Co-creation with Communities in Peru

During the weekends of July 21st and 23rd 2017, the COHESION team in Peru visited the communities of Sicacate and Pingola to hold meetings with community members and begin the brainstorming process of future COHESION interventions. Thirty people participated in the Sicacate meeting (22 women, 8 men) and 34 in the meeting in Pingola (20 women, 14 men).

The experience from previous visits to the sites allowed our team members to use effective communication strategies to invite community members and secure participation. During the two weeks preceding the co-creation session, team members made phone calls to community leaders and visited the areas to disseminate information about our activities. This included placing posters in different community settings, broadcasting messages through the local radio station and community loudspeakers, as well as carrying out interpersonal communication activities where health personnel and school teachers invited community members to join our sessions.

Each meeting lasted around two hours and project team members collected suggestions for possible actions around each of the selected diseases. The sessions began with an explanation of the project, followed by information about the diseases. Then group discussions took place to collect suggestions of possible interventions.  The suggestions revolved around getting more information about the disease, making diagnostic tests available at the PHC, and providing examples of well-balanced meals and sanitation improvement.

The next meetings will take place in mid-October where the Lima team will return to discuss a subset of potential interventions, from which community members will then make a final selection and discuss the reasons behind their selection.

Co-creation session, Pingola.

 

Co-creation meeting dissemination, Sicacate.

 

Co-creation session, Sicacate.

Research Assistant from Peru awarded scholarship for ICRD

The fourth edition of the International Conference on Research for Development (ICRD), will be co-hosted by the Swiss Programme for Research on Global Issues for Development (r4d programme) and by the University of Bern’s Centre for Development and Environment (CDE). The event will take place 5-8 September 2017 in Bern, Switzerland, with the theme “Evidence. Engagement. Policies.”

The ICRD offered young researchers the opportunity to apply for financial support to participate in the conference. Silvana Pérez León, COHESION Research Assistant in Peru, applied and was awarded the scholarship.

“I thought this was a great opportunity to build a proposal and show some of the work the COHESION project has been doing in Peru. The session that captured my attention was ‘Building transformative partnerships between health services and communities as a means to advancing the agenda towards sustainable development: a pathway forward’; because one important objective of COHESION is to build interventions in primary health care services that include the participation of the community.” – Silvana Pérez León

Silvana’s proposal to the ICRD included information gathered during the engagement and formative studies with health workers and the communities. This process enabled the Peruvian team to understand and acknowledge the needs of different stakeholders and to start thinking about how COHESION could design interventions that build transformative partnerships between health services and communities.

Silvana will be a panelist at ICRD on September 6, showing some of the work the Peruvian team has been developing in the past months.

Silvana Pérez León presenting at the ICRD.

 

Silvana Pérez León collecting data that informed her presentation at ICRD.

Seminar in Peru: Health Policies and Systems Research

The CRONICAS Center of Excellence in Chronic Diseases is sharing knowledge, building capacity and mutual understanding of health Policy and Systems Research.

Given the growing emphasis on health systems research and the role of health policy in the health of populations, the Peruvian team of COHESION, CRONICAS recently held a seminar on the topic.

Here is an overview of what took place and what the main and most important messages were:

On July 03 2017, the Institute of National Health (INS) and CRONICAS Center of Excellence in Chronic Diseases with the support of The Alliance for Health Policy and System Research- WHO, held the seminar “Health Policies and Systems Research” at the headquarters of the INS.  The objective was to show and discuss a new area of research that can be used for the implementation of policies.

Dr. Hans Vasquez from the “General office of Research and Technology Transfer” opened the seminar and stressed the importance of moving forward from diagnostic research to doing research that can have a bigger impact on health. In countries like Peru there is little research on policies, health systems or implementation.

The first presentation was provided by Nhan Tran, manager of “The Alliance for Health Policy and Systems Research (AHPSR)”. He said that the current challenge is to ensure health interventions are effectively integrated into health systems and are designed to be scaled up in different contexts. He pointed out that one of the reasons why implementation is so difficult is because implementation is about change (asking organizations to behave differently, people to do things differently, etc.). That is why it is important to think implementation as a process of change. Finally, he emphasized three main important shifts on how to do implementation: 1) applying a more systems perspective, 2) thinking about research as part of the implementation research, and 3) having local investment in implementation.

(Left to right Dr. Hhan Tran and Dr. Hans Vásquez; picture from INS https://goo.gl/iwfkAt)

The next two presentations were from representatives of the public sector, Dr. Manuel Catacora Villasante from the “Institute of assessment in technologies in Health and Research” of the Social Security; and Bio Gisely Hijar Guerra from the “National Center of Public Health-INS”. They talked about the prioritized research subjects of their institutions, gave some examples of research being developed and pointed out some opportunities of funding.

The fourth presentation was given by Dr. Ludovic Reveiz from the Pan American Organization, where he explained how there is still too little information on how to do implementation research in policies. He showed the work the program iPIER is developing in Latin America and the Caribbean, which aims to facilitate improvements in program implementation through implementation research. An important part of this program is a workshop where the grant recipients receive a basic understanding of the research methodologies in implementation research.

The fifth presentation was from Dr. Fernando Llanos of the Universidad Peruana Cayetano Heredia. He talked about his research in health systems at primary care and universal coverage. He explained some conceptual frameworks, the methodology of the study and some final conclusions. He highlighted two important conclusions; first that before thinking in primary health care, there should be a clear definition of what is considered primary health care in Peru, and second, that talking about universal coverage meant to think of the system as a whole, because in the Peruvian context there are several subsystems.

Mg. Gerardo Seminario of “Salud sin Limites” gave the final presentation where he spoke about the process of making an agenda for public policies for the health of indigenous populations in Peru. He pointed out that a policy agenda is not necessarily a rational decision but derives from other factors like power roles, negotiations, institutional frames, etc. The making of an agenda consists on the concurrence of 4 factors: a problem, a possible solution, stakeholders and a window of opportunity. He concluded that the policies for the health of indigenous populations is still fragile, because the response for intercultural health is accepted but only on the surface, because the network of experts is not consolidated, because politicians change frequently as do their interests, because the vertical structure of the health system does not facilitate an intercultural health, and because the window of opportunities is narrowing.

(Picture from INS https://goo.gl/iwfkAt)

At the end of the seminar there were two panel discussions. One, about the priorities of research policies and health systems, included the participation of Dr. Maria del Carmen Calle Dávila (General Directorate of Strategic Interventions in Public Health) and Dr. Hans Vasquez (INS). The second panel was about funding opportunities for research in policies and health systems, and included Dr. Franco Romani (INS) and Dr. Alexander Tarev (General Directorate of Strategic Interventions in Public Health). The discussions brought to our attention the efforts of the public sector to do research, and though these efforts are few and recent, the road is being build. There is still the need that the research community meets the demands of the public sector. In that sense it is necessary that the public sector opens more opportunities where policy makers and researchers can encounter each other.

This seminar was a good opportunity for the dialog between the research community, policy makers and civil organizations. For the COHESION team, it was a good moment for engagement and to gain an update of the research being done in in health policies and systems.

CRONICAS and Health Systems Research:

At CRONICAS Center of Excellence in Chronic Diseases there have been past and ongoing research projects related to the assessment of health systems. Through 2012-2013 the project “Barriers” financed by the AHPSR, piloted for the first time in Peru a research implementation manual for the evaluation of healthcare systems’ responses to chronic non-communicable diseases. Currently the COHESION project has as objective to improving the health system response for attending the double burden of Noncommunicable and Neglected Tropical Diseases. Initiatives like these are in the path to look for solutions for the current health issues the health systems face.

Additional information:

Second Advisory Board Meeting in Peru

On the 15th of June 2017 the Peruvian team had their second Advisory Board meeting of the year. This meeting included the COHESION team in Peru and Advisory Board members Jeanine Anderson, Peter Busse, Cesar Náquira, Flor Calderon and Luz M. Moyano.

Maria Amalia Pesantes and Maria Kathia Cardenas presented preliminary results related to the qualitative study of “Local perceptions in the community” and to the “Health System Assessment”. Silvana Pérez León presented the process of co-creation the COHESION team will be developing in the following months.

As a result, the Peru Advisory Board suggested:

  • A possible intervention would be training health workers in the diagnostic of neurocysticercosis by secondary methods, for example through interviews, clinical history, or other practices.
  • To consider the different type of religions in the community as important for further interventions.
  • The school would be a suitable place to teach about sanitation. Changing attitudes in people’s lives takes time and starting with the children is a good option to see changes in the future.
  • It is important to know who the community are leaders. Work with a leader of the community that has legitimacy and that is effective in providing messages to the community
  • Some possible interventions could be providing education on the diseases of the project through game platforms for the children.
  • Good interventions for these localities would be related to education in sanitation, because working with children would be a better approach than working with adults.
  • To think the interventions in terms of the prevention of the diseases in addition to the damage of the diseases.
  • It is crucial to provide information of the diseases to the communities during the co-creation process.
  • It is important to try to change habits, to give the opportunity for the community to react in response of some of the information that will be provided by us, that they would like to change.

Finally, several of the members agreed that the co-creation process should be framed carefully, so the interventions proposed by the community would not generate expectations of interventions that are not possible for the COHESION project.

Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

Summary: Engagement activity with stakeholders at the macro level of the health system in Lima- Peru

On May 3, the COHESION project in Peru held a meeting with stakeholders, where stakeholders related to the health sector and the diseases related to the project (diabetes, hypertension and neurocysticercosis) were invited. The purpose of the meeting was to present the project, create links with different institutions and receive inputs or recommendations for the project.

The meeting was attended by members of the COHESION project in Peru, part of the COHESION team from Switzerland, public officials from both the Ministry of Health and the Superintendence of Health, as well as some civil society organizations such as the Diabetes Association of Peru and the Peruvian Federation of rare diseases.

The meeting began with the words of welcome from Jaime Miranda, Director of “CRONICAS center of excellence in chronic diseases”. During his welcoming he remarked the intention of the meeting to carry out a co-creation process between the COHESION project and the assistants, to think together ways of improving the health system, especially in the attention given in the primary health care.

Following, David Beran principal investigator of the COHESION project made a presentation of the project COHESION (in Spanish). He explained the linkage between the project with the Millennium Development Goals and the Sustainable development objectives. He also pointed out important qualities of the project like being a multidisciplinary and multi-country team. Finally he explained the different stages that the project has carried out and the stages to come in the next years.

Subsequently, the words were given by María Kathia Cárdenas, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. During her presentation she explained the COHESION project in the Peruvian scenario. She specified the project is being carried out in the region of Piura, in the health posts of Sicacate and Pingola, located in the districts of Montero and Ayabaca respectively. During this presentation it was also specified two of the studies that the project is carrying on, the evaluation of policies and the health system assessment. She explained details of each study and the different levels of analysis. Furthermore, she also explained the methodology that is being implemented based on the manual “How to investigate access to care for chronic noncommunicable diseases in low and middle income countries” (2012) from the WHO, and she also explained the activities that were already performed at the community level such as interviews with patients, health workers, head of facilities, among others.

Next, María de los Ángeles Lazo, researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases, detailed the steps that will follow the project in the next months to involve the stakeholders at the macro or national level. She explained to the participants the important need of their support and expressed the intention of the project to involve them actively in the process, as well as with other key stakeholders. It was also specified that in the short term the COHESION project will be contacting them to have personal interviews, to know their opinions on the health systems facilitators and barriers.

Finally the discussion was opened to the attendees so they could express their opinions, comment or question of the project. This final part was moderated by María Amalia Pesantes, coordinator and researcher of the COHESION project and at CRONICAS Center of Excellence in Chronic Diseases. Some of the most important arguments and recommendations are detailed below:

  • To include the perspective of caregivers. It is important the health system recognized their task, not only in a financial support, but also to be trained in the care of the patients and to consider the importance of psychological support for the caregivers, who were also called “acompañantes” (companions).
  • Developing engagement with key stakeholders such as public officials and political representatives is a long-term endeavor.
  • It is necessary to establish relations with the regional health directorate in Piura. This entity is the responsible of providing the health service, while the Ministry of Health is in charge of regulating and monitoring. It was also suggested to interview the head of the department of Planning and Budget and Human Resources, and to include the Regional Government, who has also responsibilities related to health, poverty, access to water and sanitation.
  • It was also highlighted the important role played by community agents in the health system.
  • It was acknowledged the low ability of the Ministry of Health to communicate strong messages. Furthermore, civil society lack of relevant information about diseases, especially the most neglected population.
  • Past experiences on training diabetes educators were shared and it was noticed that one of the main difficulties in the training of health workers was the high rotation to other health establishments, and this should be taken in to account for the project.

Participants:

COHESION Team (Switzerland):

  • David Beran
  • Sarah Lachat
  • Suzanne Suggs
  • Nathaly Aya Pastrana

COHESION Team (Peru):

  • Jaime Miranda
  • Maria Kathia Cardenas
  • Maria Amalia Pesantes
  • Maria de los Angeles Lazo
  • Charlotte Darwis
  • Rosa Salirosa
  • Silvana Perez Leon

Participants:

  • Jorge Calderón (President of the Diabetes Association in Peru)
  • Luciana Bellido Boza (Representative of Intendance of Research and Development – SUSALUD)
  • Jorge Ferrandiz (Executive Director of the Department of Prevention and Control of Noncommunicable, Rare and Orphaned Diseases)
  • Maria Lourdes Rodriguez (President of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)
  • Lilliam Lindley (Representative of Hecho con Amor-asociation of multiple sclerosis in Peru and President of the Peruvian Federation of rare diseases)

 

Community Health Perceptions Study in Peru

The Community Health Perceptions Study is one of the baseline studies of the COHESION project. It consists of a community mapping, focus groups and in-depth interviews with the aim to understand the community’s perceptions on healthcare services, health problems, (especially those related to diabetes, hypertension, and neurocysticercosis), as well as the implications of NCDs and NTDs at the individual, family and community level.

The community mapping in Peru was conducted in November 2016 in rural and peri-urban communities located in Northern Peru, namely: Ayabaca, Montero, Pingola and Sicacate. The fieldwork team was composed of one representative of CRONICAS Center of Excellence in Chronic Diseases (Silvana Pérez León) and a member of its local partner Centro de Salud Global of Universidad Peruana Cayetano Heredia (Fernando Urizar). They visited the selected communities and identified relevant actors to engage with in future COHESION activities.

This first visit helped to gain an overall understanding of the communities as well as to plan the data collection process, which took place earlier this year (February 1-21). Data were collected by two teams comprised of a man and  woman with social sciences degrees. They were joined by Nathaly Aya Pastrana, the COHESION PhD student from Università della Svizzera italiana in Lugano Switzerland. Nathaly participated in interviewing patients, caregivers and community leaders, as well as conducting focus groups with community members.

Data collection during the rainy season was challenging as the heavy rains made it difficult to access remote areas and to recruit participants for the focus groups. Intense rainfalls and floods continued until April 2017, creating public health concerns in the region, such as the spread of infectious diseases like dengue (Ministerio de Salud del Perú 2017). Fieldworkers (Gabriela Rengifo Briceño and Jorge Tuanama Álvarez) shared the following testimony of their fieldwork experience in the area:

“The dispersion of the population and the rains represented a challenge, but we learned that these are everyday conditions that people must solve when going to work, going to the health post for a checkup or for an emergency. Some are critical of the health service but it is the nearest alternative. Besides, going to other providers is expensive in time and money. Therefore, it was difficult to talk about health without offering in exchange attention, medicines or information.”

Ms. Aya Pastrana collected additional data through 1) interviews with representatives of communication channels, 2) recorded radio programs, 3) collected samples of printed communication material from local primary health care centers, and 4) documented observations of her field experience. The findings will provide additional insights to design interventions at the community level.

Preliminary analyses of the Community Health Perceptions Study show differences in the awareness about chronic conditions. People seem more aware of hypertension, with little knowledge of diabetes and neurocysticercosis. (see COHESION Newsletter Vol.1 Ed. 1)

References:

Ministerio de Salud del Perú (2017)  Aprueban “Lineamientos Para El Manejo Del Dengue En Zonas de Desastres Perú 2017.” http://www.minsa.gob.pe/?op=51&nota=22577, accessed July 20, 2017.

Interview with patient for the Community Health Perceptions Study, Sicacate, Northern Peru.

Focus groups with old women for the Community Health Perceptions Study. Pingola, Northern Peru.

 

Recruiting participants for the Community Health Perceptions Study. Montero, Northern Peru.

 

Recruiting participants for the Community Health Perceptions Study. Montero, Northern Peru.

 

The selected sites of Ayabaca and Montero in Piura – Peru

The COHESION project assesses the barriers that underserved communities face when accessing Primary Health Care (PHC) to treat chronic conditions in Peru, Mozambique, and Nepal. In Peru, the selected districts are Ayabaca and Montero in the Ayabaca province of Piura, North-Peru.

The northern region of Piura is well known for its tropical climate, white-sand beaches and surf. Far from the beaches on the coast, we find the province of Ayabaca in the highlands of Piura. Ayabaca is about six hours away from Piura city and it can only be accessed by road. Rural Ayabaca has often been neglected and forgotten by policy makers and private investors. Although blessed with rich flora and fauna, the Ayabaca province faces poverty and exclusion.

The Peruvian COHESION project team chose as its intervention sites two districts of the Ayabaca province: Montero and Ayabaca, where 6,683 and 38,339 people live respectively1. According to the National Institute of Statistic and Informatics, the poverty rate in Ayabaca is 69.4% and 55.9% in Montero1. One of the main problems in these districts is the lack of access to sanitation and clean water. Ayabaca province has one of the highest drinking water shortages and lack of basic sanitation, with wide differences between its urban (54%) and rural (99%) areas2. Lack of sanitation is one of the major risk factors3 for some Neglected Tropical Diseases like neurocysticercosis.

Access to health in places like Ayabaca is crucial and yet, scarce. Health facilities in both Ayabaca and Montero only provide very basic health services, focusing on maternal and child health. Out of the 31 health facilities in Ayabaca, 29 are basic primary health care posts. The other two are health centres. Montero, on the other hand, has only three basic primary health care posts and one health centre. The health centres have few health professionals and rudimentary hospitalization facilities. If there is an emergency in either of these districts that requires an urgent referral of the patient, the closest regional hospital is located in Sullana-Piura and it takes about four hours to get there by private vehicle. However, the ambulance in these health centres is not always operating. Addressing diseases like neurocysticercosis, hypertension, and diabetes in resource-limited districts like Ayabaca and Montero needs effective interventions that work at a community-based level and that are focused on the poorest of the poor.

Health Center – Ayabaca

 

Pingola Main Square

 

References:

  1. Instituto Nacional de Estadística e Informática (2016). “Peru en Cifras: Ayabaca, Piura” Retrieved November 04, 2016, from https://www.inei.gob.pe/.
  2. Instituto Nacional de Estadística e Informática  (2010). “Mapa del Déficit de Agua y Saneamiento Básico a Nivel Distrital, 2007”. Lima: Instituto Nacional de Estadística e Informática. Available at: https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib0867/libro.pdf
  3. Garcia HH et al. (2016). “Elimination of Taenia solium Transmission in Northern Peru”. The New England Journal of Medicine. 2016 Jun 16; 374(24): 2335-44. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27305193

Fieldworkers trained for Community Health Perceptions work in Peru

Fieldworkers received training in data collection tools and methods before heading to the selected sites: Ayabaca and Montero, located in the region of Piura in the north of Peru. They will be conducting interviews and focus group discussions, elements of the Community Health Perceptions research component of the project. Their work will be informed by the findings of a community mapping that took place in October 2016, and will be complemented by the insights of a Ph.D. student in Social Marketing from Lugano, Switzerland, who is joining them in the field.

The fieldwork takes place in February 2017, during the rainy season and some challenges lie ahead of the team. However, the team is excited to engage with the communities.

National Policy Analysis in Peru

One of the main research outputs of COHESION consists of an analysis of global and national policies related to non-communicable (NCDs) and neglected tropical diseases (NTDs). The partners in Switzerland conducted the global policy analysis, whereas national policy analyses are in progress in Mozambique, Nepal, and Peru.

The COHESION team in Peru met on January 23rd to review the preliminary findings of their national policy analysis. Interesting perspectives were raised in relation to the Peruvian policy agenda, methodological considerations were shared and lessons learned were expressed that will be shared with the partner countries. In addition, participants spoke about potential activities that will follow once the analysis is finalized, including publications and dissemination of findings to national stakeholders.

 

 

First Meeting of the Peruvian Advisory Board

The first Peru Advisory Board meeting was held on January 25, 2017. It was an important milestone for COHESION’s work in Peru. Advisors of diverse backgrounds and local team members participated in a cooperative session where the advisors repeatedly expressed their interest in contributing to the success of the project.

The members of the Advisory Board in Peru have expertise in preventive medicine, public health, epidemiology, health innovation, health communication, medical anthropology, research methods, non-communicable diseases, parasitology and tropical diseases.

During the meeting this group of experts contributed to the discussion on COHESION’s research components and methods, and provided suggestions for the upcoming activities. Furthermore, the advisors proposed a new meeting once data collection and analysis has been completed, to work together in the design of potential interventions.