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Peruvian children's sub-optimal results on international and national assessments underscore the need for enhanced investments in early childhood development (ECD) such as shared reading between caregivers and young children. We conducted a qualitative study with 13 mothers of young children ages 11-25 months old that: used focus groups to explore caregivers' perspectives and experiences related to their daily activities, including reading and other ECD activities, with their young children; and used focus groups and video recordings to describe caregivers' experiences reading with these children during an at-home opportunity for shared reading. The mothers described daily schedules that focused on taking care of their daily chores and making sure that their young children were busy as they carried out those tasks. The mothers reported that they did not designate dedicated time to spend with their children, and children were often without adult attention for lengthy periods of time. We found that after the 1-month at-home opportunity for shared reading, there was a definite positive shift in both mothers' engagement with their children and their perspectives on reading. The caregivers improved their daily interactions with their children and observed important changes in their children thanks to reading. This study is encouraging and justifies a follow up randomized controlled trial to implement and evaluate the LIBRE shared reading program in Lima, Peru.

Despite cervical cancer being one of the leading causes of cancer-related deaths among women in Peru, cervical Pap smear coverage is low. This article uses findings from 185 direct clinician observations in four cities of Peru (representing the capital and each of the three main geographic regions of the country) to assess missed opportunities for health education on Pap smears and other preventive women's health behaviors during women's visits to a health care provider. Various types of health establishments, provider settings, and provider types were observed. Opportunities for patient education on the importance of prevention were rarely exploited. In fact, health education provided was minimal. Policy and programmatic implications are discussed. (Contains 3 tables.)

This study explores the lives of Peruvian adolescents in a low-income human settlement outside of Lima. Twenty 12-17 year olds were asked to narrate their own life stories using the life history narrative research method. Holistic content analysis was coupled with a grounded-theory approach to explore these data. Intergenerational responsibility, family tensions, economic pressures, racism and violence emerged without prompting and dominated the narrators' life stories, underscoring the degree to which these adolescents lack access to the supportive individuals and structures that are key to positive adolescent development. The challenges faced by these and the other 5.8 million 10-19 year olds in Peru require increased attention to the role of families, peers and communities in ensuring that adolescents are able to maintain their well-being and achieve their future expectations. (Contains 4 figures.)

Background: The ARMADILLO Study determined whether adolescents able to access SRH information on-demand via SMS were better able to reject contraception-related myths and misconceptions as compared with adolescents receiving pushed SMS or no intervention. Trial design: This trial was an unblinded, three-arm, parallel-group, individual RCT with a 1:1:1 allocation. Trial registration: ISRCTN85156148. Methods: This study was conducted in Lima, Peru among participants ages 13–17 years. Eligible participants were randomized into one of three arms: Arm 1: access to ARMADILLO's SMS information on-demand; Arm 2 access to ARMADILLO SMS information pushed to their phone; Arm 3 control (no SMS). The intervention period lasted seven weeks. At baseline, endline, and follow-up (eight weeks following endline), participants were assessed on a variety of contraception-related myths and misconceptions. An index of myths-believed was generated. The primary outcome assessed the subject-specific change in the mean score between baseline and endline. Knowledge retention from endline to follow-up was also assessed, as was a 'content exposure' outcome, which assessed change in participants' knowledge based on relevant SMS received. Results: In total, 712 participants were randomized to the three arms: 659 completed an endline assessment and were included in the primary analysis. Arm 2 participants believed fewer myths at endline compared with control arm participants (estimated subject-specific mean difference of -3.69% [-6.17%, -1.21%], p = 0.004). There was no significant difference between participants in Arm 1 vs. the control Arm, or between participants in Arm 1 vs. Arm 2. A further decrease in myths believed between endline and follow-up (knowledge retention) was observed in all arms; however, there was no difference between arms. The content exposure analysis saw significant reductions in myths believed for Arm 1 (estimated subject-specific mean difference of -9.47% [-14.83%, -4.11%], p =.001) and Arm 2 (-5.93% [-8.57%, -3.29%], p <.001) as compared with the control arm; however Arm 1's reduced sample size (n = 28) is a severe limitation. Discussion: The ARMADILLO SMS content has a significant (but small) effect on participants' contraception-related knowledge. Standalone, adolescent SRH digital health interventions may affect only modest change. Instead, digital is probably best used a complementary channel to expand the reach of existing validated SRH information and service programs. [ABSTRACT FROM AUTHOR]

Background: Adolescents may forego needed sexual and reproductive health (SRH) services due to a variety of concerns and barriers. The purpose of this study is to compare adolescents' perceptions of these barriers by participant characteristics including race/ethnicity, gender, sexual orientation, housing situation, and sexual experience.Methods: Adolescents in a California-wide sexual health education program completed an anonymous survey at baseline (N = 10,015) about perceived barriers to using SRH services. Logistic regression analyses that accounted for the clustered data structure assessed differences by gender, age, sexual orientation, race/ethnicity, living situation, and sexual experience.Results: The majority of participants were Hispanic/Latino (76.4%) with an average age of 14.9 years, and 28.8% had sexual experience. Half of the youth reported concerns about test results (52.7%), cost of services (52.0%), and confidentiality of services (49.8%). When controlling for other characteristics, youth identifying as transgender/non-binary/multiple genders had the highest odds of perceiving cost (odds ratio (OR) 1.89) and confidentiality (OR 1.51) as barriers. Increasing age was associated with decreasing odds of all barriers. Sexual orientation was a consistent predictor, with LGBQ+ youth having higher odds of perceiving test results (OR 1.21), cost (OR 1.36), and confidentiality (OR 1.24) as barriers. Asian or Pacific Islander/Native Hawaiian youth had higher odds of perceiving test results (OR 1.68) and cost (OR 1.37) as barriers. In contrast, Black youth had lower odds of reporting cost (OR 0.65) and confidentiality (OR 0.77) as barriers. Younger respondents and youth who identified as female, transgender/non-binary/multiple genders, LGBQ+, and Asian or Pacific Islander/Native Hawaiian had higher odds of reporting five or more barriers compared to reference groups.Conclusions: The majority of adolescents face barriers to accessing appropriate SRH services, with females, gender-minority youth, younger adolescents, LGBQ+ youth, and Asian and Pacific Islander/Native Hawaiian youth more likely than others to report barriers. Access to SRH services can be improved through strengthening linkages between clinics and SRH education programs, providing youth-friendly clinical services, and ensuring youth have sufficient information, skills, and support to access care.Trial Registration: Approved by California Health and Human Services Agency's Committee for the Protection of Human Subjects [12-08-0658, 11/30/2017]. [ABSTRACT FROM AUTHOR]

Abstract Background The recent avian influenza epidemic in Asia and the H1N1 pandemic demonstrated that influenza A viruses pose a threat to global public health. The animal origins of the viruses confirmed the potential for interspecies transmission. Swine are hypothesized to be prime "mixing vessels" due to the dual receptivity of their trachea to human and avian strains. Additionally, avian and human influenza viruses have previously been isolated in swine. Therefore, understanding interspecies contact on smallholder swine farms and its potential role in the transmission of pathogens such as influenza virus is very important. Methods This qualitative study aimed to determine swine-associated interspecies contacts in two coastal areas of Peru. Direct observations were conducted at both small-scale confined and low-investment swine farms (n = 36) and in open areas where swine freely range during the day (n = 4). Interviews were also conducted with key stakeholders in swine farming. Results In both locations, the intermingling of swine and domestic birds was common. An unexpected contact with avian species was that swine were fed poultry mortality in 6/20 of the farms in Chancay. Human-swine contacts were common, with a higher frequency on the confined farms. Mixed farming of swine with chickens or ducks was observed in 36% of all farms. Human-avian interactions were less frequent overall. Use of adequate biosecurity and hygiene practices by farmers was suboptimal at both locations. Conclusions Close human-animal interaction, frequent interspecies contacts and suboptimal biosecurity and hygiene practices pose significant risks of interspecies influenza virus transmission. Farmers in small-scale swine production systems constitute a high-risk population and need to be recognized as key in preventing interspecies pathogen transfer. A two-pronged prevention approach, which offers educational activities for swine farmers about sound hygiene and biosecurity practices and guidelines and education for poultry farmers about alternative approaches for processing poultry mortality, is recommended. Virological and serological surveillance for influenza viruses will also be critical for these human and animal populations.

Abstract Background There is evidence that female gender is associated with reduced likelihood of tuberculosis diagnosis and successful treatment. This study aimed to characterize gender-related barriers to tuberculosis control in Peruvian shantytowns. Methods We investigated attitudes and experiences relating gender to tuberculosis using the grounded theory approach to describe beliefs amongst key tuberculosis control stakeholders. These issues were explored in 22 semi-structured interviews and in four focus group discussions with 26 tuberculosis patients and 17 healthcare workers. Results We found that the tuberculosis program was perceived not to be gender discriminatory and provided equal tuberculosis diagnostic and treatment care to men and women. This contrasted with stereotypical gender roles in the broader community context and a commonly expressed belief amongst patients and healthcare workers that female health inherently has a lower priority than male health. This belief was principally associated with men's predominant role in the household economy and limited employment for women in this setting. Women were also generally reported to experience the adverse psychosocial and economic consequences of tuberculosis diagnosis more than men. Conclusions There was a common perception that women's tuberculosis care was of secondary importance to that of men. This reflected societal gender values and occurred despite apparent gender equality in care provision. The greatest opportunities for improving women's access to tuberculosis care appear to be in improving social, political and economic structures, more than tuberculosis program modification.

Abstract Background Peru has a concentrated HIV epidemic with an estimated 76,000 people living with HIV (PLHIV). Access to highly active antiretroviral therapy (HAART) expanded between 2004-2006 and the Peruvian National Institute of Health was named by the Ministry of Health as the institution responsible for carrying out testing to monitor the effectiveness of HAART. However, a national public health laboratory information system did not exist. We describe the design and implementation of an e-health driven, web-based laboratory information system - NETLAB - to communicate laboratory results for monitoring HAART to laboratory personnel, health providers and PLHIV. Methods We carried out a needs assessment of the existing public health laboratory system, which included the generation and subsequent review of flowcharts of laboratory testing processes to generate better, more efficient streamlined processes, improving them and eliminating duplications. Next, we designed NETLAB as a modular system, integrating key security functions. The system was implemented and evaluated. Results The three main components of the NETLAB system, registration, reporting and education, began operating in early 2007. The number of PLHIV with recorded CD4 counts and viral loads increased by 1.5 times, to reach 18,907. Publication of test results with NETLAB took an average of 1 day, compared to a pre-NETLAB average of 60 days. NETLAB reached 2,037 users, including 944 PLHIV and 1,093 health providers, during its first year and a half. The percentage of overall PLHIV and health providers who were aware of NETLAB and had a NETLAB password has also increased substantially. Conclusion NETLAB is an effective laboratory management tool since it is directly integrated into the national laboratory system and streamlined existing processes at the local, regional and national levels. The system also represents the best possible source of timely laboratory information for health providers and PLHIV, allowing patients to access their own results and other helpful information about their health, extending the scope of HIV treatment beyond the health facility and providing a model for other countries to follow. The NETLAB system now includes 100 diseases of public health importance for which the Peruvian National Institute of Health and the network of public health laboratories provide testing and results.

Mother-to-child transmission of HIV (MTCT) accounts for a significant proportion of new HIV infections in Peru. The purpose of this case-control study was to examine maternal and infant factors associated with MTCT in Peru from 2015 to 2016. For each biologically confirmed case infant, we randomly selected four birth year- and birth hospital-matched controls from five hospitals in Lima-Callao. Maternal and infant information were gathered from medical records. Simple conditional logistic regression was utilized to examine possible maternal and infant characteristics associated with MTCT. The rate of MTCT was 6.9% in 2015 and 2.7% in 2016. A total of 63 matched controls were identified for 18 cases. Protective factors included higher number of prenatal visits (odds ratio [OR]: 0.72; 95% confidence interval [CI]: 0.55-0.94, p = 0.012) and having more children (OR: 0.10, 95% CI: 0.01-0.79, p = 0.029). Risk factors included later maternal diagnosis (OR: 1.19; 95% CI: 1.06-1.34; p = 0.001) and greater viral load at the time of maternal diagnosis (OR: 1.05; 95% CI: 1.01-1.10; p = 0.022). Our study highlights the importance of targeting early and continued prenatal care as specific areas to target to prevent gaps in the HIV treatment cascade for pregnant HIV-infected women. These strategies can ensure early screening and initiation of antiretroviral therapy to reduce MTCT rates. [ABSTRACT FROM AUTHOR]

HIV disproportionately affects men who have sex with men and transwomen in Latin America. Globally, efforts to map, enumerate, and describe male and transwomen sex workers (MTSWs) are limited. We mapped and described venue- and non-venue–based MTSWs and enumerated venuebased MTSWs in Lima, Peru's capital. With venue-based MTSWs, we identified and described the venues, SWs, and clients and enumerated the SWs. With non-venue–based MTSWs, we described SW offerings and SWs. Male SWs (MSWs) are concentrated downtown, with many moving online. Transwomen SWs (TSWs) are spread across metropolitan Lima, with fewer online. At venues, there are more TSWs than MSWs, TSWs reported more HIV and sexual risk behaviors, and MSWs had more female partners. Non-venue–based MSWs used condoms less than venue-based MSWs. Results support systematic efforts to describe hard-to-reach MTSWs and their different types of partners, all of whom have unique, differing needs for HIV/ STI education, prevention, testing, and care services. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Although the worldwide incidence of tuberculosis (TB) is slowly decreasing, annual infection rates in Peru remain among the highest in the Americas. Pharmacies could play an important role in facilitating early detection of TB. However, the awareness, expertise and cooperation of pharmacy workers is fundamental. This study explored the TB-related knowledge, attitudes and practices of pharmacy workers in a district with one of the highest incidences of TB in Peru. Methods: This cross-sectional study applied a questionnaire that was administered face to face using smartphones with one pharmacy worker at each of 45 randomly selected pharmacies in the El Agustino district of Lima, Peru. Results: Participants were primarily female (78%) and had an average age of 31.3 years old (range 18–57 years old). Only 11% of participants were pharmacists with complete university training. The pharmacy workers’ knowledge was adequate; however, workers had important knowledge gaps and myths regarding prevention of TB transmission. Most pharmacy workers (77%) reported they would send a client with a history of cough for more than two weeks to a healthcare center, while 23% reported they would offer them antitussive medication or antibiotics. Almost all workers reported talking with clients about diseases and reported respiratory symptoms as one of the most common causes for consultation (60%). Most participants expressed interest in learning more about TB and expanding their involvement in the fight against TB in their community. Conclusion: Pharmacy workers have adequate knowledge about TB. However, we identified gaps in knowledge with respect to prevention of TB transmission. Pharmacy workers commonly see patients with respiratory symptoms and some offer recommendations, including for treatment. Pharmacy workers are willing to learn more and contribute to TB control and could be a valuable asset in the control and prevention of TB in Peru. To achieve this integration of pharmacy workers into TB control and prevention, more research is needed. [ABSTRACT FROM AUTHOR]

Objectives: To determine the socio-demographics, sexual practices, and HIV prevalence of male sex workers (MSWs), transwomen sex workers (TSWs), and their male clients in Lima, Peru. Methods: Following ethnographic mapping of sex work venues, the authors revisited randomly selected venues to survey MSWs, TSWs and their clients. Results: MSWs and TSW clients are more educated than MSW clients and TSWs. Only 50% of TSW clients have received HIV testing. Self-reported HIV positivity is highest among MSW clients and TSWs. Conclusion: Notable differences exist between MSWs and TSWs and their clients that can affect the health of these groups and warrant intervention. [ABSTRACT FROM AUTHOR]

Background: The parasitic disease, cystic echinococcosis (CE), is prevalent in low-income, livestock-raising communities and 2000 new people will be diagnosed this year in South America alone. The disease usually passes from livestock to dogs to humans, making it a zoonotic disease and part of the One Health Initiative. Control of CE has been infamously difficult; no endemic areas of South America have succeeded in maintaining sustainable eradication of the parasite. For the current study, we aimed to gain a better understanding of the knowledge, attitudes, and practices of rural sheep farmers and other community leaders regarding their sheep herding practices and perspectives about a control program for CE. We also hope to identify potential barriers and opportunities that could occur in a control program. The authors conducted Knowledge, Attitude and Practices (KAP) surveys and semi-structured interviews in rural communities in the highlands of Peru. The KAP surveys were administered to 51 local shepherds, and the semi-structured interviews were administered to 40 individuals, including shepherds, community leaders, and health care providers. Results: We found that the shepherds already deworm their sheep at a median of 2 times per year ( =49, range 2-4) and have a mean willingness-to-pay of U.S. $ 0.60 for dog dewormer medication ( = 20, range = 0.00- $2.00 USD). We were not able to learn the deworming agent or agents that were being used, for neither sheep nor dogs. Additionally, 90% of shepherds slaughter their own sheep ( = 49). We also learned that the main barriers to an effective control program include: lack of education about the cause and control options for CE, accessibility to the distant communities and sparse grazing pastures, and a lack of economic incentive. Conclusions: Findings suggest it may be feasible to develop an effective CE control program which can be used to create an improved protocol to control CE in the region. [ABSTRACT FROM AUTHOR]

In Peru, a significant proportion of people tested for HIV and syphilis do not receive timely results. Our objective was to assess the institutional feasibility of implementing simultaneous HIV/syphilis point-of-care tests and client perceptions regarding these point-of-care tests. Point-of-care tests were implemented in a hospital consultation room in a marginalised zone of Lima. A time-series design was used to compare the proportion of tested clients who received timely results, with and without the point-of-care test intervention. Experience and satisfaction with point-of-care tests was evaluated with 149 people. In the 6 months without intervention, 69% and 61% of clients tested for HIV and syphilis, respectively, received their results within the required 45-minute window. During the 2-month point-of-care test intervention, all clients tested for HIV (n = 387) and syphilis (n = 398) received their results within 45 minutes. All clients surveyed were completely satisfied (52%) or satisfied (48%) with the simultaneous HIV/syphilis point-of-care test screening process. Additionally, 73% strongly agreed with the statement ‘I feel satisfied with the rapid testing process.’ Screening using point-of-care tests represents an important opportunity to reduce the time, resource and cost burden for users and institutions and increase the proportion of users receiving their test results in a timely manner. [ABSTRACT FROM AUTHOR]

In Peru, there are few studies on male sex workers (MSWs), and existing studies explore limited subgroups or offer limited information about MSWs’ perspectives. This study provides in-depth perspectives from 40 MSWs who work in downtown Lima (Cercado) and in surrounding urban neighborhoods (non-Cercado) through interviews on their identities, lives, and HIV/STI (sexually transmitted infection) risks and vulnerabilities. Findings are that entry into sex work links economy and affection, particularly among Cercado MSWs. Continued sex work cements this link, making it difficult to exit sex work and establish goals. Ties between economics and affections influence MSWs’ perceived HIV/STI risks, vulnerabilities, and prevention practices. Although Cercado MSWs report higher HIV/STI risks and vulnerabilities than non-Cercado peers, they report fewer prevention practices given inability to buy condoms and acceptance of client offers of higher payment, especially clients they feel affection for. MSWs need support to strengthen their self-perceptions and define and pursue their goals in order to improve their HIV/STI prevention practices, health, and well-being. [ABSTRACT FROM PUBLISHER]

Background Globally, no qualitative studies have explored the perspectives of women and their partners about the integration of technology - and specifically diagnostic testing technologies - into antenatal care. The study objective was to describe the demand side for pregnancy-related diagnostic tests from the perspective of Peruvian consumers, including female and male community members, by engaging participants about their awareness of and care-seeking for pregnancy-related diagnostic tests and their preferred characteristics and testing conditions for pregnancy-related point-of-care diagnostic tests (POCTs). Methods Sixty-seven mothers and fathers of children under one from the peri-urban coast and the periurban and rural highlands and jungle of Peru participated in ten focus groups. Results Participants think that pregnancy-related diagnostic tests are important and they and their fellow community members are committed to ensuring that pregnant women receive the tests they need. Participants expressed clear demands for pregnancy-related POCTs, including important characteristics for the tests themselves (certification, rapid, reliable results) and for test implementation (well-trained, personable good communicators as test administrators at well-equipped, convenient testing sites). Participants emphasized the importance of short waiting times and explained that many people have some ability to pay for POCTs, particularly if they are innovative, rapid or multiplex. Conclusions Engaging future POCT Engaging future POCT users as consumers who are able to make key decisions about the development and implementation of pregnancy-related POCTs is valuable and informative. [ABSTRACT FROM AUTHOR]

There are between 8 and 11 million cases of America Human Trypanosomiasis, commonly known as Chagas disease, in Latin America. Chagas is endemic in southern Peru, especially the Arequipa region, where it has expanded from poor, rural areas to periurban communities. This paper summarizes the findings of four studies in periurban Arequipa: on determinants of disease-vector infestation; on prevalence, spatial patterns, and risk factors of Chagas; on links between migration, settlement patterns, and disease-vector infestation; and on the relationship between discordant test results and spatially clustered transmission hotspots. These studies identified two risk factors associated with the disease: population dynamics and the urbanization of poverty. Understanding the disease within this new urban context will allow for improved public health prevention efforts and policy initiatives. Discovered in 1909 by Brazilian physician Carlos Chagas, American Human Trypanosomiasis is a chronic and potentially life-threatening illness found throughout Latin America (Moncayo, 2003). Indeed, it is estimated that there are between 8 and 11 million cases in Mexico and Central and South America (Centers for Disease Control [CDC], 2009). Chagas disease, as it is most commonly known, is endemic in southern Peru, especially in the region of Arequipa. Once thought to be limited to poor, rural areas, the disease is now appearing in the periurban communities that surround Arequipa City, the capital of the region (Cornejo del Carpio, 2003). Understanding the urbanization of Chagas disease will allow public health and medical professionals to better combat the further transmission of the disease. After providing an overview of Chagas and introducing the scope of the disease in Latin America, this paper will summarize the findings of four recent studies conducted in periurban districts in Arequipa. Ultimately, this paper seeks to identify the risk factors associated with Chagas infection in Arequipa's periurban communities. [ABSTRACT FROM AUTHOR]

Background: There is evidence that female gender is associated with reduced likelihood of tuberculosis diagnosis and successful treatment. This study aimed to characterize gender-related barriers to tuberculosis control in Peruvian shantytowns.Methods: We investigated attitudes and experiences relating gender to tuberculosis using the grounded theory approach to describe beliefs amongst key tuberculosis control stakeholders. These issues were explored in 22 semi-structured interviews and in four focus group discussions with 26 tuberculosis patients and 17 healthcare workers.Results: We found that the tuberculosis program was perceived not to be gender discriminatory and provided equal tuberculosis diagnostic and treatment care to men and women. This contrasted with stereotypical gender roles in the broader community context and a commonly expressed belief amongst patients and healthcare workers that female health inherently has a lower priority than male health. This belief was principally associated with men's predominant role in the household economy and limited employment for women in this setting. Women were also generally reported to experience the adverse psychosocial and economic consequences of tuberculosis diagnosis more than men.Conclusions: There was a common perception that women's tuberculosis care was of secondary importance to that of men. This reflected societal gender values and occurred despite apparent gender equality in care provision. The greatest opportunities for improving women's access to tuberculosis care appear to be in improving social, political and economic structures, more than tuberculosis program modification. [ABSTRACT FROM AUTHOR]

Background: Chagas disease is one of the most important neglected tropical diseases in the Americas. Vectorborne transmission of Chagas disease has been historically rare in urban settings. However, in marginal communities near the city of Arequipa, Peru, urban transmission cycles have become established. We examined the history of migration and settlement patterns in these communities, and their connections to Chagas disease transmission. Methodology/Principal Findings: This was a qualitative study that employed focus group discussions and in-depth interviews. Five focus groups and 50 in-depth interviews were carried out with 94 community members from three shantytowns and two traditional towns near Arequipa, Peru. Focus groups utilized participatory methodologies to explore the community's mobility patterns and the historical and current presence of triatomine vectors. In-depth interviews based on event history calendars explored participants' migration patterns and experience with Chagas disease and vectors. Focus group data were analyzed using participatory analysis methodologies, and interview data were coded and analyzed using a grounded theory approach. Entomologic data were provided by an ongoing vector control campaign. We found that migrants to shantytowns in Arequipa were unlikely to have brought triatomines to the city upon arrival. Frequent seasonal moves, however, took shantytown residents to valleys surrounding Arequipa where vectors are prevalent. In addition, the pattern of settlement of shantytowns and the practice of raising domestic animals by residents creates a favorable environment for vector proliferation and dispersal. Finally, we uncovered a phenomenon of population loss and replacement by low-income migrants in one traditional town, which created the human settlement pattern of a new shantytown within this traditional community. Conclusions/Significance: The pattern of human migration is therefore an important underlying determinant of Chagas disease risk in and around Arequipa. Frequent seasonal migration by residents of peri-urban shantytowns provides a path of entry of vectors into these communities. Changing demographic dynamics of traditional towns are also leading to favorable conditions for Chagas disease transmission. Control programs must include surveillance for infestation in communities assumed to be free of vectors. Author Summary: Chagas disease affects 8–10 million people in the Americas. Although transmission was previously limited to the rural poor, Chagas increasingly affects urban populations, especially near the city of Arequipa, Peru. We interviewed residents of five communities to learn about why and when they migrated to the city and how their movements may link to Chagas vectors and to explore the settlement patterns of shantytowns and traditional towns. We found that migrants to shantytowns were unlikely to introduce Chagas vectors to the city upon first arrival. Frequent seasonal moves, however, took shantytown residents to valleys surrounding Arequipa where vectors are prevalent. In addition, the settlement pattern of shantytowns and the practice of raising domestic animals create a favorable environment for vectors. Finally, population loss and replacement by low-income migrants in one traditional town has created the human settlement pattern of a shantytown. This study exposes potential links between population dynamics and Chagas vector infestation. Suggested methods for improving vector control include focusing future vector surveillance in areas with mobile populations, creating educational campaigns for migrant workers to Chagas-endemic areas, and fomenting collaboration between the Arequipa Ministries of Health and Housing to ensure the inclusion of new shantytowns in vector surveillance. [ABSTRACT FROM AUTHOR]

• Health professional and at risk community member participants underestimated influenza prevalence. • Both also correctly identified major influenza-associated symptoms. • Providers missed opportunities to vaccinate and overestimated vaccine side-effects. • Community members had low knowledge about the influenza vaccine. • Text-messaging was identified as a possible way of disseminating information. Influenza is a major source of morbidity and mortality with an annual global attack rate estimated at 5–10% in adults and 20–30% in children. Influenza vaccination is the main strategy for reducing influenza-related morbidity and mortality. Like several other countries, Peru has low vaccination coverage, estimated at 25–50% among young children and older adults. Therefore, the study objective was to explore the knowledge, beliefs, attitudes, and practices related to influenza vaccination among populations at higher risk for infection and/or complications and health professionals in Peru, and their perspectives on health communication channels. This qualitative study was carried out in three cities. We held nine focus groups with pregnant and postpartum women, parents of young children, and older adults. We carried out 25 in-depth interviews with health professionals (HPs) working in, leading or advising immunization-related programs. HPs correctly identified the causes of influenza and HPs and at risk community members identified major symptoms. Community members had poor awareness of the potential severity of influenza and were generally unaware of influenza-related mortality. Both HPs and community members greatly underestimated the prevalence of influenza in Peru. HPs in our study overestimated major side effects of the influenza vaccine and community members perceived that the vaccine caused illness. HPs missed important opportunities to promote vaccination in patients with minor illness (runny nose, allergies, colds) and community members did not understand that the vaccine should be received annually. There is no single strategy that will increase influenza vaccination rates to World Health Organization recommended levels. Instead, it requires multi-faceted commitment from HPs, other healthcare authorities and the government. Addressing important knowledge barriers, specifically negative views regarding the influenza vaccine and the severe morbidity and mortality associated with influenza illness, both in the community and especially among HPs, could have significant impacts. [ABSTRACT FROM AUTHOR]

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., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: Explore the perspectives, decision-making process, and final mode of delivery among pregnant women with a previous C-section (Cesarean section) in a general public sector hospital in Lima, Peru. Methods: A qualitative prospective study using semistructured interviews at two time points in the outpatient obstetrics and gynecology clinic of a public sector, university-affiliated reference hospital in Lima, Peru. Seventeen adult pregnant women with a prior C-section who were deemed by their attending obstetrician to be candidates for a trial of labor were interviewed. The first interview was between 37 and 38 weeks of pregnancy, and the second interview was 24 to 48 hours after delivery., Main Outcome Measures: Predelivery decision-making process and final mode of delivery. Results: Among the 17 participants, about half (9) of the participants stated that the physician explained that they had two approaches for delivery, a trial of labor after C-section (TOLAC) or elective repeated C-section (ERCD). Two women stated that their respective providers explained only one option, either an ERCD or TOLAC. However, 6 women did not receive any information from their providers about their delivery options. Of the 10 participants that decided TOLAC, 8 ended up having a C-section, and of the 7 patients that had planned an ERCD, 1 ended up having a vaginal delivery. Conclusion: Many participants affirmed that they made the decision about their approach of delivery. However, most of the participants that decided a TOLAC ended up having a C-section because of complications during the final weeks of pregnancy or during labor.

Background: In Peru, there is little information about the HIV care continuum. Therefore, we conducted a study to describe the HIV care continuum among male sex workers (MSWs) in Lima., Methods: We applied close-ended surveys with 209 MSWs about their engagement in the HIV care continuum and open-ended surveys with 34 MSWs who are people living with HIV (PLHIV) to explore their linkage to and retention in HIV care., Results: Of 209 MSWs, only 71% (n=148) reported a lifetime HIV test and 56% (n=116) of all MSWs received confirmatory HIV test results. Of the 34 MSWs who are PLHIV, 76% had received HIV care at least once, but only 59% were currently in care, 50% were currently taking ART(antiretroviral therapy) and an even lower 32% had been on ART for 6 months or more. The primary reason for non-linkage to HIV care is the multiple visits to link at the Ministry of Health (MOH). Remaining in care was also challenging, particularly at non-governmental organizations (NGOs)., Conclusions: Substantial barriers linking to and remaining in HIV care result in significant delays in linkage and high proportions of PLHIV that remain unlinked or become unstably linked following initial linkage. Urgent implementation science research is needed to facilitate linkage to HIV care and strengthen retention in HIV care post-linkage., Competing Interests: Declaration of Competing Interests The authors declare that they have no competing interests with respect to the research, authorship or publication of this article.

Although modern contraceptive use in Peru has increased, many women still face unwanted or unplanned pregnancies and abortions remain high despite the illegality of elective pregnancy termination. To improve understanding of how men and women make reproductive decisions, we conducted this study in Lima. Fifty-two 18-37 year old low- and middle-income women and men participated in in-depth interviews and focus groups. Reproductive planning constitutes a worry among participants. The paradigm of contraception, pregnancy, childbearing and pregnancy termination is complex and contained within a context of contradictory pressures toward women: while women feel the need to be autonomous in all realms of their lives, they also need to meet the traditional roles associated with sexuality and childbearing and rearing. The woman, her partner and family members take part in reproductive decisions. However, participants expressed difficulties preventing unwanted pregnancies and social stigma if they resorted to abortion or, interestingly, if they continued a pregnancy when involved in a socially undesirable personal situation. Abortion-related stigma generated fear and guilt in addition to safety concerns given the unsafe, clandestine contexts in which pregnancy termination takes place. Despite these concerns, interviewees often opted for abortion for personal reasons, which were primarily economic.

Despite increased use of modern contraception among Mexican women, there has been a significant increase in abortions. Little is known about the experiences behind these trends. This study examines decision-making around contraception, pregnancy, childbearing and abortion. We carried out 26 in-depth interviews with 23- to 35-year-old females and males in Mexico City. Interviewees described reproductive planning 'without a plan' and sporadic contraceptive use. Linking of reproductive preferences and contraceptive use occurred only after raising a child for a few years or after experiencing an abortion. Interviewees described side effects of hormonal contraceptives and the intrauterine device (IUD) and problems with condoms. Only 8% of participants disagreed with abortion completely. Those with mixed views opposed abortion for pregnancies resulting from lack of responsibility or due to personal problems or concerns about one's future. However, these more controversial reasons were the primary motivations for terminating pregnancies. Females and males expressed that females made most decisions related to contraception, pregnancy and abortion. Further research could explore the reasons behind reproductive planning 'without a plan', 'on and off' contraceptive use and abortion beliefs and experiences that are somewhat contradictory.

Estimates of the percentage of women who have had Pap smears in Peru vary between 7% and 43%. This study explores what women know about cervical cancer and Pap smears, as well as their barriers to obtaining Pap smears. Focus group discussions (FGD) were conducted with a total of 177 women in four Peruvian cities. Discussions reveal that most women did not know what causes cervical cancer. Most women did not know the purpose of Pap smears, although knowledge about Pap smears was higher than knowledge about cervical cancer. Fear, embarrassment, and lack of knowledge were the main barriers identified for not getting Pap smears. Programs and policies aiming to increase Pap smear coverage must start by educating women on cervical cancer and its prevention in order to improve women's perceptions about the screening test and increase Pap smear seeking behaviors in the long term.

Background: Peru has a concentrated HIV epidemic with an estimated 76,000 people living with HIV (PLHIV). Access to highly active antiretroviral therapy (HAART) expanded between 2004-2006 and the Peruvian National Institute of Health was named by the Ministry of Health as the institution responsible for carrying out testing to monitor the effectiveness of HAART. However, a national public health laboratory information system did not exist. We describe the design and implementation of an e-health driven, web-based laboratory information system--NETLAB--to communicate laboratory results for monitoring HAART to laboratory personnel, health providers and PLHIV., Methods: We carried out a needs assessment of the existing public health laboratory system, which included the generation and subsequent review of flowcharts of laboratory testing processes to generate better, more efficient streamlined processes, improving them and eliminating duplications. Next, we designed NETLAB as a modular system, integrating key security functions. The system was implemented and evaluated., Results: The three main components of the NETLAB system, registration, reporting and education, began operating in early 2007. The number of PLHIV with recorded CD4 counts and viral loads increased by 1.5 times, to reach 18,907. Publication of test results with NETLAB took an average of 1 day, compared to a pre-NETLAB average of 60 days. NETLAB reached 2,037 users, including 944 PLHIV and 1,093 health providers, during its first year and a half. The percentage of overall PLHIV and health providers who were aware of NETLAB and had a NETLAB password has also increased substantially., Conclusion: NETLAB is an effective laboratory management tool since it is directly integrated into the national laboratory system and streamlined existing processes at the local, regional and national levels. The system also represents the best possible source of timely laboratory information for health providers and PLHIV, allowing patients to access their own results and other helpful information about their health, extending the scope of HIV treatment beyond the health facility and providing a model for other countries to follow. The NETLAB system now includes 100 diseases of public health importance for which the Peruvian National Institute of Health and the network of public health laboratories provide testing and results.

This study aimed to determine the psychosocial factors associated with delayed test-seeking among tuberculosis patients. The duration of symptoms before seeking medical care was assessed by interview for 108 newly diagnosed pulmonary tuberculosis patients in the city of Iquitos in the Peruvian Amazon, which has high tuberculosis incidence. Beliefs associated with test-seeking behavior and delay was assessed in these patients. The median delay from symptom onset to seeking diagnostic testing was 61 days (inter-quartile range 30-91 days). The belief that tuberculosis is curable was associated with a 100% longer test-seeking delay; the perception that tuberculosis was common was associated with a 57% longer delay; male gender was associated with a 48% longer delay; and education less than complete secondary schooling was associated with a 44% longer delay. In conclusion, current health promotion activities that emphasize tuberculosis curability and high prevalence may paradoxically increase test-seeking delay and therefore require prospective evaluation.

This article reviews the literature on body image and media use among adolescents. We begin by defining body image and how it is constructed, especially among young people. We then offer information on when one's body image perception is askew with one's perception of personal ideal, which can result in disordered eating, including obesity, anorexia, and bulimia. Next, we describe the research literature on media use and its relationship to adolescents' body image perceptions and discuss content analyses and correlational, experimental, and qualitative studies. Lastly, we recommend, beyond conducting further and improved research studies, interventions and policies that may have an impact on body image and media use.