Identifying priority double-duty actions to tackle the double burden of malnutrition in infants and young children in Peru: Assessment and prioritisation of government actions by national experts.

Multiple forms of malnutrition coexist in infants and young children (IYC) in Peru. The World Health Organization has proposed double-duty actions (DDAs) to simultaneously address undernutrition and overweight/obesity. We assessed current implementation of- and priority for- government-level actions to tackle multiple forms of malnutrition in IYC in Peru. Mapping of current policy activity was undertaken against 47 indicators of good practice for five DDAs (exclusive breastfeeding, complementary feeding, food marketing, maternal nutrition, preschool nutrition; assessed by 27 indicators) and for the enabling policy environment, i.e., 'infrastructure support' (health in all policies, platforms for interactions, financing, monitoring, governance, leadership; assessed by 20 indicators). Interviews with 16 national experts explored views on the level of and barriers to implementation of DDAs and infrastructure support, as well as their prioritisation based on likely impact and feasibility. The level of implementation of actions was categorised into two groups (agenda setting/formulation vs. implementation/evaluation). Mean scores were generated for prioritisation of DDAs and infrastructure support. Deductive qualitative analysis was undertaken to identify barriers that influence policy implementation. Only 5/27 DDA indicators were reported as fully implemented by all national experts (international code that regulates the marketing of breastmilk substitutes, iron supplementation for IYC, micronutrient powders in IYC, iron/folic acid supplementation in pregnant women, paid maternity leave). Only 1/20 infrastructure support indicator (access to nutrition information) was rated as fully implemented by all experts. Barriers to implementing DDAs and infrastructure support included: legal feasibility or lack of regulations, inadequate monitoring/evaluation to ensure enforcement, commercial influences on policymakers, insufficient resources, shifting public health priorities with the COVID-19 pandemic and political instability. The experts prioritised 12 indicators across all five DDAs and eight infrastructure support indicators. Experts highlighted the need to improve implementation of all DDAs and identified ways to strengthen the enabling policy environment.

Designing intervention prototypes to improve infant and young child nutrition in Peru: a participatory design study protocol.

INTRODUCTION: Nutrition during the complementary feeding period (6-23 months) is critical to ensure optimal growth and reduce the risk of diet-related disease across the life course. Strategies to reduce multiple forms of malnutrition (stunting, overweight/obesity and anaemia) in infants and young children (IYC) are a key priority in low-income and middle-income countries, including Peru. This study aims to co-design and develop prototypes for interventions to address the multiple forms of malnutrition in IYC in urban Peru, using a participatory design approach. METHODS AND ANALYSIS: The study will be based within peri-urban communities in two areas of Peru (Lima and Huánuco city). Following the identification of key nutritional challenges for IYC aged 6-23 months through formative research (phase I), we will conduct a series of workshops bringing together healthcare professionals from government health centres and caregivers of IYC aged 6-23 months. Workshops (on idea generation; creating future scenarios; storyboarding and early implementation and feedback) will take place in parallel in the two study areas. Through these workshops, we will engage with community participants to explore, experiment, co-design and iteratively validate new design ideas to address the challenges around IYC complementary feeding from phase I. Workshop outputs and transcripts will be analysed qualitatively using affinity diagramming and thematic analyses. The intervention prototypes will be evaluated qualitatively and piloted with the participating communities. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Ethical Review Committee of the Instituto de Investigación Nutricional (IIN) Peru (388-2019/CIEI-IIN), Loughborough University (C19-87) and confirmed by Cardiff University. Findings of the participatory design process will be disseminated through a deliberative workshop in Lima, Peru with national and regional government stakeholders, as well as participants and researchers involved in the design process. Further dissemination will take place through policy briefs, conferences and academic publications.

Diet and food insecurity among mothers, infants, and young children in Peru before and during COVID-19: A panel survey.

The COVID-19 pandemic may impact diet and nutrition through increased household food insecurity, lack of access to health services, and poorer quality diets. The primary aim of this study is to assess the impact of the pandemic on dietary outcomes of mothers and their infants and young children (IYC) in low-income urban areas of Peru. We conducted a panel study, with one survey prepandemic (n = 244) and one survey 9 months after the onset of COVID-19 (n = 254). We assessed breastfeeding and complementary feeding indicators and maternal dietary diversity in both surveys. During COVID-19, we assessed household food insecurity experience and economic impacts of the pandemic on livelihoods; receipt of financial or food assistance, and uptake of health services. Almost all respondents (98.0%) reported adverse economic impacts due to the pandemic and 46.9% of households were at risk of moderate or severe household food insecurity. The proportion of households receiving government food assistance nearly doubled between the two surveys (36.5%-59.5%). Dietary indicators, however, did not worsen in mothers or IYC. Positive changes included an increase in exclusive breastfeeding <6 months (24.2%-39.0%, p < 0.008) and a decrease in sweet food consumption by IYC (33.1%-18.1%, p = 0.001) and mothers (34.0%-14.6%, p < 0.001). The prevalence of sugar-sweetened beverage consumption remained high in both mothers (97%) and IYC (78%). In sum, we found dietary indicators had not significantly worsened 9 months into the COVID-19 pandemic. However, several indicators remain suboptimal and should be targeted in future interventions.

Using formative research to design context-specific animal source food and multiple micronutrient powder interventions to improve the consumption of micronutrients by infants and young children in Tanzania, Kenya, Bangladesh and Pakistan.

Optimal complementary feeding practices including consumption of multiple micronutrient powders (MNP) are recommended to improve micronutrient intake by infants and young children (IYC) 6-23 months. Formative research was used to design the behaviour change strategy to improve IYC micronutrient intake for the multicountry ENRICH project in rural impoverished areas of Tanzania, Kenya, Bangladesh and Pakistan. Employing a qualitative approach with multiple methods and guided by a social ecological framework, the study was conducted in several phases: data collection in the community, household and health facilities, initial analysis and household trials (HHT). Results found limited use of animal source foods (ASF) for feeding IYC and MNP largely unavailable. Although cost constrained access to ASF, potential more affordable context-specific ASF options were identified in each setting. Caregivers associated ASF with many positive attributes for IYC, but barriers to feeding them included lack of caregiver time and knowledge of specific preparation techniques, and limited advice from health workers. Feeding practices were identified that used time-efficient, specific preparations for eggs and other ASF, and demonstrated good initial acceptability and feasibility during HHT. Testing MNP in HHT found good initial feasibility and acceptability and provided an understanding of the facilitators and constraints for preparing, feeding and promoting MNP. In conclusion, formative research led to the design of context-specific ASF and MNP complementary feeding promotion strategies to improve IYC consumption of micronutrients by identifying the practices, benefits, motivations and alternative actions to overcome the barriers in each setting.

Strengthening health services to deliver nutrition education to promote complementary feeding and healthy growth of infants and young children: formative research for a successful intervention in peri-urban Trujillo, Peru.

Formative research is critical for developing effective nutrition-specific interventions to improve infant and young child (IYC) feeding practices and promote healthy growth. Health workers interact with caregivers during health facility visits, yet there is limited research about how to optimize delivery of such interventions during these visits. The extensive reach of IYC health services globally calls for research to address this gap. In Trujillo, Peru, formative research was conducted to explore complementary feeding practices with caregivers as well as health worker routines and interactions with caregivers related to feeding and healthy growth; results informed the development and delivery of an educational intervention. Multiple qualitative methods were used to collect data on a purposive sample of health workers and caregivers from three health facilities and communities: household trials followed. Complementary feeding messages with doable behaviours were developed, and three were selected as key to promote based on their nutritional impact and cultural acceptability. In the health facilities, medical consultation, well-child visits and nutrition consultation all dealt with aspects of IYC nutrition/growth during their interactions with caregivers but were independent and inconsistent in approach. A nutrition education strategy was developed based on consistency, quality and coverage in the IYC health services. We conclude that formative research undertaken in the community and IYC health services was critical to developing a successful and culturally relevant intervention to promote optimal complementary feeding practices and healthy growth during interactions between health workers and caregivers at routine health facility visits. © 2016 John Wiley & Sons Ltd.

Fruits and vegetables are incorporated into home cuisine in different ways that are relevant to promoting increased consumption.

Fruits and vegetables are essential for healthy life. We examined the fruits and vegetables consumption by 240 caregivers and their children aged 1-17 years in peri-urban Lima, and the ways that they were incorporated into local cuisine. A randomized cross-sectional household survey collected information on the weight of all foods eaten the previous day (24 h) including fruits and vegetables, their preparation and serving sizes. Fruit and vegetable consumption was low and very variable: fruit intake was mean 185.2 ± 171.5 g day-1 , median 138 g day-1 for caregivers and 203.6 ± 190.6 g day-1 and 159 g day-1 for children, vegetable intake was mean 116.9 ± 94.0 g day-1 median 92 g day-1 for caregivers, mean 89.3 ± 84.7 g day-1 median 60 g day-1 for children. Only 23.8% of children and 26.2% of caregivers met the recommended ≥400 g of fruit or vegetable/day. Vegetables were mainly eaten either as ingredients of the main course recipe, eaten by about 80% of caregivers and children, or as salads eaten by 47% of caregivers and 42% of children. Fruits were most commonly eaten as whole fresh fruits eaten by 68% of caregivers and 75% of children. In multivariate analysis of the extent to which different presentations contributed to daily fruit and vegetable consumption, main courses contributed most to determining vegetable intake for caregivers, and for children, main course and salads had similar contributions. For fruit intake, the amount eaten as whole fruit determined total fruit and total fruit plus vegetable intake for both caregivers and children. Local cuisine should be considered in interventions to promote fruit and vegetable consumption. © 2016 John Wiley & Sons Ltd.

Influences on eating: a qualitative study of adolescents in a periurban area in Lima, Peru.

BACKGROUND: Peruvian adolescents are at high nutritional risk, facing issues such as overweight and obesity, anemia, and pregnancy during a period of development. Research seeking to understand contextual factors that influence eating habits to inform the development of public health interventions is lacking in this population. This study aimed to understand socio-cultural influences on eating among adolescents in periurban Lima, Peru using qualitative methods. METHODS: Semi-structured interviews and pile sort activities were conducted with 14 adolescents 15-17 years. The interview was designed to elicit information on influences on eating habits at four levels: individual (intrapersonal), social environmental (interpersonal), physical environmental (community settings), and macrosystem (societal). The pile sort activity required adolescents to place cards with food images into groups and then to describe the characteristics of the foods placed in each group. Content analysis was used to identify predominant themes of influencing factors in interviews. Multidimensional scaling and hierarchical clustering analysis was completed with pile sort data. RESULTS: Individual influences on behavior included lack of financial resources to purchase food and concerns about body image. Nutrition-related knowledge also played a role; participants noted the importance of foods such as beans for anemia prevention. At the social environmental level, parents promoted healthy eating by providing advice on food selection and home-cooked meals. The physical environment also influenced intake, with foods available in schools being predominantly low-nutrient energy-dense. Macrosystem influences were evident, as adolescents used the Internet for nutrition information, which they viewed as credible. CONCLUSIONS: To address nutrition-related issues such as obesity and iron-deficiency anemia in Peruvian adolescents, further research is warranted to elucidate the roles of certain factors shaping behavior, particularly that of family, cited numerous times as having a positive influence. Addressing nutrition-related issues such as obesity and iron-deficiency anemia in this population requires consideration of the effect of social and environmental factors in the context of adolescent lifestyles on behavior. Nutrition education messages for adolescents should consider the cultural perceptions and importance of particular foods, taking into account the diverse factors that influence eating behaviors.

Timing of umbilical cord-clamping and infant anaemia: the role of maternal anaemia.

BACKGROUND: Evidence from randomized controlled trials has shown that delayed cord-clamping is beneficial to infant iron status. The role of maternal anaemia in this relationship, however, has not been established. OBJECTIVE: To determine the effect of maternal anaemia at delivery on the association between timing of umbilical cord-clamping and infant anaemia at 4 and 8 months of age. METHODS: A cohort of pregnant women admitted to the labour room of Hospital Iquitos (Iquitos, Peru) and their newborns were recruited into the study during two time periods (18 May to 3 June and 6-20 July 2009). Between the two recruitment periods, the hospital's policy changed from early to delayed umbilical cord-clamping. Maternal haemoglobin levels were measured before delivery, and the time between delivery and cord-clamping was recorded at delivery for the entire cohort. Mother-infant pairs were followed-up at 4 (n = 207) and 8 months (n = 184) post partum. Infant haemoglobin levels were measured at follow-up visits. Data were analysed using logistic regression models. RESULTS: The prevalence of maternal anaemia (Hb <11.0 g/dl) at delivery was 22%. Infant haemoglobin levels at 4 and 8 months of age were 10.4 g/dl and 10.3 g/dl, respectively. Infant haemoglobin levels did not differ significantly between infants born to anaemic mothers and those born to non-anaemic mothers at either 4 or 8 months of age. However, the association between the timing of cord-clamping and infant anaemia was modified by the mother's anaemia status. Significant benefits of delayed cord-clamping in preventing anaemia were found in infants born to anaemic mothers at both 4 months (aOR = 0.59, 95% CI 0.36-0.99) and 8 months (aOR = 0.38, 95% CI 0.19-0.76) of age. CONCLUSION: The study contributes additional evidence in support of delayed cord-clamping. This intervention is likely to have most public health impact in areas with a high prevalence of anaemia during pregnancy.

[How to feed children? Healthy eating behaviors starting at childhood]. / ¿Cómo alimentar a los niños? La práctica de conductas alimentarias saludables desde la infancia.

Interventions to prevent malnutrition or overweight in children focus on the diet, and give little attention to the behaviors of their caretakers. In their first two years of life, children adopt practices that are embedded in their environment and the behaviors of their caretakers, thus turning into nutrition patterns that will persist during their lifetimes. Therefore, children and caretakers establish a relationship in which they recognize, construe and respond to verbal and non verbal communication signs. Feeding a child by adopting a "responsive" behavior in which caretakers provide guidance and structure, and respond to children's signs of hunger and satiety promotes self-regulation and children's awareness of healthy nutrition. In this article, we give recommendations to include responsive nutrition and model healthy eating behaviors in nutritional interventions.

¿Cómo alimentar a los niños? La práctica de conductas alimentarias saludables desde la infancia / How to feed children? Healthy eating behaviors starting at childhood

Las intervenciones para prevenir la desnutrición o el exceso de peso en los niños se enfocan en la dieta, y dan poca atención a los comportamientos de las personas responsables de su cuidado. En sus primeros dos años los niños adoptan prácticas establecidas en su entorno y las conductas de sus cuidadores, los cuales constituyen patrones alimentarios que persistirán a lo largo de su vida. Así, los niños y sus cuidadores establecen una relación en que reconocen, interpretan y responden a las señales de comunicación verbal y no verbal. Alimentar al niño adoptando una conducta “responsiva” en la que los cuidadores proveen la dirección y estructura, y responden a los señales de hambre y saciedad de los niños, promueve la autorregulación y la responsabilidad de los niños para una alimentación sana. En este artículo, damos recomendaciones para incorporar la alimentación responsiva y modelar conductas alimentarias saludables en las intervenciones nutricionales.

Interventions to prevent malnutrition or overweight in children focus on the diet, and give little attention to the behaviors of their caretakers. In their first two years of life, children adopt practices that are embedded in their environment and the behaviors of their caretakers, thus turning into nutrition patterns that will persist during their lifetimes. Therefore, children and caretakers establish a relationship in which they recognize, construe and respond to verbal and non verbal communication signs. Feeding a child by adopting a “responsive” behavior in which caretakers provide guidance and structure, and respond to children’s signs of hunger and satiety promotes self-regulation and children’s awareness of healthy nutrition. In this article, we give recommendations to include responsive nutrition and model healthy eating behaviors in nutritional interventions.

Effect of a two-component intervention to change hospital practice from early to delayed umbilical cord clamping in the Peruvian Amazon.

OBJECTIVE: To investigate the effect of a two-component intervention to change hospital practice with regard to the timing of umbilical cord clamping. METHODS: A pre-/post-study design was used to measure the effect of a two-component intervention on mean time to clamp the umbilical cord. The study took place at Hospital Iquitos "César Garayar García" in Iquitos, Peru. A total of 224 women were recruited from the hospital labor room: 112 pre-intervention, from 18 May-3 June 2009, and 112 post-intervention, from 6-20 July 2009. The intervention consisted of 1) a "best practice" three-day training workshop on birthing, and 2) a hospital directive. All deliveries were observed and the time between delivery of the first shoulder and clamping of the umbilical cord was measured with a digital stopwatch. RESULTS: The mean time between delivery and cord clamping before the intervention was 56.8 seconds (95% confidence interval [CI]: 51.0, 62.7). This increased to 169.8 seconds (95% CI: 153.8, 185.8) following the intervention. The difference in mean time to clamp remained significant in multivariate analyses (ß adjusted = 113.2 seconds, 95% CI: 96.6, 129.9). CONCLUSIONS: Hospital policy and practice can be successfully changed from early to delayed umbilical cord clamping using a simple, two-component intervention.

Infant and young child feeding in the Peruvian Amazon: the need to promote exclusive breastfeeding and nutrient-dense traditional complementary foods.

The study objective was to understand the role of traditional Awajún foods in dietary quality and the potential impacts on growth of Awajún infants and young children 0-23 months of age. Research took place in April and May of 2004, along the Cenepa River in six Awajún communities. Anthropometry estimated nutritional status for 32 infants (0-23 months). Repeat dietary recalls and infant feeding histories were completed with 32 mothers. Adequacy of the complementary foods was compared with World Health Organization guidelines. Anthropometry indicated a high prevalence of stunting (39.4% of infants and young children), with nutritional status declining with age. Half of the Awajún mothers practised exclusive breastfeeding. Dietary recalls and infant food histories suggested that many of the infants were getting adequate nutrition from complementary foods and breastfeeding; however, there was variation in breastfeeding and complementary feeding practices among the mothers. Complementary feeding for young children 12-23 months generally met nutrient recommendations, but mean intakes for iron, zinc, calcium and vitamin A were inadequate in infants 6-11 months. Traditional foods provided 85% of energy and were more nutrient dense than market foods. Appropriate infant and complementary feeding was found among some women; however, given the range of feeding practices and introduction of market foods, health promotion targeting infant and young child feeding is warranted.

Effect of a two-component intervention to change hospital practice from early to delayed umbilical cord clamping in the Peruvian Amazon / Efecto de una intervención de dos componentes para modificar la práctica hospitalaria de pinzamiento del cordón umbilical de precoz a tardío en la Amazonia peruana

OBJECTIVE: To investigate the effect of a two-component intervention to change hospital practice with regard to the timing of umbilical cord clamping. METHODS: A pre-/post-study design was used to measure the effect of a two-component intervention on mean time to clamp the umbilical cord. The study took place at Hospital Iquitos "César Garayar García" in Iquitos, Peru. A total of 224 women were recruited from the hospital labor room: 112 pre-intervention, from 18 May-3 June 2009, and 112 post-intervention, from 6-20 July 2009. The intervention consisted of 1) a "best practice" three-day training workshop on birthing, and 2) a hospital directive. All deliveries were observed and the time between delivery of the first shoulder and clamping of the umbilical cord was measured with a digital stopwatch. RESULTS: The mean time between delivery and cord clamping before the intervention was 56.8 seconds (95 percent confidence interval [CI]: 51.0, 62.7). This increased to 169.8 seconds (95 percent CI: 153.8, 185.8) following the intervention. The difference in mean time to clamp remained significant in multivariate analyses (βadjusted = 113.2 seconds, 95 percent CI: 96.6, 129.9). CONCLUSIONS: Hospital policy and practice can be successfully changed from early to delayed umbilical cord clamping using a simple, two-component intervention.

OBJETIVO: Investigar el efecto de una intervención de dos componentes para modificar la práctica hospitalaria respecto del momento en que se practica el pinzamiento del cordón umbilical. MÉTODOS: Se empleó un estudio con diseño antes-después para medir el efecto de una intervención de dos componentes sobre el tiempo medio de pinzamiento del cordón umbilical. El estudio se llevó a cabo en el Hospital Iquitos "César Garayar Gar-cía" en Iquitos (Perú). Se incluyeron en total 224 mujeres atendidas en la sala de trabajo de parto del hospital: 112 antes de la intervención, entre el 18 de mayo y el 3 de junio del 2009, y 112 después de la intervención, entre el 6 y el 20 de julio del 2009. La intervención consistió en: 1) un taller de capacitación sobre las "mejores prácticas" en la atención del parto, de 3 días de duración y 2) una directiva del hospital. Se observaron todos los partos y se midió el tiempo entre la salida del hombro anterior y el pinzamiento del cordón umbilical con un cronómetro digital. RESULTADOS: El tiempo medio entre el parto y el pinzamiento del cordón antes de la intervención fue de 56,8 segundos (intervalo de confianza [IC] de 95 por cento: 51,0-62,7), y aumentó a 169,8 segundos (IC 95 por cento: 153,8-185,8) después de la intervención. La diferencia en el tiempo medio hasta el pinzamiento siguió siendo significativa en los análisis multivariados (βajustado = 113,2 segundos, IC 95 por cento: 96,6-129,9). CONCLUSIONES: Es posible cambiar las normas y las prácticas hospitalarias de pinzamiento del cordón umbilical de precoz a tardío mediante una intervención sencilla de dos componentes.

Responsive feeding and child undernutrition in low- and middle-income countries.

Growth faltering and nutritional deficiencies continue to be highly prevalent in infants and young children (IYC) living in low- and middle-income (LAMI) countries. There is increasing recognition that feeding behaviors and styles, particularly responsive feeding (RF), could influence acceptance of food and dietary intake and thus the growth of IYC. This paper presents the evolution of RF research and the strength of the evidence for RF on child undernutrition in LAMI countries. Multiple approaches were used to identify studies, including keyword searches in many databases, hand searches of retrieved articles, and consultation with experts in the field. Articles were included if they contained a RF exposure and child undernutrition outcome. In total, we identified 21 studies: 15 on child growth, 4 on dietary intake, 3 on disease, and 8 on eating behaviors. Most studies were conducted among children <36 mo of age and were published in the last 10 y. Cross-study comparisons were difficult due to multiple definitions of RF. One-half of the studies were observational with cross-sectional designs and few interventions were designed to isolate the effect of RF on child undernutrition. Overall, few studies have demonstrated a positive association between RF and child undernutrition, although there is promising evidence that positive caregiver verbalizations during feeding increase child acceptance of food. Recommendations for future research include consensus on the definition and measurement of RF, longitudinal studies that begin early in infancy, and randomized controlled trials that isolate the effect of RF on child undernutrition.

Formative research to shape HPV vaccine introduction strategies in Peru / Investigación formativa relacionada con el diseño de estrategias para introducir la vacuna contra el VPH en Perú

OBJECTIVE: To understand the sociocultural environment, health systems' capacities, and policy processes related to cervical cancer and HPV vaccines in order to inform HPV vaccine introduction. MATERIAL AND METHODS: Mixed-method formative research using qualitative and quantitative data collection techniques. Participants included girls, parents, community leaders, health and education officials, and policymakers. RESULTS: Respondents, including policymakers, generally supported HPV vaccine introduction, due partly to appreciation for the benefits of vaccination and the desire to prevent cancer. Community-level concerns regarding safety and quality of services will need to be addressed. The immunization system in Peru is strong and has capacity for including the HPV vaccine. CONCLUSION: Formative research provides key insights to help shape an effective program for HPV vaccine introduction.

OBJETIVO: Comprender el contexto sociocultural, las capacidades del sistema de salud y las condiciones políticas vinculadas al cáncer cervical y a la vacuna contra el VPH para diseñar una estrategia apropiada de introducción de la vacuna contra el VPH. MATERIAL Y MÉTODOS: Investigación formativa usando técnicas cualitativas y cuantitativas. Los participantes incluyeron niños, padres, líderes, funcionarios del sector salud y educación, y diseñadores de políticas. RESULTADOS: Generalmente se apoya la introducción de la vacuna contra el VPH, dado que se aprecian los beneficios de la vacunación y se desea prevenir el cáncer. En la comunidad se encontraron preocupaciones sobre seguridad, confianza y calidad de atención. El sistema de inmunizaciones en el Perú es eficiente y tiene la capacidad para incluir la vacuna contra el VPH. CONCLUSIONES: La investigación formativa permite comprender elementos clave que ayudan a diseñar un programa efectivo para la introducción de la vacuna contra el VPH.

Formative research to shape HPV vaccine introduction strategies in Peru.

OBJECTIVE: To understand the sociocultural environment, health systems' capacities, and policy processes related to cervical cancer and HPV vaccines in order to inform HPV vaccine introduction. MATERIAL AND METHODS: Mixed-method formative research using qualitative and quantitative data collection techniques. Participants included girls, parents, community leaders, health and education officials, and policymakers. RESULTS: Respondents, including policymakers, generally supported HPV vaccine introduction, due partly to appreciation for the benefits of vaccination and the desire to prevent cancer. Community-level concerns regarding safety and quality of services will need to be addressed. The immunization system in Peru is strong and has capacity for including the HPV vaccine. CONCLUSION: Formative research provides key insights to help shape an effective program for HPV vaccine introduction.

Determinants of human papillomavirus vaccine acceptability in Latin America and the Caribbean.

Prophylactic human papillomavirus (HPV) vaccines provide promise as a key component of future cervical cancer prevention programs in the Latin America and the Caribbean region. The successful introduction and acceptance of these vaccines will depend on a range of factors including awareness of cervical cancer as a problem, affordability of the vaccine, political will, competition with other vaccines, feasibility of vaccine delivery and acceptability of the vaccine among the range of groups who will influence uptake. While existing data about acceptability from Latin America and the Caribbean is scarce, it is clear that health policymakers, providers and the general public lack knowledge about HPV and cervical cancer. Furthermore, they would value more local epidemiologic data related to cervical cancer. Price is currently a major barrier to vaccine acceptability and a priority for advocacy. More research is required in Latin America and the Caribbean to determine what messages and strategies will work in these communities.

Implementation examined in a health center-delivered, educational intervention that improved infant growth in Trujillo, Peru: successes and challenges.

Process evaluation was used to examine the implementation of a randomized, controlled trial of an education intervention that improved infant growth in Trujillo, Peru. Health personnel delivered the multi-component intervention as part of usual care in the government health centers. Quantitative and qualitative methods were used to examine process indicators, which included the extent of delivery (dose), fidelity to intervention protocol, barriers to implementation and context. Results demonstrated that most intervention components were delivered at a level of 50-90% of expectations. Fidelity to intervention protocol, where measured, was lower (28-70% of expectations). However, when compared with existing nutrition education, as represented by the control centers, significant improvements were demonstrated. This included both improved delivery of existing educational activities as well as delivery of new intervention components to strengthen overall nutrition education. Barriers to, and facilitators of, implementation were explored with health personnel and helped to explain results. This study demonstrates the importance of examining actual versus planned implementation in order to improve our understanding of how interventions succeed. The information gained from this study will inform future evaluation designs, and lead to the development and implementation of more effective intervention programs for child health.

The cost-effectiveness of a child nutrition education programme in Peru.

This article reports impact and cost results from a health facility-based nutrition education programme targeting children less than 2 years of age in Trujillo, Peru. Key elements of the programme included participative complementary feeding demonstrations, growth monitoring sessions and an accreditation process. Data were collected from six intervention and six control health facilities to measure utilization and costs associated with the intervention. To calculate the unit costs of services, these costs are allocated using activity-based costing. To measure the effects of the intervention, 338 children were followed through household surveys at regular intervals from birth until the age of 18 months. The intervention had a clear positive impact both on the use of nutrition-related services and on children's growth outcomes. Children in the intervention areas made 17.6 visits to health facilities in the first 18 months of life, compared with 14.1 visits for children in the control areas (P < 0.001). This pattern holds true for all socioeconomic groups. The intervention prevented 11.1 cases of stunting per 100 children. In multivariate logistic regression analysis, children in the intervention were 0.33 times as likely to be stunted as the controls (P = 0.002). The marginal cost of the intervention - including external costs, training, health education materials and extra travel and equipment - is 6.12 US dollars per child reached and 55.16 US dollars per case of stunting prevented. The estimated marginal cost of the intervention per death averted is 1952 US dollars.