# Difficulties with clinical practice guidelines for congenital syphilis prevention in Colombia: a qualitative study

Ana Estrada-Jaramillo, Mike Michael, Hannah Farrimond

► To cite this version:

Ana Estrada-Jaramillo, Mike Michael, Hannah Farrimond. Difficulties with clinical practice guidelines for congenital syphilis prevention in Colombia: a qualitative study. BMC Infectious Diseases, In press, 10.1186/s12879-026-12652-9. pasteur-05506959

HAL Id: pasteur-05506959

https://pasteur.hal.science/pasteur-05506959v1

Submitted on 12 Feb 2026

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons CC BY 4.0 - Attribution - International License
# Difficulties with clinical practice guidelines for congenital syphilis prevention in Colombia: a qualitative study

Received: 12 February 2025

Accepted: 16 January 2026

Published online: 29 January 2026

Cite this article as: Estrada-Jaramillo A., Michael M. & Farrimond H. Difficulties with clinical practice guidelines for congenital syphilis prevention in Colombia: a qualitative study. BMC Infect Dis (2026). https://doi.org/10.1186/s12879-026-12652-9

Ana Estrada-Jaramillo, Mike Michael & Hannah Farrimond

We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. Please note there may be errors present which affect the content, and all legal disclaimers apply.

If this paper is publishing under a Transparent Peer Review model then Peer Review reports will publish with the final article.
1 **Difficulties with clinical practice guidelines for congenital syphilis**
2 **prevention in Colombia: a qualitative study.**

3 Ana Estrada-Jaramillo1*, Mike Michael2†, Hannah Farrimond3†.

4 1* Anthropology and Ecology of Disease Emergence, Institut Pasteur -
5 Université Paris Cité, 25 Rue du Dr Roux, Paris, 75015, France.

6 2 Social and Political Sciences, Philosophy and Anthropology; University of
7 Exeter, Rennes Drive, Exeter, EX4 4RJ, United Kingdom.

8 3 Egenis, University of Exeter, Saint German's Road, Exeter, EX4 4PJ, United
9 Kingdom.

10 Corresponding author: Ana Estrada-jaramillo [ana-lucia.estrada-jaramillo@pasteur.fr](mailto:ana-lucia.estrada-jaramillo@pasteur.fr);

12 Contributing authors: [m.michael@exeter.ac.uk](mailto:m.michael@exeter.ac.uk); [h.r.farrimond@exeter.ac.uk](mailto:h.r.farrimond@exeter.ac.uk);
13 †This author(s) contributing equally to this work.

14 **Abstract**

15 **Background:** Congenital syphilis (CS) is considered a preventable disease.
16 However, it remains a major public-health concern in Colombia, where
17 healthcare authorities have suggested that the main issue is the incorrect
18 implementation of the clinical practice guidelines (CPG). This study aimed to
19 understand why this preventable disease cannot be prevented in Chocó and
20 Caldas, two regions of Colombia.
21 **Methods:** A qualitative online study, using a multi-method approach following interpretative and ethnographic online research principles, was conducted in two regions of Colombia (Chocó and Caldas) during the COVID-19 pandemic.

24 **Results:** Besides the difficulties of, and barriers to, implementing the CPG identified in other studies in Colombia and elsewhere, three main gaps are highlighted as results of the study. 1) The CPG is usually implemented in a fragmented system. It specifies timelines and trajectories to be met in dynamic, inter-connected and under-resourced systems. 2) The CPG's implementation requires measures and activities that go before and beyond prenatal care and involve more than pregnant women and healthcare workers. 3) The CPG are for preventing the specific disease, but the implementation is enacted in relation to other diseases (HIV, COVID-19, hepatitis B, hypertension, diabetes) and their protocols and clinical guidelines.

34 **Conclusions:** The implementation of the CPG is important but insufficient for CS prevention. The CPG does not operate in isolation. In addition to the knowledge of the CPG and the provision of the necessary resources, it is crucial to consider the activities and processes before and after prenatal care to address the fragmentation of the healthcare system and healthcare services provision. Moreover, it is essential to coordinate with the activities and practices for other diseases (HIV, COVID-19, hypertension, hepatitis B, diabetes) with those of the CPG.
42 **Keywords:** Congenital syphilis, prevention, Colombia, clinical practice guidelines, migrants, Indigenous, Afro-descendants.

44 **Background**

45 Congenital syphilis (CS), the transmission of mother-to-child syphilis is considered a preventable disease, insofar as syphilis in pregnant women and their sexual contacts can be readily diagnosed and treated. Since 2014, clinical practice guidelines (CPG) indicating the screening of pregnant women during prenatal care, the use of rapid tests and same-day treatment at the point of care have been introduced in Colombia (1). Despite the implementation of the guidelines, CS has not decreased in Colombia (2).

52 Several difficulties for CS prevention are indicated in the literature, for instance, the provision of penicillin in a primary care setting (3), the rapid test sensitivity and availability (4), the execution of timely and effective prenatal care appointments (5), and sexual contact's treatment provision (6).

56 On the other hand, Colombian health authorities have identified the incorrect implementation of the CPG as the major hindrance to CS prevention (7).

58 Research on CPGs in relation to a diverse range of diseases and in various countries has highlighted challenges for their implementation (8,9). Studies in Colombia have indicated that healthcare workers' lack knowledge of the CPG (10,11) and administrative barriers and difficulties with healthcare insurance companies (12,13) are the major obstacles to CPG implementation and CS prevention in Colombia.
There are two types of healthcare insurance in Colombia. A contributory insurance for those with payment capacity, and a subsidised insurance funded by the government's fiscal resources and cross-subsidies from contributory insurance. Healthcare service administrators (EPS is the acronym in Spanish) receive contributions from both insurance systems and establish contracts with healthcare service providers (IPS): hospitals, clinics, and laboratories.

Healthcare service provision can be affected by administrative reasons, such as changes in affiliation type from contributory to subsidised due to job loss or lack of EPS coverage in certain regions.

Several studies have emphasised the fragmentation of care in Colombia (9,(14)). This fragmentation not only refers to the discontinuity in health service provision among different medical specialists, but also the lack of integration among healthcare providers. The studies show delayed service provision, adverse health outcomes and differences among regions, highlighting the need for coordination and integration of healthcare (15).

The present research explores why a preventable disease such as CS has not been prevented, or at least not prevented as expected.

Rather than focusing on the lack of knowledge of the CPG or the individual values and attitudes of healthcare workers and pregnant women towards the CPG and CS prevention, the study focuses on practices.

Recent developments in practice theory (16) have emphasised the necessity to analyse action in context, where instead of focusing on lifestyles and
individual behaviours or decision making for behavioural change, the focus is
on activities where routines, objects, infrastructures, institutions and collective
norms and interdependence with other activities configure practices (17).

A “practice” is an “organised form of activities” (18) that involves materials
(objects, infrastructures), competences (understandings of the situation,
know-how) and meanings (significance of the practice and past experiences).
An analysis of practices requires, on one hand, attention to the “nexus of
connections” (19) with other elements and practices, and on the other hand,
how practices remain together in the present and matter for future interactions
(16,20).

A considerable number of studies have integrated this approach (21-23),
particularly regarding electricity and food consumption, to identify potential
interventions. Others (17,24) have explored how practice theory can
contribute to understanding drinking, smoking and addiction in order to
change those practices.

101 Methods

The qualitative multimethod (25) online study (26) was conducted during the
COVID-19 pandemic, between January and August 2021. The Consolidated
Criteria for Reporting Qualitative Research (COREQ) guidelines (27) have been
used for reporting.

The present research encompassed documentary evidence and qualitative
data collection with healthcare workers and administrators, pregnant women
or recent mothers and their partners from Quibdó, Lloró (Chocó) and Manizales, Riosucio (Caldas). These two regions have different ethnic, social and political characteristics, Chocó being one of the poorest regions with the highest incidence of CS in Colombia (28,29). Most of Chocó's population self-identifies as Afro-descendant, but there are also indigenous groups - namely, the Emberá, Tule, Cuna, and Wuanan people. In contrast, in Caldas, the majority self-identifies as "without ethnic affiliation", according to the last census (30).

The research participants were between 19 and 70 years old, with the age range of 19 - 34 years, specifically among pregnant women and recent mothers. The participants self-identified as mixed background, Indigenous (Embera Chami), and Afro-descendants. There were two international migrants and one Internally Displaced Person from the armed conflict (see Table 1).

121

122

<table><caption>**Table 1. Characteristics of participants**</caption><thead><tr><td>Participants</td><td>Number</td></tr></thead><tbody><tr><td>Healthcare workers</td><td>6 (1 male)</td></tr><tr><td>Healthcare administrators</td><td>10 (2 males)</td></tr><tr><td>Researchers</td><td>2 (females) national level</td></tr><tr><td>Pregnant women and recent mothers</td><td>Interviews (27) OAFG (19), (3) diaries (all females)</td></tr><tr><td>Partners</td><td>2 (males)</td></tr></tbody></table>
<table><tr><td>Traditional midwives</td><td>3 (females)</td></tr><tr><td>Documents</td><td>7</td></tr></table>

123

124 We recruited participants through snowballing, including referrals from the Secretaries of Health, an Association of Traditional Midwives in Chocó (ASOREDIPARCHOCO), an NGO in Manizales (Sagrada Familia), and other participants. For the document analysis, criterion sampling (31) was employed for the documents most relevant to CS prevention.

129

130 *Design and setting of the study.*

131 The study included document analysis of the CPG (1,(32) (particularly CS, pregnancy and birth complications); decrees and laws; 47 semi-structured interviews; 3 online asynchronous focus groups (OAFG), with 19 participants in total; and 3 diaries written by pregnant women.

135 The rationale behind the multimethod approach rests on the benefits that each method provides for the study. The documents offer insights into organisational routines (33), knowledge and implementation practices (34). In addition, semi-structured interviews offer insights into the participants' experiences (35). The potential of focus groups lies in their ability to facilitate the discussion of sensitive topics (36) and the inclusion of underrepresented groups (37,38). Besides allowing access to personal experiences, diaries are
also beneficial when participants have privacy concerns (39-41), as was the case during the COVID-19 pandemic.

144

145 *Description of processes*

All potential participants received an information sheet about the research project, complemented by an infographic for the pregnant women and recent mothers and an informed consent form. Eight healthcare workers and administrators refused to participate and one recent mother dropped out from the OAFG during the second day. In both situations, tight work schedules and responsibilities were the reasons for their non-participation.

The OAFG and diaries were conducted through WhatsApp, and the interviews were conducted through WhatsApp or mobile phones.

The document analysis, interviews, diaries and OAFG were conducted in Spanish by (AEJ) (a female anthropologist with extensive experience in qualitative research), who already knew some of the participants from her previous work on barriers to, and facilitators of, the implementation of CPG in Cali (Colombia).

Due to the COVID-19 pandemic restrictions, the interviews, OAFG, and diaries were conducted online at participants' home, workplaces or public space. It is not possible to identify with certainty whether other people (besides the participants) were present during those times, but in five interviews and two
163 OAFGs, background noises could be heard and some participants made
164 comments in this regard.

165 The semi-structured interviews were audio-recorded on a digital recorder by
166 AEJ and lasted between 25 and 80 minutes. They included questions regarding
167 prenatal care, pregnancy experiences, difficulties with implementing the CPG,
168 and CS prevention.

169 Three WhatsApp groups were set up as OAFGs over three days, starting at 8:30
170 a.m. and finishing by 6:00 p.m. Each group had between 6 and 7 participants,
171 and between 8 and 10 questions in total were prompted in the chat, one every
172 two hours. Interactions between participants and the moderator (AEJ) included
173 text messages, voice messages, emojis, stickers, links, and songs. Seven
174 interviewees and two diary participants also participated in the OAFG. More
175 information on the OAFGs can be found at (42).

176 Three pregnant women shared their thoughts, feelings and opinions about
177 their experiences of pregnancy between March and August 2021 by journaling
178 for at least one week in every trimester.

179 Following the recommendations of healthcare workers and administrators,
180 seven key documents were selected and the connections between procedures,
181 laws, decrees and administrative requirements for the implementation of the
182 CPG were analysed. The documents were the CPG for gestational syphilis (GS)
183 and CS (1), the CPG for pregnancy and birth complications (13), Law 1751 of
184 2015 in Health (Intercultural Health Law), *Protocolo de Atención*
185 *Preconcepcional*/[Preconception Counselling Protocol] (43), *Sistematización de
experiencias de parteras ASOREDIPARCHOCÓ* [Systematisation of
experiences], and reports from National Institute of Health regarding CS and
GS prevalence during 2020 and 2021 (28,29).

189 The interviews, OAFGs and diaries were verbatim transcribed in Spanish by AEJ
190 (Spanish native speaker), following the conventions for conversation analysis
191 (44). Special emphasis was placed on including silences, nonverbal cues,
192 background noises, text, emojis, stickers, and links shared in the OAFGs. The
193 transcripts of the interviews, OAFGs and diaries were not returned to
194 participants for comments or corrections.

195 Fieldnotes were also considered for the analysis, including contextual
196 information and reflection on emails, calls, text exchanges and descriptions
197 before, during, and after the interviews, OAFGs, document analysis and diaries.
198 All the data was initially analysed in Spanish by AEJ. After AEJ derived the
199 themes, these were shared with relevant translated data in English by AEJ (C2
200 English level) and double checked for sense and robustness with English native
201 speakers MM and HF for further analysis.

202

203 *Type of analysis.*

204 The research involved an iterative process (26), alternating between inductive
205 and deductive strategies. After we (MM, HF, AEJ) had identified themes,
206 processes and interactions during the initial document analysis and
familiarised ourselves with the data, a set of themes and categories for each
type of participant was identified from the interviews, diaries, documents and
OAFGs, following the principles of thematic analysis (45,46) (Fig.1
preconceived themes). One of these ("miscellaneous") included categories
and sub-themes that seemed to lack a clear connection with others. Contrary
to the accustomed tendency to seek consensus in thematic analysis (i.e.
grounded theory), a search for contradictions, controversies and negotiations
was followed, as proposed by McGaw and Vance (47). Discussions held by the
authors (MM, HF, AEJ) around categories continue as they deepen the analysis,
leading to some emergent themes and categories as shown in Fig. 1 (revised
themes). The discussions held monthly between August 2021 and June 2023
were conducted remotely, with notes and minutes prepared by AEJ and agreed
with MM and HF. The focus of those discussions was initially situating the data
and themes within the broader empirical field (Colombian health system,
cultural framings, social settings etc), and the broader conceptual field
(science and technology studies, medical sociology and anthropology).

Using mind maps and discussions, the authors (AEJ, MM, HF) identified 12 final
themes and categories (Fig. 1), following reiterative patterns and theoretical
questions from the research. The themes were silence - fragmentation and
discontinuity; the body; syphilis; sex; practices; pandemics; risk and danger;
gender; care; sex education; taboo and stigma; and pregnancy. These refined
themes were contrasted and analysed against the data.

229
230

231

232

233

234

<figure><img src="image_2.png" /><figcaption>Figure 1. Thematic Analysis</figcaption></figure>

<figure><img src="image_3.png" /></figure>

<figure><img src="image_4.png" /></figure>

<table><thead><tr><th>Preconceived themes</th></tr></thead><tbody><tr><td><ul><li>Silence</li><li>Fragmentation</li><li>Body</li><li>Syphilis</li><li>Sex talk</li><li>Sex practices</li><li>Pandemics</li><li>Risk</li><li>Danger</li><li>Gender</li><li>Care</li><li>Sex education</li><li>Taboo</li><li>Stigma</li><li>Pregnancy</li><li>Miscellaneous</li></ul></td></tr></tbody></table>

<table><thead><tr><th>Revised themes</th></tr></thead><tbody><tr><td><ul><li>Silence</li><li>Fragmentation</li><li><strong>Temporalities</strong></li><li>Body</li><li><strong>Sex</strong></li><li><strong>Practices</strong></li><li><strong>Covid 19</strong></li><li>Pandemics</li><li><strong>Risk and danger</strong></li><li>Gender</li><li><strong>Care</strong> -<br><strong>carelessness</strong></li><li>Sex education</li><li>Taboo and stigma</li></ul></td></tr></tbody></table>

<table><thead><tr><th>Final themes</th></tr></thead><tbody><tr><td><ul><li><strong>Silence</strong><br><strong>fragmentation</strong><br><strong>and discontinuity</strong></li><li>Body</li><li><strong>Syphilis</strong></li><li>Sex</li><li>Practices</li><li>Pandemics</li><li>Risk and danger</li><li>Gender</li><li>Care</li><li>Sex education</li><li>Taboo and stigma</li><li>Pregnancy</li></ul></td></tr></tbody></table>

235

236 **Fig.1** Coding process. The figure displays the coding process according to Iterative Thematic Analysis (29). Emergent categories are in bold, showing the analytical process.

238

239 In this research, the multimethod approach, beyond secure triangulation (31), enabled the exploration of practices and interactions without requiring closure, 240 highlighting the multiplicity, fluidity, and emergence of realities (48) (49). 241
242 **Results**

243 Through the analysis, several difficulties related to the implementation of the
244 CPG and CS prevention reported by the literature were also found in the
245 interviews, OAFG, diaries and documents. Appropriate and timely prenatal
246 care, information on STIs during pregnancy, test availability and sensitivity,
247 the provision of penicillin in a primary care setting due to potential adverse
248 reactions, and the provision of treatment to sexual contacts were consistently
249 highlighted.

250 Nevertheless, the results presented here focus mainly on three themes that
251 particularly illuminate the difficulties arising during the implementation of the
252 CGP that are limiting CS prevention.

253 The data analysis showed underlying assumptions in the design and
254 implementation of the CPG. In particular, the guidelines aimed to integrate
255 institutions, people, procedures, laws, and activities at specific trajectories and
256 timelines. However, the data also revealed that the CPG is not implemented in
257 isolation and, rather, requires the coordination of processes, practices,
258 materials, institutions and people for its implementation. In what follows, to
259 reiterate, three broad themes are highlighted that both provide insights into
260 the shortcomings of the CPG, but also can facilitate specific actions for a
261 potentially better implementation of the CPG and disease prevention. Those
262 three themes concern the configuration of the healthcare system, the span of
263 CS prevention, and the connection of CS with other diseases.
264 1. The CPG is implemented in a healthcare system that is usually
265 fragmented.

266 The implementation of the CPG requires precise times and trajectories. Women
267 are supposed to start prenatal care before the tenth week of pregnancy and
268 are expected to attend at least seven appointments before giving birth.
269 Besides information on their physical and psychological state collected in
270 prenatal cards and medical records, several screenings, including for syphilis,
271 are run during prenatal care appointments.

272 According to the CPG (1), women should be screened with a rapid syphilis test
273 during the first prenatal care appointment, in the second trimester, and before
274 giving birth. If a positive result is obtained, the first dose of penicillin is
275 administered at the point of care if there is no history of allergic reaction. A
276 treponemal test (VDRL or RPR) is also taken to establish reactivity and for
277 follow-up. Three doses are provided (one weekly) to the pregnant woman, and
278 at least one is given to her partner.

279 The continuity and linearity needed to complete these activities are – the
280 participants made clear – constantly interrupted. A healthcare worker
281 indicated that pregnant women start their prenatal care "late":

282 "It is common that pregnant women start prenatal care during the third
283 trimester, 30 weeks of pregnancy approximately, and they do not have a
284 complete treatment... there are several factors for that [starting prenatal care
285 late], and one of the reasons is cultural. They think prenatal care must start
286 after the third month of pregnancy. We tell them that they should start
287 prenatal care as soon as they realise they are pregnant. But they prefer to stay
288 at home, and during the pandemic, they don't want to go to the hospital"
289 (Interview 3, Nurse prenatal care).

290 Another reason to start late prenatal care is that the pregnancy was
291 unplanned. Only two participants in the study had preconception counselling;
292 for most of them, the pregnancy was unexpected. Access to contraception
293 during the pandemic was difficult for four participants, as was also the case for
294 other women in Colombia (50).

295 There are also difficulties in healthcare access related to the characteristics of
296 the Colombian healthcare system.

297 In this study, the data also showed high mobility in the population in Colombia
298 (between municipalities, regions, types of job contracts, temporary jobs,
299 healthcare insurance, and EPSs). This suggests difficulties regarding access to
300 healthcare services. Information regarding insurance affiliation, medical
301 records, lab tests, and treatment is not integrated into different parts of the
302 healthcare system. As explained by several research participants:

303 "... These institutions buy their own software, so each patient comes with a
304 printed

305 medical record from each hospital that she has attended. Usually, these
306 patients
307 have their prenatal care at the first level. They rarely end up at the third level
308 for

309 syphilis. Sometimes it is because of something else - like early birth,
310 preeclampsia...

311 Even in hospitals with the same software, we cannot see the medical records
312 from

313 another hospital" (Interview 37, Healthcare worker).

314 "... the GP nagged me because I didn't have the medical records, I didn't have
315 the test results, and because I didn't know what they had done to me"
316 (Interview 23, Pregnant woman).

317 The contract with an IPS depends on the EPS and its regional coverage, which
318 might, in some cases, result in the partner of a pregnant woman with a positive
319 diagnosis not receiving treatment if the two individuals belong to different
320 EPSs.

321 There are also limitations on service provision according to migratory status
322 (particularly for undocumented people), despite the efforts made by the
323 government and other organisations to provide healthcare services to
324 migrants.

325 "The year before last year (...) 30% of gestational syphilis cases occurred
326 among
327 women without healthcare insurance. 90% of those were undocumented
328 migrants

329 from Venezuela. So, that is difficult (...) There are people who don't have
330 insurance

331 because they don't have a job, right? But they also don't have money to pay".
332 (Interview 7, Healthcare administrator).

333 The integration between healthcare services and the transmission of
334 information is an important function of prenatal cards. However, this is not
335 necessarily accomplished during prenatal care. Healthcare workers
336 interviewed, privileged information recorded on the medical record regarding
337 syphilis diagnosis and treatment over the information on prenatal cards. Even
338 if medical records are used, they pose difficulties regarding healthcare
339 integration due to the different formats (paper, digital), the software used
340 across medical settings, and, consequently, the software restriction policies
341 imposed on users.

342 Additionally, the need for multiple authorisations for service provision and the
343 fragmentation of care impose yet more barriers to healthcare access. All the
344 pregnant women and recent mothers interviewed had been required to access
345 health services at distant sites, some even outside their municipality. Some of
346 these difficulties had been exacerbated by the COVID-19 pandemic,
347 particularly during the first months of lockdown, when travel and economic
348 restrictions also played a role. For the CPG to be adequately implemented,
349 more fluid financial and administrative systems are required in order to limit
350 the barriers and borders imposed by the classification and demarcation
351 between types of health insurance, types of affiliation, regions and
352 municipalities.

353 For example, it is paramount that there is correspondence between
354 contributory and subsidised health-insurance systems, given the movement of
355 people between types of health insurance and regions. Similarly, the systems'
356 integration will need to accommodate a constant flux of information on health-
357 insurance affiliation, medical records and lab tests that should flow between
358 institutions and health practitioners to facilitate prenatal care and the
359 prevention of CS.

360 2. The CPG for the prevention of CS requires other measures and activities
361 that take place before and beyond prenatal care, involving others in
362 addition to pregnant women and healthcare workers.

363 Besides assuring resource availability (syphilis rapid tests, penicillin, the
364 necessary equipment to assist in case of an adverse reaction at a point of care)
365 and competencies (knowledge of syphilis, the CPG, the interpretation of test
366 results), other measures and activities are also necessary. For example, it is
367 important to provide sex education, beyond at-risk or sexually active people,
368 to the general population. One pregnant woman - along with many other
369 interviewees - explained that, typically, no sex education is provided at all:
370 "At home? No, we never talked about those things [about sex] or at school. We
371 didn't

372 have a teacher to talk to about it, no ... {how did you learn} Well, to be honest,
373 having sex with your boyfriend [was how you learned about sex] but we didn't
374 talk about it... We talked with our friends and shared our experiences and
375 things like that". (Interview 36, Pregnant woman).

376 Similarly, a healthcare administrator highlighted:

377 "...we have to teach people how to use condoms and dental dams, explain
378 what happens with lubricants, what happens with oral sex and anal sex, and
379 what happens with sex toys. We have to talk about it because there are many
380 options, and there are risks associated with those things. But we don't [talk
381 about it] and we should". (Interview 18, Healthcare administrator).

382 Sex education is intended to limit the taboos around sex, sex talk (especially
383 during pregnancy), STIs and their prevention.

384 In this regard, interviewed healthcare workers and administrators emphasised
385 the relevance of activating syphilis screening for the general population, which
386 is not only directed to at-risk groups and pregnant women. They also indicated
387 that there were inconveniences implicated by the syndromic management of
388 STDs as recommended by WHO, as well as the potential of this to lead to
389 antimicrobial resistance.

390 This was highlighted by several healthcare workers and exemplified in the
391 following testimony:
392 "...something that has to change is the syndromic treatment... in countries like ours, we have good labs, and STDs are common.... someone can have a genital ulcer, and it can be syphilis, but it is not diagnosed as syphilis; it is diagnosed as genital ulcer... or you can have a patient with urethral discharge, you will never know if it was chlamydia or gonorrhoea, if it is gonorrhoea resistant, nothing! You can't know anything" (Healthcare worker, Interview 12).

398 A combination of sex education and STI screening directed to the general population would encourage people to relate to their own bodies - and those of others - in different ways and promote other disease-prevention practices.
401 Knowledge of one's own body allows people to identify signs and symptoms that usually go unnoticed. It also encourages people to ask questions and talk openly about those signs and symptoms, and can help with identifying pregnancy and STD diagnoses in the early stages. General population screening can also identify cases at early stages and potentially reduce stigmatisation if accompanied by sex education.

407

408 3. The CPG for CS prevention is not isolated, but interconnected with the prevention of other diseases, such as HIV, COVID-19, hypertension, diabetes and hepatitis B, each of which has its own CPG. It is crucial to consider these connections, particularly when providing care to pregnant women and their babies during the first months.

413
414 During the COVID-19 pandemic, there was more emphasis on COVID-19
415 (prevention, diagnosis and treatment), which had the effect of diminishing the
416 time and resources set aside for CS prevention. Healthcare workers and
417 administrators dedicated more effort to the pandemic; those who would
418 usually carry out CS prevention activities also had to support the COVID-19
419 pandemic response.

420 Healthcare workers and administrators tend to focus more on risks associated
421 with diabetes, hypertension and anaemia during pregnancy, rather than signs
422 of syphilis. During prenatal care, in pamphlets, and even during the interviews,
423 there were constant comments about "warning signs" and what to do in case
424 of those signs, as exemplified in the following testimony:

425 "If I bleed, have lower pain or pain that doesn't stop, or contractions for more
426 than

427 four minutes, or unbearable headaches or earaches or blurry vision (...) or if I
428 don't

429 *feel the baby"* (Interview 24, Pregnant woman).

430 Among pregnant women or recent mothers, syphilis was not well known in
431 comparison to HIV. Several of the pregnant women who were interviewed
432 asked what syphilis is, as they had heard (and knew) little about it. In
433 comparison, three of the pregnant women who were interviewed recalled that
434 some of their relatives had experienced HIV. In the words of one interviewee:
"What is syphilis? ... I had an HIV test [during prenatal care], and they told me that if it is positive, the psychologist will explain to me the risks, and they would also test the baby after birth" (Interview 11, Recent mother).

In line with other STIs, syphilis also carries stigma that becomes greater for pregnant women because they are usually considered responsible for the outcomes (i.e. CS in their babies). There is a close relationship between HIV and syphilis, as both can be asymptomatic and go unnoticed for a period of time. There is also a proportion of co-occurrence between HIV and syphilis, which further complicates their treatment. The use of rapid dual tests (HIV and syphilis) has been seen as an advantage, particularly during prenatal care screening. Nevertheless, more attention is directed to HIV prevention.

One healthcare interviewee said,

"...to me, syphilis is like the Cinderella of all the diseases. I don't know why, but we can see that other diseases have a lot more resources. I have spoken about it, but there was no echo... Penicillin is cheap and there are so few exams for its diagnosis, but no. I don't know why". (Interview 18, Healthcare administrator).

Even if other conditions like maternal mortality can have higher prevalence compared to gestational syphilis and CS, the latter continues to be a public health concern in Latin America, and lately, in high-income countries where it was not traditionally a concern (51). Historically, several goals for CS reduction and elimination have been established, highlighting CS as a preventable
disease that does not pose difficulties in its treatment (cost, technology, or effectiveness). It is precisely by researching CS and the CPG that this study aims to contribute to their visibility and relevance.

CS prevention would benefit from measures also considered for preventing other diseases, including those related to mother-to-child transmission. These include measures to overcome financial and administrative barriers to healthcare service provision, as well as test screening, sex education, and knowledge of signs to look for beyond those considered 'warning signs'.

## Discussion

Besides knowledge of the CPG and the limitations imposed by barriers to its implementation, as highlighted by studies conducted in Colombia (6,8), it is crucial to address how the CPG is implemented in a context in which the healthcare system is fragmented (9) and where the timing by which women engage with the relevant services is highly variable. As indicated by other studies (52), even if resources are allocated and sufficient knowledge and training are provided, this does not mean that the recommendations of CPG can be enacted. Moreover, as shown by research conducted in Brazil (53), increased access to and testing during prenatal care do not necessarily translate into a reduction in CS. Reduction of syphilis incidence and prevalence during pregnancy as well as in the general population is also needed. The increase in syphilis worldwide and among certain groups (men who have sex
478 with men, MSM) (54) also implicates the necessity of coordinated efforts for syphilis control besides prenatal care.
479

480 The CPG should not be considered a tool or device that functions in isolation.
481 In fact, the CPG requires coordination between activities, processes, institutions, objects, infrastructures, people and communities. Therefore, it is crucial to involve more patients and communities during the design and implementation of the CPG to provide a better contextualisation of the implementation of the CPG, as it has also been highlighted by (55).
482
483
484
485

486 Identifying connections between several CPGs and disease prevention is necessary, as diseases do not occur in isolation, and various measures can be taken to ensure the implementation of both CPGs and disease prevention. This is in line with other studies (9) that have identified that the multiplicity of CPGs is a barrier to their implementation.
487
488
489
490

491 **Limitations of the study**

492 The Covid-19 pandemic affected the recruitment of participants, particularly healthcare workers, who had to manage Covid-19-related activities (prevention, diagnosis, surveillance) alongside their usual duties. This was particularly the case in the region of Chocó, where GPs did not participate.
493
494
495

496 Contrary to classical ethnographic studies, the observation of practices was limited to online interactions. Some non-verbal and contextual information is missing, including some routinised activities, workarounds or implicit norms.
497
498
Nevertheless, by considering practices as a mix of actants, objects, discourses and technologies that perform a particular reality (48), other data (including sounds, silences, connections between processes and actions, and absences) provided rich insights. The mix of interviews, OAFG, diaries and documents provided complementary and contrasting elements regarding the experiences and conditions of prenatal care and the implementation of the CPG according to HCW, healthcare administrators and pregnant women. It leads to constantly reflecting on what was missing, what was covered, and what was made absent.

The translation of data from Spanish to English, made by a proficient English speaker and double-checked by native English speakers, nonetheless implies that some sense is lost in translation.

The COVID-19 pandemic brought additional difficulties for the implementation of the CPG, limiting the range of the conclusions from the present study to non-pandemic contexts. Nevertheless, several conditions, situations and practices were and are still present after the pandemic. Difficulties in accessing healthcare services (56) especially for migrants (57,58), and fragmentation in care provision (13,14) continue in Colombia.

The study does not represent the diversity of regions in Colombia and the multiple ethnic groups, diverse administrative procedures, and economic characteristics (with considerable variations in inequality). Moreover, since there is variability between the CS case definitions and the diagnosis algorithms used for treatment (traditional or reverse), variability that further
manifests differences between high-income and low- and middle-income countries (59), the conclusions might only apply to some contexts.

Furthermore, this study does not account for the implementation of the EMTCT Plus strategy developed by the Pan American Health Organisation (60) to prevent several mother-to-child transmitted diseases, since it had yet to be implemented in these regions at the time the fieldwork was conducted.

## 527 Conclusions

While implementing the CPG is important, it is insufficient for CS prevention. The CPG does not operate in isolation. In addition to promoting knowledge of the CPG and providing the necessary resources for its implementation, it is crucial to consider the activities and processes that occur before and after prenatal care, when the CPG is typically implemented. It is also essential to address the fragmentation of the healthcare system and the provision of healthcare services. To improve CS prevention, it is paramount to coordinate activities across diverse institutions and practices involving healthcare workers, pregnant women and their families. The engagement of patients, institutions, communities, and leaders during the design and implementation of the CPG might contribute to its contextualisation and coordination in specific settings.

## 540 List of abbreviations

CPG: Clinical practice guidelines; CS: Congenital syphilis; GS: Gestational syphilis; HIV: Human immunodeficiency virus; STI: Sexually transmitted
543 infection; STD: Sexually transmitted disease; OAFG: Online asynchronous focus

544 groups; ASOREDIPARCHOCO: Association of Traditional Midwives in Chocó;

545 NGO: Non-governmental organisation; EPS: Healthcare service administrators

546 (acronym in Spanish); IPS: Healthcare service providers (acronym in Spanish),

547 VDRL: Venereal disease research laboratory test; RPR: Rapid plasma regain;

548 PAHO: Pan American Health Organisation; EMTCT Plus: Framework for

549 elimination of mother-to-child transmission of HIV, syphilis, hepatitis B and

550 Chagas; WHO: World Health Organization.

551 **Declarations**

552 **Ethics approval and consent to participate**

553 The University of Exeter Ethical Committee approved and monitored this study

554 (Approval number: 202021-018). Written informed consent was obtained from

555 healthcare workers and administrators participants. Oral informed consent

556 from the participants who were pregnant women and recent mothers, their

557 partners and the traditional midwives was obtained by following a script and

558 recorded as voice or text messages. Oral informed-consent was sought due to

559 the mistrust that some ethnic groups have regarding signing documents and

560 the large number of scams occurring in Colombia via WhatsApp and mobile

561 phones.

562 **Consent for publication**

563 Not applicable, because no individual data is included.

564 **Availability of data and materials**
The data presented in this study is available on request, subject to authorisation by the University of Exeter ethics committee. Requests can be sent to the corresponding author at: ana-lucia.estrada-jaramillo@pasteur.fr.

## Competing interests

The authors declare that they have no known competing financial interests or personal relationships that could appear to influence the work reported in this paper.

## Funding

This study was funded by the Ministry of Science and Technology of Colombia (MinCiencias) as part of a PhD scholarship. Convocatoria Doctorados en el Exterior 860 de 2019. The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

## Authors' contributions

Conceptualisation: AEJ, MM, HF; Data Curation: AEJ; Formal Analysis: AEJ, MM, HF; Funding Acquisition: AEJ. Investigation: AEJ, MM, HF; Methodology: AEJ, MM, HF; Project Administration: AEJ; Resources: AEJ; Software: not applicable; Supervision: MM, HF; Validation: MM, HF; Visualization: AEJ; Writing—Original Draft Preparation: AEJ; Writing—Review and Editing: AEJ, MM, HF. All authors read and approved the final manuscript.

## Acknowledgements
We are grateful to the study participants for their time and for sharing their experiences. Many thanks to the Secretary of Health of Quibdó, Dirección Territorial de Salud de Caldas, Corporación Sagrada Familia in Manizales, and Traditional Midwives Association in Chocó (ASOREDIPARCHOCÓ).

## 589 Author's information

Ana Estrada-Jaramillo has a PhD in Anthropology, and her work focuses on disease prevention. Mike Michael is a Professor in Anthropology and Sociology with a special interest in Science and Technology Studies. Hannah Farrimond is a Senior Lecturer in Medical Sociology, and her work focuses on stigma.

## 594 References

1. Ministerio de Salud y Protección Social y Fondo de Población de las Naciones Unidas. Guía de Práctica Clínica basada en la evidencia para la atención integral de la sífilis gestacional y congénita. Bogotá; 2014.

2. Ospina-Joaqui WL, Usma-Duque CA, Gálvez-Castaño YA, Gulloso-Pedrozo L, Giraldo-Ospina B. Ospina-Joaqui WL, et al. Comportamiento de la sífilis gestacional y congénita en Colombia (2014-2021). Análisis ecológico, georreferenciado por departamentos. Ginecol Obstet Mex [Internet]. 2023 [cited 2025 Oct 13];91(3):147-54. Available from: http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0300-90412023000300147&lng=es&nrm=iso&tlng=es

3. Blumenthal KG, Smith LR, Mann JTS, Salciccioli I, Accarino JJO, Shah RJ, et al. Reaction Risk to Direct Penicillin Challenges: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024 Nov 4;184(11):1374-83.

4. Pham MD, Ong JJ, Anderson DA, Drummer HE, Stoové M. Point-of-Care Diagnostics for Diagnosis of Active Syphilis Infection: Needs, Challenges and the Way Forward. Int J Environ Res Public Health. 2022;19(13).

5. Hawkes SJ, Gomez GB, Broutet N. Early Antenatal Care: Does It Make a Difference to Outcomes of Pregnancy Associated with Syphilis? A Systematic Review and Meta-Analysis. PLoS One. 2013 Feb 28;8(2).
614 6. Swayze EJ, Cambou MC, Melo M, Segura ER, Raney J, Santos BR, et al. Ineffective penicillin treatment and absence of partner treatment may drive the congenital syphilis epidemic in Brazil. AJOG Global Reports. 2022 May 1;2(2).

618 7. Instituto Nacional de Salud. Sífilis Gestacional y Congénita 2018 [Internet]. Protocolo de Vigilancia en Salud Pública. 2018. Available from: https://www.ins.gov.co/buscador-eventos/Lineamientos/PRO Sifilis_.pdf

621 8. Ahmedov M, Green J, Azimov R, Avezova G, Inakov S, Mamatkulov B. Addressing the challenges of improving primary care quality in Uzbekistan: A qualitative study of Chronic Heart Failure management. Health Policy Plan. 2013;28(5):458-66.

625 9. Hobbs FDR, Erhardt L. Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: The Reassessing European Attitutudes about Cardiovascular Treatment (REACT) survey. Fam Pract. 2002;19(6):596-604.

630 10. Garcés JP, Rubiano LC, Orobio Y, Castaño M, Benavides E, Cruz A. La educación del personal de salud: clave para la eliminación de la sífilis congénita en Colombia. Biomédica. 2017;37(3):416-24.

633 11. Salas-Romero SP, Barrios-Puerta Z, Madero-Zambrano KP, Bello-Trujillo AM. Guía de Sífilis Gestacional y Congénita: perspectivas de profesionales de la salud en Bolívar (Colombia). Rev Colomb Obstet Ginecol. 2023;74(4):297-309.

637 12. Potes L, Rubiano L, Ramirez L, Tunubalá G, Orobio Y, Salazar J. Feasibility of a Point-of-Care Model for the prevention of mother to child transmission of syphilis in Cali, Colombia. Sex Transm Infect. 2017;93(2):A1-272.

641 13. Gamboa O, Buitrago G, Patino AF, Rozo N, Saldana L. Fragmentation of Care and Its Association With Survival and Costs for Patients With Breast Cancer in Colombia. JCO Global Oncol. 2023;May:1-10.

644 14. Patiño-Benavidez AF, Buitrago G, Rozo-Agudelo N, Saldaña-Espinel LE, Gamboa-Garay ÓA, Eslava-Schmalbach J, et al. Association of Healthcare Fragmentation and the Survival of Patients with Colorectal Cancer in Colombia. Value Health Reg Issues. 2024 May 1;41:63-71.

648 15. Barrera-Lozano LM, Sánchez-Santiesteban D, Buitrago G. Association of healthcare fragmentation with three-year survival among kidney transplant recipients in Colombia. PLoS One. 2025 Aug 1;20(8 August).
651 16. Shove E, Pantzar M, Watson M. The Dynamics of Social Practice: Everyday Life and How it Changes. London: Sage Publications; 2012. 208 p.

653 17. Blue S, Shove E, Carmona C, Kelly M. Theories of practice and public health: understanding (un)healthy practices. Crit Public Health. 2016;26(1):36-50.

656 18. Shove E. Matters of Practice. In: Hui A, Schatzki T, Shove E, editors. The Nexus of Practices [Internet]. Routledge; 2017. p. 1-12. Available from: http://www.demand.ac.uk/wp-content/uploads/2016/06/11_Ch11-Shove.pdf

660 19. Welch D. Behaviour change and theories of practice: Contributions, limitations and developments. Social Business. 2017;7(3-4):241-61.

662 20. Shove E, Blue S, Kelly MP. Categorising and cohabiting: practices as the site of biosocial becoming. Social Theory and Health. 2024 Jun 1;22(2):156-71.

665 21. Gram-Hanssen K. Consuming technologies - developing routines. J Clean Prod. 2008 Jul;16(11):1181-9.

667 22. Tomassini L, Staffieri S, Cavagnaro E. Local food consumption and practice theory: A case study on guests' motivations and understanding. Research in Hospitality Management. 2021 May 4;11(2):93-100.

670 23. Vasseur V, Backhaus J, Fehres S, Goldschmeding F. Capabilities and social practices: A combined conceptual framework for domestic energy use. J Clean Prod. 2024 May 25;455.

673 24. Meier PS, Warde A, Holmes J. All drinking is not equal: How a social practice theory lens could enhance public health research on alcohol and other health behaviours. Addiction. 2018 Feb 1;113(2):206-13.

676 25. Creswell J, Plano C, Gutmann M, Hanson W. Advanced mixed methods research designs. In: Tashakkori A, Teddlie C, editors. Handbook on Mixed Methods in the Behavioral and Social Sciences. Thousand Oaks: SAGE; 2003. p. 209-40.

680 26. Pink S, Horst H, Postill J, Hjorth L, Lewis T, Tacchi J. Digital Ethnography. Principles and Practice. London: SAGE; 2016. 223 p.

682 27. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007 Dec;19(6):349-57.

685 28. Instituto Nacional de Salud. Informe del Evento Sífilis Gestacional y Congénita Colombia 2020. 2020.
687 29. Instituto Nacional de Salud. Informe de Evento Sífilis Congénita Periodo
688 Epidemiológico XIII Colombia 2021. 2021.

689 30. DANE. Censo Nacional de Población y Vivienda Colombia 2018 [Internet].
690 2019. Available from: https://www.dane.gov.co/index.php/estadisticas-
691 por-tema/demografia-y-poblacion/censo-nacional-de-poblacion-y-
692 vivenda-2018

693 31. Creswell J. Qualitative Inquiry & Research Design. Choosing Among Five
694 Approaches. Third Edit. Thousand Oaks: Sage Publications; 2013. 448 p.

695 32. Ministerio de Salud y Protección Social. Guías de Práctica Clínica para la
696 prevención, detección temprana y tratamiento de las complicaciones del
697 embarazo, parto o puerperio. Bogotá; 2013.

698 33. Dupret K. Performative Silences: Potentiality of Organizational Change.
699 Organization Studies. 2019;40(5):681-703.

700 34. Escobar A. Encountering Development: The Making and Unmaking of the
701 Third World. Princeton University Press; 1995. 312 p.

702 35. Hermanowicz JC. The Great Interview : 25 Strategies for Studying People
703 in Bed. Qual Sociol. 2002;25(4):479-99.

704 36. MacNamara N, Mackle D, Trew JD, Pierson C, Bloomer F. Reflecting on
705 asynchronous internet mediated focus groups for researching culturally
706 sensitive issues. Int J Soc Res Methodol [Internet]. 2021;24(5):553-65.
707 Available from: https://doi.org/10.1080/13645579.2020.1857969

708 37. Reisner SL, Randazzo RK, White Hughto JM, Peitzmeier S, DuBois LZ,
709 Pardee DJ, et al. Sensitive Health Topics With Underserved Patient
710 Populations: Methodological Considerations for Online Focus Group
711 Discussions. Qual Health Res. 2018;28(10):1658-73.

712 38. Ranieri V, Kennedy E, Walmsley M, Thorburn D, McKay K. Rare but heard:
713 Using asynchronous virtual focus groups, interviews and roundtable
714 discussions to create a personalised psychological intervention for
715 primary sclerosing cholangitis: A protocol. BMJ Open. 2019;9(10):1-5.

716 39. Ahlin T, Li F. From field sites to field events. Med Anthropol Theory.
717 2019;6(2):1-24.

718 40. Williamson I, Leeming D, Lyttle S, Johnson S. "It should be the most
719 natural thing in the world": Exploring first-time mothers' breastfeeding
720 difficulties in the UK using audio-diaries and interviews. Matern Child
721 Nutr. 2012;8(4):434-47.
722 41. Day M, Thatcher J. "I'm really embarrassed that you're going to read this
723 ...": Reflections on using diaries in qualitative research. Qual Res Psychol.
724 2009;6(4):249-59.

725 42. Estrada-Jaramillo A, Michael M, Farrimond H. Absence, multiplicity and
726 the boundaries of research? Reflections on online asynchronous focus
727 groups. Qualitative Research. 2022;

728 43. Ministerio de Salud y Protección Social. Protocolo de Atención
729 Preconcepcional [Internet]. 2014. Available from:
730 https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/PP/
731 SM-Protocolo-atencion-preconcepcional.pdf

732 44. Oliver D, Serovich J, Mason T. Constraints and Opportunities with
733 Interview Transcription: Towards Reflection in Qualitative Research.
734 Social Forces. 2005;84(2):1274-89.

735 45. Morgan DL, Nica A. Iterative Thematic Inquiry: A New Method for
736 Analyzing Qualitative Data. Int J Qual Methods. 2020;19(January-
737 December):1-16.

738 46. Naeem M, Ozuem W, Howell K, Ranfagni S. A Step-by-Step Process of
739 Thematic Analysis to Develop a Conceptual Model in Qualitative
740 Research. Int J Qual Methods. 2023;22:1-25.

741 47. McGaw J, Vance A. Dissonance, Disagreement, Difference: Challenging
742 Thematic Consensus to Decolonise Grounded Theory. Int J Qual Methods.
743 2023;22:1-18.

744 48. Law J. After Method: Mess in Social Science Research. London: Routledge;
745 2004. 200 p.

746 49. Oosterhoff A, Thompson TL, Oenema-Mostert I, Minnaert A. Meeting
747 ontologies: actor-network theory as part of a methodologically
748 heterogeneous research project. Studies in Continuing Education.
749 2021;43(3):377-92.

750 50. Profamilia. Efectos de la Pandemia COVID-19 sobre la sexualidad, la salud
751 sexual y la salud reproductiva de las personas. Resultados de la encuetas
752 I-SHARE Colombia [Internet]. Bogotá; 2021. Available from:
753 https://profamilia.org.co/wp-content/uploads/2022/02/I-Share-informe-
754 final.pdf

755 51. Moseley P, Bamford A, Eisen S, Lyall H, Kingston M, Thorne C, et al.
756 Resurgence of congenital syphilis: new strategies against an old foe. Vol.
757 24, The Lancet Infectious Diseases. Elsevier Ltd; 2024. p. e24-35.
758 52. Wharton-Smith A, Green J, Loh EC, Gorrie A, Omar SFS, Bacchus L, et al. Using clinical practice guidelines to manage dengue: A qualitative study in a Malaysian hospital. BMC Infect Dis. 2019;19(1):1-10.

761 53. Cerda R, Perez F, Maria Domingues RS, Luz PM, Grinsztejn B, Veloso VG, et al. Prenatal Transmission of Syphilis and Human Immunodeficiency Virus in Brazil: Achieving Regional Targets for Elimination. 2015;

764 54. Rosset F, Celoria V, Delmonte S, Mastorino L, Sciamarrelli N, Boskovic S, et al. The Epidemiology of Syphilis Worldwide in the Last Decade. J Clin Med. 2025 Jul 28;14(15):5308.

767 55. Wang T, Tan JY (Benjamin), Liu XL, Zhao I. Barriers and enablers to implementing clinical practice guidelines in primary care: an overview of systematic reviews. BMJ Open. 2023;13(1):1-18.

770 56. Agarwal-Harding P, Ruscitti B, Shepard DS, et al. Disparities in healthcare-seeking behaviors and associated costs between Venezuelan migrants and Colombians residing in Colombia. Int J Equity Health. 2024;(23,202).

773 57. Ibáñez AM, Rozo S V., Urbina MJ. Forced Migration and the Spread of Infectious Diseases. J Health Econ. 2021;79(July).

775 58. Acosta-Reyes J, Bonilla-Tinoco LJ, Aguirre M, Rojas-Botero M, Anillo LÁ, Rodríguez DA, et al. Longitudinal health survey of women from Venezuela in Colombia (ELSA-VENCOL): first report. PLoS One. 2022;18(3):1-16.

778 59. Freyne B, Nourse C, Walls T. Congenital Syphilis: Controversies and Questions. A Global Perspective. Pediatric Infectious Disease Journal. 2023;42(5):166-9.

781 60. Pan American Health Organization. EMTCT Plus. Framework for Elimination of HIV, Syphilis, Hepatitis B and Chagas [Internet]. 2017. Available from: http://iris.paho.org/xmlui/bitstream/handle/123456789/34306/PAHOCHA_17009-eng.pdf?sequence=1&isAllowed=y

786