The downstream effects of COVID-19 on adolescent girls in the Peruvian Amazon: qualitative findings on how the pandemic affected education and reproductive health.

Due to COVID-19, schools were closed to mitigate disease spread. Past studies have shown that disruptions in education have unintended consequences for adolescents, including increasing their risk of school dropout, exploitation, gender-based violence, pregnancy and early unions. In Peru, the government closed schools from March 2020 to March 2022, declaring a national emergency that affected an estimated 8 million children. These closures may have unintended consequences, including increased adolescent pregnancy, particularly in Peru's rural, largely indigenous regions. Loreto, located in the Peruvian Amazon, has one of the highest adolescent pregnancy rates in the country and poor maternal and child health outcomes. The underlying causes may not be fully understood as data are limited, especially as we transition out of the pandemic. This qualitative study investigated the downstream effects of COVID-19 on adolescent education and reproductive health in Loreto's districts of Nauta and Parinari. In-depth interviews (n=41) were conducted with adolescents and community leaders. These were held in June 2022, 3 months after the reinstitution of in-person classes throughout Peru. Focus group discussions (FGDs) were also completed with community health workers and educators from the same study area in October 2022 to supplement our findings (3 FGDs, n=15). We observed that the economic, educational and health effects of the COVID-19 pandemic contributed to reduced contraceptive use, and increased school abandonment, early unions and adolescent pregnancy. The interplay between adolescent pregnancy and both early unions and school abandonment was bidirectional, with each acting as both a cause and consequence of the other.

'You have a lot of mirrors': structural and socioecological factors impacting adolescent pregnancy and reproductive health in the Amazon basin, Peru, a qualitative study.

Loreto, in the Peruvian Amazon, has one of the highest adolescent pregnancy rates in the country. However, underlying causes of adolescent pregnancy are not fully understood as data are limited in Indigenous and remote Amazonian communities. This study investigated adolescent reproductive health within Loreto using an ecological systems framework. Forty-one semi-structured interviews were conducted in June 2022: community leaders (n = 12) and adolescent participants between 15 and 17 years of age (pregnant girls, n = 11; never pregnant girls, n = 9; and boys, n = 9). We also conducted focus group discussions with community health workers and educators in October 2022 (three focus groups, n = 15). Adolescent reproductive health is complex with multi-layered factors that put girls at higher risk of pregnancy. We found a paradoxical relationship between expected social and gender norms and individual desires. This research provides a contextual understanding of the lived experience of adolescents and young people in the Amazon region of Peru. Our findings suggest the need for greater exploration of the contradictory ideas surrounding adolescent pregnancy and female sexuality.

Effect of the Mamás del Río programme on essential newborn care: a three-year before-and-after outcome evaluation of a community-based, maternal and neonatal health intervention in the Peruvian Amazon.

Background: Despite remarkable progress in maternal and neonatal health, regional inequalities persist in Peru. In rural areas of Amazonian Loreto, access to quality care is difficult, home births are frequent, and neonatal mortality is high. We conducted a prospective before-and-after study to assess the effect after implementation and over time of a community-based intervention on essential newborn care (ENC). Methods: Mamás del Río consists of tablet-enhanced educational home visits by Community health workers (CHW) to pregnant women and mothers of newborns, with supportive training on ENC of traditional birth attendants and facility staff. The study area comprised 79 rural communities of three districts in Loreto. Primary outcomes were ENC practices in home births, secondary outcomes were ENC in facility births as well as healthcare seeking, measured at baseline before and at year 2 and year 3 after intervention implementation. Community censuses included questionnaires to women aged 15-49 years with a live birth. We calculated prevalence of outcomes at each time point and estimated adjusted prevalence differences (PD) between time points using post-estimation based on logistic regression. Findings: Following implementation early 2019, 97% of communities had a trained CHW. At year 2 follow-up, 63% (322/530) of women received a CHW visit during pregnancy. Seven out of nine ENC indicators among home births improved, with largest adjusted prevalence differences in immediate skin-to-skin contact (50% [95% CI: 42-58], p < 0.0001), colostrum feeding (45% [35-54], p < 0.0001), and cord care (19% [10-28], p = 0.0001). Improvements were maintained at year 3, except for cord care. At year 2, among facility births only three ENC indicators improved, while more women gave birth in a facility. Sensitivity analyses showed ENC prevalence was similar before compared to after onset of Covid-19 lockdown. Interpretation: ENC practices in home births improved consistently and changes were sustained over time, despite the onset of the Covid-19 pandemic. A community-based approach for behaviour-change in home-based newborn care appears effective. Process evaluation of mechanisms will help to explain observed effects and understand transferability of findings. Funding: Grand Challenges Canada and Peruvian National Council of Science and Technology.

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.

Hear my voice: understanding how community health workers in the Peruvian Amazon expanded their roles to mitigate the impact of the COVID-19 pandemic through community-based participatory research.

INTRODUCTION: The COVID-19 pandemic led to the collapse of the Peruvian health system, disrupting healthcare access for indigenous communities in the Amazon. Our study analysed how community health workers (CHWs) from indigenous communities in the Peruvian Amazon expanded their roles to mitigate the effects of the COVID-19 pandemic. METHODS: Fourteen CHWs from Loreto, Peru, participated in a community-based participatory research project using Photovoice, a technique encouraging vulnerable groups to take photos and develop stories illustrating their lived experiences. Participants were recruited from Mamás del Río, a local university-based programme, through purposive sampling. CHWs were asked to photograph how the pandemic affected their lives and work. Participants met four times over 5 months to share photos and develop action items. Data were organised into key themes using thematic analysis. CHWs shared photo galleries with policy-makers in Loreto and Lima. RESULTS: CHWs produced 36 photos with 33 texts highlighting their roles during COVID-19. Three core themes emerged: the (1) collapse of health infrastructure, (2) use of medicinal plants versus pharmaceuticals and (3) community adaptations and struggles. The leadership of CHWs emerged as a cross-cutting theme as CHWs supported COVID-19 efforts without government training or resources. CHWs asked policy-makers for formal integration into the health system, standardisation of training and management of community pharmacies. CONCLUSION: CHWs demonstrated their leadership and expanded their roles during the pandemic with little to no training from the government. Global investment in robust CHW programmes can fortify healthcare delivery.

Prevalence of essential newborn care in home and facility births in the Peruvian Amazon: analysis of census data from programme evaluation in three remote districts of the Loreto region.

Background: Essential newborn care (ENC) covers optimal breastfeeding, thermal care, and hygienic cord care. These practices are fundamental to save newborn lives. Despite neonatal mortality remaining high in some parts of Peru, no comprehensive data on ENC is available. We sought to estimate the prevalence of ENC and assess differences between facility and home births in the remote Peruvian Amazon. Methods: We used baseline data from a household census of rural communities of three districts in Loreto region, collected as part of the evaluation of a maternal-neonatal health (MNH) programme. Women between 15 and 49 years with a live birth in the last 12 months were invited to complete a questionnaire about MNH-related care and ENC. Prevalence of ENC was calculated for all births and disaggregated by place of birth. Adjusted prevalence differences (PD) were post-estimated from logistic regression models on the effect of place of birth on ENC. Findings: All 79 rural communities with a population of 14,474 were censused. Among 324 (>99%) women interviewed, 70% gave birth at home, most (93%) without skilled birth assistance. Among all births, prevalence was lowest for immediate skin-to-skin contact (24%), colostrum feeding (47%), and early breastfeeding (64%). ENC was consistently lower in home compared to facility births. After adjusting for confounders, largest PD were found for immediate skin-to-skin contact (50% [95% CI: 38-62]), colostrum feeding (26% [16-36]), and clean cord care (23% [14-32]). ENC prevalence in facilities ranged between 58 and 93%; delayed bathing was lower compared to home births (-19% [-31 to -7]). Interpretation: Low prevalence of ENC practices among home births in a setting with high neonatal mortality and difficult access to quality care in facilities suggests potential for a community-based intervention to promote ENC practices at home, along with promotion of healthcare seeking and simultaneous strengthening of routine facility care. Funding: Grand Challenges Canada and Peruvian National Council of Science, Technology, and Technology Innovation.

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.

Kuskaya: a training program for collaboration and innovation in global health.

To solve increasingly complex global health problems, health professionals must collaborate with professionals in non-health-related fields. The Universidad Peruana Cayetano Heredia and University of Washington created the NIH-funded Kuskaya training program in response to the need for transformative global health training for talented graduates from all disciplines. Kuskaya is a 1-year, interdisciplinary training program that teaches Peruvian and US graduates critical skills related to public health research through the design and implementation of a collaborative research project in Peru. Between 2014 and 2018, the program has trained 33 fellows, of which one third were from non-health disciplines. The program is unique because it targets junior trainees from disciplines outside of the health field, the program's curriculum is adapted to fit the fellows' backgrounds and professional aspirations, and the structure of the program allows for collaboration within the cohort and encourages fellows to apply for additional funding and pursue advanced degrees. Lessons learned in designing the Kuskaya program include: 1) involving mentors in the fellow selection process, 2) involving fellows in existing lines of research to increase mentor involvement, 3) institutionalizing mentoring through regular works-in-progress meetings and providing mentoring materials, and 4) defining a core curriculum for all fellows while providing additional supplementary materials to meet each cohort's needs, and evaluating their progress. Kuskaya provides an innovative model for bi-national, global health training to engage and provide a public health career pathway for all professionals.

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.

[How to produce a video to promote HIV testing in men who have sex with men?]. / ¿Cómo producir un video para promover la prueba del VIH en hombres que tienen sexo con hombres?

The aim of the study was to describe the process of designing and producing a video to promote HIV testing in Peruvian men who have sex with men (MSM). The process involved the following steps: identification of the theories of behavior change; identifying key messages and video features; developing a script that would captivate the target audience; working with an experienced production company; and piloting the video. A video with everyday situations of risk associated with HIV infection was the one preferred by participants. Key messages identified, and theoretical constructs models chosen were used to create the video scenes. Participants identified with the main, 9 minute video which they considered to be clear and dynamic. It is necessary to work with the target population to design a video according to their preferences.

HPV Prevalence in Multiple Anatomical Sites among Men Who Have Sex with Men in Peru.

BACKGROUND: Human Papilloma Virus (HPV) infection is the most common sexually transmitted viral infection worldwide. HPV is highly prevalent in sexually active men who have sex with men (MSM) and has been associated with anal cancer, penile cancer, and oropharyngeal cancer. METHODS: From March to September 2011, we conducted a cross-sectional study of HPV prevalence among MSM above age 18 years. Participants were recruited using respondent driven sampling at Clinica Cayetano Heredia. All participants provided anal, genital, and oral samples for HPV DNA testing, and blood for HIV and HPV antibody testing. RESULTS: A total of 200 MSM were recruited in the study. The mean age was 34 years (range 18-59 years, SD = 9.4) and101 participants were HIV negative (99 HIV positive). HPV 6/11/16/18 or quadrivalent HPV vaccine (HPV4) genotype seroprevalence among HIV negative and positive MSM was 64.3% (55%-75.9%) and 93.8% (87.6%-99.2%) respectively (p<0.001). HIV positivity was associated with a higher prevalence of HPV4 and HPV 16/18 DNA at external genital sites and the anal canal. HPV4 DNA prevalence at external genital sites among HIV negative and positive MSM was 14.9% and 28.7% (p = 0.02) respectively, at anal canal was 50.9% and 79.0% (p = 0.001), and at the oral cavity was 9.9% and 8.5% (p = 0.6). CONCLUSIONS: HPV4 seroprevalence was high in our study among both HIV positives and negatives, with HPV DNA prevalence much lower, and the anal canal being the anatomical site with the highest HPV DNA prevalence. HPV prevention interventions are needed among MSM at high-risk for HIV infection.