Gender inequality, women's empowerment, and adolescent birth rates in 363 Latin American cities.

BACKGROUND: Gender inequality is high in Latin America (LA). Empowering girls and young women and reducing gender gaps has been proposed as a pathway to reduce adolescent pregnancy. We investigated the associations of urban measures of women's empowerment and gender inequality with adolescent birth rates (ABR) in 366 Latin American cities in nine countries. METHODS: We created a gender inequality index (GII) and three Women Achievement scores reflecting domains of women's empowerment (employment, education, and health care access) using censuses, surveys, and political participation data at city and sub-city levels. We used 3-level negative binomial models (sub-city-city-countries) to assess the association between the GII and scores, with ABR while accounting for other city and sub-city characteristics. RESULTS: We found within country heterogeneity in gender inequality and women's empowerment measures. The ABR was 4% higher for each 1 standard deviation (1-SD) higher GII (RR 1.04; 95%CI 1.01,1.06), 8% lower for each SD higher autonomy score (RR 0.92; 95%CI 0.86, 0.99), and 12% lower for each SD health care access score (RR 0.88; 95%CI 0.82,0.95) after adjustment for city level population size, population growth, homicide rates, and sub-city population educational attainment and living conditions scores. CONCLUSION: Our findings show the key role cities have in reducing ABR through the implementation of strategies that foster women's socioeconomic progress such as education, employment, and health care access.

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.

Adolescent birth rates and the urban social environment in 363 Latin American cities.

INTRODUCTION: Latin America has the second-highest adolescent birth rate (ABR) worldwide. Variation between urban and rural areas and evidence linking country development to ABR points towards upstream factors in the causal pathway. We investigated variation in ABR within and between cities, and whether different features of urban social environments are associated with ABR. METHODS: We included 363 cities in 9 Latin American countries. We collected data on social environment at country, city and subcity levels and birth rates among adolescents (ages 15-19). We investigated variation in ABR within and between countries and cities along with associations between social environment and ABR by fitting three-level negative binomial models (subcities nested within cities nested within countries). RESULTS: The median subcity ABR was 58.5 per 1000 women 15-19 (IQR 43.0-75.3). We found significant variability in subcity ABR between countries and cities (37% of variance between countries and 47% between cities within countries). Higher homicide rates and greater population growth in cities were associated with higher ABR (rate ratio (RR) 1.09; 95% CI 1.06 to 1.12 and RR 1.02; 95% CI 1.00 to 1.04, per SD, respectively), while better living conditions and educational attainment in subcities were associated with lower ABR after accounting for other social environment characteristics (RR 0.95; 95% CI 0.92 to 0.98 and 0.78; 95% CI 0.76 to 0.79, per SD, respectively). CONCLUSIONS: The large heterogeneity of ABR found within countries and cities highlights the key role urban areas have in developing local policies. Holistic interventions targeting education inequalities and living conditions are likely important to reducing ABR in cities.

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.

Association between informal employment and depressive symptoms in 11 cities in Latin America.

Background: Mental health is an important contributor to the global burden of disease, and depression is the most prevalent mental disorder in Latin America and the Caribbean (LAC). Informal jobs, often characterized by precarious working conditions, low wages, and limited employment benefits, are also highly prevalent in LAC and may be associated with poorer mental health. Our study tests the association between informal employment and major depressive symptoms in LAC cities. Methods: We used individual-level data collected by the Development Bank of Latin America via their "Encuesta CAF" (ECAF) 2016, a cross-sectional household survey of 11 LAC cities (N = 5430). Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Short Depression Scale with possible total score ranging from 0 to 30. Scores were dichotomized, with a score > ‾ 16 indicating the presence of major depressive symptoms. Informal employment was defined based on self-reported lack of contribution to the social security system. We used generalized estimating equation (GEE) log-binomial models to estimate the association between informal employment and depressive symptoms overall and by gender. Models were adjusted for age, education, and household characteristics. Results: Overall, individuals employed in informal jobs had a 27% higher prevalence of major depressive symptoms (Prevalence Ratio [PR]: 1.27; 95% Confidence Interval [CI]: 1.00, 1.62) compared to those in formal jobs. The prevalence of depressive symptoms among individuals with informal jobs was higher compared to those with formal jobs in both women (PR: 1.36, 95% CI: 1.06, 1.74) and men (PR: 1.22; 95% CI: 0.90, 1.65). Conclusions: Informal employment in LAC was associated with a higher prevalence of major depressive symptoms. It is important to develop policies aiming at reducing informal jobs and increasing universal social protection for informal workers.

Satisfaction and perceptions about aspects of the city that affect health, by socioeconomic status, 2010-2019, in Lima. / Satisfacción y percepciones sobre aspectos de la ciudad que afectan la salud, por nivel socioeconómico, 2010-2019, en Lima Metropolitana.

We aimed to characterize the satisfaction and perceptions of the residents of Lima about different aspects of urban life that can affect their quality of life and health, identifying differences by socioeconomic status (SES) and changes over time. A secondary data analysis of the "Lima Cómo Vamos" survey was conducted between 2010 and 2019. Results are reported through percentages, with differences between SES for each year and between years. In 2019, satisfaction and perceptions were mostly unfavorable, and have decreased by up to 30% over time. People with lower SES had more unfavorable evaluations and with greater reductions over time. This dissatisfaction and unfavorable perceptions reveal deficiencies in public services and urban conditions that could negatively affect the quality of life and health, making it necessary to design and implement policies that reduce socioeconomic gaps and improve the health of Lima citizens.

Se buscó caracterizar la satisfacción y percepciones de los residentes de Lima Metropolitana sobre distintos aspectos de la ciudad que pueden afectar su calidad de vida y salud, identificando diferencias por nivel socioeconómico (NSE) y cambios en el tiempo. Se realizó un análisis secundario de la Encuesta «Lima Cómo Vamos¼ entre 2010 y 2019, reportando los resultados mediante porcentajes, con diferencias entre NSE para cada año y entre años. En 2019 la satisfacción y percepciones eran mayoritariamente desfavorables, y han disminuido hasta en 30 puntos porcentuales con el tiempo. Las personas de NSE más bajos tenían valoraciones más desfavorables y con mayores reducciones en el tiempo. Esta insatisfacción y percepciones desfavorables revelan deficiencias en servicios públicos y condiciones urbanas que podrían afectar negativamente la calidad de vida y salud, haciendo necesarias políticas que reduzcan las brechas socioeconómicas y mejoren la salud de los ciudadanos de Lima Metropolitana.

Satisfacción y percepciones sobre aspectos de la ciudad que afectan la salud, por nivel socioeconómico, 2010-2019, en Lima Metropolitana / Satisfaction and perceptions about aspects of the city that affect health, by socioeconomic status, 2010-2019, in Lima

RESUMEN Se buscó caracterizar la satisfacción y percepciones de los residentes de Lima Metropolitana sobre distintos aspectos de la ciudad que pueden afectar su calidad de vida y salud, identificando diferencias por nivel socioeconómico (NSE) y cambios en el tiempo. Se realizó un análisis secundario de la Encuesta «Lima Cómo Vamos¼ entre 2010 y 2019, reportando los resultados mediante porcentajes, con diferencias entre NSE para cada año y entre años. En 2019 la satisfacción y percepciones eran mayoritariamente desfavorables, y han disminuido hasta en 30 puntos porcentuales con el tiempo. Las personas de NSE más bajos tenían valoraciones más desfavorables y con mayores reducciones en el tiempo. Esta insatisfacción y percepciones desfavorables revelan deficiencias en servicios públicos y condiciones urbanas que podrían afectar negativamente la calidad de vida y salud, haciendo necesarias políticas que reduzcan las brechas socioeconómicas y mejoren la salud de los ciudadanos de Lima Metropolitana.

ABSTRACT We aimed to characterize the satisfaction and perceptions of the residents of Lima about different aspects of urban life that can affect their quality of life and health, identifying differences by socioeconomic status (SES) and changes over time. A secondary data analysis of the "Lima Cómo Vamos" survey was conducted between 2010 and 2019. Results are reported through percentages, with differences between SES for each year and between years. In 2019, satisfaction and perceptions were mostly unfavorable, and have decreased by up to 30% over time. People with lower SES had more unfavorable evaluations and with greater reductions over time. This dissatisfaction and unfavorable perceptions reveal deficiencies in public services and urban conditions that could negatively affect the quality of life and health, making it necessary to design and implement policies that reduce socioeconomic gaps and improve the health of Lima citizens.

A Mobile Health Intervention for Patients With Depressive Symptoms: Protocol for an Economic Evaluation Alongside Two Randomized Trials in Brazil and Peru.

BACKGROUND: Mobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development. OBJECTIVE: This paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both. METHODS: The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in São Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top-down and bottom-up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds. RESULTS: The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. CONCLUSIONS: We expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26164.

Design of financial incentive interventions to improve lifestyle behaviors and health outcomes: A systematic review.

Background: Financial incentives may improve the initiation and engagement of behaviour change that reduce the negative outcomes associated with non-communicable diseases. There is still a paucity in guidelines or recommendations that help define key aspects of incentive-oriented interventions, including the type of incentive (e.g. cash rewards, vouchers), the frequency and magnitude of the incentive, and its mode of delivery.  We aimed to systematically review the literature on financial incentives that promote healthy lifestyle behaviours or improve health profiles, and focused on the methodological approach to define the incentive intervention and its delivery. The protocol was registered at PROSPERO on 26 July 2018 ( CRD42018102556). Methods: We sought studies in which a financial incentive was delivered to improve a health-related lifestyle behaviour (e.g., physical activity) or a health profile (e.g., HbA1c in people with diabetes). The search (which took place on March 3 rd 2018) was conducted using OVID (MEDLINE and Embase), CINAHL and Scopus. Results: The search yielded 7,575 results and 37 were included for synthesis. Of the total, 83.8% (31/37) of the studies were conducted in the US, and 40.5% (15/37) were randomised controlled trials. Only one study reported the background and rationale followed to develop the incentive and conducted a focus group to understand what sort of incentives would be acceptable for their study population. There was a degree of consistency across the studies in terms of the direction, form, certainty, and recipient of the financial incentives used, but the magnitude and immediacy of the incentives were heterogeneous. Conclusions: The available literature on financial incentives to improve health-related lifestyles rarely reports on the rationale or background that defines the incentive approach, the magnitude of the incentive and other relevant details of the intervention, and the reporting of this information is essential to foster its use as potential effective interventions.

[Healthcare challenges for people with diabetes during the national state of emergency due to COVID-19 in Lima, Peru: primary healthcare recommendations]. / Los retos del cuidado de las personas con diabetes durante el estado de emergencia nacional por COVID-19 en Lima, Perú: recomendaciones para la atención primaria.

Patients diagnosed with type 2 diabetes mellitus, who then become infected with SARS-CoV-2, are at greater risk of developing complications from COVID-19, which may even lead to death. Diabetes is a chronic condition that requires continuous contact with healthcare facilities; therefore, this type of patients should have regular access to medicines, tests and appointments with healthcare personnel. In Peru, care and treatment continuity have been affected since the national state of emergency due to COVID-19 began; because many healthcare facilities suspended outpatient consultations. The strategies presented in this study were developed by different Peruvian health providers in the pandemic context to ensure care continuity for people with diabetes. This article provides recommendations to strengthen primary healthcare, because it is the first level of healthcare contact for patients with diabetes.

Las personas con diabetes mellitus tipo 2 infectadas por SARS-CoV-2 tienen mayores riesgos de desarrollar COVID-19 con complicaciones y de morir como consecuencia de ella. La diabetes es una condición crónica en la que se requiere continuidad de cuidados que implican un contacto con los establecimientos de salud, pues deben tener acceso regular a medicamentos, exámenes y citas con personal de salud. Esta continuidad de cuidados se ha visto afectada en el Perú a raíz de la declaratoria del estado de emergencia nacional, producto de la pandemia por la COVID-19 pues muchos establecimientos de salud han suspendido las consultas externas. Este artículo describe algunas estrategias que han desarrollado los diferentes proveedores de salud peruanos en el marco de la pandemia para proveer continuidad del cuidado a las personas con diabetes y finalmente brinda recomendaciones para que reciban los cuidados que necesitan a través del fortalecimiento del primer nivel de atención, como el punto de contacto más cercano con las personas con diabetes.

Perceptions of Community Involvement in the Peruvian Mental Health Reform Process Among Clinicians and Policy-Makers: A Qualitative Study.

BACKGROUND: The global burden of mental health conditions has led to the implementation of new models of care for persons with mental illness. Recent mental health reforms in Peru include the implementation of a community mental health model (CMHM) that, among its core objectives, aims to provide care in the community through specialized facilities, the community mental health centers (CMHCs). Community involvement is a key component of this model. This study aims to describe perceptions of community engagement activities in the current model of care in three CMHCs and identify barriers and potential solutions to implementation. METHODS: A qualitative research study using in-depth semi-structured interviews with clinicians from three CMHCs and with policy-makers involved in the implementation of the mental health reforms was conducted in two regions of Peru. The interviews, conducted in Spanish, were digitally recorded with consent, transcribed and analyzed using principles of grounded theory applying a framework approach. Community engagement activities are described at different stages of patient care. RESULTS: Twenty-five full-time employees (17 women, 8 men) were interviewed, of which 21 were clinicians (diverse health professions) from CMHCs, and 4 were policy-makers. Interviews elucidated community engagement activities currently being utilized including: (1) employing community mental health workers (CMHWs); (2) home visits; (3) psychosocial clubs; (4) mental health workshops and campaigns; and (5) peer support groups. Inadequate infrastructure and financial resources, lack of knowledge about the CMHM, poorly defined catchment areas, stigma, and inadequate productivity approach were identified as barriers to program implementation. Solutions suggested by participants included increasing knowledge and awareness about mental health and the new model, implementation of peer-training, and improving productivity evaluation and research initiatives. CONCLUSION: Community engagement activities are being conducted in Peru as part of a new model of care. However, their structure, frequency, and content are perceived by clinicians and policy-makers as highly variable due to a lack of consistent training and resources across CMHCs. Barriers to implementation should be quickly addressed and potential solutions executed, so that scale-up best optimizes the utilization of resources in the implementation process.

Peruvian Mental Health Reform: A Framework for Scaling-up Mental Health Services.

BACKGROUND: Mental, neurological, and substance (MNS) use disorders are a leading cause of disability worldwide; specifically in Peru, MNS affect 1 in 5 persons. However, the great majority of people suffering from these disorders do not access care, thereby making necessary the improvement of existing conditions including a major rearranging of current health system structures beyond care delivery strategies. This paper reviews and examines recent developments in mental health policies in Peru, presenting an overview of the initiatives currently being introduced and the main implementation challenges they face. METHODS: Key documents issued by Peruvian governmental entities regarding mental health were reviewed to identify and describe the path that led to the beginning of the reform; how the ongoing reform is taking place; and, the plan and scope for scale-up. RESULTS: Since 2004, mental health has gained importance in policies and regulations, resulting in the promotion of a mental health reform within the national healthcare system. These efforts crystallized in 2012 with the passing of Law 29889 which introduced several changes to the delivery of mental healthcare, including a restructuring of mental health service delivery to occur at the primary and secondary care levels and the introduction of supporting services to aid in patient recovery and reintegration into society. In addition, a performance-based budget was approved to guarantee the implementation of these changes. Some of the main challenges faced by this reform are related to the diversity of the implementation settings, eg, isolated rural areas, and the limitations of the existing specialized mental health institutes to substantially grow in parallel to the scaling-up efforts in order to be able to provide training and clinical support to every region of Peru. CONCLUSION: Although the true success of the mental healthcare reform will be determined in the coming years, thus far, Peru has achieved a number of legal, policy and fiscal milestones, thereby presenting a unique and fertile environment for the expansion of mental health services.

[Social programs and reducing obesity in Peru: reflections from the research]. / Programas sociales y reducción de la obesidad en el Perú: reflexiones desde la investigación.

In recent decades, overweight or obesity have increased dramatically in middle- and low-income countries; a situation which consolidates chronic non-communicable diseases (NCD) as one of the leading causes of mortality and disability worldwide. Currently, half the people in Peru over the age of 15 years are overweight, and one fifth suffer from obesity. The situation is worsening and increasingly affects people in poverty, who frequently benefit from food supplement programs designed to combat food insecurity and malnutrition. There is an urgent worldwide need to find policies and programs that help fight the problem of obesity at the population level, a task that is still pending. In this article, we review the current epidemic of overweight and obesity in Peru and the world and its most significant consequences and causes, with an emphasis on access to and availability of foods. We describe the largest food supplement programs and synthesize the research on interventions in order to reflect on how their findings might help social programs work as a platform to reduce obesity and prevent NCD in Peru.

Programas sociales y reducción de la obesidad en el Perú: reflexiones desde la investigación / Social programs and reducing obesity in Peru: reflections from the research

RESUMEN En las últimas décadas, el sobrepeso y la obesidad han aumentado de forma acelerada en los países de ingresos medios y bajos, una situación que consolida a las enfermedades crónicas no transmisibles (ENT) como una de las más importantes causas de mortalidad y discapacidad a nivel global. Actualmente, uno de cada dos peruanos mayores de 15 años tiene exceso de peso y uno de cada cinco sufre de obesidad, una situación que está en continuo crecimiento y afecta cada vez más intensamente a los que viven en condiciones de pobreza, quienes, con frecuencia, son beneficiarios de programas de complementación alimentaria, dirigidos a enfrentar la inseguridad alimentaria y la desnutrición. Existe globalmente una urgente necesidad de encontrar políticas y programas que permitan enfrentar el problema de la obesidad a nivel poblacional, una tarea todavía pendiente. En este artículo revisamos la situación actual de la epidemia de sobrepeso y obesidad en el Perú y el mundo, sus consecuencias y determinantes más importantes, con énfasis en el acceso y disponibilidad de alimentos; describimos los programas de complementación alimentaria más importantes y sintetizamos información de algunas investigaciones e intervenciones para reflexionar sobre cómo sus hallazgos podrían servir para que los programas sociales sean una como plataforma para reducir la obesidad y prevenir las ENT en el Perú.

ABSTRACT In recent decades, overweight or obesity have increased dramatically in middle- and low-income countries; a situation which consolidates chronic non-communicable diseases (NCD) as one of the leading causes of mortality and disability worldwide. Currently, half the people in Peru over the age of 15 years are overweight, and one fifth suffer from obesity. The situation is worsening and increasingly affects people in poverty, who frequently benefit from food supplement programs designed to combat food insecurity and malnutrition. There is an urgent worldwide need to find policies and programs that help fight the problem of obesity at the population level, a task that is still pending. In this article, we review the current epidemic of overweight and obesity in Peru and the world and its most significant consequences and causes, with an emphasis on access to and availability of foods. We describe the largest food supplement programs and synthesize the research on interventions in order to reflect on how their findings might help social programs work as a platform to reduce obesity and prevent NCD in Peru.

Inclusion of persons with disabilities in systems of social protection: a population-based survey and case-control study in Peru.

OBJECTIVE: This study aims to assess the needs of people with disabilities and their level of inclusion in social protection programmes. DESIGN: Population based-survey with a nested case-control study. SETTING: Morropon, a semiurban district located in Piura, northern Peru. PARTICIPANTS: For the population survey, a two-stage sampling method was undertaken using data from the most updated census available and information of each household member aged ≥5 years was collected. In the nested case-control study, only one participant, case or control, per household was included in the study. PRIMARY AND SECONDARY OUTCOME MEASURES: Disability was screened using the Washington Group short questionnaire. A case, defined as an individual aged ≥5 years with disabilities, was matched with one control without disabilities by sex and age (±5 years). Information was collected on socioeconomic status, education, health and rehabilitation and social protection participation. RESULTS: The survey included 3684 participants, 1848 (50.1%) females, mean age: 36.4 (SD: 21.7). A total of 290 participants (7.9%; 95% CI 7.0% to 8.7%) were classified as having disability. Adults with disabilities were more likely to be single (OR=3.40; 95% CI 1.54 to 7.51) and not to be working (OR=4.36; 95% CI 2.26 to 8.40), while those who did work were less likely to receive the national minimum wage (ie, 750 PEN or about US$265; p=0.007). People with disabilities were more likely to experience health problems. There was no difference between those enrolled in any social protection programme among participants with and without disabilities. CONCLUSIONS: People with disabilities were found to have higher needs for social protection, but were not more likely to be enrolled in social protection programmes. The Peruvian social protection system should consider adding disability status to selection criteria in their cash transfer programmes as well as implementing disability-specific interventions.

Effectiveness of an mHealth intervention to improve the cardiometabolic profile of people with prehypertension in low-resource urban settings in Latin America: a randomised controlled trial.

BACKGROUND: Poor diet and physical inactivity strongly affect the growing epidemic of cardiovascular disease worldwide. Mobile phone-based health interventions (mHealth) have been shown to help promote weight loss and increase physical activity and are an attractive approach for health-care systems with limited resources. We aimed to assess whether mHealth with advice for lifestyle improvements would reduce blood pressure, promote weight loss, and improve diet quality and physical activity in individuals with prehypertension living in low-resource urban settings in Latin America. METHODS: In this parallel-group, randomised controlled trial, we recruited individuals (aged 30-60 years) with systolic blood pressure between 120 and 139 mm Hg, diastolic blood pressure between 80 and 89 mm Hg, or both from health-care centres, workplaces, and community centres in low-resource urban settings in Argentina, Guatemala, and Peru. Participants were randomly assigned to receive either monthly motivational counselling calls and weekly personalised text messages to their mobile phones about diet quality and physical activity for 12 months, or usual care. Randomisation was stratified by country, and we applied minimisation by sex and age groups. Study personnel collecting and analysing data were masked to group assignment. The primary outcomes were mean between-group differences in the changes in systolic and diastolic blood pressure from baseline to 12 months in an intention-to-treat analysis of all participants who completed assessments at 12 months. Secondary outcome measures were changes in bodyweight, waist circumference, and self-reported target behaviours from baseline to 12 months. The trial is registered with ClinicalTrials.gov, number NCT01295216. FINDINGS: Between March 1, 2012, and Nov 30, 2012, we randomly assigned 637 participants to receive intervention (n=316) or usual care (n=321). 266 (84%) participants in the intervention group and 287 (89%) in the control group were assessed at 12 months. The intervention did not affect change in systolic blood pressure (mean net change -0·37 mm Hg [95% CI -2·15 to 1·40]; p=0·43) or diastolic blood pressure (0·01 mm Hg [-1·29 to 1·32]; p=0·99) compared with usual care. However, we noted a significant net reduction in bodyweight (-0·66 kg [-1·24 to -0·07]; p=0·04) and intake of high-fat and high-sugar foods (-0·75 [-1·30 to -0·20]; p=0·008) in the intervention group compared with the control group. In a prespecified subanalysis, we found that participants in the intervention group who received more than 75% of the calls (nine or more, from a maximum of 12) had a greater reduction of bodyweight (-4·85 [-8·21 to -1·48]) and waist circumference (-3·31 [-5·95 to -0·67]) than participants in the control group. Additionally, participants in the intervention group had an increase in the intake of fruits and vegetables and a decrease in diets high in sodium, fat, and simple sugars relative to participants in the control group. However, we found no changes in systolic blood pressure, diasatolic blood pressure, or physical activity in the group of participants who received more than 75% of the calls compared with the group who received less than 50% of the calls. INTERPRETATION: Our mHealth-based intervention did not result in a change in blood pressure that differed from usual care, but was associated with a small reduction in bodyweight and an improvement in some dietary habits. We noted a dose-response effect, which signals potential opportunities for larger effects from similar interventions in low-resource settings. More research is needed on mHealth, particularly among people who are poor and disproportionally affected by the cardiovascular disease epidemic and who need effective and affordable interventions to help bridge the equity gap in the management of cardiometabolic risk factors. FUNDING: National Heart, Lung, and Blood Institute (US National Institutes of Health) and the Medtronic Foundation.

Disability, caregiver's dependency and patterns of access to rehabilitation care: results from a national representative study in Peru.

PURPOSE: To determine the prevalence of disability in Peru, explore dependency on caregiver's assistance and assess access to rehabilitation care. METHOD: Data from Disability National Survey (ENEDIS), including urban and rural areas, were analyzed. Disability was defined as a permanent limitation on movement, vision, communication, hearing, learning/remembering or social relationships. Dependency was defined as the self-reported need for a caregiver to help with daily activities; and access to rehabilitation care was defined as the self-report of any therapy for disabilities. Estimates and projections were calculated using sample strata, primary sampling units and population weights, and prevalence ratios (PRs) and 95%CI were reported. RESULTS: From 798,308 people screened, 37,524 (5.1%; 95%CI 4.9--5.2%) had at least one disability. A total of 37,117 were included in further analysis, mean age 57.8 (SD ± 24.1) years, 52.1% women. Dependency was self-reported by 14,980 (40.5%; 95%CI: 39.2-41.9%) individuals with disabilities. A family member, usually female, was identified as a caregiver in 94.3% (95%CI: 93.3-95.3%) of dependent participants. Only 2881 (10.7%; 95%CI: 9.7-11.9%) of people with disabilities reported access to rehabilitation care. Major inequality patterns of disability burden versus access to rehabilitation care were observed by age and education level. Older age groups had higher disability burden yet lower chances of access to rehabilitation care. Conversely, the higher the education level, the lesser the overall disability burden but also the higher chances of reporting receiving care. Private healthcare insurance doubled the probability of having access to rehabilitation compared with those without insurance. CONCLUSIONS: Approximately 1.6 million Peruvians have at least one disability, and 40% of them require assistance with daily activities. Informal caregiving, likely female and relative-provided, is highly common. Rehabilitation care access is low and inequitable. Our results signal a major need to implement strategies to guarantee the highest standard of health care for people with disabilities. IMPLICATIONS FOR REHABILITATION: Major inequality patterns in terms of burden of disability versus access to rehabilitation care were observed: those groups who concentrate more disability reported receiving less rehabilitation care. Caregiving is mostly informal and provided by a direct relative, mainly a woman, who resigned to their usual activities in order to help care for the person with disability. As a result, there is a need to develop appropriate support and training for caregivers. Access to care services in Peru is low and inequitable, but especially for people with disabilities: they experience greater barriers when accessing healthcare services even in the case of having health insurance.

Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme.

BACKGROUND: The Global Alliance for Chronic Diseases comprises the majority of the world's public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects. METHODS: Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings. RESULTS: There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation. CONCLUSIONS: The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies.

Aceptabilidad de una intervención basada en salud móvil para modificar estilos de vida en prehipertensos en Argentina, Guatemala y Perú: un estudio piloto / Acceptability of a mobile health based intervention to modify lifestyles in prehypertensive patients in Argentina, Guatemala, and Peru: a pilot study

Objetivos. Evaluar la aceptabilidad y factibilidad de una intervención basada en salud móvil, para la adopción de estilos de vida saludables en personas prehipertensas que viven en zonas urbanas de bajos recursos en Argentina, Guatemala y Perú. Materiales y métodos. Se reclutaron prehipertensos entre 30 a 60 años para un estudio piloto. La intervención incluyó dos llamadas de consejería realizadas por una nutricionista, seguidas de un mensaje de texto customizado semanal. Una plataforma basada en Internet ofreció el soporte para la implementación de la intervención. Utilizando entrevistas semiestructuradas se evaluó el alcance y la aceptabilidad de esta intervención en los participantes, y la facilidad de uso en las nutricionistas. Resultados. Se logró contactar a 43 de los 45 participantes (95%). El número promedio de llamadas para contactar a un sujeto fue de dos, con un rango de 1-9 llamadas. Dos participantes pudieron ser contactados en su teléfono celular y cinco no recibieron una exposición completa a la intervención. Basados en las entrevistas semiestructuradas, los resultados mostraron una buena aceptabilidad a la intervención en los participantes. Las nutricionistas percibieron a la plataforma como amigable y de fácil manejo. Las barreras para ofrecer esta intervención se relacionaron con dificultades para obtener una señal de telefonía celular adecuada. Conclusiones. Dada la alta penetración de la telefonía celular en países en desarrollo, se concluye que una intervención basada en salud móvil es factible y aceptable para ofrecer una intervención orientada a la modificación del estilo de vida en prehipertensos o personas de alto riesgo de enfermedades crónicas.

Objectives. To evaluate the acceptability and feasibility of an intervention based on mobile health, for the adoption of healthy lifestyles in prehypertensive people living in low-income urban areas in Argentina, Guatemala and Peru. Materials and methods. Prehypertensive people aged 30-60 years were recruited for a pilot study. The intervention included two counseling calls made by a nutritionist followed by a weekly customized text message. An internet-based platform offered support for the implementation of the intervention. Using semi-structured interviews, we evaluated the reach and acceptability of the intervention in the participants and ease of use for the nutritionists. Results. It was possible to contact 43 of the 45 participants (95%). The average number of calls to contact a subject was two, with a range of 1-9 calls. Two participants could not be reached on their cell phone; five did not receive complete exposure to the intervention. Based on semi-structured interviews, the results showed good acceptability for the intervention by the participants. Nutritionists perceived the platform as friendly and easy to use. Barriers to deliver this intervention were related to difficulties in obtaining an adequate cellular signal. Conclusions. Given the high penetration of mobile phones in developing countries, it is concluded that it is feasible and acceptable to offer a mobile health based intervention oriented towards lifestyle modification in people with prehypertension or high risk of chronic disease intervention.

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.