Research Translation to Promote Urban Health in Latin America: The SALURBAL Experience.

In highly urbanized and unequal Latin America, urban health and health equity research are essential to effective policymaking. To ensure the application of relevant and context-specific evidence to efforts to reduce urban health inequities, urban health research in Latin America must incorporate strategic research translation efforts. Beginning in 2017, the Urban Health in Latin America (SALURBAL) project implemented policy-relevant research and engaged policymakers and the public to support the translation of research findings. Over 6 years, more than 200 researchers across eight countries contributed to SALURBAL's interdisciplinary network. This network allowed SALURBAL to adapt research and engagement activities to local contexts and priorities, thereby maximizing the policy relevance of research findings and their application to promote policy action, inform urban interventions, and drive societal change. SALURBAL achieved significant visibility and credibility among academic and nonacademic urban health stakeholders, resulting in the development of evidence and tools to support urban policymakers, planners, and policy development processes across the region. These efforts and their outcomes reveal important lessons regarding maintaining flexibility and accounting for local context in research, ensuring that resources are dedicated to policy engagement and dissemination activities, and recognizing that assessing policy impact requires a nuanced understanding of complex policymaking processes. These reflections are relevant for promoting urban health and health equity research translation across the global south and worldwide. This paper presents SALURBAL's strategy for dissemination and policy translation, highlights innovative initiatives and their outcomes, discusses lessons learned, and shares recommendations for future efforts to promote effective translation of research findings.

Association between maternity leave policies and postpartum depression: a systematic review.

PURPOSE: Working mothers are at greater risk for postpartum depression. Maternity leave characteristics, including length, wage replacement and employment protection, could have relevant implications for mothers' mental health. We propose to explore whether there is an association between maternity leave characteristics and postpartum depression. METHODS: We conducted a systematic review searching for randomized controlled trials, quasi-experimental, cohort or cross-sectional studies on five databases using search terms including maternity and parental leave and depression, as well as references in relevant articles. We identified 500 articles and included 23 of those. We used the EPHPP Quality Assessment Tool for Quantitative Studies to assess the quality of the studies. RESULTS: Paid and longer maternity leaves tend to be associated with a reduction of postpartum depression symptoms in high-income countries. No studies explored the association between employment protection and postpartum depression. The quality of studies ranged from strong to weak, mostly influenced by study design. CONCLUSION: More restrictive maternity leave policies tend to be associated with higher rates of postpartum depression, although more research needs to be conducted in the Global South.

Sugar-sweetened beverage purchases in urban Peru before the implementation of taxation and warning label policies: a baseline study.

BACKGROUND: Sugar-sweetened beverage consumption is associated with obesity and chronic disease. In 2018, Peru increased the tax on high-sugar beverages (≥6 g of sugar per 100 mL) from 17 to 25%, yet little is known about pre-existing beverage trends or demographic characteristics associated with purchases in the country. The aim of this study was to explore beverage purchasing trends from 2016 to 2017 and examine variation in purchase volume by sociodemographic characteristics among urban households in Peru. METHODS: This study used monthly household purchase data from a panel of 5145 households from January 2016-December 2017 from Kantar WorldPanel Peru. Beverage purchases were categorized by type and tax status under the 2018 regulation (untaxed, lower-sugar taxed, high-sugar taxed). To assess beverage purchasing trends, per-capita volume purchases were regressed on a linear time trend, with month dummies for seasonality and clustered standard errors. Mean volume purchases by beverage tax status (total liters purchased per month), overall and by key demographic characteristics (education, socioeconomic status, and geographic region), were calculated. Mean volume by beverage type was assessed to identify the largest contributors to total beverage volume. RESULTS: The trends analysis showed a decline in total beverage volume of - 52 mL/capita/month (95% CI: - 72, - 32) during the 24-month study period. Over 99% of households purchased untaxed beverages in a month, while > 92% purchased high-sugar taxed beverages. Less than half of all households purchased low-sugar taxed beverages in a month and purchase volume was low (0.3 L/capita/month). Untaxed beverage purchases averaged 9.4 L/capita/month, while households purchased 2.8 L/capita/month of high-sugar taxed beverages in 2017. Across tax categories, volume purchases were largest in the high education and high socioeconomic (SES) groups, with substantial variation by geographic region. The highest volume taxed beverage was soda (2.3 L/capita/month), while the highest volume untaxed beverages were milk and bottled water (1.9 and 1.7 L/capita/month, respectively). CONCLUSIONS: Nearly all households purchased high-sugar taxed beverages, although volume purchases of taxed and untaxed beverages declined slightly from 2016 to 2017. Households with high SES and high education purchased the highest volume of taxed beverages, highlighting the need to consider possible differential impacts of the tax policy change by sub-population groups.

The value of process evaluation for public health interventions: field-case studies for non-communicable disease prevention and management in five countries.

Complex interventions are needed to effectively tackle non-communicable diseases. However, complex interventions can contain a mix of effective and ineffective actions. Process evaluation (PE) in public health research is of great value as it could clarify the mechanisms and contextual factors associ-ated with variation in the outcomes, better identify effective components, and inform adaptation of the intervention. The aim of this paper is to demonstrate the value of PE through five case studies that span the research cycle. The interven-tions include using digital health, salt reduction strategies, use of fixed dose combinations, and task shifting. Insights of the methods used, and the implications of the PE findings to the project, were discussed. PE of complex interventions can refute or confirm the hypothesized mechanisms of action, thereby enabling intervention refinement, and identifying implementation strategies that can address local contextual needs, so as to improve service delivery and public health outcomes.

Going digital: opportunities and barriers in the use of technology for health research.

Digital health refers to the use of novel information com-munication technologies in healthcare. The use of these technologies could positively impact public health and health outcomes of populations by generating timely data, and facili-tating the process of data collection, analysis, and knowledge translation. Using selected case studies, we aim to describe the opportunities and barriers in the use of technology applied to health-related research. We focus on three areas: strategies to generate new data using novel data collection methods, strategies to use and analyze existing data, and using digital health for health-related interventions. Exemplars from seven countries are provided to illustrate activity across these areas. Although the use of health-related technologies is increasing, challenges remain to support their adoption and scale-up -especially for under-served populations. Research using digital health approaches should take a user-centered design, actively working with the population of interest to maximize their uptake and effectiveness.

Effect of a Digital Intervention on Depressive Symptoms in Patients With Comorbid Hypertension or Diabetes in Brazil and Peru: Two Randomized Clinical Trials.

Importance: Depression is a leading contributor to disease burden globally. Digital mental health interventions can address the treatment gap in low- and middle-income countries, but the effectiveness in these countries is unknown. Objective: To investigate the effectiveness of a digital intervention in reducing depressive symptoms among people with diabetes and/or hypertension. Design, Setting, and Participants: Participants with clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10) who were being treated for hypertension and/or diabetes were enrolled in a cluster randomized clinical trial (RCT) at 20 sites in São Paulo, Brazil (N=880; from September 2016 to September 2017; final follow-up, April 2018), and in an individual-level RCT at 7 sites in Lima, Peru (N=432; from January 2017 to September 2017; final follow-up, March 2018). Interventions: An 18-session, low-intensity, digital intervention was delivered over 6 weeks via a provided smartphone, based on behavioral activation principles, and supported by nurse assistants (n = 440 participants in 10 clusters in São Paulo; n = 217 participants in Lima) vs enhanced usual care (n = 440 participants in 10 clusters in São Paulo; n = 215 participants in Lima). Main Outcomes and Measures: The primary outcome was a reduction of at least 50% from baseline in PHQ-9 scores (range, 0-27; higher score indicates more severe depression) at 3 months. Secondary outcomes included a reduction of at least 50% from baseline PHQ-9 scores at 6 months. Results: Among 880 patients cluster randomized in Brazil (mean age, 56.0 years; 761 [86.5%] women) and 432 patients individually randomized in Peru (mean age, 59.7 years; 352 [81.5%] women), 807 (91.7%) in Brazil and 426 (98.6%) in Peru completed at least 1 follow-up assessment. The proportion of participants in São Paulo with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 40.7% (159/391 participants) in the digital intervention group vs 28.6% (114/399 participants) in the enhanced usual care group (difference, 12.1 percentage points [95% CI, 5.5 to 18.7]; adjusted odds ratio [OR], 1.6 [95% CI, 1.2 to 2.2]; P = .001). In Lima, the proportion of participants with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 52.7% (108/205 participants) in the digital intervention group vs 34.1% (70/205 participants) in the enhanced usual care group (difference, 18.6 percentage points [95% CI, 9.1 to 28.0]; adjusted OR, 2.1 [95% CI, 1.4 to 3.2]; P < .001). At 6-month follow-up, differences across groups were no longer statistically significant. Conclusions and Relevance: In 2 RCTs of patients with hypertension or diabetes and depressive symptoms in Brazil and Peru, a digital intervention delivered over a 6-week period significantly improved depressive symptoms at 3 months when compared with enhanced usual care. However, the magnitude of the effect was small in the trial from Brazil and the effects were not sustained at 6 months. Trial Registration: ClinicalTrials.gov: NCT02846662 (São Paulo) and NCT03026426 (Lima).

Sustainability of mHealth Effects on Cardiometabolic Risk Factors: Five-Year Results of a Randomized Clinical Trial.

BACKGROUND: The long-term effects of mobile health (mHealth) interventions have not been documented, especially in resource-constrained settings. OBJECTIVE: This study aimed to assess the effects of a 1-year mHealth intervention on blood pressure levels and body weight in low-resource urban settings in Peru, 4 years after the completion of the original study. METHODS: Four years after the original Grupo de Investigación en Salud Móvil en America Latina (GISMAL) study, we attempted to contact the 212 individuals originally enrolled in the study in Peru. The primary outcomes were systolic and diastolic blood pressure levels and hypertension incidence. Secondary outcome measures were body weight, BMI, and self-reported target behaviors. The study personnel collecting the data were masked to the group assignment. Linear mixed models were used to evaluate the effects of the intervention on primary and secondary outcomes in an intention-to-treat analysis. RESULTS: Data from 164 (77.4%) of the 212 originally enrolled participants were available and analyzed (80 in the intervention group and 84 in the control group). The intervention did not result in changes in systolic (-2.54 mm Hg, 95% CI -8.23 to 3.15) or diastolic (3.41 mm Hg, 95% CI -0.75 to 7.57) blood pressure compared with the control group. The intervention reduced the risk of developing hypertension, but the result was not significant (risk ratio (RR) 0.76, 95% CI 0.45-1.28). However, those who received the intervention had lower body weight (-5.42 kg, 95% CI -10.4 to -0.48) and BMI (-2.56 kg/m2, 95% CI -4.46 to -0.66). In addition, compared to the control participants, those who received ≥50% of the scheduled calls during the intervention had greater reductions in body weight (-6.23 kg, 95% CI -11.47 to -0.99) and BMI (-2.81 kg/m2, 95% CI -4.77 to -0.85). CONCLUSIONS: An mHealth intervention comprising motivational interview calls and SMS text messaging appears to have effects on health 4 years after intervention completion. Although there were no effects on blood pressure levels, important reductions in body weight and BMI were seen 5 years after randomization. Thus, mHealth appears to be a promising preventive strategy for noncommunicable diseases in resource-constrained settings. TRIAL REGISTRATION: Clinicaltrials.gov NCT01295216; https://clinicaltrials.gov/ct2/show/NCT01295216.

[Qualitative study of the implementation of the Continuity of Care and Rehabilitation Program for people with severe mental disorders in PeruEstudo qualitativo sobre a implementação do Programa de Continuidade de Cuidados e Rehabilitação para pessoas com transtornos mentais graves no Peru]. / Estudio cualitativo sobre la implementación del Programa de continuidad de cuidados y rehabilitación para personas con trastornos mentales graves en el Perú.

OBJECTIVE: Describe the implementation of the Continuity of Care and Rehabilitation Program (PCC-R) in community mental health centers (CSMCs, Spanish acronym) in Peru. METHODS: Qualitative study of the implementation of the PCC-R in four CSMCs in Lima and La Libertad, Peru. Forty-two individual semi-structured interviews were conducted, as well as a focus group with five participants, for a total of 47 informants, including users, family members, and professionals involved in the design, implementation, and monitoring of the program. RESULTS: The PCC-R is a key program for community mental health services in Peru and it enjoys broad acceptability. Providers and users report satisfaction with its results; however, the program lacks a policy document specifying its objectives, organization, and activities. This would explain the variability in its implementation. The PCC-R has limitations in terms of management of financial and human resources, and it is necessary to improve training and supervision. There is consensus on the need, usefulness, and viability of developing a system to monitor the PCC-R. Good practices and suggestions are presented with a view to addressing these challenges. CONCLUSIONS: The PCC-R is a flagship program for the CSMCs and for the mental health reform in Peru. It has achieved broad acceptability among providers and users. Its implementation combines successes and difficulties, with pending tasks that include developing a policy document, improving resource management, strengthening training and supervision, and implementing a monitoring system for continuous improvement of the program.

OBJETIVO: Descrever a implementação do Programa de Continuidade de Cuidados e Reabilitação (PCC-R) em centros de saúde mental comunitária (CSMCs) do Peru. MÉTODOS: Estudo qualitativo sobre a implementação do PCC-R em quatro CSMCs em Lima e La Libertad, no Peru. Realizamos 42 entrevistas semiestruturadas individuais e um grupo focal com cinco participantes, com um total de 47 participantes, entre usuários, familiares e profissionais envolvidos na elaboração, implementação e monitoramento do PCC-R. RESULTADOS: O PCC-R é um programa central dos serviços de saúde mental comunitária no Peru, conta com ampla aceitabilidade e os prestadores e usuários dizem estar satisfeitos com seus resultados. No entanto, o programa não possui um documento normativo que detalhe os seus objetivos, organização e atividades, o que pode explicar a variabilidade em sua aplicação. Existem limitações na gestão dos recursos financeiros e humanos do PCC-R e necessidades de capacitação e supervisão, que devem ser melhoradas. Há consenso sobre a necessidade, utilidade e viabilidade de se desenvolver um sistema de monitoramento do PCC-R. Apresentamos aqui um conjunto de boas práticas e sugestões para enfrentar esses desafios. CONCLUSÕES: O PCC-R é um programa emblemático dos CSMCs e da reforma da saúde mental no Peru, tendo obtido ampla aceitação entre prestadores e usuários. A sua implementação combina acertos e dificuldades e revela tarefas pendentes, tais como o desenvolvimento de um documento normativo, uma melhor gestão de recursos, o reforço da capacitação e supervisão e a aplicação de um sistema de monitoramento para fomentar a melhoria contínua do programa.

Qualitative study of the implementation of the Continuity of Care and Rehabilitation Program for people with severe mental disorders in Peru.

OBJECTIVE: Describe the implementation of the Continuity of Care and Rehabilitation Program (PCC-R) in community mental health centers (CSMCs, Spanish acronym) in Peru. METHODS: Qualitative study of the implementation of the PCC-R in four CSMCs in Lima and La Libertad, Peru. Forty-two individual semi-structured interviews were conducted, as well as a focus group with five participants, for a total of 47 informants, including users, family members, and professionals involved in the design, implementation, and monitoring of the program. RESULTS: The PCC-R is a key program for community mental health services in Peru and it enjoys broad acceptability. Providers and users report satisfaction with its results; however, the program lacks a policy document specifying its objectives, organization, and activities. This would explain the variability in its implementation. The PCC-R has limitations in terms of management of financial and human resources, and it is necessary to improve training and supervision. There is consensus on the need, usefulness, and viability of developing a system to monitor the PCC-R. Good practices and suggestions are presented with a view to addressing these challenges. CONCLUSIONS: The PCC-R is a flagship program for the CSMCs and for mental health reform in Peru. It has achieved broad acceptability among providers and users. Its implementation combines successes and difficulties, with pending tasks that include developing a policy document, improving resource management, strengthening training and supervision, and implementing a monitoring system for continuous improvement of the program.

Parental body mass index and blood pressure are associated with higher body mass index and blood pressure in their adult offspring: a cross-sectional study in a resource-limited setting in northern Peru.

OBJECTIVES: High body mass index (BMI) and blood pressure (BP) are major contributors to the high burden of non-communicable diseases in adulthood. Individual high-risk and population approaches for prevention require newer strategies to target these risk factors and focusing on the family to introduce prevention initiatives appears as a promising scenario. Characterisation of the relationship between BMI and BP among the adult members of a given family merits evaluation. We conducted a secondary analysis of an implementation study in Tumbes, Peru, benefiting from data derived from families with at least one adult offspring. METHODS: The exposures of interest were the BMI, systolic BP (SBP) and diastolic BP (DBP) of the mother and father. The outcomes were the BMI, SBP and DBP of the offspring. Mixed-effects linear regression models were conducted. RESULTS: The mean age of the offspring, mothers and fathers was 29 (SD: 9.5), 54 (SD: 11.8) and 59 (SD: 11.6) years, respectively. Father's BMI was associated with a quarter-point increase in offspring BMI, regardless of the sex of the offspring. Mother's BMI had a similar effect on the BMI of her sons, but had no significant effect on her daughters'. Mother's SBP was associated with almost one-tenth of mmHg increase in the SBP of the adult offspring. There was no evidence of an association for DBP. CONCLUSIONS: In families with adult members, the higher the parents' BMI and SBP, the higher their adult offspring's levels will be.

Integration of a Technology-Based Mental Health Screening Program Into Routine Practices of Primary Health Care Services in Peru (The Allillanchu Project): Development and Implementation.

BACKGROUND: Despite their high prevalence and significant burden, mental disorders such as depression remain largely underdiagnosed and undertreated. OBJECTIVE: The aim of the Allillanchu Project was to design, develop, and test an intervention to promote early detection, opportune referral, and access to treatment of patients with mental disorders attending public primary health care (PHC) services in Lima, Peru. METHODS: The project had a multiphase design: formative study, development of intervention components, and implementation. The intervention combined three strategies: training of PHC providers (PHCPs), task shifting the detection and referral of mental disorders, and a mobile health (mHealth) component comprising a screening app followed by motivational and reminder short message service (SMS) to identify at-risk patients. The intervention was implemented by 22 PHCPs from five health centers, working in antenatal care, tuberculosis, chronic diseases, and HIV or AIDS services. RESULTS: Over a period of 9 weeks, from September 2015 to November 2015, 733 patients were screened by the 22 PHCPs during routine consultations, and 762 screening were completed in total. The chronic diseases (49.9%, 380/762) and antenatal care services (36.7%, 380/762) had the higher number of screenings. Time constraints and workload were the main barriers to implementing the screening, whereas the use of technology, training, and supervision of the PHCPs by the research team were identified as facilitators. Of the 733 patients, 21.7% (159/733) screened positively and were advised to seek specialized care. Out of the 159 patients with a positive screening result, 127 had a follow-up interview, 72.4% (92/127) reported seeking specialized care, and 55.1% (70/127) stated seeing a specialist. Both patients and PHCPs recognized the utility of the screening and identified some key challenges to its wider implementation. CONCLUSIONS: The use of a screening app supported by training and supervision is feasible and uncovers a high prevalence of unidentified psychological symptoms in primary care. To increase its sustainability and utility, this procedure can be incorporated into the routine practices of existing health care services, following tailoring to the resources and features of each service. The early detection of psychological symptoms by a PHCP within a regular consultation, followed by adequate advice and support, can lead to a significant percentage of patients accessing specialized care and reducing the treatment gap of mental disorders.

Family Support and Diabetes: Patient's Experiences From a Public Hospital in Peru.

Family support is crucial for managing chronic conditions but it is often overlooked when designing behavioral interventions in type 2 diabetes mellitus (T2DM). As part of the formative phase of a feasibility randomized control trial (RCT), we conducted 20 semistructured interviews with people with T2DM from Lima, Peru. Based on such results, we describe the support people with T2DM receive from their families and the role that such support has in their efforts to implement diabetes management practices. We learned that participants receive support from family members, but mostly from their spouses and children. Their relatives encourage them and motivate them to fight for their health, they also provide instrumental support by preparing healthy meals, reminding them to take medications, and sharing physical activity. Participants also reported controlling actions which were not always "well received." Thus, any intervention supporting self-management practices need to work with key family members. We support the literature that suggests that interventions should target family members to ensure improved T2DM self-management practices.

Towards sustainable partnerships in global health: the case of the CRONICAS Centre of Excellence in Chronic Diseases in Peru.

Human capital requires opportunities to develop and capacity to overcome challenges, together with an enabling environment that fosters critical and disruptive innovation. Exploring such features is necessary to establish the foundation of solid long-term partnerships. In this paper we describe the experience of the CRONICAS Centre of Excellence in Chronic Diseases, based at Universidad Peruana Cayetano Heredia in Lima, Peru, as a case study for fostering meaningful and sustainable partnerships for international collaborative research. The CRONICAS Centre of Excellence in Chronic Diseases was established in 2009 with the following Mission: "We support the development of young researchers and collaboration with national and international institutions. Our motivation is to improve population's health through high quality research." The Centre's identity is embedded in its core values - generosity, innovation, integrity, and quality- and its trajectory is a result of various interactions between multiple individuals, collaborators, teams, and institutions, which together with the challenges confronted, enables us to make an objective assessment of the partnership we would like to pursue, nurture and support. We do not intend to provide a single example of a successful partnership, but in contrast, to highlight what can be translated into opportunities to be faced by research groups based in low- and middle-income countries, and how these encounters can provide a strong platform for fruitful and sustainable partnerships. In defiant contexts, partnerships require to be nurtured and sustained. Acknowledging that all partnerships are not and should not be the same, we also need to learn from the evolution of such relationships, its key successes, hurdles and failures to contribute to the promotion of a culture of global solidarity where mutual goals, mutual gains, as well as mutual responsibilities are the norm. In so doing, we will all contribute to instil a new culture where expectations, roles and interactions among individuals and their teams are horizontal, the true nature of partnerships.

Reducing salt in bread: a quasi-experimental feasibility study in a bakery in Lima, Peru.

OBJECTIVES: To explore salt content in bread and to evaluate the feasibility of reducing salt contained in 'pan francés' bread. DESIGN: The study had two phases. Phase 1, an exploratory phase, involved the estimation of salt contained in bread as well as a triangle taste test to establish the amount of salt to be reduced in 'pan francés' bread without detection by consumers. In Phase 2, a quasi-experimental, pre-post intervention study assessed the effects of the introduction of low-salt bread on bakery sales. SETTING: A municipal bakery in Miraflores, Lima, Peru. SUBJECTS: Sixty-five clients of the bakery in Phase 1 of the study; sales to usual costumers in Phase 2. RESULTS: On average, there was 1·25 g of salt per 100 g of bread. Sixty-five consumers were enrolled in the triangle taste test: fifty-four (83·1 %) females, mean age 58·9 (sd 13·7) years. Based on taste, bread samples prepared with salt reductions of 10 % (P=0·82) and 20 % (P=0·37) were not discernible from regular bread. The introduction of bread with 20 % of salt reduction, which contained 1 g of salt per 100 g of bread, did not change sales of 'pan francés' (P=0·70) or other types of bread (P=0·36). Results were consistent when using different statistical techniques. CONCLUSIONS: The introduction of bread with a 20 % reduction in salt is feasible without affecting taste or bakery sales. Results suggest that these interventions are easily implementable, with the potential to contribute to larger sodium reduction strategies impacting the population's cardiovascular health.

Factors behind job preferences of Peruvian medical, nursing and midwifery students: a qualitative study focused on rural deployment.

BACKGROUND: Deployment of health workforce in rural areas is critical to reach universal health coverage. Students' perceptions towards practice in rural areas likely influence their later choice of a rural post. We aimed at exploring perceptions of students from health professions about career choice, job expectations, motivations and potential incentives to work in a rural area. METHODS: In-depth interviews and focus groups were conducted among medical, nursing and midwifery students from universities of two Peruvian cities (Ica and Ayacucho). Themes for assessment and analysis included career choice, job expectations, motivations and incentives, according to a background theory a priori built for the study purpose. RESULTS: Preference for urban jobs was already established at this undergraduate level. Solidarity, better income expectations, professional and personal recognition, early life experience and family models influenced career choice. Students also expressed altruism, willingness to choose a rural job after graduation and potential responsiveness to incentives for practising in rural areas, which emerged more frequent from the discourse of nursing and midwifery students and from all students of rural origin. Medical students expressed expectations to work in large urban hospitals offering higher salaries. They showed higher personal, professional and family welfare expectations. Participants consistently favoured both financial and non-financial incentives. CONCLUSIONS: Nursing and midwifery students showed a higher disposition to work in rural areas than medical doctors, which was more evident in students of rural origin. Our results may be useful to improve targeting and selection of undergraduate students, to stimulate the inclination of students to choose a rural job upon graduation and to reorient school programmes towards the production of socially committed health professionals. Policymakers may also consider using our results when planning and implementing interventions to improve rural deployment of health professionals.

Engagement of adolescents in a health communications program to prevent noncommunicable diseases: Multiplicadores Jóvenes, Lima, Peru, 2011.

BACKGROUND: Several risk factors for noncommunicable diseases (NCDs), including obesity, are associated with behaviors established in infancy that persist throughout adolescence and adulthood. As such, adolescents should be engaged in the design and implementation of NCD prevention strategies. COMMUNITY CONTEXT: In Lima, Peru's capital, the proportion of adolescents aged 15 to 19 is 9.3% of the city's population, and school enrollment rates are high. The prevalence of excess weight in Peruvian adolescents is 14.2%, and prevalence has not declined in recent years. Also recently, NCDs and their risk factors have gained more attention in public health and policy areas, with regulatory action focusing on healthful nutrition to address obesity and related NCDs. The Multiplicadores Jóvenes (Young Multipliers) project was conducted among adolescents aged 15 to 17 from 9 public secondary schools in peri-urban areas of Lima, Peru. METHODS: The project provided basic communication tools and knowledge of NCD prevention and public health research to adolescents during 16 weekly participatory sessions to enable them to design and disseminate healthful lifestyle promotion messages to their school peers. OUTCOME: Thirty of 45 participants finished the program. Seven communications campaigns were designed and implemented in schools, reaching 1,200 students. The participants gained motivation, increased knowledge, and developed communication skills that were combined to implement healthful lifestyle promotion campaigns. INTERPRETATION: Engaging young people in public health promotion activities was feasible and advantageous for the design of tailored prevention-related content and its dissemination among peers.

Telehealth in community mental health centers during the COVID-19 pandemic in Peru: A qualitative study with key stakeholders.

Aim: To describe the perceptions and experiences of key stakeholders to understand the use of telehealth in community mental health centers (CMHCs) during the COVID-19 pandemic in Lima and Callao, Peru. Methods: A qualitative study was carried out in four CMHCs in Lima and Callao, Peru. Forty-nine individual semi-structured interviews were conducted between September 2021 and March 2022, considering CMHCs' users and their relatives, health and administrative workers, directors, as well as local and national policymakers. Data was analyzed using thematic analysis. Results: Regarding the transition from in-person care to telehealth, CMHCs' directors and workers identified some of the regulations issued by the Government during the pandemic, such as the continuity of care through telehealth, especially for pregnant women and for people with comorbidities related to COVID-19. Regarding benefits, workers and users indicated that it allowed better communication, such as constant follow-ups. Directors and workers recognized that Google Drive facilitated access to user information, since they did not have an electronic medical record. Additionally, workers said they used social media to share educational information on mental health, and explained that some new users began their treatment this way. Regarding difficulties, participants reported a lack of devices and poor internet connection in CMHCs. Users mentioned that scheduling an appointment was difficult because the phone lines were usually saturated, and they could not find available appointments. Conclusion: Although the pandemic forced an immediate and disruptive change towards telehealth, CMHCs were able to adapt most of their services. This study reports the adaptations made by CMHCs to move from in-person to remote care, identifying the benefits and challenges faced, information that can be used for the nationwide implementation of telehealth in CMHCs. We recommend ensuring technological equipment and internet connection and adapt the telehealth system to make it responsive to the routine practices of CMHCs.

Multimorbidity and acute infectious diseases in urban and semi-urban settings in Peru: A mixed-methods study.

Background: The co-occurrence of chronic diseases and acute infectious events exacerbates disability and diminishes quality of life, yet research in Low- and Middle-Income countries is scarce. We aimed to investigate the relationship between infectious events and multimorbidity in resource-constrained settings. Methods: We conducted a sequential mixed-method study in Lima and Tumbes, Peru, with participants having multimorbidity from the CRONICAS Cohort Study. They completed a questionnaire on the occurrence, treatment, and health-seeking behaviour related to acute infectious events. Qualitative interviews explored the perceptions and links between multimorbidity and acute infectious events for a subgroup of participants. Findings: Among individuals with multimorbidity, low awareness of chronic conditions and poor medication adherence. The cumulative incidence for respiratory and gastrointestinal infections, the most reported acute conditions, was 2.0 [95%CI: 1.8-2.2] and 1.6 [1.2-1.9] events per person per year, respectively. Individuals with cancer (6.4 [1.6-11.2] events per person per year) or gastrointestinal reflux (7.2 [4.4-10.1] events per person per year) reported higher cumulative incidence of infectious events than others, such as those with cardiovascular and metabolic conditions (5.2 [4.6-5.8] events per person per year). Those with three or more chronic conditions had a slightly higher cumulative incidence compared with individuals with two conditions (5.7 [4.4-7.0] vs 5.0 [4.4-5.6] events per person per year). Around 40% of individuals with multimorbidity sought healthcare assistance, while others chose drugstores or didn't seek help. Our qualitative analysis showed diverse perceptions among participants regarding the connections between chronic and acute conditions. Those who recognized a connection emphasized the challenges in managing these interactions. Interpretation: Our study advances understanding of multimorbidity challenges in resource-limited settings, highlighting the impact of acute infections on patients' existing multimorbidity burden.

Nutritional information on the labels of processed and ultra-processed foods and beverages marketed in a supermarket chain in Lima in 2022. / Declaración de información nutricional en el etiquetado de bebidas y alimentos procesados y ultraprocesados ofertados en una cadena de supermercados de Lima en el 2022.

OBJECTIVES.: Motivation for the study. Peruvian Law No. 30021 establishes the use of warning octagons for foods with high content of critical nutrients (sugar, sodium, saturated and trans fats); however, the declaration of nutritional information is not mandatory. Main findings. Of a total of 4404 processed and ultra-processed foods marketed in supermarkets in Lima, only 71.4% declared some type of nutritional information. In addition, only 46.0% declared information on the content of critical nutrients regulated by Law No. 30021. Implications. There is a need for a mandatory and standardized declaration of nutritional information on packaged foods marketed in Peru, in order to allow the population to make healthy decisions when choosing their food and to monitor the correct use of warning octagons. . To estimate the number of processed and ultra-processed beverages and foods that provide nutritional information on their packaging, and to describe the characteristics of this information, as well as to determine the presence of nutritional information on products with octagons. MATERIALS AND METHODS.: Photographs were taken of the labels of 4404 processed and ultra-processed beverages and foods marketed in supermarkets in Metropolitan Lima. The information on the label was collected and registered in the mobile and web version of the Food Label Information Program (FLIP). We analyzed variables related to the nutritional information, the way in which such information is declared and the information in beverages and foods with octagons. RESULTS.: Only 71.4% of the products had some type of nutritional information. Of these, 13.8% provided the nutritional information as a text and not in a table, and only 56.3% declared it per 100 grams or milliliters. Of the total number of foods with the octagon "Contains trans fats", only 19.2% declared their content. CONCLUSIONS.: More than a quarter of the beverages and packaged foods in the Peruvian market did not provide nutritional information of any kind, and of those that did, only one did so in different formats and units. In addition, we found that a proportion of beverages and foods for each type of octagon did not declare information of the nutrient that is mentioned in the octagon.

OBJETIVOS.: Estimar la cantidad de bebidas y alimentos procesados y ultraprocesados que declaran información nutricional en su empaque y describir las características de esta información, así como determinar la presencia de información nutricional en los productos con octógonos. MATERIALES Y MÉTODOS.: Se tomaron fotografías del etiquetado de 4404 bebidas y alimentos procesados y ultraprocesados ofertados en supermercados de Lima Metropolitana. La información declarada en la etiqueta se recogió y se registró en la versión móvil y web del Programa de Información de Etiquetas de Alimentos (FLIP por sus siglas en inglés). Se analizaron las variables correspondientes a la declaración de información nutricional, la forma en que se declara dicha información y la declaración de la misma en bebidas y alimentos con octógonos. RESULTADOS.: De todos los productos recolectados solo el 71,4% declara algún tipo de información nutricional. De estos, el 13,8% declara la información nutricional en texto y no en tabla, además sólo 56,3% la declara por cada 100 gramos o mililitros. Del total de alimentos con el octógono «Contiene grasas trans¼, sólo 19,2% declara su contenido. CONCLUSIONES.: Más de la cuarta parte de bebidas y alimentos envasados expendidos en el mercado peruano no declaran información nutricional de ningún tipo, y de los que declaran, existe una que lo hace en diferentes formatos y unidades. Además, se halló que hay una proporción de bebidas y alimentos para cada tipo de octógono que no declaran la información del nutriente advertido en el mismo.

Experiences of users and family members on the care received at community mental health centers in Lima and Callao during the COVID-19 pandemic. / Experiencias de usuarios y familiares sobre la atención recibida en centros de salud mental comunitaria de Lima y Callao durante la pandemia de la COVID-19.

OBJECTIVE.: To understand the experiences of new and continuing users of Community Mental Health Centers (CMHC) of Lima and Callao, and their relatives, regarding the mental health care they received during the COVID-19 pandemic. MATERIALS AND METHODS.: Qualitative study conducted between September 2021 and February 2022, in which we interviewed 24 users and family members who interacted with the services provided by three CMHCs in Lima and one in Callao during the COVID-19 pandemic. We carried out a thematic analysis of the transcribed interviews. RESULTS.: Participants perceived that the pandemic exacerbated the symptoms of people with mental health problems. During the pandemic, mental health care relied on the use of technology, mainly telephone calls, which were used to monitor the emotional state and pharmacological treatment of users, as well as to schedule and remember appointments. The users emphasized that frequent telephone calls made them feel accompanied and highlighted the commitment of the CMHC workers. Among the difficulties, they reported an increase in the demand for care, problems in accessing video calls, and low quality in virtual care. CONCLUSIONS.: COVID-19 had an emotional impact on people with mental health problems; in turn, CMHC services were affected by the type of care (face-to-face or virtual), resources, frequency, time and quality of care, finding limitations and benefits in the use of technology.

OBJETIVOS.: Comprender las experiencias de usuarios nuevos y continuadores de los Centros de Salud Mental Comunitaria (CSMC) de Lima y Callao, y de sus familiares, en relación a la atención en salud mental que recibieron durante la pandemia de la COVID-19. MATERIALES Y MÉTODOS.: Estudio cualitativo realizado entre septiembre del 2021 y febrero del 2022, en el que se entrevistó a 24 usuarios y familiares que interactuaron con los servicios brindados por tres CSMC de Lima y uno del Callao, durante la pandemia de la COVID-19. Se realizó un análisis temático de las entrevistas transcritas. RESULTADOS.: Los informantes percibieron que la pandemia exacerbó los síntomas de las personas con problemas de salud mental. Durante la pandemia, las atenciones de salud mental se apoyaron en el uso de tecnología, principalmente de llamadas telefónicas, las que sirvieron para monitorear el estado emocional y el tratamiento farmacológico de los usuarios, así como para programar y recordar citas. Los usuarios destacan que las llamadas telefónicas frecuentes les hicieron sentirse acompañados y resaltan el compromiso de los trabajadores de los CSMC. Como dificultades, reportan el incremento en la demanda de atención, problemas para acceder a videollamadas, y menor calidad en las atenciones virtuales. CONCLUSIONES.: La COVID-19 impactó emocionalmente a las personas con problemas de salud mental, a su vez, los servicios de los CSMC vieron afectada la modalidad (presencial o virtual), recursos, frecuencia, tiempo y calidad de la atención, encontrando limitaciones y beneficios en el uso de la tecnología.