Increasing use of systems science in cardiovascular disease prevention to understand how to address geographic health disparities in communities with a disproportionate burden of risk.

Objective: Marginalized communities shoulder a disproportionate burden of cardiovascular disease (CVD) driven by concentrated neighborhood social risk factors. We provide a case study of systems science application to address geographic CVD health disparities at the community level - informing the science of CVD health disparities research. Methods: We conducted a two-phased, multi-methods needs assessment in the Denver, Colorado area. Phase I consisted of a social network analysis to map a two-mode network of existing CVD prevention interventions and their implementing organizations. In Phase II, group model building (GMB) sessions with key community, public health, and healthcare provider stakeholders, were utilized to identify and visualize community factors contributing to disparities in CVD risk, producing a consensus-based causal loop diagram. Results: Between May 2021 and June 2022, we conducted 24 virtual, semi-structured interviews in Phase I to describe CVD prevention interventions, and 7 virtual GMB sessions in Phase II to describe experiences of disparities in CVD risk. For the purposes of this paper, we focus on a subset of results for both phases. In Phase I we identified 89 active CVD prevention interventions, 29 of which addressed tobacco use. In Phase II, causal loop diagrams revealed root causes of disparities in CVD risk. We provide an example of a causal loop diagram that focuses on the community prevalence of tobacco use, identifying stress as a key underlying factor driving disparities. The integration of findings from both phases highlighted the alignment and misalignment between quit tobacco intervention goals and how they are being experienced in marginalized communities. Conclusion: Systems science methods were useful to organize a large number of CVD prevention efforts, and evaluate the root causes of CVD health disparities in a high risk community. By integrating these two aspects, interventions may be reoriented to more effectively address the root causes of CVD health disparities.

Protocol for a scoping review of health equity frameworks and models applied in empirical studies of chronic disease prevention and control.

BACKGROUND: Chronic diseases, such as cancers and cardiovascular diseases, present the greatest burden of morbidity and mortality worldwide. This burden disproportionately affects historically marginalized populations. Health equity is rapidly gaining increased attention in public health, health services, and implementation research, though many health inequities persist. Health equity frameworks and models (FM) have been called upon to guide equity-focused chronic disease and implementation research. However, there is no clear synthesis of the health equity FM used in chronic disease research or how these are applied in empirical studies. This scoping review seeks to fill this gap by identifying and characterizing health equity FM applied in empirical studies along the chronic disease prevention and control continuum, describing how these FM are used, and exploring potential applications to the field of implementation science. METHODS: We follow established guidance for conducting scoping reviews, which includes six stages: (1) identify the research question; (2) identify relevant studies; (3) select studies for inclusion; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) consultation. This protocol presents the iterative, collaborative approach taken to conceptualize this study and develop the search strategy. We describe the criteria for inclusion in this review, methods for conducting two phases of screening (title and abstract, full text), data extraction procedures, and quality assurance approaches taken throughout the project. DISCUSSION: The findings from this review will inform health-equity focused chronic disease prevention and control research. FM identified through this review will be added to an existing website summarizing dissemination and implementation science frameworks, and we will offer case examples and recommendations for utilizing a health equity FM in empirical studies. Our search strategy and review methodology may serve as an example for scholars seeking to conduct reviews of health equity FM in other health disciplines. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework Registration https://doi.org/10.17605/OSF.IO/SFVE6.

Use of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to guide iterative adaptations: Applications, lessons learned, and future directions.

Introduction: Implementation science frameworks have been used widely for planning and evaluation, but seldom to guide adaptations during program implementation. There is great potential for these frameworks to be used to inform conceptual and data-driven decisions about adaptations. Methods: We summarize recent applications using Iterative RE-AIM to capture and guide adaptations. Iterative RE-AIM can be repeated at multiple time points customized to each project and involves the following activities: identification of key implementation partners; rating importance of and progress on each RE-AIM dimension (reach, effectiveness, adoption, implementation, and maintenance); use of summary data on ratings to identify one or two RE-AIM dimensions for adaptations and implementation strategies; and evaluation of progress and impact of adaptations. We summarize recent and ongoing Iterative RE-AIM applications across multiple care coordination and pain management projects within the Veterans Health Administration, a hypertension control trial in Guatemala, a hospital-based lung ultrasound implementation pilot, and a colorectal cancer screening program in underserved communities. Results: Iterative RE-AIM appears feasible, helpful, and broadly applicable across diverse health care issues, interventions, contexts, and populations. In general, the RE-AIM dimension showing the largest gap between importance and progress has been Reach. The dimensions most frequently selected for improvement have been Reach and Implementation. We discuss commonalities, differences and lessons learned across these various applications of Iterative RE-AIM. Challenges include having objective real time data on which to make decisions, having key implementation staff available for all assessments, and rapidly scoring and providing actionable feedback. We discuss print and online resources and materials to support Iterative RE-AIM. Conclusions: The use of Iterative RE-AIM to guide and support understanding of adaptations has proven feasible across diverse projects and in multiple case studies, but there are still questions about its strengths, limitations, essential components, efficiency, comparative effectiveness, and delivery details. Future directions include investigating the optimal frequency and timing for iterative applications; adding contextual assessments; developing more continuous and rapid data on which to make adaptation decisions; identifying opportunities to enhance health equity; and determining the level of facilitation that is most cost-effective.

Chronic kidney disease among children in Guatemala / Enfermedad renal crónica en niños de Guatemala

OBJECTIVE: To describe the distribution of pediatric chronic kidney disease (CKD) in Guatemala, estimate incidence and prevalence of pediatric end-stage renal disease (ESRD), and estimate time to progress to ESRD. METHODS: This study analyzed the registry of the only pediatric nephrology center in Guatemala, from 2004-2013. Incidence and prevalence were calculated for annual periods. Moran's index for spatial autocorrelation was used to determine significance of geographic distribution of incidence. Time to progress to ESRD and associated risk factors were calculated with multivariate Cox regression. RESULTS: Of 1 545 patients from birth to less than 20 years of age, 432 had chronic renal failure (CRF). Prevalence and incidence of ESRD were 4.9 and 4.6 per million age-related population, respectively. Incidence was higher for the Pacific coast and Guatemala City. The cause of CRF was undetermined in 43% of patients. Average time to progress to ESRD was 21.9 months; factors associated with progression were: older age, diagnosis of glomerulopathies, and advanced-stage CKD at consultation. CONCLUSIONS: Prevalence and incidence of ESRD in Guatemala are lower than in other countries. This may reflect poor access to diagnosis. Areas with higher incidence and large proportion of CKD of undetermined cause are compatible with other studies from the geographic subregion. Findings on progression to ESRD may reflect delayed referral.

OBJETIVO: Describir la distribución de enfermedad renal crónica en niños en Guatemala, y calcular la incidencia y la prevalencia de nefropatía terminal en niños, así como el tiempo de progresión hasta la nefropatía terminal. MÉTODOS: Este estudio analizó el registro del único centro de nefrología pediátrica de Guatemala, del 2004 al 2013. La incidencia y la prevalencia se calcularon por períodos anuales. Se utilizó el índice de Moran como medida de la autocorrelación espacial con objeto de determinar la significación de la distribución geográfica de la incidencia. El tiempo de progresión a la nefropatía terminal, así como los factores de riesgo asociados, se calcularon mediante la regresión de Cox de variables múltiples. RESULTADOS: De 1 545 pacientes menores de 20 años, 432 padecían insuficiencia renal crónica. La prevalencia y la incidencia de nefropatía terminal fueron de 4,9 y 4,6 por millón de habitantes de esa misma edad, respectivamente. La incidencia fue mayor en la costa del Pacífico y en la Ciudad de Guatemala. En 43% de los pacientes la causa de la insuficiencia renal crónica era indeterminada. El tiempo promedio de progresión a una nefropatía terminal fue de 21,9 meses; los factores asociados con esa progresión fueron: la edad mayor, el diagnóstico de glomerulopatía y la enfermedad renal crónica en etapa avanzada en el momento de la consulta. CONCLUSIONES: La prevalencia y la incidencia de la nefropatía terminal en Guatemala son inferiores a las de otros países. Ello podría reflejar un acceso limitado al diagnóstico. La mayor incidencia y la amplia proporción de enfermedad renal crónica de causa indeterminada en algunas zonas son compatibles con las de otros estudios de la subregión geográfica. Los resultados en cuanto a progresión a una nefropatía terminal podrían ser el reflejo de la tardanza en la derivación.

Implementation and progress of an inclusive primary health care model in Guatemala: coverage, quality, and utilization / Ejecución y avance de un modelo inclusivo de atención primaria de salud en Guatemala: cobertura, calidad y utilización

OBJECTIVE: To describe a primary health care model designed specifically for Guatemala that has been implemented in two demonstration sites since 2004 and present results of a process evaluation of utilization, service coverage, and quality of care from 2005 to 2009. METHODS: Coverage, utilization, and quality were assessed by using an automated database linking census and clinical records and were reported over time. Key maternal and child health coverage measures were compared with national-level measures. RESULTS: The postnatal coverage achieved by the Modelo Incluyente de Salud of nearly 100.0 percent at both sites contrasts with the national average of 25.6 percent. Vaccination coverage for children aged 12-23 months in the Modelo Incluyente de Salud reached 95.6 percent at site 1 (Bocacosta, Sololá) and 92.7 percent at site 2 (San Juan Ostuncalco), compared with the national average of 71.2 percent. Adherence to national treatment guidelines increased significantly at both sites with a marked increase between 2006 and 2007. Utilization increased significantly at both sites, with only 7.5 percent of families at site 1 and 11.2 percent of families at site 2 not using services by the end of the 5-year period. CONCLUSIONS: Coverage, quality of care, and utilization measures increased significantly during the 5-year period when the service delivery model was implemented. This finding suggests a strong possibility that the model may have a benefit for health outcomes as well as for process measures. The Modelo Incluyente de Salud will be financially sustained by the Ministry of Health and extended to at least three additional sites. The model provides important lessons for primary care programs internationally.

OBJETIVO: Describir un modelo de atención primaria de salud diseñado específicamente para Guatemala que se ha ejecutado en dos sitios piloto desde 2004 y presentar los resultados de una evaluación de la utilización, la cobertura de servicios y la calidad de la atención entre 2005 y 2009. MÉTODOS: Se evaluaron la cobertura, la utilización y la calidad mediante una base de datos automatizada que relaciona los datos obtenidos a partir de un censo con los registros clínicos, y su evolución se informó a lo largo del tiempo. Se compararon las medidas clave de cobertura de la salud maternoinfantil con las medidas obtenidas en el nivel nacional. RESULTADOS: La cobertura posnatal lograda por el Modelo Incluyente de Salud, de casi 100,0 por ciento en ambos sitios, contrasta con el promedio nacional de 25,6 por ciento. La cobertura de vacunación de los niños de 12 a 23 meses de edad en dicho modelo alcanzó 95,6 por ciento en el sitio 1 (Bocacosta, Sololá) y 92,7 por ciento en el sitio 2 (San Juan Ostuncalco), en comparación con el promedio nacional de 71,2 por ciento. El cumplimiento de las directrices nacionales de tratamiento aumentó significativamente en los dos sitios, con un aumento acentuado entre 2006 y 2007. La utilización aumentó significativamente en ambos sitios; al finalizar el período de 5 años no usaban los servicios solo 7,5 por ciento de las familias en el sitio 1 y 11,2 por ciento de las familias en el sitio 2. CONCLUSIONES: Las medidas de cobertura, calidad de la atención y utilización aumentaron significativamente durante el período de 5 años durante el cual se ejecutó el modelo de prestación de servicios. Estos datos indican firmemente que el modelo puede mejorar tanto los resultados relacionados con la salud como las medidas de proceso. El Modelo Incluyente de Salud será mantenido económicamente por el Ministerio de Salud Pública y Asistencia Social y se extenderá, al menos, a tres sitios más. El modelo proporciona enseñanzas importantes para los programas de atención primaria de otros países.