Problems perceived and experienced by health professionals rendering social service in Ancash , Peru . 2015

1 Universidad Peruana Cayetano Heredia CRONICAS Center for Excellence in Chronic Diseases Lima Peru. 2 Universidad de San Martín de Porres Centro de Epidemiología Clínica y Medicina Basada en Evidencias Lima Perú 3 Regional Health Directorate of Ancash Regional SERUMS Coordination Ancash Peru. 4 Universidad Peruana de Ciencias Aplicadas Faculty of Health Sciences School of Medicine Lima Perú. 5 Universidad Científica del Sur Research and Development Directorate Lima Perú.


Introduction
Given the inequities in the distribution of human resources in health, many countries establish social service policies, which encourage, condition or force health professionals to work in areas with poor access to health services to serve the most vulnerable populations (1)(2)(3).In Latin America, the obligatory nature of social service has been discussed in publications of Colombia (1), Mexico (2) and Peru (3).
In Peru, social service in health is known as Rural and Urban Marginal Health Service (SERUMS in Spanish) and the professionals who render their services are known as serumists.SERUMS regulates the practice of physicians, dentists, nurses, obstetricians, chemistpharmacists, nutritionists, medical technologists, social workers, biologists, psychologists, veterinarians and sanitary engineers.Rendering SERUMS is mandatory to apply for positions in public entities, study professional specialization programs in Peru, and receive scholarships or other equivalent aids from the State (4).
SERUMS has managed to locate health professionals in many rural and remote areas of Peru.However, serious problems for professionals have been reported when rendering their services, such as the mandatory nature of the service, risky working conditions and real danger of death (3).In addition, studies carried out in physicians who render SERUMS have identified poor health insurance (5) and high mortality due, to a great extent, to traffic events (6,7).
In spite of the relevance of these problems, studies on serumists are scarce and have focused only on physicians.Due to the lack of information on the frequency of the problems and their risk groups, designing and prioritizing the corresponding interventions is difficult (8).Therefore, this study aims to describe the problems perceived and experienced by serumists in Ancash -Peru, and to evaluate their association with the professional practice of serumists and the category of the facilities where SERUMS is rendered.

Study design and context
An analytical cross -sectional study was carried out applying surveys to healthcare professionals rendering SERUMS in Ancash, Peru.
In Peru, health facilities are divided into first, second and third level of care.First level prioritizes health prevention and promotion, and is divided into four categories: I-1, I-2, I-3 and I-4.Usually, category I-1 includes facilities with few equipment and are found in most rural areas away from reference health centers (9).
SERUMS is regulated by Law 23330 (4), which establishes that it must be rendered in public health facilities of the Ministry of Health (MINSA), Social Security (EsSalud) or the Health Departments of the Armed Forces and the National Police of Peru for a year.Each year two processes are opened to award contracts: one in May (with the highest number of open positions) and another in October (with fewer positions).

Participants
This study included health professionals who were rendering SERUMS at a MINSA facility in Ancash during April 2015.This region was chosen because of the logistical support provided by the Regional Health Directorate of Ancash (DIRESA-Ancash).Working with MINSA health facilities was agreed because more serumist specialists are found there, and contact between them and the SERUMS coordinators, who were in charge of applying the surveys, is more frequent.
DIRESA-Ancash is divided into six geographically distributed health networks: Pacífico Sur (South Pacific), Pacífico Norte (North Pacific), Huaylas Sur (South Huaylas), Huaylas Norte (North Huaylas), Conchucos Sur (South Conchucos) and Conchucos Norte (North Conchucos).Each health network has a SERUMS coordinator, who is in charge of directing the work of the serumist specialists in their network.
During April 2015, 644 health professionals were rendering SERUMS in DIRESA-Ancash: 573 (89.0%) were located in MINSA health facilities, 42 (6.5%) in EsSalud health facilities, and 29 (4.5%) in health facilities of the Health Departments of the Armed Forces and the National Police.
Out of 573 MINSA members, the coordinators managed to involve 364 (63.5%), all of whom agreed to participate in this study.The health network with the highest percentage of respondents was Conchucos Sur (92.3%), and the lowest percentage was observed in Pacífico Norte (23.6%) (Figure 1).

Procedures
DIRESA-Ancash permission was requested to carry out the study and, with their support, the SERUMS coordinators of each health network in Ancash were trained to apply the surveys and respond the questions raised by serumists.The telephone number of the principal investigator was provided in all the surveys so that serum specialists could contact him in case of doubt.
In order to apply the surveys in their respective network, the SERUMS coordinators used two methods: a) applying the survey to serumists in person during meetings and supervision sessions in the health facilities, and b) sending the surveys to the health facilities where the serumists worked.In both cases, the participants used an envelope to submit their answers anonymously.This data collection was conducted throughout April 2015.
Then, two authors typed the surveys twice in the Excel 2010 program (Microsoft Corporation, USA), while a third author verified if both versions coincided.Mismatches were typed again.

Variables
The survey was developed by the researchers and included the following sections: general data such as age, sex, marital status, place where the undergraduate program was studied, financing of the university where the undergraduate program was studied, profession, year of graduation, as well as characteristics of the SERUMS such as type of contract, category of the health facility, process of enrollment in SERUMS (2014-I or 2014-II), at least three months being the head of the health facility, SERUMS problems, among others.
Regarding problems with SERUMS, the survey inquired about experiencing the following during the past month or at some point of their SERUMS: perception of lack of supplies that has prevented the basic management of a patient, some traffic accidents while working or traveling to the health facility, some other accidents (blows, burns, falls, etc.) while working that has caused incapacity for at least a few hours, or some theft while working.
In addition, data on other variables that are not included in this article were collected and will be presented in a subsequent analysis.These variables correspond to the following parts of the survey: difficulty of SERUMS, violence during SERUMS, depressive symptoms during the last two weeks, professional expectations and retention.

Analysis plan
Data analysis was performed using the statistical software Stata v14.0 (StataCorp LP, USA).Central tendency measures, dispersion measures, absolute frequencies and relative frequencies were used for a descriptive presentation of the results.Prevalence ratios (PR) and 95% confidence intervals (95%CI) were estimated using crude and adjusted Poisson regressions with robust variance.p<0.05 was considered statistically significant.
The regression models evaluated the association between five outcomes of interest (excessive workload in last month, lack of supplies in last month, traffic accident during SERUMS, another type of accident during SERUMS, robbery during SERUMS), and two variables of interest (being a physician and rendering SERUMS in a category I-1 health facility).
For multiple regression models, the associations were adjusted for sex, age, undergraduate studies in Ancash, years passed since graduation until starting SERUMS, having a remunerated SERUMS contract, having served as head of the health facility for at least three months during SERUMS, rending SERUMS at an I-1 health facility, and being a physician.

Ethical considerations
The project was approved by the Ethics Committee of Hospital Nacional Docente Madre-Niño San Bartolomé (RCEI-40).Surveys were voluntary and anonymous, so participants signed an informed consent.The confidentiality of the collected data was preserved.

Results
364 surveys were applied to professionals who rendered SERUMS at MINSA facilities in Ancash in April 2015.79.3% were female, the mean age was 27.4±5.0,75.0% were single, 70.1% studied an undergraduate program in a university of Ancash, 45.6% were nurses, 24.3% were physicians, 47.4% entered the SERUMS just after graduating, 79.5% were rendering SERUMS in an I-1 health facility, and 81.5% were rendering SERUMS and being remunerated (Table 1).
When evaluating the problems faced by serumists during their service, it was found that 80.0% perceived that they lacked the necessary supplies for the basic management of a patient, and 51.6% perceived it during the last month.54.4% perceived that the workload was excessive at some point, while 28.8% perceived it in the last month.14.7% suffered some traffic accident during SERUMS while working or when traveling to their workplace, and 4.0% suffered it in the last month.26.2% suffered other accidents (bumps, burns, falls, etc.) during SERUMS, which made them unable to work for at least a few hours, and 9.3% suffered an accident during the last month.12.4% were robbed during SERUMS activities, and 9.3% was robbed during the last month (Table 2).
When evaluating the association between variables in the adjusted model, it was observed that rendering SERUMS at an I-1 health facility was associated with traffic accidents (PR=2.64;95%CI: 1.00-6.99)and to suffering another accident during SERUMS (PR=2.81;95%CI: 1.26-6.26).Similarly, being a physician was a factor associated with suffering another accident during SERUMS (PR=1.66;95%CI: 1.00-2.75)(Table 3).
Joined SERUMS during the 2014-I process (May) * 237 (66.0) Paid service agreement for rendering the SERUMS † 290 (81.5) Chief of the health facility for at least three months 118 (32.9) * The others entered during the 2014-II process (October).† The others had an equivalent contract (ad honorem).Source: Own elaboration based on data obtained in the study.

Discussion
Excessive workload 54.4% of respondents perceived that the workload during SERUMS was excessive at some point, while 28.8% perceived it in the last month.These high figures could reflect the lack of staff in the health facilities where SERUMS is rendered, as well as inadequate training of serumists or lack of support from senior staff of the health facility.
Serumists often have little work experience.In addition, they must perform administrative and institutional management tasks for which they may not have adequate preparation during undergraduate training.It is therefore necessary to explore this workload and to evaluate proposed solutions such as telemedicine -which has proven to be effective to reduce the burden on health professionals working in rural areas in other countries- (10) or different training methods to assist serumists in their clinical and administrative work.
Lack of supplies 51.6% of the respondents said that the lack of supplies hindered the fulfillment of their duties some time during the last month.These shortcomings are characteristic in rural health services worldwide, especially in low and middle-income countries.They usually occur because budgets prioritize urban areas, while the budget allocated to rural areas is misapplied under the belief that these areas are "small cities" and that their health facilities are supplied in the same way as urban areas (11,12).
In Peru, first level health facilities are designed to carry out mostly promotional and preventive activities and to manage a small group of pathologies, deriving the most complex conditions to higherlevel health facilities (13).However, this is not always possible due to the patients' fear, their economic status, the need for immediate action, the distance from higher-level health facilities or their denial to receive patients.These situations force health professionals to treat pathologies for which they do not have enough supplies (14,15), and to provide suboptimal care that ends up promoting health inequity in rural areas (12).
To intervene this inequity, it is necessary to study in depth the lack of supplies and the best ways to overcome the situation.A recent qualitative study indicates that the interviewed serumists require diagnostic tests for specific decisions such as making a differential diagnosis between malaria and pneumonia in the jungle (14).These studies would identify the particular needs of each region and guide an efficient investment in supplies that could be used in rural areas (16).
In addition, it is important for health personnel at all levels of care to know what kind of pathologies they can treat in the health facilities where they are working and how they should refer patients to the next level of care.These issues could be assessed during pre-SERUMS training (17,18).

Figure 1 .
Figure 1.Serumists from the Ministry of Health surveyed in each of the six networks of the Ancash Regional Health Directorate.Source: Own elaboration based on the data obtained in the study.

Table 2 .
Problems perceived and experienced sometime during SERUMS and sometime during the last month.

Table 3 .
Variables observed and their association with working in a category I-1 health facility or being a physician.Adjusted for sex, age, university region, year of graduation (delay), equivalent contract, head of health facility and profession.‡ Adjusted for sex, age, university region, year of graduation (delay), equivalent contract, head of health facility and health facility category.Source: Own elaboration based on data obtained in the study.