Behavioral Insights Into Micronutrient Powder Use for Childhood Anemia in Arequipa, Peru.

Childhood anemia remains a significant driver of morbidity in low- and middle-income countries, including Peru. To identify behavioral challenges to using micronutrient powder (MNP) that is given to supplement children's diets and prevent anemia, we applied a behavioral design approach to interviews and focus groups with 129 caregivers in Arequipa, Peru. We examined 3 key points in the decision-making process: accessing MNP through the health system; forming intentions to use MNP; and MNP use at the time of child feeding. Using the NUDGE (Narrow, Understand, Discover, Generate, Evaluate) approach, we identified the following behavioral barriers and facilitators: (1) caregivers' experiences with health care providers shaped their motivation to access MNP; (2) caregivers felt accessing MNP at clinics was inconvenient and created hassle factors; (3) caregivers' mental models about anemia prevention shaped MNP intentions and use; (4) caregivers' salient negative experiences could have caused them to stop giving MNP; (5) caregivers forgot to give MNP if they did not have cues to remind them but could be prompted with salient cues; and (6) caregivers were affected by emotional, cognitive, and attentional factors during feeding that were difficult to anticipate. Our results, based on a behavioral design approach, suggest opportunities to adapt current messaging, counseling, and education around MNP use. Adaptations include providing culturally relevant messages, leveraging caregivers' emotional and cognitive states, and encouraging small but impactful changes to feeding routines to address barriers to MNP use.

Micronutrient powder use in Arequipa, Peru: Barriers and enablers across multiple levels.

In Peru, nearly half of children aged 6-36 months were diagnosed with anaemia in 2017. To address this disease, the Peruvian Ministry of Health implemented a national programme in 2014, distributing free micronutrient powders (MNPs) to all children of this age. However, rates of childhood anaemia remain high. The aim of this study was to explore factors at all levels of the Social-Ecological Model that affect MNP use and adherence in Arequipa, an Andean city with childhood anaemia rates higher than the national average. We conducted in-depth interviews with 20 health personnel and 24 caregivers and 12 focus group discussions with 105 caregivers. We identified numerous barriers, including negative side effects (constipation, vomiting, and diarrhoea), poor taste of MNP, lack of familial and peer support for its use, insufficient informational resources provided by the health system, and limited human resources that constricted health personnel abilities to implement MNP programming successfully. Facilitators identified included concern about the long-term effects of anaemia, support from organizations external to the health system, well-coordinated care within the health system, and provision of resources by the Ministry of Health. We found that community or organizational and societal factors were key to limited MNP use and adherence, specifically the limited time health personnel have to address caregivers' doubts during appointments and the lack of informational resources outside of these appointments. Potential policy implications could be to increase informational resources available outside of individualized counselling by strengthening existing collaborations with community organizations, increasing media coverage, and providing group counselling.

A foodborne outbreak of brucellosis at a police station cafeteria, Lima, Peru.

Brucella melitensis is highly infectious for humans and can be transmitted to humans in a number of epidemiological contexts. Within the context of an ongoing brucellosis surveillance project, an outbreak at a Peruvian police officer cafeteria was discovered, which led to active surveillance (serology, blood culture) for additional cases among 49 police officers who had also eaten there. The cohort was followed up to 18 months regardless of treatment or symptoms. Active surveillance estimated the attack rate at 26.5% (13 of 49). Blood cultures from four cases were positive; these isolates were indistinguishable using multiple locus variable number tandem repeat analysis. This investigation indicates the importance of case tracking and active surveillance for brucellosis in the context of potential common source exposure. These results provide rationale for public health investigations of brucellosis index cases including the bioterrorism-related dissemination of Brucella.