by age and sex in Peru between 2003 and 2016. METHODS AND RESULTS: A secondary data analysis using national deaths registries was conducted. Categories were created according to the 27 most frequent sites of presentation of cancer. We found that deaths attributed to cancer increased from 15.4% of all deaths in 2003 to 18.1% in 2016 (p<0.001). According to the cancer site, stomach cancer (19.1%) and lung cancer (11.5%) were the most frequent causes of death overall. In childhood (0 to 14 years), the two most frequent fatal cancers were leukemia (54.6% for boys and 53.5% for girls) and brain and nervous system tumors (19.4% for boys and 20.3% for girls). For teenagers and young male adults (15-49 years), stomach cancer (18.1%) and brain cancer (17.4%) were the leading causes of death; in their female counterparts, cervix uteri (20.0%) and breast cancer (16.1%) were the most mortal cancers. In adults (≥50 years), stomach (20.9% for men and 18.6% for women) and lung (12.7% for men and 10.4% for women) were the leading contributors to the burden of cancer deaths. CONCLUSIONS: Between the years 2003 and 2016, almost one fifth of deaths were attributed to cancer in Peru. Absolute and relative number of deaths due to cancer has increased in this period for both men and women; however, standardized mortality rates due to cancer have declined.

[Insulin: prices, availability, and affordability in public and private Peruvian pharmaciesPreço, disponibilidade e acessibilidade à insulina em farmácias públicas e privadas no Peru]. / Precios, disponibilidad y asequibilidad de insulina en farmacias públicas y privadas en Perú.

OBJECTIVE: Measure and compare the price, availability, and affordability of insulin and metformin in public and private pharmacies in six regions of Peru. METHODS: Cross-sectional study using the World Health Organization/Health Action International (WHO/HAI) revised methodology. Public and private pharmacies in six regions of Peru were surveyed. Data were collected on availability and prices for insulin (all types) and 850 mg metformin. Availability is expressed as percentages and prices are reported in medians. Affordability is defined as the number of days that a person must work at minimum wage to cover the cost of one month of treatment. RESULTS: Availability in public pharmacies is 63.2% for regular insulin and 68.4% for NPH (isophane) insulin, but differences in availability were observed between levels of care and between regions. Private pharmacies have a greater variety of insulin, but availability is less than 11%. The median price of human insulin was three to four times higher in private pharmacies than in public pharmacies. In comparison, availability of metformin was 89.5% in public pharmacies and 77.7% in private ones. Affordability in public pharmacies for one month of treatment with human insulin or generic metformin is less than one day's wages. CONCLUSIONS: The price for human insulin and generic metformin in public pharmacies is affordable. However, efforts are needed to improve their availability in the different regions and levels of care.

OBJETIVO: Avaliar o preço, a disponibilidade e a acessibilidade à insulina e metformina, como comparativo, em farmácias públicas e privadas em seis regiões do Peru. MÉTODOS: Estudo transversal conduzido com metodologia adaptada da Organização Mundial da Saúde/Ação Internacional para a Saúde (OMS/AIS). Farmácias públicas e privadas foram pesquisadas em seis regiões do Peru com a coleta de dados sobre a disponibilidade e os preços da insulina (de todos os tipos) e metformina na apresentação de 850 mg. A disponibilidade é expressa em porcentagem e os preços estão descritos como mediana. A acessibilidade foi definida no estudo como o número de dias que um indivíduo que ganha salário mínimo precisa trabalhar para arcar com o custo de um mês de tratamento. RESULTADOS: A disponibilidade em farmácias públicas da insulina regular foi de 63,2% e da insulina isófana (NPH) foi de 68,4%, porém se observou diferença de disponibilidade entre os níveis de atenção e as regiões. Nas farmácias privadas, a variedade de insulinas é maior, mas a disponibilidade é inferior a 11%. A mediana de preços para a insulina humana nas farmácias privadas é 3 a 4 vezes maior que nas farmácias públicas. Comparativamente, a disponibilidade da metformina foi de 89,5% nas farmácias públicas e 77,7% nas farmácias privadas. A acessibilidade nas farmácias públicas para um mês de tratamento com insulina humana ou metformina genérica é inferior à remuneração de um dia de trabalho. CONCLUSÕES: As insulinas humanas e a metformina genérica têm preço acessível nas farmácias públicas. Porém, esforços devem ser empreendidos para aumentar a disponibilidade destes medicamentos nos níveis de atenção e nas regiões.

Precios, disponibilidad y asequibilidad de insulina en farmacias públicas y privadas en Perú

[RESUMEN]. Objetivo. Medir el precio, disponibilidad y asequibilidad de insulina y metformina, como comparador, en farmacias públicas y privadas en seis regiones del Perú. Métodos. Estudio transversal con uso de la metodología adaptada de la Organización Mundial de la Salud/Acción Internacional para la Salud (OMS/AIS). Se encuestaron farmacias públicas y privadas de seis regiones del Perú. Se recolectaron datos de disponibilidad y precio de insulina (todos los tipos) y metformina en presentación de 850 mg. La disponibilidad se expresa en porcentajes y los precios se reportan en medianas. La asequibilidad se define como el número de días que debe laborar una persona con el salario mínimo para cubrir el costo de un mes de tratamiento. Resultados. La disponibilidad en farmacias públicas es de 63,2% para insulina regular y 68,4% para isófana-NPH, pero se observaron diferencias de disponibilidad entre los niveles de atención y entre las regiones. En farmacias privadas, la variedad de insulina es mayor, pero la disponibilidad es menor del 11%. La mediana de precios para la insulina humana en farmacias privadas fue entre tres a cuatro veces mayor que en farmacias públicas. En comparación, la disponibilidad de metformina alcanza 89,5% en farmacias públicas y 77,7% en privadas. La asequibilidad en farmacias públicas para un mes de tratamiento con insulina humana o metformina genérica es menor a lo percibido por un día laborable. Conclusiones. El precio de insulinas humanas y de metformina genérica en farmacias públicas es asequible. Sin embargo, se necesitan esfuerzos para mejorar su disponibilidad en las regiones y los niveles de atención.

[ABSTRACT]. Objective. Measure and compare the price, availability, and affordability of insulin and metformin in public and private pharmacies in six regions of Peru. Methods. Cross-sectional study using the World Health Organization/Health Action International (WHO/HAI) revised methodology. Public and private pharmacies in six regions of Peru were surveyed. Data were collected on availability and prices for insulin (all types) and 850 mg metformin. Availability is expressed as percentages and prices are reported in medians. Affordability is defined as the number of days that a person must work at minimum wage to cover the cost of one month of treatment. Results. Availability in public pharmacies is 63.2% for regular insulin and 68.4% for NPH (isophane) insulin, but differences in availability were observed between levels of care and between regions. Private pharmacies have a greater variety of insulin, but availability is less than 11%. The median price of human insulin was three to four times higher in private pharmacies than in public pharmacies. In comparison, availability of metformin was 89.5% in public pharmacies and 77.7% in private ones. Affordability in public pharmacies for one month of treatment with human insulin or generic metformin is less than one day’s wages. Conclusions. The price for human insulin and generic metformin in public pharmacies is affordable. However, efforts are needed to improve their availability in the different regions and levels of care.

[RESUMO]. Preço, disponibilidade e acessibilidade à insulina em farmácias públicas e privadas no Peru RESUMO Objetivo. Avaliar o preço, a disponibilidade e a acessibilidade à insulina e metformina, como comparativo, em farmácias públicas e privadas em seis regiões do Peru. Métodos. Estudo transversal conduzido com metodologia adaptada da Organização Mundial da Saúde/Ação Internacional para a Saúde (OMS/AIS). Farmácias públicas e privadas foram pesquisadas em seis regiões do Peru com a coleta de dados sobre a disponibilidade e os preços da insulina (de todos os tipos) e metformina na apresentação de 850 mg. A disponibilidade é expressa em porcentagem e os preços estão descritos como mediana. A acessibilidade foi definida no estudo como o número de dias que um indivíduo que ganha salário mínimo precisa trabalhar para arcar com o custo de um mês de tratamento. Resultados. A disponibilidade em farmácias públicas da insulina regular foi de 63,2% e da insulina isófana (NPH) foi de 68,4%, porém se observou diferença de disponibilidade entre os níveis de atenção e as regiões. Nas farmácias privadas, a variedade de insulinas é maior, mas a disponibilidade é inferior a 11%. A mediana de preços para a insulina humana nas farmácias privadas é 3 a 4 vezes maior que nas farmácias públicas. Comparativamente, a disponibilidade da metformina foi de 89,5% nas farmácias públicas e 77,7% nas farmácias privadas. A acessibilidade nas farmácias públicas para um mês de tratamento com insulina humana ou metformina genérica é inferior à remuneração de um dia de trabalho. Conclusões. As insulinas humanas e a metformina genérica têm preço acessível nas farmácias públicas. Porém, esforços devem ser empreendidos para aumentar a disponibilidade destes medicamentos nos níveis de atenção e nas regiões.

Efecto antioxidante y citoprotector del tocosh de Solanum tuberosum "papa" en la mucosa gástrica de animales de experimentación / Antioxidant and cytoprotector effects of Solanum tuberosum "papa" tocosh in gastric mucose in experimental animals

El tocosh es un producto alimenticio obtenido por una técnica de conservación andina y que tiene propiedades nutritivas y terapéuticas. Objetivo: Demostrar la capacidad antioxidante y el efecto citoprotector del tocosh de Solanum tuberosum æpapaÆ en la mucosa gástrica de animales de experimentación. Diseño: Experimental. Institución: Centro de Investigación de Bioquímica y Nutrición, Facultad de Medicina, Universidad Nacional Mayor de San Marcos, Lima, Perú. Material biológico: Tocosh seco y molido administrado a ratas albinas. Intervenciones: A 6 grupos de ratas albinas machos (200 ± 50 g) se les dividió en: (GI) solución NaCl 0,9 por ciento, 10 mL/kg; (GII) etanol al 70 por ciento a 10 mL/kg; (GIII, IV y V) Tocosh equivalente a 900 mg/kg, 1 800 mg/kg y 2 700 mg/kg, respectivamente, y (GVI) sucralfato 30 mg/kg. En todos los casos, una hora después se indujo injuria con etanol 70 grados a 10 mL/kg y por laparotomía abdominal se obtuvo el tejido gástrico. Principales medidas de resultados: Porcentaje de citoprotección gástrica en imagen digitalizada por image analysis software for plant disease quantification y capacidad antioxidante por lipoperoxidación método espectrofotométrico de la reacción de especies reactivas al ácido tiobarbitúrico (TBARS). Resultados: La marcha fitoquímica identificó compuestos fenólicos, alcaloides, triterpenoides y esteroides, azúcares reductores y aminoácidos libres como metabolitos secundarios. Las dosis de 2 700 mg/kg y 900 mg/kg resultaron en 0,72 y 1,81 nmol/g tejido de lipoperoxidación, respectivamente. La dosis de 1 800 mg/kg protegió un 97 por ciento del área de la mucosa gástrica, 2 700 mg/kg un 95 por ciento y la de 900 mg/kg, 88 por ciento (p<0,05). La dosis de 1 800 mg/kg exhibió mejor efecto citoprotector y la de 2 700 mg/kg mejor actividad antioxidante, comparada con sucralfato 30 mg/kg. Conclusiones: El tocosh de Solanum tuberosum æpapaÆ tuvo efecto citoprotector y actividad antioxidante...

Tocosh is a nutritious product obtained by an Andean preservation technique with nutritive and therapeutic properties. Objective: To demonstrate antioxidant and cytoprotector effects of Solanum tuberosum æpapaÆ tocosh in the gastric mucosa of experimental animals. Design: Experimental. Institution: Biochemistry and Nutrition Research Center, Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru. Biologic material: Dry and grounded administered to albino rats. Interventions: Six groups of male albino rats (200 ± 50 g) were divided in: (GI) NaCl 0.9 per cent solution, 10 mL/kg; (GII) ethanol 70 per cent 10 mL/kg; (GIII, IV y V) Tocosh equivalent to 900 mg/kg, 1 800 mg/kg, and 2 700 mg/kg respectively, and (GVI) sucralfate 30 mg/kg. One hour after, in all cases injury with ethanol 70 degrees 10 mL/kg was induced and gastric tissue was obtained by abdominal laparotomy. Main outcome measures: Percentage of gastric cytoprotection in digitalized image by image analysis software for plant disease quantification, and antioxidant ability by lipoperoxidation spectrophotometric method of reactive species reaction to thiobarbituric acid (TBARS). Results: The phytochemist progress identified phenolic compounds, alcaloids, triterpenoids and steroids, reducing sugars and free aminoacids as secondary metabolites. The 2 700 mg/kg and 900 mg/kg doses resulted respectively in 0.72 and 1.81 nmol/g lipoperoxidation tissue. The 1800 mg/kg doses protected 97 per cent of the gastric mucosa, 2 700 mg/kg 95 per cent and the 900 mg/kg, 88 per cent (p<0.05). The 1 800 mg/kg doses exhibited better cytoprotector effect and the 2 700 mg/kg doses better antioxidant activity, compared with sucralfate 30 mg/kg. Conclusions: Solanum tuberosum æpapaÆ tocosh showed cytoprotector effect and antioxidant activity...