AN INTRODUCTION TO HEALTH ISSUES IN PERU

Peru has been recognized for making strides to curb maternal and infant mortality, and increase life expectancy.  Peru’s economy has been growing at an impressive rate and generous funds have been allocated to improve health care delivery and organize interventions to address urgent issues at a local level.  Peru’s national Ministry of Health recognizes its critical role in increasing access to health care services and addressing the health issues plaguing children which prevent them from becoming productive adults.

The Ministry of Health has outlined a plan of action to address a range of health issues across several target populations, and has partnered with Peace Corps Peru to carry out critical interventions to ensure adequate development of children under three years of age and adolescents aged 12-17.  Nationally, one in five Peruvian children suffer from malnutrition, caused by poor nutrition and loss of nutrients resulting from frequent diarrheal diseases and parasite infections. 

In addition, the Ministry of Health has partnered with Peace Corps Peru to direct programs that ensure adequate preparation of adolescents to become productive members of their communities.  Adolescents are generally lacking in reproductive health education and prevention of unwanted pregnancy, HIV and sexually transmitted infections.  The teen pregnancy rate nationally hovers around 13% (for girls aged 15-19) but is slowly creeping upwards.  Locally, in the Piura region, statistics from 2012 show the rate has shot above 16%, a dramatic increase from 9% in 2000.

Please continue reading below to find more about health issues impacting small children.
Please click here to read more about health issues impacting adolescents.

COMMUNITY DIAGNOSTIC

My first task in my community of El Tallan, Piura was to undertake a community diagnostic to determine the health needs of the target populations.  The diagnostic included a survey of homes with children under 3 years of age, a SWOT analysis with adolescents, and interviews with key community leaders, including representatives from local food banks and mother’s groups.  The results from these efforts were meshed with health statistics reported by the district office of the department of health to create a Community Diagnostic Report, on which I based recommendations for public health improvement interventions. 

I presented the findings from the Community Diagnostic Report in a public forum which was attended by representatives from the local municipal government, academic leaders, health center staff and concerned citizens.  After reviewing the findings, I facilitated a discussion with attendees who prioritized each issue to address with a public health program.  Once we had collectively identified the priorities, I formed a committee of local leaders and we worked tirelessly to design and implement programs that suited the community’s needs and desire for change.

I worked closely with the local health center to identify 300 families in the community with children under three years of age, and we trained 8 volunteer health promoters to administer a household survey.  The survey was based on one developed by Peace Corps Peru, in coordination with Peru’s Ministry of Health.   We reviewed the questions as group and altered them to be culturally appropriate for the community, changing the wording as needed and omitting irrelevant questions.  We retained questions pertaining to sanitation, hygiene, prevention and identification of diarrhea and respiratory illnesses, food preparation, nutrition, as well as early childhood growth and development, as these are areas identified by the local health center as relevant to the community.

We marched from house to house under the blazing 100-plus degree summer sun in February 2013 and managed to complete surveys on 135 families in four main neighborhoods of the district of El Tallan before the enthusiasm of the volunteer health promoters finally surrendered to the heat and demands of their families.

The results of the survey showed that the main issue affecting people of all ages across the entire district is respiratory illness.  Not surprising, given the high percentage of people who cook over an open fire inside their homes, exposing themselves and their families to toxic smoke.  The main issues impacting the health of small children are diarrheal diseases and malnutrition. (Please click here to read the Community Diagnostic report in Spanish).

The health post has already been conducting some minimal outreach in the community to address issues of diarrhea and malnutrition but the level of success was not documented.  Truthfully, there is no way to know to what degree the outreach efforts have impacted the health of the community because no monitoring of activities or evaluation of programs had ever been conducted.  In this part of Peru, it is not customary to set goals or measure progress or evaluate results.  The traditional definition of success is too often that an educational session occurred and people attended.  Period.  There is rarely any coordinated follow-up to determine whether the participants changed behavior as a result of the intervention, and never any before/after assessments to determine the impact of the intervention on prevalence of an illness or condition.

For example, the health center has effectively become a broken record with respect to hosting educational sessions to review the steps to wash hands correctly and encouraging mothers to do so in key moments, such as prior to preparing meals for their children.  The mothers proudly demonstrate the steps accurately and can recite the key moments, but the health workers are often dismayed to discover that the mothers do not practice this at home.  Instead of wondering what they could do differently to help mothers change their habits or inquire about which barriers they may be facing, the health workers assume that the information provided to mothers is sufficient for influencing their behavior. They continue leading the same hand washing educational sessions and are repeatedly frustrated by the lack of positive results.

Please continue reading to find out how we tackled these issues with the Healthy Homes project.

HEALTHY HOMES: Project Overview

The good news is that the main causes of morbidity among children in the rural agricultural community of El Tallan, Peru -- respiratory illnesses, diarrhea and malnutrition -- are preventable.

The dual issues of diarrhea illness and malnutrition are inextricably linked together through a pattern of contracting a bacterium, parasite or other insidious microbe and losing essential nutrients during the body’s process of expelling the invading critter.  When diarrhea occurs frequently, a child’s growth and development can be permanently effected, and it can become more difficult for the child to recover after each episode. 

A telltale sign that a person has experienced malnutrition (through diarrhea illness or by other causes) is by examining the person's height.  A healthy child should grow at least 12 centimeters in their first year of life and an additional 24 centimeters in their second.  This period of growth, during the first two years of life, is essential for proper physical and mental development.  If a child does not reach 80 centimeters by their 3^rd birthday, the child is considered to be stunted and there is a good chance that the child will suffer from permanent cognitive issues and chronic health problems. 

One potential sign of the impact that malnutrition has had in my community reflected in the dramatic differences in height.  At 5’3” (160cm) tall, I am considered to be a relatively short person in the United States.  However, in Peru I was one of the tallest people in my community, towering nearly a foot over other women my age.

Another less dramatic (but heart-wrenching) sign of the likely impact of malnutrition on brain development in my community was the difficulty many children and adults had while reading during my library book project.

(Photo of Alonso and Jose loving to read. Jose is 9 years old in this photo, and he could not read more than a handful of words when I launched the library book project.  
Together we read the Where the Wild Things Are until he had memorized it).

By talking with health center staff, community leaders, health promoters and mothers of young children, I understood that many mothers knew what they should do to prevent illnesses but failed to take preventative action in the home.  This indicated to me that many mothers were most likely in the Contemplation or Preparation phases of change and ripe for a public health intervention.

The families with small children at risk for preventable illness and malnutrition needed a structured program that would be comprised of the following components:

1.      allow health center staff to verify the participants’ knowledge of target attitudes and behaviors;

2.      document the application of knowledge and adoption of new behaviors in the home; and 

3.      provide incentives for change.

Clearly there was a need for an aggressive and complex intervention that would require training the health center staff and volunteer health promoters to utilize new tools for planning, organization and execution of the project, including tracking and measurement of specific goal-based outcomes.  This required ongoing planning, communication and training throughout the project to raise the comfort level with the new tools and subsequent adoption, with goal of sustainable use of the tools on a long-term basis.

I worked with health center staff, volunteer health promoters and the multi-sectoral health community to design and implement a Healthy Homes project that include the following elements:

1.      once-monthly educational sessions for participants;

2.      house visits after each educational session; and 

3.      construction of an improved cook stove for each family that had satisfied the requirements of the program.

The educational sessions addressed the target behaviors (listed below) and revolved around the main health issues impacting children under three years of age, a critical period for brain and physical development.  The educational sessions covered the treatment and prevention of diarrheal illness and respiratory infections, nutrition (including exclusive breastfeeding and complimentary feeding practices), tracking growth milestones, and stimulating early childhood development.  

I used a session planning tool to guide the presenters through the process of developing a presentation for each educational session.  It was critical for my local counterparts to be equally involved in developing the presentations so that they would feel comfortable replicating the presentations in the future when I would no longer be present in the community. 

Each educational session had learning objectives and key facts for the participants to memorize, such as the warning signs of pneumonia or ways to prevent infections.  I created handouts for each session that listed the key facts using words and pictures so that mothers who cannot read would be able to use the handout as a memory trigger, and health promoters could refer to the handout during the house visit to stimulate recall.

For the house visits, I adopted the learning objectives from our session plans to create monitoring forms to be used during house visits after each educational session for the purpose of documenting the knowledge gained during the session and observing whether requested changes were made in the home.  One form was intended to be completed for each house visit that covered the topic presented at the previous educational session.

Eight volunteer health promoters agreed to co-present the educational sessions and conduct house visits, which gave them ample opportunities to gain presentation skills and confidence using the monitoring tools, contributing to the sustainability of the program. 

Thirty participants were selected by the health center staff based on the following criteria:

·        Families have children under three years of age

·        Children are at risk of malnutrition and have documented cases of preventable illnesses during the previous year

·        Families reside in the main neighborhood of Sinchao Grande

Participants were invited to attend an introductory meeting during which the benefits and requirements of the program were explained.  If a mother expressed interest in participating, she was asked to sign a contract stating that she would attend the four educational sessions and allow a health promoter to conduct a house visit after each session.  At the end of the project, if all of the requirements were satisfied by any of the participating families, an improved cook stove would be constructed in the family’s home.

DESIRED BEHAVIOR CHANGES

We identified 25 behaviors (knowledge, attitudes and practices) to target for change and associated them with the following indicators:

Knowledge, Attitude or Practice	Indicator
1.      Mother knows how to treat a child with diarrhea illness	Mother can describe how to prepare oral rehydration solution, Mother brings child to health center for treatment
2.      Mother knows how to prevent diarrhea	Mother can name at least two ways to prevent diarrhea
3.      Mother makes improvements in the home directly related to the prevention of diarrhea illness	Mother mentions adopting at least two new practices to maintain a healthy home
4.      Mother can identify a parasite infection in her child	Mother can name at least two signs of a parasite infection
5.      Mother brings her child to health center for parasite testing (and treatment, if necessary)	Child tests negative for parasite infections in past 3 months
6.      Mother recognizes the signs of diarrhea illness	Mother reports that the child has not had diarrhea in the past three months
7.      Mother knows the key moments to wash hands	Mother can name at least 3 key moments to wash hands
8.      Mother knows how to correctly wash hands	Mother can demonstrate correctly how to wash hands
9.      Mother washes hands regularly	Mother reports hand washing the previous day
10.   Mother prepares treated water for drinking	Mother reports preparing and drinking treated water
11.   Treated water is available in the home	Clean and covered receptacles for treated water exist in the home
12.   A dedicated area for hand washing is maintained in the home	A dedicated area for hand washing exists in the home with a receptacle to hold water and soap
13.   Child is fed breast milk exclusively until at least 6 months of age	Mother reports exclusively breastfeeding until at least 6 months of age
14.   Mother is aware of which locally produced foods are high in protein	Mother can name foods high in protein
15.   Mother provides child with protein-rich foods	Child received foods containing protein on the previous day
16.   Mother provides food to child with adequate frequency	Mother reports that child was served food at least three times the previous day
17.   Mother understands that exposure to smoke can cause respiratory infections	Mother names exposure to smoke as a cause of respiratory infections
18.   Mother can identify pneumonia illness	Mother can name at least two symptoms of pneumonia
19.   Mother utilizes resources to prevent respiratory infection	Mother uses an improved cook stove every day (which funnels smoke outside the home through a chimney)
20.   Mother is aware of activities and exercises that she can use to stimulate early childhood development	Mother attended an educational session covering early childhood development and demonstrated knowledge
21.   Child participates in activities to promote early childhood development	Mother conducts activities to stimulate intellectual and physical development of child
22.   Mother notes the mental and physical development of her child	Mother can name three changes in the development of her child
23.   Mother possesses knowledge of practices related to the prevention and treatment of diarrheal illness	Mother attended an educational session that covers prevention and treatment of diarrhea illnesses and demonstrated knowledge
24.   Mother possesses knowledge of practices related to the improvement of child nutrition, including exclusive breastfeeding and complimentary feeding	Mother attended an educational session that covers nutrition, including exclusive breastfeeding and complimentary feeding and demonstrated knowledge
25.   Mother possesses knowledge of practices related to the identification of respiratory illnesses	Mother attended an educational session that covers identification and prevention of respiratory infections and demonstrated knowledge

When considering developing a program to encourage participants to adopt specific behaviors, it is important to consider the influencers of behavior and determinants or barriers to change.  It should be noted that the culture of this northern, coastal Peruvian community dictated that the mother of the family is fully responsible for the care and raising of small children and often the most active caretaker in the home.  Thus, the target for the intervention were the mothers of each participating family.

Determinants or barriers to change have an impact on whether a person will adopt a new behavior.  For each of the desired behaviors, there can be a variety of barriers limiting the willingness to adopt a new practice which should be noted and addressed throughout a public health program.  The strongest barriers to change noted among the community of mothers with children under three years of age were the following:

For behaviors related to treatment and prevention of diarrheal illness, the most common barriers to change were

·        Perceived Social Norms – belief that the new behavior, such as hand washing, is not a common practice in among peers in the community

·        Perceived Action Efficacy – belief that the new behavior, such as boiling drinking water or washing hands, will not solve the problem

·        Perceived Severity – belief that the risk for infection by microbes that cause diarrhea does not warrant changes in behavior

·        Cues for Action – reminders are not present in the home that trigger behavior, such as washing hands before preparing meals

For behaviors related to identification and treatment of respiratory infections, the most common barriers to change were

·        Perceived Self-efficacy/Skills – belief that the person will not be capable of accurately identifying the signs and symptoms of respiratory infection or pneumonia

·        Perceived Negative Consequences – belief that taking action to prevent respiratory infections will result in a loss of income if the mother stops cooking moonshine over an open fire inside the home

For behaviors related to nutrition, the most common barriers to change were

·        Access – some families lack access to sources of protein

·        Perceived Negative Consequences – belief that the financial benefit to the family is greater if the sources of protein cultivated by the family are sold for profit instead of consumed

·        Perceived Action Efficacy – belief that the quantity of food is more important than the quality, that eating a balanced diet is not important if the child is at an adequate weight

For behaviors related to tracking growth milestones and stimulating early childhood development, the most common barriers to change were

·        Perceived Social Norms – perception that peers within the community do not engage their children in activities that stimulate development and mother feels socially awkward engaging child in these activities

·        Perceived Action Efficacy – belief that actions taken now to stimulate development will not have any impact on the future achievements of the child

·        Cues for Action - reminders are not present in the home that trigger the parent to conduct activities with child or notice changes in development of child

·        Perceived Self-efficacy/Skills – belief that mother is not capable of conducting activities adequately

The example below shows an analysis one of the barriers to change experienced by the mothers of small children with regard to washing hands regularly (#9 from the list of target behaviors) and the potential strategies to help program participants overcome the barriers:

Determinant/Barrier	Description	Results of Analysis	Strategies/Activities
Perceived Self-efficacy/Skills	An individual's belief that he or she can do a particular behavior given their current knowledge and skills; the set of knowledge, skills or abilities necessary to perform a particular behavior.	Mothers will proudly recount the steps to wash hands and know the key moments to do so.  They will demonstrate if requested.  Most mothers have attended multiple educational sessions on hand washing presented by the health post, or the topic was covered during house visits. Not lacking information.	Review the correct steps and key moments
Perceived Social Norms	Perception that people important to an individual think that s/he should do the behavior; norms have two parts: who matters most to the person on a particular issue, and what s/he perceives those people think s/he should do.	Mothers understand that they are expected to wash their hands, but know that others are not doing it regularly.  It is not a regular social custom and there is no social stigma against failure to wash hands in the key moments.	Provide group-based trainings where mothers wash hands together and speak publicly about it. Highlight one mother who can serve as a role model to others. Host competitions to practice new behaviors. Use a chart or graphic to highlight progress that can be observed by all.
Perceived Positive or Negative Consequences	What a person thinks will happen, either positive or negative, as a result of performing a behavior. This includes advantages (benefits)/disadvantages of the behavior, and attitudes about the behavior.	Positive: clean hands Negative: waste water, waste soap that could be used to wash dishes or clothes, wet floor, need to use a pitcher or other device for running water (as water from tap is available for few hours each day), awkward to pour water on your own hands to rinse	Remind mothers that washing hands can prevent illnesses and it is worth it to take the time and use resources to do it.
Perceived Action Efficacy	Whether or not the person thinks the action will be effective in overcoming a problem or accomplishing something that the person wants	Mothers do not recognize the connection between washing hands and killing germs that cause illness.	Explain with graphic detail the connection between hand washing and preventing illness.
Access	The degree of availability of the needed products or services required to adopt a given behavior. This also includes an audience's comfort in accessing desired types of products or using a service.	All homes have soap, which is typically for washing clothes or dishes.  Running water is available for a few hours per day. Mothers have buckets and pitchers to use for hand washing.	Resources are available, need to be utilized for hand washing.
Perceived Barriers	What makes it more difficult to perform a given behavior.	Not having a device that holds water and can release small amounts as needed to wash hands, not having it conveniently located, having limited hours of running water	Provide bucket with tap or Tipi Tapa, make sure it is located in a convenient location
Perceived Enablers	What makes it easier to perform a given behavior.	Newly constructed homes through a government program are installing plumbing in homes that connects to the treated water and wastewater. Residents of older homes need a bucket with tap or a pitcher (or a Tipi Tapa) to get running water.	Provide bucket with tap or Tipi Tapa or encourage moms to use buckets and pitchers that currently exist in the home
Cues for Action / Reminders:	The presence of reminders which help a person to remember to do a particular behavior or remember the steps involved in doing the behavior. This also includes key powerful events that triggered a behavior change in a person	The key moments to wash hands are often emphasized during educational sessions.	During house visits, mothers are asked to demonstrate hand washing and show their hand washing station, which serves as a reminder. Require that all participants wash hands before serving refreshments at meetings.
Perceived Susceptibility/Risk	A person's perception of how vulnerable they feel. For example, do they feel that it’s possible that their crops could have cassava wilt? Is it possible for them to become HIV+?	Regarding diarrhea, adults often have diarrhea and, while it is uncomfortable, they do not perceive it to be a problem for themselves or for their children. It is perceived as a normal inconvenience.	Teach mothers what constitutes a normal bowel movement.
Perceived Severity:	Belief that the problem (which the behavior can prevent) is serious.	Diarrhea illnesses are not perceived as being serious.	Teach mothers that diarrhea is dangerous and potentially fatal to children, the impact on development (height and weight) and the long-term effects.
Perception of Divine Will	A person’s belief that it is God’s will (or the gods’ will) for her/him to have the problem; and /or to overcome it.	Members of the community practice either Catholic or Evangelical religion, however few mention religious beliefs as a barrier.	Not an issue to be addressed in this project.
Policy	Laws and regulations that affect behaviors and access to products and services.	Treated running water is provided to the community at very low cost.  Most homes have running water available a few hours every day.	Not an issue to be addressed in this project.
Culture	The set of history, customs, lifestyles, values and practices within a self-defined group.	Mothers are the guardians of maintaining the home and raising the children, and they take this responsibility very seriously and take pride in their homes	Capitalize upon the pride shown by participants to inspire them to make changes.

Combining the collective inputs listed above provided a basis for structuring the educational sessions and related activities.  Please continue reading to find out more about the Healthy Homes project activities, such as the educational sessions and cook stove construction.

Alternatively, you are welcome to jump straight to the challenges and the results.