Available health-seeking behaviour options
Households reported using various and multiple approaches to address their health concerns. The four major HSBs were: visiting a governmental health post; self-treating with pharmaceuticals; self-treating with traditional home remedies; and visiting a traditional health practitioner. These were categorized into three sectors: the professional sector which includes governmental healthcare; the popular sector which includes both forms of self-treatment; and the traditional sector which includes traditional health practitioners [27,28,29]. To determine the most appropriate HSB for a particular illness, participants reported that they first consulted their spouse, and occasionally sought subsequent advice from other family members. In the case of a child, mothers reportedly recognized the illness first, and a joint treatment decision was made with their spouse.
Governmental health facilities
Almost all residents of both communities were part of the SIS program, and could therefore receive subsidized or free treatment in the governmental facility assigned to their community. For primary healthcare, residents of Community A must travel 1 h by foot, while Community B has its own health post. Secondary care for both communities was located in Balsapuerto, which takes between seven and 8 h on foot or by boat from each community. Tertiary care was located in Yurimaguas.
Participants described that men play an important role when seeking governmental healthcare, as they are responsible for arranging transportation, paying for treatment and other expenses (e.g. accommodation when seeking care in the city), and, due to their comparably higher Spanish proficiency, conversing with government healthcare providers.
Self-treatment with pharmaceuticals purchased in the city
Participants reported that the household head purchased pharmaceuticals from bodegas (small grocery stores) or pharmacies in Yurimaguas. Commonly purchased pharmaceuticals included paracetamol, ibuprofen, aspirin, and vitamins, which are sold without prescription. Two nurse technicians expressed their concerns regarding product quality from bodegas, arguing that these pharmaceuticals could cause allergic reactions or physical discomfort, which could lead to rejection or fear of pharmaceuticals, and consequently affect future treatment choices.
Self-treatment with traditional home remedies
Members of both communities widely used traditional remedies for illness treatment and prevention. Knowledge of traditional remedies was transmitted within families. As one participant explained, “I learned from my mother. I used to watch her preparing the plants and now that I have my own children I do the same things she did” (Woman, 20–30 years old, Community B).
With the exception of families containing a male traditional healer or herbalist, women were primarily responsible for planting and maintaining medicinal plants, as well as making traditional remedies.
Traditional health practitioners
Participants classified traditional health practitioners into three groups: vegetalistas (herbalists), curanderos or brujos (healers), and penunturu’sa (shamans).
Participants described that herbalists can recognize and use dozens of medicinal plants for remedies. This knowledge could be obtained from several sources including attending government courses on phytotherapeutic remedies that were offered from 1990 to 2001, observing other herbalists, or asking spirits who manifest their teaching through dreams. As one traditional health practitioner explained,
When my children are sick, I ask the spirits to help me. In my sleep they show me what plants to use, how to prepare them, and where to get them. The next day, I go to the monte [woods] and I find the plants they showed. I remember [the spirits´] instructions and test the remedies with my kids. Then people ask for my help. Herbalist, Community B
Some herbalists reported including pharmaceuticals in their preparations, including mixing coconut water with Sal de Andrews to treat fever, and paracetamol to treat headaches.
In contrast to herbalists, healers reportedly relied on a combination of traditional remedies and alternative methods for treatment. Healers were viewed as experts in restoring energy imbalances and extracting dark energies from people’s bodies. Tobacco is the preferred tool used during healing sessions to purify the surroundings, provide protection, and/or extract unwanted energies from an affected person. Along with the ícaros (songs performed during healing rituals), healers smoked the tobacco on the patient’s energetic points (temple, forehead, heart, back, and hands) or where the illness was located, to alleviate pain and heal the body and spirit.
Shamans were also considered healers, but, as distinguished by participants, have stronger powers and can use spirits’ powers to heal others. Participants described that shamans diagnose and treat illnesses using a variety of plants, including the Ka’pi’ or Ayahuasca (Banisteropsis caapi). Participants explained that shamans learn through visions and dreams that the initiates experience while dieting; success in healing and the level of power and knowledge acquired was reported to depend on the length of the diets and the number of plants ingested. Few community members become shamans due to the extensive commitment and sacrifice required. As described by participants, in the previous years, 14 Shawi shamans were killed around Balsapuerto, allegedly for sorcery, political, religious, and racist reasons, and as punishment for the district’s high infant mortality rates [30]. The low availability of shamans was partly attributed to these incidents, since shamans were reportedly hiding their powers for fear of being mistaken for sorcerers, who have the power to make people sick. Shamans were located in a variety of communities, ranging from one to 8 days away.
When visiting local traditional practitioners, female participants described that, although not mandatory, the presence of their husband was preferable. When seeking treatment from a shaman in an adjacent community, spouses often travelled together, as the male was responsible for payment.
Health-seeking behaviour pathways
Participants were asked to provide a detailed description of their HSBs for ‘common’ ailments (e.g. diarrhoea, calentura (increased body heat)). For such illnesses, more than three quarters (A: 82%; B: 77%) of households’ primary HSB was self-treatment with traditional home remedies (Fig. 2). As one mother described,
When my children get sick I always give them plants. I use malva for fever. [ … ] Now we have longer summers and children get overheated. I wet their heads with malva chapeada and in one night they feel better. Woman, 30-40 years old, Community A
Conversely 18% of households in each community reported using governmental healthcare as their primary HSB due to their limited medicinal plant knowledge.
If the first strategy was deemed unsuccessful, approximately three quarters (A: 73%; B: 79%) of households reported subsequently visiting a governmental health facility. Participants explained that if medicinal plants were not curing the ailment, then pharmaceuticals from the health post were trusted.
As a tertiary HSB, 56% of households in Community A returned to self-treatment with traditional home remedies, compared to 31% of households in Community B. In contrast, more than half (56%) of Community B households consulted a traditional practitioner as a tertiary HSB, compared to one third (33%) of Community A households.
When considering all stages of HSBs, only one household in Community A used neither traditional home remedies nor a traditional practitioner due to not believing in their efficacy. Only one household in Community A reported never having used pharmaceuticals. It is noteworthy that although all households reported several HSBs, almost all households cited using treatments sequentially rather than in parallel.
Factors influencing health-seeking behaviours
Households’ decisions regarding primary HSB were based on a variety of factors, including: illness type, perceived aetiology, perceived severity, and treatment characteristics.
Illness type
Local concepts of illness type were a major determinant of primary HSBs. Traditional home remedies were considered the main option for preventing and treating everyday maladies. Visiting a governmental health facility was also considered effective for everyday illnesses; however, participants preferred using medicinal plants when possible. Healers were sought for unknown illnesses, which caused unbearable pain, and for treating children affected by susto (acute fear) and cutipados (spirits of the forest). In contrast, shamans were considered to be the only effective treatment option for serious unknown illnesses, or other traditional illnesses caused by spirits or sorcery, including daño (harm caused by sorcery). It is important to note, however, that participants described that good traditional practitioners would acknowledge the limitations of traditional medicine and recommend what is best for the patient. As one man explained, “Sometimes I consult [community’s healer] and if he knows he cannot cure me, then he tells me that I should go to the health post.” (Man, 40–50 years old, Community A). As such, although participants may initially seek a healer, they may be referred to a governmental health post.
Governmental healthcare was perceived to be most effective for treating ‘new diseases’, physical ailments, and pain. ‘New diseases’ included AIDS, yellow fever, cancer, cholera, and the flu, for which no traditional remedies exist. Although participants mentioned the existence of traditional remedies for malaria, most acknowledged that pharmaceuticals were more effective. Governmental healthcare was also often sought for pregnancy check-ups, childbirth, contraceptives, and monthly child check-ups. However, according to a health technician, this was typically only to collect JUNTOS money, a national cash transfer program that pays families if mothers have regular pregnancy appointments and children have regular health check-ups and attend school.
Perceived illness aetiology
Local concepts of illness aetiology contributed to HSBs due to the differing perceived effectiveness of treatments for particular causal factors. This was best exemplified by the differential HSBs for childhood diarrhoea between the two communities. In Community A, households reported that ingesting microbes from contaminated river water caused the majority of diarrhoea cases, and that this was best treated with pharmaceuticals from the health post. This knowledge reportedly originated from radio advertisements or from the community’s herbalist who had been taught by government staff. In contrast, in Community B, diarrhoea was ascribed to more traditional explanations such as eating unripe fruits or spending too much time in the water under the sun. Traditional remedies were seen to be more effective in these cases. Households in both communities cited healers as the best treatment option for diarrhoea cases caused by heated breast milk due to a mother spending the day working under the sun, sorcery (which is marked by sudden diarrhoea, vomiting, and pain), or spirits (which may be the result of a snake looking at a mother carrying her child). Additionally, participants from both communities described seeking a healer’s help if the cause of diarrhoea were unknown or if initial treatment with traditional remedies or pharmaceuticals was unsuccessful. One herbalist described,
Sometimes a person can confuse diarrhoea caused by heat with a diarrhoea cause by cold. That’s why one should consult a good healer. If you give the patient a plant boiled in hot water without knowing that the diarrhoea was caused by heat; then it will make the patient feel worse. That heat worsens the diarrhoea. I can tell the type of diarrhoea by measuring the person’s pulse. When it is caused by heat, the pulse is like if you had run. It’s really fast. If it is caused by cold, the pulse is really slow. Herbalist, Community A
Perceived illness severity
For certain ailments, perceived severity dictated the preferred treatment. For example, certain households reported that traditional remedies were effective for diarrhoea, unless there were more than ten stools in a day, in which case pharmaceuticals were required.
Treatment characteristics
Most households reported that traditional remedies were more effective than pharmaceuticals (A: 80%; B: 54%) for common ailments, which was reflected in the predominant preference for traditional remedies (Fig. 3). Widely reported reasons for this preference included that traditional medicines are fresh, natural, and treat the root cause of the disease, whereas pharmaceuticals were believed to hide pain rather than actually heal the patient. Nevertheless, due to the lengthy time required to make some traditional remedies or the occasional need to adhere to a strict diet while using these remedies, some households used pharmaceuticals as an easier alternative:
I’ve had gastritis for 8 years. There was a time when I was feeling well. I was taking the plants that the brujo recommended, but I couldn’t eat meat or drink my masato [traditional beverage]. I couldn’t do it [follow the restrictions]. I like my wife’s masato. Man, 40-50 years old, Community B
Similarly, households described a strong taste associated with many traditional remedies, whereas pills were “tasteless and easier to swallow”. Pills were, therefore, often preferred for children who may spit out traditional remedies. In contrast, several participants questioned the taste of medicinal syrups, arguing that such a sweet taste could start or worsen diarrhoea.
Perceived healthcare barriers
During interviews, households were asked to discuss barriers to obtaining healthcare; participants focused primarily on governmental healthcare. Barriers were classified according to lack of healthcare availability, accessibility, affordability, and acceptability [11].
Availability
The restriction of secondary and tertiary care facilities to urban centres was a commonly cited barrier with respect to healthcare availability. Participants from both communities also reported frequent absence or shortage of health providers at the health post, which a health technician described as being partly attributable to a difficulty in retaining health personnel, since few doctors enjoy jobs in remote communities. For example, one health technician explained that,
The obstetrician in charge only stayed here for one year. He got a better job in the city and now the post has no director. There’s only me and [a community member that cleans the post]. No one wants to work here. Health technician
Further dissatisfaction with governmental healthcare stemmed from insufficient pharmaceutical supplies: at times, participants reported visiting the health post and being sent away due to medications being out-of-stock. Comparatively, traditional healers and herbalists were considered as being almost always available. Moreover, even in the absence of a traditional practitioner, most families could prepare basic traditional remedies, thus rendering traditional medicine more available than governmental healthcare services.
Accessibility
Physical access to care was a barrier for many healthcare types. Households that needed to cross the river to access the health post reported occasionally foregoing governmental healthcare, even if it was the preferred option, due to the geographical barriers. Similarly, a nurse technician described that most sick patients are unable to make the long journey to the secondary healthcare facility and are therefore referred directly from primary to tertiary care. However, travelling to Yurimaguas for tertiary care remains challenging, especially for households in Community B: “People die here because it is too difficult to get to Yurimaguas” (Woman, 40–50 years old, Community B). Travelling to Yurimaguas in the summer, when the river level was low, required patients to be carried on a locally constructed stretcher. This journey could take upwards of 6 h, thus increasing the risks of complications and resulting in community members dismissing this option in favour of care in the popular or traditional sectors:
“Both plants and pharmaceuticals work well. The plants, the difference that there is [with pharmaceuticals] is that I can just take them from the monte, with no cost. They are more accessible. The pills … sometimes the river is too big [and I cannot get to the health centre] or the technician isn’t at the health centre.” Man, 40-50 years old, Community B
Although fluvial transportation is possible during the winter when the river level rises, high fuel costs, low fuel availability, a lack of motorboats, and a lack of money to pay for road transportation services following the boat ride render this option impossible for most households.
It is interesting to note, however, that many participants described that some of the best and most powerful shamans are located in Chazuta district, which is a four-hour drive from Yurimaguas. Although visiting a shaman could take days of travel, participants did not cite this as an accessibility barrier.
Affordability
Almost all members of both communities were insured by the SIS, and could therefore receive subsidized or free governmental healthcare at a designated health facility. Nevertheless, indirect expenses, related to transportation and accommodation, barred access to higher levels of care. Households often reported foregoing necessary care to which they were referred due to an inability to pay for transportation to Yurimaguas. Similarly, a few participants who required specialized treatment in Lima reported that although most of the patient’s travel expenses are covered, no funds were provided for a travel companion. Some participants therefore sought alternative care within the community.
Similar to accessibility barriers, although participants described that the costs associated with visiting a shaman could reach between 400 and 800 nuevos soles (~ 120-240USD), costs of traditional healthcare were not mentioned as a barrier. Several participants even stated that they would spend all of their savings to seek a shaman’s help to treat a case of daño or sorcery.
Acceptability
Participants reported that several characteristics of governmental health facilities presented barriers with respect to healthcare acceptability. All participants noted that the staff’s inability to speak the native language affected their trust and the perceived quality of care. For example, one woman commented,
I want a change in the health post’s personnel. They are all mestizos and when I speak in Shawi, they don’t understand me. Sometimes I cannot understand Spanish, and even if I understand I cannot speak in Spanish. I cannot trust someone I don’t understand. Woman, 20-30 years old, Community B
In Community B, over three quarters of households also reported poor healthcare quality at the health post. Health technicians were not provided with any training regarding working in Indigenous contexts, which participants described as resulting in culturally insensitive staff. Due to these complaints of language barriers, poor treatment quality, and lack of respect, some participants reported avoiding governmental health facilities even if they were not improving with traditional remedies or knew that professional healthcare was necessary.
With respect to higher levels of care, excessive bureaucracy and lack of guidance once having reached the hospital were mentioned as barriers. Although a health technician occasionally accompanied patients to the hospital to personally refer them to a doctor, once alone, participants reported not knowing what to do. The mandatory hospital health forms were another barrier, as they are complicated and in Spanish. This was particularly problematic for women, as their understanding of Spanish was typically more limited than that of men.
