Healthcare and Health Problems from the Perspective of Indigenous Population of the Peruvian Amazon: A Qualitative Study

International Journal of Environmental Research and Public Health Article Healthcare and Health Problems from the Perspective of Indigenous Population of the Peruvian Amazon: A Qualitative Study Bárbara Badanta 1, Giancarlo Lucchetti 2, Sergio Barrientos-Trigo 1, Elena Fernández-García1, Lorena Tarriño-Concejero 1,* , Juan Vega-Escaño 3,* and Rocío de Diego-Cordero 4 1Research Group PAIDI-CTS 1050 Complex Care, Chronicity and Health Outcomes, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain; [email protected] (B.B.); [email protected] (S.B.-T.); [email protected] (E.F.-G.) 2School of Medicine, Universidade Federal de Juiz de Fora, Juiz de Fora 36036-900, Brazil; [email protected] 3Research Group CTS 1054 “Interventions and Health Care. Red Cross, Spanish Red Cross Nursing School, University of Seville, 41009 Seville, Spain 4Research Group CTS 969 Innovation in HealthCare and Social Determinants of Health, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain; [email protected] *Correspondence: [email protected] (L.T.-C.); [email protected] (J.V.-E.) Received: 17 September 2020; Accepted: 19 October 2020; Published: 22 October 2020   Abstract: Indigenous communities usually experience higher levels of mortality and poorer access to healthcare services compared to non-indigenous communities. This study aims to understand the most prevalent health problems and their treatment in the Ash á ninka indigenous communities of the Peruvian Amazon. We conducted an ethnographic study in order to explore the perceived health problems, the use of traditional medicine and the resources offered by the official Peruvian healthcare system. Field notes and semi-structured interviews were used. A total of 16 indigenous and four non-indigenous people were interviewed, and interpretative analysis was used to identify themes. The Ash á ninka community is an overlooked population, which, due to distance restrictions, misconceptions and ethnical disparities, is far away from an appropriate healthcare system and is subjected to acute medical conditions such as infections and gastrointestinal problems. This group tends to seek traditional medicine, mostly herbal medications and traditional healers. The use of a health professional is seen as a last resort. Although the official Peruvian health system incorporates community participation strategies to improve the healthcare of indigenous people, the shortage of material, human resources and cultural sensitivity makes this difficult. Healthcare strategies should be devised and implemented in order to minimize health inequality in this population. Keywords: health inequalities; community-engaged research; culturally appropriate; indigenous; Peruvian Amazon; traditional medicine 1. Introduction According to official numbers, it is estimated that 372,000 indigenous persons live in the Peruvian Amazon region, representing 51 out of the 55 indigenous groups living in Peru [ 1 ]. These indigenous communities suffer more social inequalities than any other group [ 2 ], having higher rates of infant mortality rate, lower access to health services, and worse nutritional status compared to the general population [ 3 – 5 ]. This remarkable inequality leads to several health problems in this population, such Int. J. Environ. Res. Public Health 2020,17, 7728; doi:10.3390/ijerph17217728 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020,17, 7728 2 of 18 as higher levels of gastrointestinal problems [ 6 ], infectious diseases (e.g., tuberculosis) [ 7 ] and poor oral health [8]. Cultural factors seem to have a strong influence on these health outcomes and studies have shown that traditional healers are still the primary source of healthcare for most of the indigenous population in the Amazon [ 9 ]. These healers tend to use plant-, animal- and mineral-based therapies, spiritual healing and manual techniques in order to treat, diagnose and prevent illnesses in order to maintain the wellbeing of their patients [ 10 ]. In a previous study, 83% of the indigenous persons in Loreto (Peru) had used traditional medicine in the previous year and almost 40% had never seen a doctor [11]. Although the use of traditional medicine is common among the indigenous population, the distance to healthcare facilities, a lack of money and a lack of health access provided by the government are the most noted factors that prevent these groups from seeing a doctor [ 11 ]. The Peruvian government offers health services to the uninsured population through Comprehensive Health Insurance (Seguro Integral de Salud, SIS) [ 12 ]. However, the Peruvian Health System (PHS) has serious difficulties in providing health coverage to the indigenous population. A recent study found that only 64.8% of the rainforest population received medical care compared to 73.1% in the general population [13]. These challenges seem to increase when the indigenous population lives in rural communities with difficult access [ 14 ]. Each healthcare facility in Peru has a limited coverage (500 to 800 families) and usually is composed of a physician, an obstetrician, a nurse, nursing technicians and Community Health Agents (CHA). CHAs are usually community persons working as volunteers and are very important figures to make a connection with the traditional healers and to promote treatment for vulnerable populations [15]. All these factors make this population difficult to treat. Therefore, it is important to understand how the indigenous population who live in the Central Jungle of the Peruvian Amazon use their traditional therapies as well as the official health resources to overcome their health problems. It is important to highlight that the Peruvian government does not separate data by ethnicity and, for this reason, little is known about the population living in the rainforest [ 13 ]. This is a potential problem, since the rates of health problems and infectious diseases are not reliable [ 16 ], making this population overlooked in Latin America. Therefore, the objective of the current study was to explore and understand the most prevalent health problems and their treatment in the indigenous Ash á ninka of the Peruvian Amazon. Our research questions were as follows: “What are the main perceived health problems and how does the indigenous Ash á ninka population address them?”, “What are the main factors associated with the use of Peruvian official healthcare services?”, and “Which barriers for healthcare are reported by the indigenous Peruvian population?”. 2. Materials and Methods 2.1. Design A qualitative ethnographic study was conducted in the Amazon region of Peru in South America. We chose a focused ethnographic approach based on Roper and Shapira’s framework (2000) [ 17 ], as this allows us to explore a particular topic of interest in a specific context, and to perform the analysis focusing on subcultural groups rather than on entire societies. This approach is characterized by (a) a conceptual orientation provided by a research team; (b) a focus on a discrete community; (c) a focus on a problem within a specific context; (d) a limited number of participants; (e) the use of participants who may hold specific knowledge; and (f) the use of selected episodes of participant observation [ 18 ]. Data collection consisted of participant observation, field notes, and semi-structured interviews, all conducted by the principal investigator (BB) over three months in 2019. Int. J. Environ. Res. Public Health 2020,17, 7728 3 of 18 2.2. Population and Setting Our study took place in the Central Jungle of the Peruvian Amazon, specifically in 10 areas belonging to the Jun í n and Atalaya provinces (Jun í n and Ucayali departments), all of them situated in the country of Peru (Figure 1). According to the last Peruvian Census, there are 372,000 indigenous persons living in the Amazon region and the districts of Jun í n (35,920 people) and Ucayali (35,920 people) represent 16.9% and 17.3% of the indigenous population in Peru, respectively [ 1 ]. Inside these districts, the provinces of Llaiya and Nopoki are rural villages with indigenous and settler inhabitants, while the remaining areas (i.e., Shonori, San Pedro de Lagarto, Huantashiri, Shintoriato, San Juan de Cheny, Quimiriki, Bajo Capiri and Maranquiari) are native indigenous communities (CC.NN). For the present study, an indigenous person was defined as “the one that descends from populations that lived in the country before the colonial era. They are organised mainly in native and peasant communities and they generally maintain all or some of the customs and traditions” (National Institute of Statistics and Informatics of Peru, INEI). Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 3 of 18 persons living in the Amazon region and the districts of Junín (35,920 people) and Ucayali (35,920 people) represent 16.9% and 17.3% of the indigenous population in Peru, respectively [1]. Inside these districts, the provinces of Llaiya and Nopoki are rural villages with indigenous and settler inhabitants, while the remaining areas (i.e., Shonori, San Pedro de Lagarto, Huantashiri, Shintoriato, San Juan de Cheny, Quimiriki, Bajo Capiri and Maranquiari) are native indigenous communities (CC.NN). For the present study, an indigenous person was defined as “the one that descends from populations that lived in the country before the colonial era. They are organised mainly in native and peasant communities and they generally maintain all or some of the customs and traditions” (National Institute of Statistics and Informatics of Peru, INEI). Figure 1. Map of Peru: Central Jungle of the Peruvian Amazon. Junín and Ucayali departments [19–21]. Healthcare is mainly offered in rural and community settings. The most basic healthcare assistance is located in the closest areas or districts (i.e., Mazamari and Río Negro), while a more specialised care is offered in Satipo (central health network). The rural medical centers that serve the Asháninka population offer general medicine, pediatrics, obstetrics and dentistry services. In addition, the Llaiya center offers a clinical analysis laboratory. Five towns or communities can be accessed by vehicle, and only Huantashiri has a rural primary healthcare center within the community. Other communities have their centers relatively close, and the indigenous population must walk between 10 to 45 min to get into these health facilities (Shonori, Shintoriato, San Juan de Cheny, Quimiriki, Bajo Capiri). Finally, people who live in Maranquiari and San Pedro de Lagarto should take a boat in order to get to the nearest healthcare service, taking between 45 and 90 min. Although the researcher (BB) made an effort to observe most people living in the geographic areas of the study (i.e., children, adults, and older people), the direct participants (i.e., interviewed people) were selected if they were adults (18 years old or more) from the indigenous Asháninka ethnicity, relevant persons in this community and living in the Amazon Peruvian region. The choice of the Asháninka ethnicity lies in the fact that this is the most representative ethnicity in the region (representing a total of 520 communities). Thus, this seems to be an appropriate group to investigate the influence of cultural beliefs on healthcare [22]. Assemblies were held in each community in which, Figure 1. Map of Peru: Central Jungle of the Peruvian Amazon. Jun í n and Ucayali departments [ 19 – 21 ]. Healthcare is mainly offered in rural and community settings. The most basic healthcare assistance is located in the closest areas or districts (i.e., Mazamari and R í o Negro), while a more specialised care is offered in Satipo (central health network). The rural medical centers that serve the Ash á ninka population offer general medicine, pediatrics, obstetrics and dentistry services. In addition, the Llaiya center offers a clinical analysis laboratory. Five towns or communities can be accessed by vehicle, and only Huantashiri has a rural primary healthcare center within the community. Other communities have their centers relatively close, and the indigenous population must walk between 10 to 45 min to get into these health facilities (Shonori, Shintoriato, San Juan de Cheny, Quimiriki, Bajo Capiri). Finally, people who live in Maranquiari and San Pedro de Lagarto should take a boat in order to get to the nearest healthcare service, taking between 45 and 90 min. Int. J. Environ. Res. Public Health 2020,17, 7728 4 of 18 Although the researcher (BB) made an effort to observe most people living in the geographic areas of the study (i.e., children, adults, and older people), the direct participants (i.e., interviewed people) were selected if they were adults (18 years old or more) from the indigenous Ash á ninka ethnicity, relevant persons in this community and living in the Amazon Peruvian region. The choice of the Ash á ninka ethnicity lies in the fact that this is the most representative ethnicity in the region (representing a total of 520 communities). Thus, this seems to be an appropriate group to investigate the influence of cultural beliefs on healthcare [ 22 ]. Assemblies were held in each community in which, after explaining the objective of this study, its members named the most relevant people in their community, offering supporting arguments. The main researcher respected the majority of votes towards those relevant people and their voluntary acceptance to participate. In the present study, a total of 16 indigenous Asháninka agreed to participate. In addition to these participants, researchers opted to include other non-indigenous key informants (which provided different perspectives), in order to corroborate the information obtained from indigenous Ash á ninka. Therefore, the inclusion of other four participants was accepted and in-depth interviews were carried out. The following inclusion criteria were established: living or working in the community, and being considered a relevant adult as determined by indigenous members. In order to include different perceptions and insights, we included a sample of participants with different profiles concerning sex, place of residence, social characteristics, jobs and ethnicity (Table 1). Table 1. Demographic details of participants. Code Indigenous *** Sex Place of Residence Social/Labor Profile I-1 Yes Woman Nopoki (Atalaya) University professor I-2 Yes Woman Shonori Community leader I-3 Yes Woman Shonori Healer I-4 Yes Woman Shonori JASS member * I-5 Yes Woman Quimiriki Traditional midwife I-6 Yes Man Llaiya Agricultural Technician I-7 No Woman Llaiya Doctor I-8 No Woman Llaiya Pediatrician I-9 Yes Woman Satipo (Junín) Coordinator of a residence for students I-10 No Woman Huantashiri Doctor I-11 Yes Woman Huantashiri CHA ** I-12 Yes Woman San Pedro de Lagarto Secretary I-13 No Man San Pedro de Lagarto Priest I-14 Yes Man San Pedro de Lagarto Project technician I-15 Yes Man San Juan de Cheny Cocoa producer I-16 Yes Man Maranquiari Community leader I-17 Yes Woman Maranquiari CHA ** I-18 Yes Woman Bajo Capiri Agricultural Technician I-19 Yes Man Bajo Capiri Community leader I-20 Yes Woman Shintoriato JASS member * * JASS: Sanitation Services Administration Board (Junta de Administraci ó n de Servicios de Saneamiento), ** CHA: Community Health Agents, *** Indigenous: An indigenous people is one that descends from populations that lived in the country before the colonial era. They are organised mainly in native and peasant communities and they generally maintain all or some of the customs and traditions (National Institute of Statistics and Informatics of Peru, INEI). 2.3. Procedure Purposive and snowball sampling were used to select the participants [ 23 ]. They were identified and invited by the main researcher, who is a nurse with expertise in transcultural nursing and health inequalities. She started working in the field of International Development Cooperation in these areas, specifically monitoring and evaluating projects for housing adaptation, agricultural production and child health, identifying health problems for women and girls (all this projects were demanded by the communities themselves). She also met and lived inside some Ash á ninka communities. In this Int. J. Environ. Res. Public Health 2020,17, 7728 5 of 18 study, the main researcher maintained a guest role, expressing interest in the traditional approach to health problems, but not serving the community members as a nurse. A certain educational level or age was not required on behalf of the nurse. The focus was on participants’ shared behaviors and experiences and for this reason, we worked under the assumption that they would share cultural perspectives, even if they did not know each other [ 17 ]. In line with a focused ethnographic approach [ 17 , 24 ], observations were performed as part of the main researcher’s everyday work and occurred at selected times of the day, inside the researcher’s communities. Observational data were recorded as handwritten field notes, focusing on common characteristics from all geographic areas, the available health resources, and how the participants dealt with their health problems. All of those aspects were agreed upon and accepted by members of the communities here studied. Field notes included information about witnessed events, verbatim verbal exchanges, and the researcher’s personal interpretations of events. Informal conversations and the interviews allowed the researcher to examine if interpretations of meanings behind observed behavior coincided with participants’ own understanding. Participants were asked to evaluate the material and their responses were analyzed and added. A total of 20 interviews were carried out face-to-face (one per participant without repetitions), in Spanish, and they lasted 30–60 min. Although Ash á ninka is the local language of the indigenous participants, Spanish is the official language of Peru, and both the indigenous and non-indigenous participants and the main researcher shared this characteristic. They were audiotaped by the main researcher, transcribed verbatim by two researchers, then translated into English by a translation company. Data collection continued until data saturation was reached. Informed consent was obtained from all participants and the researcher also obtained the approval of the indigenous community leader, the local non-governmental organization and the public administration of the departments where the study was carried out. 2.4. Instrument The interview script was based on the idea that the most common health problems of this population are related to living conditions and that the indigenous population alternates the use of traditional medicine with official government healthcare. An expert panel, using the Delphi method, carried out an analysis of the content of the script to assess its appropriateness and the collection of data was carried out in the period between January and March 2019 [ 25 ]. Assessment of the initial script by the panel was done online in two rounds. In addition, a pilot testing of the interview guide was done to confirm its coverage and relevance, to test its implementation and to identify the need to reformulate questions. Six indigenous Ash á ninka (3 men and 3 women) attended for two days and the local Non-Governmental Organization (NGO) that works in the area participated. The interview script included information on sociodemographic characteristics (indigenous group, sex, place of residence, social and labor profiles and ethnicity). All interviews were conducted using open questions starting with the following: How is the health of people living in your native community? What kinds of diseases are most common among children? And among adults? What factors have an influence on the health problems experienced by the people in your community? What is usually done when a person is sick? How is traditional medicine used? For what kind of problems? How is the official healthcare system accessed? What services are provided to you? Do you experience any barriers to access the official healthcare system? In the case of non-indigenous respondents, the questions were based on their knowledge concerning the native population they work with. Int. J. Environ. Res. Public Health 2020,17, 7728 6 of 18 2.5. Data Analysis The qualitative analysis was carried out following the steps proposed by Braun et al. [ 26 ]: (1) familiarity with the data; (2) generation of categories; (3–5) search, review, and definition of themes; and (6) the final report. Transcription, literal reading, and theoretical manual categorization were performed and the NUDIST Nvivo (version 12, University of Seville, Seville, Spain ) software was used. Data analysis started with a thorough reading of the information collected (field notes and interview transcripts) in order to ascertain an overview of the respondents’ experiences and to gain an understanding of the content. This was done by two researchers. The analysis continued by organizing descriptive labels, focusing on emerging or persistent concepts and similarities/differences in participants’ behaviors and statements. The coded data from each participant were examined and compared with the data from all the other participants to develop categories of meanings. In addition, 2 participants checked the results. They were asked to evaluate material through open-ended responses and their proposals were analyzed and added. Finally, the different categories were gathered (grouped) under two main themes: “Health problems” and “Health practices”. The categorization and coding of the data are shown in Table 2. Table 2. Emergent themes, categories and subcategories. Theme Category Subcategory Description Health Problems Health Problems Diseases diagnosed Signs/symptoms The health problems reflect alterations of a bio–psychosocial–spiritual nature identified by the indigenous population and health professionals. In addition to signs and symptoms, perceptions of the causes of health problems or certain factors that contribute to perpetuating poor health conditions are also incorporated. Attributed Related Factors - Health Practices Traditional care Self-care at home Traditional specialized care The use of traditional medicine includes all those popular health practices, preventive, curative or palliative derived from beliefs, customs and ancestral knowledge, not associated with the usual practices of care of Westernized health systems. It also includes care providers, either at home or outside, such as specialized health agents (e.g., healer, midwife or huesero *). Health professionals have a perception about the health problems of the indigenous population and their methods of approaching these issues. The official health system uses strategic mechanisms to care for indigenous people and faces weaknesses that make care difficult. Official health system Use of the official health system Strategies for attention Weaknesses/barriers to healthcare * This is a traditional healthcare provider specialized in the treatment of musculoskeletal system problems. The professionals of the Peruvian health system attribute similar characteristics to that of the traumatologist in Western medicine. 2.6. Trustworthy This research followed The Consolidated Criteria for Reporting Qualitative Studies (COREQ) [ 27 ]. The methods used for guaranteeing quality were data triangulation, including participants with different sociodemographic characteristics, and the triangulation of data analysis via different researchers (see the Supplementary Material Table S1). Int. J. Environ. Res. Public Health 2020,17, 7728 7 of 18 2.7. Ethical Considerations The study was approved by the Andalusian Research Ethics Committee (Code: 1469-N-19). All participants received written and oral information about the study, including the right to withdraw and a guarantee of anonymity. Data were anonymized by removing names/locations and by changing details. Interview transcripts and audiotapes have been kept in locked files. Persons not involved directly in the study were not interviewed or identified in any analysis. 3. Results The native communities of this study are composed of indigenous Ash á ninka families living in the Central Jungle of the Peruvian Amazon. A common feature of these families is their dedication to agriculture, making their farmland (chacras) their main source of income. Unfortunately, little income is provided by this activity, having a negative impact in the acquisition of uncultivated food. The lack of resources seems to be responsible for the high rates of acute diseases in this population, mainly related to gastrointestinal and pulmonary problems. In order to treat these problems, our participants report that they use traditional therapies, administered by family members or specialized people such as local healers. 3.1. Health Problems Health problems were an important category presented in our analysis. Statements included some factors associated with the prevalence of disease in children and adults (Table 3). Although specific health problems were mentioned, there is a general idea that indigenous persons have a poor health condition (“we are all sick, we are not healthy”) and that their economic situation may interfere with healthcare access and the proper treatment of these diseases. Table 3. Main health problems perceived and related factors by indigenous people and health professionals. Health Problems Statements (n) Attributed Causes/Related Factors Respiratory problems 16 I-2; indigenous, woman, community leader “We get the flu from people who come from other places, but we don’t take care of ourselves either”. I-4; indigenous, woman, JASS member “When it rains we get wet and because of the distance we have to walk to the post, our body heats up and we get the flu. I was until last week almost 15 days wrong”. I-7; non-indigenous, woman, doctor “We also cannot improve the situation of respiratory infections if we do not have the influenza vaccine for adults”. I-17; indigenous, woman, community health agent “We all needed housing here, when the wind blows strong our entire roof flies and the rain wets our bed”. I-8; non-indigenous, woman, pediatrician “There is quite a lot of overcrowding, they all live together with their little animals inside, they cook with coal and their room is next door. There is no smoke elimination, so that in the long term will affect them with respiratory infections”. Gastrointestinal infections 15 I-18; indigenous, woman, agricultural technician “Sometimes we work in the farm with the machete and when we rest we grab our coconut (refered to using the same machete) and of course, this is how gastritis appears”. I-11; indigenous, woman, community health agent “We are improving on not consuming cold water [referred to water without boiling] because it contains several parasites, so sometimes children get sick from the belly”. Int. J. Environ. Res. Public Health 2020,17, 7728 8 of 18 Table 3. Cont. Health Problems Statements (n) Attributed Causes/Related Factors Malnutrition and childhood anemia 11 I-20; indigenous, woman, JASS member “Fish farming is not constant; neither is the daily protein consumption or that of other necessary nutrients habitual”. Musculoskeletal problems 8 I-7; non-indigenous, woman, doctor “Due to continuous work in the farms, older patients have muscle contractures and arthralgic problems. I tell them they have to rest but they tell me they can’t because they eat that” (they feed from that). Other health problems Oral: 4 Ophthalmological: 4 Teenage pregnancies: 7 Injuries, accidents: 5 I-6; indigenous, man, agricultural technician “Everyone here has teeth problems. The dentist says there are some special toothbrushes for babies, but they cost expensive and we can’t afford it”. I-10; non-indigenous, woman, doctor “I detect quite a lot of cataract problems, because the sun is very strong here and it affects a lot, so I am warning them and they are spreading the word. But when they come I find them wrong because nobody tells you anything, they think it’s normal with age”. I-19; indigenous, woman, JASS member “The last time I went to the doctor was because I cut myself with a knife working on the farm. They had to sew my hand”. Participants (both indigenous and non-indigenous participants) have agreed that gastrointestinal infections and respiratory problems (i.e., flu, sore throat and runny nose, that occur mainly in the winter) are important problems in the indigenous community. In the case of children, they often suffer from colds, pneumonia and fever complaints, the latter being recognized by indigenous mothers as a disease. All these respiratory infections seem to be related to the low vaccination rates and the poor housing conditions (i.e., houses are not adequate for the climate conditions faced in the rainforest). Gastrointestinal infections also appear frequently in most statements and are mostly linked to the poor sanitation and the lack of hygiene. The first author observed that, when indigenous persons work in the cocoa plantations, they commonly eat fruits by bringing their hands to their mouth without washing them. Another important problem reported by health professionals was the fact that indigenous communities did not have treated water. In fact, there were no water chlorination systems nor storage reservoirs in this region and the indigenous persons chlorinated their water only when the municipality provided them with the resources. Likewise, few people boiled water for consumption and there was a lack of information concerning the contamination of water. As an example, the principal investigator commonly observed that indigenous persons used water from the same spot where they showered themselves or washed clothes. Due to this lack of hygiene, high rates of malnutrition and chronic childhood anemia are also observed in children, probably as a consequence of the constant diarrheal episodes and certain nutritional deficits (I-8; non-indigenous, woman, pediatrician) “We have achieved a 50% reduction in malnutrition, but I must recognize that more than a year ago, it affected 100% of the children in this community”. During participation in public health campaigns in three communities, the principal investigator observed that parameters such as height, weight, and blood hemoglobin levels were all lower than expected in the pediatric group. Other sources of infection noted in these communities were caused by bacteria (e.g., cystitis), insects and parasites. In most situations, a lack of hygiene was considered to be responsible for the infection: (I-7; non-indigenous, woman, doctor) “People lack personal hygiene, they don’t bathe much. I check them and sometimes the pant is not clean, or there is a rotten smell”; (I-10; non-indigenous, woman, doctor) “Sometimes the population itself is not aware that hygienic conditions can be the source of health problems, they think they have a virus but not that it is due to their hygiene”. Int. J. Environ. Res. Public Health 2020,17, 7728 9 of 18 All health professionals interviewed agree that skin infections are also common problems in these communities. Scabies are associated with the overcrowding of people in homes, and leishmaniasis is linked to the presence of insects and the absence of preventive measures, such as repellents or mosquito nets. In general, houses were built with low-durability materials (i.e., wooden slats with openings between them that allow the entry of vectors and water) and these conditions perpetuate the presence of mosquitos. Other prominent health problems are musculoskeletal, unwanted pregnancies and cancer. Musculoskeletal conditions among adults are attributed to daily work activities carried out for years, with forced postures that increase the risk of bone pain and contractures. Unintended pregnancies are another remarkable problem, being reported even in 11-year-old girls, and complications during childbirth and vaginal tears are also commonly observed. The poor prenatal control and the hygienic conditions in which childbirth takes place could be related to some cases of neonatal sepsis attended by the health staff. Cancer, sometimes called “lumps” by indigenous people, also begins to affect these communities. Specifically, health professionals mention cases of prostate, stomach or breast cancer. In the Shonori community, the healer talked about her newly diagnosed breast cancer: (I-3; indigenous, woman, healer) “It hurts this part of my breast and a doctor told me to take a radiograph and that I have a principle of small malignant tumor. I noticed it because especially when working, it hurts a lot, when I take the machete”. The indigenous population also mentions “non-physical” health problems, known as “spiritual problems”. Different girls and the coordinator of a residence for students reported continuous episodes of spiritual suffering that affected several of their partners: (I-9; indigenous, woman, coordinator or a residence for students) “She was as if awake, but sleeping. She said she saw a person who was suffering and wanted to kill her. Some men came and could not control her. This started with a girl, and then with another and another. They say that sometimes this person still chases them and they see him and they get scared”. 3.2. Health Practices The information obtained from the participants’ observation, informal conversations and interviews have allowed the researchers to understand the different “levels of care” that are used by the indigenous communities to address their health problems. The first level of care in this community is the use of traditional medicine, which can be homemade or provided by a specific healer. In the case of an unsuccessful treatment, participants search for the second level of care, which is provided by the health professionals of the official Peruvian healthcare system. 3.2.1. Traditional Medicine As reported previously, the first level of care for the indigenous community is the use of traditional medicine. Indigenous persons tend to use plants as the first level treatment, but the types and amount of plants used can vary significantly according to the community studied. While some medicinal plants are used as crushed ointments or poultices (e.g., chupasangre against bumps or the leaf of tobacco for wound healing), other seeds are ingested, such as yahuar piri piri for the treatment of intestinal infections and bloody diarrhea. Another method of preparation is boiling in water, as in the case of oregano for heavy digestion or stomach pain. Some of them may even have different application options, such as sangre de grado: (I-12; indigenous, woman, secretary) “tears serve for all inflammations and healing. It is also taken for the gut, as antiseptics, for operations. You can apply directly or drink 2 or 3 drops in a glass of water, no more because it is very strong”. In other cases, traditional medicine could also include animal remedies. This is the case of the gall of the majaz (large rat of the bush), whose use for a year provides contraceptive protection. Other animals are used as antidotes; for example, the river shrimp (camar ó n de rio) for scorpion stings or the termite comején for certain butterflies’ bites. Int. J. Environ. Res. Public Health 2020,17, 7728 16 of 18 Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Acknowledgments: The authors want to thank all the indigenous communities for welcoming and participating in this study. 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