Out of sight out of mind: intercultural health technicians in the Peruvian Amazon

This dissertation assesses the complexity inherent in the use of the concept of interculturalidad to implement projects and policies for indigenous people. The research is based on a case study of a grassroots initiative in intercultural health promoted by AIDESEP, an organization that represents indigenous communities from the Peruvian Amazon. The findings demonstrate the limitations of the strategies of both the indigenous organizations and the state around intercultural health and the creativity that, despite these limitations, a group of indigenous nurse technicians use to provide intercultural health care. Interculturalidad does not have a single static meaning; rather, its meaning is specific to the context and actor using it. Two different meanings of interculturalidad are discussed in this dissertation, Critical and Functional interculturalidad. Critical interculturalidad is the one usually used by indigenous organizations which aim to effect changes to policy-making processes that have historically marginalized indigenous people and their knowledge. On the other hand, the state’s use of interculturalidad is often limited to a superficial acknowledgement of cultural difference without questioning root causes of discrimination against indigenous people during policy-making. This is known as Functional interculturalidad and, in contrast with Critical interculturalidad, does not aim to make radical changes in indigenous peoples’ social position. In this dissertation I show that beyond discussions about the meaning of interculturalidad, intercultural policies require flexibility from bureaucratic state structures, and openness for negotiation on behalf of indigenous organizations. Through the analysis of the approaches used by the Peruvian state and AIDESEP to provide intercultural health in Peru, this research shows that without structural changes in the state’s support and promotion of indigenous medicine, intercultural health will only produce superficial changes. Furthermore, this dissertation shows that without active political support from indigenous organizations, changes in healthcare delivery for indigenous people will remain limited. In the context of health services for indigenous communities in the Peruvian Amazon interculturalidad remains a well-intentioned idea, yet its implementation in health care by indigenous organizations and the state falls short of delivering the transformation it seeks to promote

Taking care of undocumented children: how parents and providers secure health care for uninsured latino children in a new growth community

This research explores the decision-making process of Latino parents when confronted with the health needs of their undocumented children in Allegheny and Washington Counties of the Commonwealth of Pennsylvania, a New Growth Community where Latinos represent fewer than 5% of the population. The research objectives were to: (1) describe the strategies deployed by parents, social workers and healthcare providers to secure health care for uninsured Latino children in a New Growth Community, (2) illustrate the complexity of addressing the health needs of Latino children whose legal status in the USA prevents them from accessing health care, (3) identify the most effective strategies to provide health care for uninsured Latino children from the variety of approaches currently used by parents, social workers and healthcare providers, and (4) propose possible measures to ensure the long-term sustainability of these strategies. During the summer of 2010, I conducted in-depth interviews with parents of undocumented children, social workers and healthcare providers serving Latinos. Testimonies indicated that health needs of undocumented Latino children in the study area are not addressed in a timely manner. This affected children’s health status and their participation in school and afterschool physical activities. Undocumented children in these counties do not have access to preventive health care and mostly rely on free or low-cost clinics, emergency room visits or the generosity of local doctors and providers. Lack of information about available services, fear of questions on immigration status, and concerns about medical expenses make healthcare decisions harder for parents. Parents and providers often depend on personal, professional and community networks to deal with urgent medical conditions and/or specialized care. Such strategies, by their very nature, are impermanent and unsustainable. Institutional healthcare options for undocumented uninsured children in this New Growth Community are few and not optimal. This research is of public health importance because it suggests that Latinos and organizations that work with Latinos need to develop advocacy strategies that will guarantee access to low-cost health insurance for all children regardless of their immigration status. Arguments should center in both financial and public health implications of having uninsured children in the county

Lessons learned about co-creation: developing a complex intervention in rural Peru.

Background: Co-creation is the process of involving stakeholders in the development of interventions. Although co-creation is becoming more widespread, reports of the process and lessons learned are scarce.Objective: To describe the process and lessons learned from using the COHESION manual, a co-creation methodology to develop interventions aimed at the improvement of diagnosis and/or management of chronic diseases at the primary healthcare level in a low-resource setting in Peru.Methods: Observational study to describe the use of the COHESION manual 'Moving from Research to Interventions: The COHESION Model' developed for a multi-country project in low- and middle-income countries for co-creation and the adaptations needed to customize it to the local context of rural communities in northern Peru.Results: The actual process of co-creation in Peru included co-creation-related questions in the formative research; an initial consultation with stakeholders at the micro, meso, and macro levels (e.g. community members, health workers, and policy-makers); the analysis of the collected data; a second consultation with each stakeholder group; the prioritization of intervention options; and finally the design of a theory of change for all activities included in the complex intervention. The complex intervention included: 1) offer training in specific diseases and soft skills to health workers, 2) create radio programs that promote chronic disease prevention and management plus empower patients to ask questions during their visits to primary health care (PHC) facilities, and 3) provide a small grant to the PHC for infrastructure improvement. Small adaptations to the COHESION manual were necessary for this co-creation process.Conclusion: This study provides a practical example of the process of co-creating complex interventions to increase access and quality of health care in a low-resource setting. The process, components, challenges and opportunities identified could be useful for other researchers who want to co-create interventions with beneficiaries in similar settings

Rethinking research processes to strengthen co-production in low and middle income countries.

Article - No abstract available

[Healthcare challenges for people with diabetes during the national state of emergency due to COVID-19 in Lima, Peru: primary healthcare recommendations].

Patients diagnosed with type 2 diabetes mellitus, who then become infected with SARS-CoV-2, are at greater risk of developing complications from COVID-19, which may even lead to death. Diabetes is a chronic condition that requires continuous contact with healthcare facilities; therefore, this type of patients should have regular access to medicines, tests and appointments with healthcare personnel. In Peru, care and treatment continuity have been affected since the national state of emergency due to COVID-19 began; because many healthcare facilities suspended outpatient consultations. The strategies presented in this study were developed by different Peruvian health providers in the pandemic context to ensure care continuity for people with diabetes. This article provides recommendations to strengthen primary healthcare, because it is the first level of healthcare contact for patients with diabetes

High-quality health systems: time for a revolution in research and research funding.

Comment - No abstract available

Moving from formative research to co-creation of interventions: insights from a community health system project in Mozambique, Nepal and Peru.

Different methodological approaches for implementation research in global health focusing on how interventions are developed, implemented and evaluated are needed. In this paper, we detail the approach developed and implemented in the COmmunity HEalth System InnovatiON (COHESION) Project, a global health project aimed at strengthening health systems in Mozambique, Nepal and Peru. This project developed innovative formative research at policy, health system and community levels to gain a comprehensive understanding of the barriers, enablers, needs and lessons for the management of chronic disease using non-communicable and neglected tropical diseases as tracer conditions. After formative research, COHESION adopted a co-creation approach in the planning of interventions. The approach included two interactions with each type of stakeholder at policy, health system and community level in each country which aimed to develop interventions to improve the delivery of care of the tracer conditions. Diverse tools and methods were used in order to prioritise interventions based on support, resources and impact. Additionally, a COHESION score that assessed feasibility, sustainability and scaling up was used to select three potential interventions. Next steps for the COHESION Project are to further detail and develop the interventions propositioned through this process. Besides providing some useful tools and methods, this work also highlights the challenges and lessons learned from such an approach

Towards sustainable partnerships in global health: the case of the CRONICAS Centre of Excellence in Chronic Diseases in Peru.

Human capital requires opportunities to develop and capacity to overcome challenges, together with an enabling environment that fosters critical and disruptive innovation. Exploring such features is necessary to establish the foundation of solid long-term partnerships. In this paper we describe the experience of the CRONICAS Centre of Excellence in Chronic Diseases, based at Universidad Peruana Cayetano Heredia in Lima, Peru, as a case study for fostering meaningful and sustainable partnerships for international collaborative research. The CRONICAS Centre of Excellence in Chronic Diseases was established in 2009 with the following Mission: "We support the development of young researchers and collaboration with national and international institutions. Our motivation is to improve population's health through high quality research." The Centre's identity is embedded in its core values - generosity, innovation, integrity, and quality- and its trajectory is a result of various interactions between multiple individuals, collaborators, teams, and institutions, which together with the challenges confronted, enables us to make an objective assessment of the partnership we would like to pursue, nurture and support. We do not intend to provide a single example of a successful partnership, but in contrast, to highlight what can be translated into opportunities to be faced by research groups based in low- and middle-income countries, and how these encounters can provide a strong platform for fruitful and sustainable partnerships. In defiant contexts, partnerships require to be nurtured and sustained. Acknowledging that all partnerships are not and should not be the same, we also need to learn from the evolution of such relationships, its key successes, hurdles and failures to contribute to the promotion of a culture of global solidarity where mutual goals, mutual gains, as well as mutual responsibilities are the norm. In so doing, we will all contribute to instil a new culture where expectations, roles and interactions among individuals and their teams are horizontal, the true nature of partnerships

Healthcare of Indigenous Amazonian Peoples in response to COVID-19: marginality, discrimination and revaluation of ancestral knowledge in Ucayali, Peru.

Editorial - No abstract available