Lessons from Peru to reduce under-5 mortality: understanding program implementation and context.

BACKGROUND: Health policymakers aiming to reduce under-5 mortality (U5M) often lack data regarding how successful interventions in other countries were implemented. The Exemplars in U5M Study identified countries that achieved significant reductions in amenable U5M. This case study in Peru used implementation research to explore the contextual factors and strategies that contributed to the successful implementation of key evidence-based interventions (EBIs). METHODS: This research utilized a hybrid implementation research framework and a mixed-methods approach to understand the factors associated with EBI implementation and the successful reduction of U5M between 2000-2015. A desk review of existing literature on EBIs and U5M in Peru was completed, and in-depth interviews were performed with key Peruvian informants to understand the implementation strategies employed and the contextual factors that facilitated or were barriers to success. For the purposes of this analysis, three EBIs were selected and evaluated: antenatal care visits (ANC), facility-based deliveries, and infant vaccination. RESULTS: Between 2000-2015, the percent of mothers attending at least four antenatal care visits rose from 69% to 96.9%, and the percent of facility-based deliveries increased from 56 to 91%. Three doses of the tetanus/diphtheria/pertussis vaccine, widely acknowledged as a key global health indicator, reached 90% by 2015. Key informants noted that economic growth, financial reforms, strong national commitment to reduce poverty in Peru, and national prioritization of maternal and child health, were important contextual factors that contributed to the successful reduction of U5M. They noted key strategies that helped achieve success during the implementation of EBIs, including utilization of data for decision-making, adaptation driven by cultural sensitivity to address gaps in coverage, and a focus on equity and anti-poverty initiatives with the participation of government, civil society, and political parties to assure continuity of policies. CONCLUSION: Several EBIs contributed to the successful reduction of U5M in Peru between 2000-2015. Strategies such as the focus on equity throughout the study period contributed to an increase in coverage of EBIs like ANC visits, facility-based deliveries and infant vaccination which worked to reduce U5M. Understanding how Peru successfully implemented programs that reduced preventable infant and child deaths could be useful to replicating this substantial public health success in other low- and middle-income countries.

Factors associated with crack-cocaine early initiation: a Brazilian multicenter study.

BACKGROUND: Crack-cocaine dependence is a serious public health issue, related to several psychiatric and psychosocial problems. Crack-cocaine users are usually embedded in a context of great social vulnerability, often associated with violence, poverty, family conflict and easy and early access to alcohol, tobacco and other drugs. METHODS: This cross-sectional study enrolled a consecutive sample of 577 patients admitted to 20 therapeutic communities located in Southern Brazil, between September 2012 and September 2013. A structured interview assessed life-time exposure to risk and protective factors for drug use, such as parental monitoring in childhood, deviant behaviors and peer pressure. RESULTS: Presence of family conflict (p = 0.002), maltreatment (p = 0.016), and deviant behavior prior to age 15 in a bivariate analysis predicted an earlier age of crack-cocaine initiation, whereas adolescents experiencing parental monitoring during adolescence started use later (p < 0.001). In the multivariate model, perceptions related to ease of access of illicit drugs (marijuana: p = 0.028, 95% CI = - 3.81, - 0.22; crack-cocaine: p < 0.001, 95% CI = - 7.40, - 4.90), and deviant behavior (threatening someone with a gun: p = 0.028, 95% CI = - 2.57, - 0.14) remained independent predictors of early age of crack-cocaine initiation. CONCLUSIONS: Early onset of crack-cocaine use seems to be associated with exposure to family conflict, easy access to drugs and deviant behavior. Treatment and preventive programs should take these factors into account when designing and implementing community interventions.

Methylation potential associated with diet, genotype, protein, and metabolite levels in the Delta Obesity Vitamin Study.

Micronutrient research typically focuses on analyzing the effects of single or a few nutrients on health by analyzing a limited number of biomarkers. The observational study described here analyzed micronutrients, plasma proteins, dietary intakes, and genotype using a systems approach. Participants attended a community-based summer day program for 6-14 year old in 2 years. Genetic makeup, blood metabolite and protein levels, and dietary differences were measured in each individual. Twenty-four-hour dietary intakes, eight micronutrients (vitamins A, D, E, thiamin, folic acid, riboflavin, pyridoxal, and pyridoxine) and 3 one-carbon metabolites [homocysteine (Hcy), S-adenosylmethionine (SAM), and S-adenosylhomocysteine (SAH)], and 1,129 plasma proteins were analyzed as a function of diet at metabolite level, plasma protein level, age, and sex. Cluster analysis identified two groups differing in SAM/SAH and differing in dietary intake patterns indicating that SAM/SAH was a potential marker of nutritional status. The approach used to analyze genetic association with the SAM/SAH metabolites is called middle-out: SNPs in 275 genes involved in the one-carbon pathway (folate, pyridoxal/pyridoxine, thiamin) or were correlated with SAM/SAH (vitamin A, E, Hcy) were analyzed instead of the entire 1M SNP data set. This procedure identified 46 SNPs in 25 genes associated with SAM/SAH demonstrating a genetic contribution to the methylation potential. Individual plasma metabolites correlated with 99 plasma proteins. Fourteen proteins correlated with body mass index, 49 with group age, and 30 with sex. The analytical strategy described here identified subgroups for targeted nutritional interventions.

[Translation and adaptation of the Motorcycle Rider Behavior Questionnaire: a Brazilian version]. / Tradução e adaptação da escala Motorcycle Rider Behavior Questionnaire: versão brasileira.

Traffic accidents are a leading cause of death in young adults. In Brazil, traffic accidents are proportionally more prevalent among motorcyclists as compared to automobile drivers. Although numerous data indicate that individual characteristics are involved in traffic accident risk, there is no instrument in Brazil to assess motorcyclists' traffic behavior. The authors thus proposed to perform translation and cultural adaptation of the Motorcycle Rider Behavior Questionnaire (MRBQ) into Brazilian Portuguese. The translation process consisted of: two independent translations into Brazilian Portuguese; unification of the translations; back-translation into English; formal assessment of semantic equivalence; application of a summary version in a convenience sample of motorcyclists; generation of a final version; and back-translation and submission to the original author, who approved this version. The Brazilian version maintained its semantic equivalence and was accepted by the convenience sample, an important characteristic for a self-completed instrument. Further studies are necessary to evaluate the questionnaire's psychometric properties in the Brazilian cultural context.

Desenvolvimento de um jogo terapêutico para prevenção da recaída e motivação para mudança em jovens usuários de drogas / Development of a therapeutic game for relapse prevention and motivation for change in young drug users

Apesar da alta prevalência do abuso, e dependência de drogas entre jovens, existe uma falta de intervenções originais desenvolvidas especificamente para o tratamento dessa população. Este estudo objetivou desenvolver uma técnica no formato de um jogo de cartas para ser utilizado no tratamento de jovens usuários de drogas. A técnica foi intitulada 'Jogo da Escolha', e a sua elaboração envolveu: adaptação da linguagem, avaliação do conteúdo e elaboração de suas instruções junto aos profissionais de dependência química. Após um estudo-piloto, foram realizadas modificações nas instruções e no formato de aplicação, obtendo-se a versão atual do 'Jogo da Escolha'. O jogo demonstra ser útil para trabalhar crenças típicas de jovens usuários de drogas e promover estratégias de enfrentamento em situações de risco(AU)

In spite of the high prevalence of drug abuse and dependence among youngsters, there is a lack of original interventions specifically developed for the treatment of this population. This study aimed at developing a technique in the format of a card game to be used in the treatment of young drug users. The technique was entitled: 'Game of Choice' and its elaboration involved: adaptation of the language, evaluation of its content and elaboration of its instructions next to addiction specialists. After a pilot-study, modifications in the instructions and in the application format were made, and the present version of the 'Game of the Choice' was obtained. The game demonstrates to be useful to approach typical core beliefs of young drug users and to promote coping skills in risk situations(AU)

Desenvolvimento de um jogo terapêutico para prevenção da recaída e motivação para mudança em jovens usuários de drogas / Development of a therapeutic game for relapse prevention and motivation for change in young drug users

Apesar da alta prevalência do abuso, e dependência de drogas entre jovens, existe uma falta de intervenções originais desenvolvidas especificamente para o tratamento dessa população. Este estudo objetivou desenvolver uma técnica no formato de um jogo de cartas para ser utilizado no tratamento de jovens usuários de drogas. A técnica foi intitulada 'Jogo da Escolha', e a sua elaboração envolveu: adaptação da linguagem, avaliação do conteúdo e elaboração de suas instruções junto aos profissionais de dependência química. Após um estudo-piloto, foram realizadas modificações nas instruções e no formato de aplicação, obtendo-se a versão atual do 'Jogo da Escolha'. O jogo demonstra ser útil para trabalhar crenças típicas de jovens usuários de drogas e promover estratégias de enfrentamento em situações de risco.

In spite of the high prevalence of drug abuse and dependence among youngsters, there is a lack of original interventions specifically developed for the treatment of this population. This study aimed at developing a technique in the format of a card game to be used in the treatment of young drug users. The technique was entitled: 'Game of Choice' and its elaboration involved: adaptation of the language, evaluation of its content and elaboration of its instructions next to addiction specialists. After a pilot-study, modifications in the instructions and in the application format were made, and the present version of the 'Game of the Choice' was obtained. The game demonstrates to be useful to approach typical core beliefs of young drug users and to promote coping skills in risk situations.