Community Assessment of Resources and Healthcare ... - IUPUI

Community Assessment of Resources and
Healthcare Experiences
(CARE)
Alto Cayma Community
Arequipa, Peru
P R I N C I P L E I N V E S T I G A T O R :
D R . K A E L I V S E Y
A S S I S T A N T P R O F E S S O R
U N C W I L M I N G T O N S C H O O L O F N U R S I N G
CO- I N V E S T I G A T O R S :
D R . W A Y N E C E N T R O N E
E X E C U T I V E D I R E C T O R
H E A L T H B R I D G E S I N T E R N A T I O N A L
D R . S U S A N R O B E R T S
A S S I S T A N T P R O F E S S O R
U N C W I L M I N G T O N S C H O O L O F N U R S I N G
C L I N I C A L R E S E A R C H P R O G R A M

Acknowledgements
This study would not have been possible without the assistance of numerous people, both here in
the United States and in the community of Alto Cayma. The researchers are indebted to :
Father Alex Busuttil and staff members of the Maria Madre de los Missiones clinic.
Roberta Allred Dr. Jennifer Horan Clark Luikart Dr. Susan Pierce
Karen Falkenstein of Health Bridges International
UNCW Nursing students who assisted in data collection for the study:
Amanda Bodnar
Matthew Bowers
Cassandra Mindt
Amber Cox
Rebecca Cox
Danielle Allison Cray
Amy Elliott
Aissel Faquir Gonzalez
Kristen Grimsley
Stephanie Holderman
Adam Sturkey
Alyssa Horne
Alyson Insull
Stephanie Ivey
Brandi Knight
Rachel Livingston
Meredith Lomax
Brittany Pearson
Bryan Sisk
Alison Watkins
Elizabeth Wolfson

Background
• 44.5% of the Peruvian population lives in poverty
(CIA World Factbook,2009).
• 60% of people in communities covered by the Census lack
access to a healthcare facility (Amnesty International, 2009)
• Expanded primary and preventive care services to
impoverished and marginalized populations to improve
health outcome measures are needed (Miranda, et.al, 2008; Guanais&
Macinko, 2009).
• Very few studies have been conducted that evaluate the
access and utilization patterns of individuals living in
peri-urban squatter communities of the large cities of
Peru

Arequipa
• 2 nd largest city in Peru – after Lima
• Founded in 1540 (population @850K)
• Southern Peru – 7,740 feet above sea level
• 70 miles from Pacific Ocean
• Andes Mountains – highlands
• “The White City” – silliar stone
• Foot of snow capped volcano, Mt. Misti
• Language - Spanish

Alto Cayma District
• Outskirts of Arequipa
• Made up of 4 parishes – each with about 25,000
people
• Migration down from mountains
• Houses – made of stone bricks – tin roofs -no
running water or electricity
• Dirt roads – no trees or plants – dusty
• Dogs

Peruvian Health Care System
• Five major care delivery systems:
◦ military and police
◦ SIS (a Medicaid-like system for low-income and vulnerable
populations)
◦ MINSA (Ministerio de Salud, National)
◦ Private clinics
◦ Es Salud 9 (social security based health care program)

About the study
University-NGO Partnership
• This study was jointly conducted by Health Bridges
International, Inc. and faculty from the University of
North Carolina Wilmington School of Nursing.
• Health Bridges International (HBI) is a non
governmental organization based in Portland, Oregon
and has been working in Peru to create collaborative
projects and support for the people of Peru for over 15-
years.
• Students and faculty from UNCW have been going to
the Alto Cayma area for clinical and cultural immersion
experiences since 2004.

Purpose of the Study
• Cross-sectional descriptive survey designed to
evaluate:
◦ healthcare access
◦ demographic and socioeconomic information on households
within the community
◦ patterns of healthcare utilization
◦ awareness of area health clinics and government and charity
resources.
◦ objective and subjective barriers to healthcare

Hypotheses and Assumptions
• Individuals living in the communities of Alto Cayma and
the surrounding metropolitan area of Arequipa, Peru do not
have access to adequate primary care services.
• A lack of primary health care service utilization has led to
greater overall disease burden in the communities’
populations when compared to a more socioeconomically
affluent cohort of individuals living in Arequipa.

Hypotheses and Assumptions
• Healthcare usage patterns reflects individuals’ learned
behaviors, and is based on lack of knowledge of available
resources and a proper understanding of “primary care” as
a longitudinal medical model.
• Poor, peri-urban squatter community populations are
disproportionately uninsured.
• A significant barrier to individuals seeking services is their
lack of insurance and lack of knowledge regarding how to
properly utilize free and low-cost healthcare options.

Study Population
• Participants in the study were selected by means of a
convenience sample of 800 families in the Alto Cayma
Community
• A sample of this size would represent 10% of the
population, based on an estimate of family size of four.
• Participants who do not maintain a domicile residence in
one of the communities of Alto Cayma, or who are under
the age of eighteen were excluded from this study.

Research Questions
1. What are the living conditions of the people in the Alto
Cayma community, in terms of access to basic services
such as water, sewage and electricity?
2. Do members of the community treat their water prior to
consumption?
3. What is the demographic makeup of households in Alto
Cayma (including size of household, income and
education)?
4. What types of assistance (government or private) are
households in Alto Cayma receiving?

Research Questions
5. Where do individuals in Alto Cayma seek healthcare and
dental care services?
6. How frequently are health and dental care services
accessed by members of the Alto Cayma community?
7. For what reasons do community members seek health and
dental services?
8. What barriers exist to healthcare access and utilization in
Alto Cayma?

Study Methods
Recruitment Methods-Announcements about the
study were made at the parish center and at various
local community meetings a few weeks prior to data
collection, which occurred between March 11 and
March 19, 2009.

Human Subject Protections
Permission from the UNC Wilmington Institutional Review Board
(IRB) was obtained prior to data collection for the study.
• All study staff received prior training in non-leading interviewing
techniques and IRB training.
• An introductory information sheet was read to all potential survey
participants through a Spanish language interpreter.
• All survey questionnaires were conducted through a trained
Spanish-English interpreter.
• Written informed consent forms were provided in Spanish.
• In instances where participants had literacy deficits, the informed
consent was read to the participant by the interpreter.
• All participants were asked whether they understood the
requirements and conditions for participation in the study prior to
obtaining signed informed consent.

Data Collection Methods
• Data collection teams included an
UNCW student, a volunteer
translator/interpreter, and an HBI
trained staff person.
• Data collection occurred in a central
location within the community.
• Student data collectors read the
questions in English, which were then
translated verbatim by the interpreter.
• Responses were obtained in Spanish and
translated by the interpreter.

Results
Sample- N=455 households
Average number of members in each household:
4.64 (SD=1.782, range 1-11)
• Adults- 2.52 (SD= 1.172, range 1-8)
• Children 2.12 (SD= 1.385, range 0-8)
• Only 10% of households had no children
• 91.2% reported speaking Spanish as the primary
language used in the home

Access to Basic Services
• 92% of households reported having electricity in the
home.
• 43.5% of households report having water access in
the home
• Approximately 31% of households have access to
public water for five-hours per day or less
• 84% report getting water from public spigot

Water Treatment
• Public water sources are not treated, however 96.7% of respondents
indicated that they treat water prior to consumption
Method of Water
Treatment
Boil
Filter
Bleach
Boil/Bleach
Unknown/Not
Reported/Does not
Treat
Total
N
Percentage
386
84.8%
48
10.5%
3
0.7%
1
0.2%
17
3.7%
455 100%

Household Income
• Average number workers in the home 1.4
(SD= .677, range 0-4).
• Households averaged 0 to 28 hours per week worked (mean 7.2
hours per week per family)
• Average reported income per day was 28.46 Peruvian Soles or
less than $10USD per day worked
• Monthly household income estimates indicate that members of
this community are living just above the World Bank defined
poverty level ($150USD/month for a family of four).

Educational Attainment
Less than half of adults in household have education
beyond primary level.
Fathers
Mothers
Nine percent of households reported that parents had never attended school,
with mothers being almost three times as likely as fathers of having
had no formal education

Sponsorship/Assistance
• Less than half (48.7%)
of respondents
indicated that
children in the home
were receiving
sponsorship from
either a governmental
or private charitable
organization.
Type of Sponsorship Program
Christian Foundation for Children and Aging
Vasode Leche
Acercandenos
Grupo Arcano
Prona
Unknown/Not Reported
5% 0% 1% 3%
37%
54%

Government Support for Healthcare
• Given the average reported income by households
surveyed in this study, many of the households
would be eligible for SIS program services.
• Most respondents (73.4%) were aware of the
government SIS program, however only 13.6% of the
respondents and 47.4% of the children in the
household reportedly received benefits from the SIS
program.

Healthcare Utilization
32% of adults reported
that they a health care
provider 2-3x per year

Type of clinics used
Adults
Children
Type of Clinic N % N %
MINSA 194 42.6% 212 51.8%
Private Clinic 164 36.0% 147 35.9%
Es Salud 28 6.2% 26 6.4%
Not Reported 27 5.9% 8 2.0%
Other 23 5.1% 9 2.2%
None/doesn't
go 19 4.2% 7 1.7%
Total 455 100.0% 409 100.0%

Reasons for Healthcare Visits
• Most common ailments being upper respiratory
conditions (24%)
(cold, cough, sore throat, bronchitis or flu)
• Gastrointestinal symptoms (17.1%)
(gastritis, stomach ache/infection, nausea/vomiting).

Dental Care Utilization-Adults
• 53.0% of respondents indicated that they received
dental care
• 36.1% indicated that they only sought dental care
when issues arise, such as a visible cavity.
• Only 3.7% of respondents indicated that they had
visited the dentist for preventative services, such as
cleaning or a checkup.

Dental Care Utilization-Children
• 54.5% of children in the communities surveyed
receive dental care services.
• 39.0% of children accessed dental care services 2-3
times per year, compared to 26.6% of adult
respondents.
• Some respondents that children accessed dental
services through school programs.

Emergency Care
Frequency
Percent
Do you know where to receive urgent or emergent medical care
if you are involved in an accident or injury?
Unknown/Not Reported 5 1.1
No 56 12.3
Yes 394 86.6
Total 455 100

Table 15. Prescription Access
Prescription Access
Frequency
Percent
Able to afford to fill prescription
No 305 67.0%
Yes 147 32.3%
Not Reported 3 0.7%
Total 455 100%

Barriers to Care
Reasons for not accessing healthcare services
Money 295 80.4%
Money and Transportation 11 3.0%
Transportation 11 3.0%
Lack of trust/unfavorable
experience 10 2.7%
Childcare/eldercare 8 2.2%
Time 6 1.6%
Money and child/elder care 4 1.1%
Money, lack of trust/unfavorable
experience 4 1.1%
Don't know where to go 1 0.3%
Job 1 0.3%
Physical limitations 1 0.3%
Uses pharmacy or tolerates pain 1 0.3%
Not Reported 14 3.8%

Study Limitations
• Convenience sampling
• Limited sample size
• Measurement error, since an interpreter was used to
administer the survey.
• Culturally different conceptualizations of health,
health seeking behaviors and health care utilization.
• These findings cannot be generalized to other
communities within Arequipa or other areas of Peru.

Discussion
• Findings from this study indicate a need for
additional access to basic public health services such
as clean water and sewer, as well as primary health
care and dental services for individuals living the
Alto Cayma Community.
• Barriers to healthcare are evident, primarily related
to poverty and lack of income. Other barriers to be
further explored include transportation needs, and
lack of knowledge about available support programs
and services.

Discussion
• Other challenges in the area include lack of
education among adults, and presence of unstable
and low wage employment.
• Services to improve educational opportunities and
job training would be beneficial in this community,
especially for adult women.

Suggestions for additional research
• More information is needed as to whether current
healthcare programs in the area are functioning at
maximum capacity and what resources for these
programs may be needed.
• Future studies should further explore the presence of
other barriers to healthcare access, especially related
to health seeking behaviors, and whether issues of
trust are also a barrier to seeking care.

Lessons Learned
• Pilot your instrument before embarking on large
scale study
• Informed consent procedures in this population
group

Questions?
Thank you!
Kae Rivers Livsey RN, MPH, PhD
University of North Carolina Wilmington
School of Nursing
livseyk@uncw.edu