National Institute of Environmental Health Sciences

By CJ Reuland

Puno, Peru, a city of around 130,000 residents, is located on the highest navigable lake in the world, Lake Titicaca, at 12,500 meters above sea level in the Andes Mountains. Before the invasion of the Spanish, the land was inhabited by the Aymara and Quechua peoples, whose languages are still spoken in Peru today, particularly in the rural areas surrounding Puno. With these ancient languages, the Indigenous cultures and traditions of the Aymara and Quechua peoples also persist.

The communities we visited for my study were often proud representatives of these cultures. Families frequently wore traditional clothing, farmed ancient grains like quinoa, and lived nearly independently of the city of Puno. Cooking and heating were derived from the burning of biomass fuels, a practice that has been shown to increase household air pollution (HAP) and negatively affect various health outcomes. ¹ , ² , ³ , ⁴

The Household Air Pollution Intervention Network (HAPIN) trial randomized households to exclusive use of either biomass fuels or liquified petroleum gas - a safer alternative to burning biomass - for cooking and heating throughout pregnancy and the child's first year of life to assess health outcomes in women and children based on HAP exposure. ⁵ My study focused on a cohort of children from the Peru arm of the HAPIN trial, comparing growth, development, and anemia between the two groups, hypothesizing that there would be increased stunting, anemia, and delayed psychomotor development in the group using biomass fuels.

We measured height, weight, and hemoglobin, and performed psychomotor assessments of children, 2-3 years old, who had been born into HAPIN. We found the biomass group had a higher prevalence of growth stunting and anemia than the intervention group, though the trend was not statistically significant. The psychomotor outcomes, however, were more difficult to assess and interpret.

A team of five interviewers, including myself, two psychologists, and two nurses, were trained in administration of the Bayley Scales of Infant and Toddler Development - a test of cognitive, language, and motor domains developed and validated in American children and translated into Castilian Spanish. ⁶ This test was used for a study in Iquitos, a northern jungle region of Peru, with some modifications based on local dialect (for example, substitution of the word "carro" for "coche" when asking the kids to identify the car on a page of sketched objects). Even when our team employed these alterations, there were items that were consistently missed by our cohort. I learned that the Spanish word for car more commonly used by our participants was "titi." We encountered other issues with the test; for example, some items required children to identify a person using a vacuum cleaner or a laundry machine - concepts completely foreign to most of our cohort - and some children spoke more Quechua or Aymara than Spanish. We adjusted our exam based on these difficulties and started to use the word "titi" in addition to "carro," avoided the items focused on foreign technologies, and our Quechua- and Aymara-speaking nurses translated as needed.

These modifications and inconsistencies make it difficult to interpret our results. When analyzing each Bayley domain independently, the biomass group performed significantly better than the intervention group in the language and cognitive domains, with no significant difference for the motor domain. Importantly, we found large interviewer differences (native Spanish speakers and nurses awarded higher scores on average). As we continue to analyze our results with multivariate analysis, I am reflecting on the number of ways that our assessment could have been improved to be more culturally appropriate.

Though these misalignments between our selected test and our participants' realities of life make analysis of our results difficult, they also gave me a unique opportunity to learn about rural Andean culture. Looking back, I can think of few better ways to learn about a new culture than observing the way children are taught and integrated within their communities. While most children could not identify a washing machine, nearly every child could identify all the farm animals we showed them - and would often correlate the pictures with the real animals outside their doors. Some children could not count to ten in Spanish but taught me to count in Quechua or Aymara.

My time in Peru taught me about research methodology, the importance of choosing culturally appropriate assessments, and complex data analysis. But perhaps even more valuable was the privilege of learning about the culture of rural Puno and its reflections of ancient Indigenous groups, particularly through the shortcomings of our cognitive assessment. That kind of learning is not one that can be derived from a desk or a laboratory and is the reason that I intend to continue global health research in my career.

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