Socioeconomic and environmental factors associated with dengue fever incidence in Guatemala: Rising temperatures increase dengue risk.

Dengue fever is a mosquito-borne illness that infects 390 million people annually. Dengue outbreaks in Guatemala have been occurring more often and at increased rates since the first dengue outbreak in Guatemala in the 1970s. This study will examine environmental and socioeconomic factors associated with dengue in Guatemala at the municipality (county) level. Socioeconomic factors included population density, Mayan population, economic activity, and attending school. Environmental factors included average minimum annual temperature and annual precipitation. The relationship between environmental and socioeconomic variables and dengue fever incidence was initially evaluated through univariate zero-inflated negative binomial models, and then again through three zero-inflated multivariate negative binomial regression models. For all three models, elevation was considered a predictor of zero-inflation. In the combined model, there was a positive relationship between minimum temperature, economic activity and dengue fever incidence, and a negative relationship between population density, Mayan population and dengue fever. Predicted rates of dengue fever incidence and adjusted confidence intervals were calculated after increasing minimum yearly temperature by 1°C and 2°C. The three municipalities with the highest minimum yearly temperature (El Estor, Iztapa, and Panzós) and the municipality of Guatemala, all had an increase in the magnitude of the risk of dengue fever incidence following 1°C and 2°C increase in temperature. This research suggests that these socioeconomic and environmental factors are associated with risk of dengue in Guatemala. The predicted rates of dengue fever also highlight the potential effect that climate change in the form of increasing temperature can have on dengue in Guatemala.

Women's health and well-being in five birth cohorts from low- and middle-income countries: Domains and their associations with early-life conditions.

Background: Women's health and well-being (WHW) have been receiving growing attention, but limited progress has been made on how to measure its different domains in low- and middle-income countries (LMICs). We used data from five long-term birth cohorts in Brazil, Guatemala, the Philippines and South Africa to explore different domains of adult WHW, and how these domains relate to early life exposures. Methods: Based upon an a priori conceptualisation of eight postulated WHW outcomes available in the data, we grouped them as follows: human capital (intelligence quotient, schooling, height, and teenage childbearing), metabolic health (body mass index and metabolic syndrome score), and psychological (happiness and Self-Reported Questionnaire (SRQ) scores). Correlation analyses confirmed the variables theoretically belonging to the same dimension of WHW were statistically related. We then applied principal component analysis to each group of variables separately and used the first principal component as a summary quantitative measure of the corresponding WHW dimension. Finally, we assessed the association of each domain with a range of early-life factors: wealth, maternal education, maternal height, water, and sanitation, birthweight, length at two years and development quotient in mid-childhood. Results: The three domains were largely uncorrelated. Early determinants were positively associated with human capital, while birth order was negatively associated. Fewer associations were found for the metabolic or psychological components. Birthweight and weight at age two years were inversely associated with metabolic health. Maternal education was associated with better psychological health. Conclusions: Our findings indicate that WHW is multidimensional, with most women in the cohorts being compromised in one or more domains while few women scored highly in all three domains. Our analyses are limited by lack of data on adolescent exposures and on other relevant WHW dimensions such as safety, agency, empowerment, and violence. Further research is needed in LMICs for identifying and measuring the multiple domains of WHW.

Replication guide. Applying the human security approach to advance an integrated response to health and migration in El Salvador, Guatemala, Honduras, and Mexico

In 2022, the program on Applying the Human Security Approach to Advance an integrated response to Health and Migration in the Northern Triangle of Central America and Mexico was jointly launched by the Pan American Health Organization/World Health Organization (PAHO/WHO) and the International Organization for Migration (IOM). The program grant was sponsored by the United Nations Trust Fund for Human Security (UNTFHS). Among its main goals was the intention of raising awareness of the human security approach and how it can be used as a successful operational tool to advance universal access to health and universal health coverage, as well as the Sustainable Development Goals (SDGs), by contextualizing the added value of human security to health and migration in the four countries in which it was implemented: El Salvador, Guatemala, Honduras, and Mexico. Sustainability and replicability of the program were specifically integrated in the program’s design to promote continuity and scale-up of the activities, ensuring that knowledge obtained on the ground be disseminated and used to mainstream the human security approach throughout the region and beyond. This guide is part of those activities to facilitate the process of further replicating the program and its outcomes, taking into consideration lessons learned through its implementation also this publication is crucial in promoting the human security approach as an operational tool in health and migration, demonstrating its effectiveness in improving universal health access and advancing the SDGs. It also provides a practical guide for replicating the program in other regions, ensuring the sustainability and expansion of its benefits.

Variability in the Timing of Respiratory Syncytial Virus Epidemics in Guatemala, 2008-2018.

BACKGROUND: The description of local seasonality patterns in respiratory syncytial virus (RSV) incidence is important to guide the timing of administration of RSV immunization products. METHODS: We characterized RSV seasonality in Guatemala using the moving epidemic method (MEM) with absolute counts of RSV-associated acute respiratory infections (ARI) from hospital surveillance in Santa Rosa and Quetzaltenango departments of Guatemala. RESULTS: From Week 17 of 2008 through Week 16 of 2018, 8487 ARI cases tested positive for RSV by rRT-PCR. Season onsets varied up to 5 months; early seasons starting in late May to early August and finishing in September to November were most common, but late seasons starting in October to November and finishing in March to April were also observed. Both epidemic patterns had similar durations ranging from 4 to 6 months. Epidemic thresholds (the levels of virus activity that signal the onset and end of a seasonal epidemic) calculated prospectively using previous seasons' data captured between 70% and 99% of annual RSV detections. Onset weeks differed by 2-10 weeks, and offset weeks differed by 2-16 weeks between the two surveillance sites. CONCLUSIONS: Variability in the timing of seasonal RSV epidemics in Guatemala demonstrates the difficulty in precisely predicting the timing of seasonal RSV epidemics based on onset weeks from past seasons and suggests that maximal reduction in RSV disease burden would be achieved through year-round vaccination and immunoprophylaxis administration to at-risk infants.

Pretest-post-test evaluation with lay midwives in remote Guatemala after educational activities about COVID-19.

INTRODUCTION: Guatemalan lay midwives are well-respected community leaders in a country that lacks the institutional capacity to meet healthcare needs related to pregnancy, newborns, and COVID-19. Thus, Guatemalan lay midwives, who attend the majority of births in their country and who attend most births at home, are in an optimal position to offer frontline support to pregnant women and newborns regarding the global pandemic. The primary objective of this program of study was to dispel myths about COVID-19 and to provide culturally relevant educational activities to low-literacy Guatemalan lay midwives about issues related to the virus, such as signs and symptoms, risks to the mother and fetus, which patients are most vulnerable, appropriate responses, benefits and side-effects of the vaccine, timing of the vaccine, how the virus interacts with breastfeeding, and breastfeeding recommendations. METHODS: In a partnership among the Guatemalan Ministry of Health, expert faculty at the University of Utah College of Nursing, and Madre y Niño, a non-profit organization from the US, evidence-based educational activities about COVID-19 were offered orally in the native language of participants. Two hundred and ten lay midwives attended educational sessions at 11 locations throughout the remote Peten department. Educational activities included repetition, storytelling, and role plays. A pretest-post-test evaluation of 10 questions with 24 correct answers was used to determine if the educational activities changed lay midwife knowledge about COVID-19. Participants were given essential birth supplies and laminated COVID Reminder Cards, which were designed to increase visual literacy, to encourage knowledge retention after the educational sessions. RESULTS: Participants showed a significant increase in knowledge scores (possible 0-24) from prescores 7.09 (standard deviation (SD)=3.06) to 15.20 (SD=4.61), Student's t-test p<0.001. In addition, a significantly higher proportion of participants mistakenly thought COVID-19 passed through breast milk on the pretest (70.1%) compared to post-test (8.4%) (McNemar test, p<0.001). Regarding breastfeeding, 12.6% of participants knew on the pretest that women with COVID-19 who breastfeed should wear a mask and wash their hands compared to 74.3% of participants who knew these recommendations on the post-test (Wilcoxon signed-rank test, p<0.001). Finally, 2% of participants knew on the pretest that pregnant women with COVID-19 should take a low-dose aspirin compared to 67% of participants on the post-test (χ² (1)=194.7, p<0.001). CONCLUSION: These essential primary care providers misunderstood many critical issues related to COVID-19, pregnancy, and newborns. Culturally relevant educational activities provided orally in the native language of participants dispelled myths about the virus and significantly improved lay midwife knowledge. Providing evidence-based educational activities in a culturally relevant format is critical to protecting remote, vulnerable populations, such as pregnant Guatemalan women and newborns, during a global pandemic.

Molecular epidemiology of enteroviruses from Guatemalan wastewater isolated from human lung fibroblasts.

The Global Specialized Polio Laboratory at CDC supports the Global Poliovirus Laboratory Network with environmental surveillance (ES) to detect the presence of vaccine strain polioviruses, vaccine-derived polioviruses, and wild polioviruses in high-risk countries. Environmental sampling provides valuable supplementary information, particularly in areas with gaps in surveillance of acute flaccid paralysis (AFP) mainly in children less than 15 years. In collaboration with Guatemala's National Health Laboratory (Laboratorio Nacional de Salud Guatemala), monthly sewage collections allowed screening enterovirus (EV) presence without incurring additional costs for sample collection, transport, or concentration. Murine recombinant fibroblast L-cells (L20B) and human rhabdomyosarcoma (RD) cells are used for the isolation of polioviruses following a standard detection algorithm. Though non-polio-Enteroviruses (NPEV) can be isolated, the algorithm is optimized for the detection of polioviruses. To explore if other EV's are present in sewage not found through standard methods, five additional cell lines were piloted in a small-scale experiment, and next-generation sequencing (NGS) was used for the identification of any EV types. Human lung fibroblast cells (HLF) were selected based on their ability to isolate EV-A genus. Sewage concentrates collected between 2020-2021 were isolated in HLF cells and any cytopathic effect positive isolates used for NGS. A large variety of EVs, including echoviruses 1, 3, 6, 7, 11, 13, 18, 19, 25, 29; coxsackievirus A13, B2, and B5, EV-C99, EVB, and polioviruses (Sabin 1 and 3) were identified through genomic typing in NGS. When the EV genotypes were compared by phylogenetic analysis, it showed many EV's were genomically like viruses previously isolated from ES collected in Haiti. Enterovirus occurrence did not follow a seasonality, but more diverse EV types were found in ES collection sites with lower populations. Using the additional cell line in the existing poliovirus ES algorithm may add value by providing data about EV circulation, without additional sample collection or processing. Next-generation sequencing closed gaps in knowledge providing molecular epidemiological information on multiple EV types and full genome sequences of EVs present in wastewater in Guatemala.

Prevalence of diabetes among Indigenous women in Guatemala: a retrospective chart review.

OBJECTIVE: The objective of this study is to investigate the prevalence of diabetes in a clinical population of primarily Indigenous women in Guatemala. RESULTS: In a retrospective chart review of a clinical program serving 13,643 primarily Indigenous women in Guatemala, crude diabetes prevalence was 8.3% (95% Confidence Interval [CI]: 7.8 to 8.7) and age-adjusted diabetes prevalence was 7.9% (95% CI: 7.3 to 8.5). Among those with diabetes, 37.9% (95% CI: 35.1 to 40.8) of women were undiagnosed. Diabetes prevalence rose significantly with increasing age and was significantly higher among women with obesity (risk ratio: 1.4 [95% CI: 1.1 to 1.8]) and among women least likely to be in poverty (risk ratio: 2.0 [95% CI: 1.5 to 2.6]). Diabetes prevalence was significantly lower among Indigenous women (risk ratio: 0.7 [95% CI: 0.6 to 0.9]) and among women who spoke Mayan languages rather than Spanish (risk ratio: 0.7 [95% CI: 0.6 to 0.9]). There was no significant difference in diabetes prevalence between women who lived in rural settings and women who lived in urban settings.

Body mapping: A decolonial method towards intergenerational healing.

In this paper, I examine the embodied transformative memory of GuateMaya feminist group, GuateMaya Mujeres Resistiendo-Los Angeles (GMR-LA). Through a decolonial feminist perspective and feminist ethnographic approach, I built an intimate relationship with the grassroot group in Los Angeles. GMR-LA comprises Guatemala's 36-year (1960-1996) war survivors and women in the diaspora who continue to amplify the cultural memory of the disappeared. The article will delve into the concept of healing cartographies and the ethnographic work I employed in Los Angeles from 2019 to 2023. A particular method I used was body mapping to examine the embodied transformative memory of the groups and women who seek justice. Body mapping has been used with HIV-positive patients and migrant children. Latin American feminist decolonial geographers (Cabnal, 2010; Zaragocin and Caretta 2020; GeoBrujas, 2021b) are using the method of body mapping as a decolonial, counter-cartographic perspective that highlights Indigenous peoples' lived experiences. I use the method to explore the relationships between the body, memory, and healing from intergenerational trauma. Informed by decolonial feminists, I aim to center the oral and embodied testimonios of the GuateMaya feminist group and be guided by a body-mind-spirit perspective to amplify the concerns, visions, and futures of GuateMaya feminist groups across the hemisphere.

Comprehensive profiling of social mixing patterns in resource poor countries: A mixed methods research protocol.

BACKGROUND: Low-and-middle-income countries (LMICs) bear a disproportionate burden of communicable diseases. Social interaction data inform infectious disease models and disease prevention strategies. The variations in demographics and contact patterns across ages, cultures, and locations significantly impact infectious disease dynamics and pathogen transmission. LMICs lack sufficient social interaction data for infectious disease modeling. METHODS: To address this gap, we will collect qualitative and quantitative data from eight study sites (encompassing both rural and urban settings) across Guatemala, India, Pakistan, and Mozambique. We will conduct focus group discussions and cognitive interviews to assess the feasibility and acceptability of our data collection tools at each site. Thematic and rapid analyses will help to identify key themes and categories through coding, guiding the design of quantitative data collection tools (enrollment survey, contact diaries, exit survey, and wearable proximity sensors) and the implementation of study procedures. We will create three age-specific contact matrices (physical, nonphysical, and both) at each study site using data from standardized contact diaries to characterize the patterns of social mixing. Regression analysis will be conducted to identify key drivers of contacts. We will comprehensively profile the frequency, duration, and intensity of infants' interactions with household members using high resolution data from the proximity sensors and calculating infants' proximity score (fraction of time spent by each household member in proximity with the infant, over the total infant contact time) for each household member. DISCUSSION: Our qualitative data yielded insights into the perceptions and acceptability of contact diaries and wearable proximity sensors for collecting social mixing data in LMICs. The quantitative data will allow a more accurate representation of human interactions that lead to the transmission of pathogens through close contact in LMICs. Our findings will provide more appropriate social mixing data for parameterizing mathematical models of LMIC populations. Our study tools could be adapted for other studies.

A New Method for Low Density Distribution Modeling and Near Threatened Species: The Study Case of Plectrohyla Guatemalensis.

We introduce a model that can be used for the description of the distribution of species when there is scarcity of data, based on our previous work (Ballesteros et al. J Math Biol 85(4):31, 2022). We address challenges in modeling species that are seldom observed in nature, for example species included in The International Union for Conservation of Nature's Red List of Threatened Species (IUCN 2023). We introduce a general method and test it using a case study of a near threatened species of amphibians called Plectrohyla Guatemalensis (see IUCN 2023) in a region of the UNESCO natural reserve "Tacaná Volcano", in the border between Mexico and Guatemala. Since threatened species are difficult to find in nature, collected data can be extremely reduced. This produces a mathematical problem in the sense that the usual modeling in terms of Markov random fields representing individuals associated to locations in a grid generates artificial clusters around the observations, which are unreasonable. We propose a different approach in which our random variables describe yearly averages of expectation values of the number of individuals instead of individuals (and they take values on a compact interval). Our approach takes advantage of intuitive insights from environmental properties: in nature individuals are attracted or repulsed by specific features (Ballesteros et al. J Math Biol 85(4):31, 2022). Drawing inspiration from quantum mechanics, we incorporate quantum Hamiltonians into classical statistical mechanics (i.e. Gibbs measures or Markov random fields). The equilibrium between spreading and attractive/repulsive forces governs the behavior of the species, expressed through a global control problem involving an energy operator.

Impact of a Regional Pediatric Hematology/Oncology Fellowship Program in Guatemala.

PURPOSE: This study aimed to describe and assess the regional experience of a pediatric hematology/oncology fellowship program based in Guatemala. METHODS: The Unidad Nacional de Oncología Pediátrica (UNOP) in Guatemala City, Guatemala, is the only hospital in Central America dedicated exclusively to childhood and adolescent cancer. To address the regional need for specialists, a fellowship program in pediatric hematology/oncology was launched in 2003. The UNOP fellowship program comprises 3 years of training. Although the program is based at UNOP, it also includes rotations locally and internationally to enhance clinical exposure. The curriculum is based on international standards to cover clinical expertise, research, professionalism, communication, and health advocacy. Trainees are selected according to country or facility-level need for pediatric hematologists/oncologists, with a plan for them to be hired immediately after completing their training. RESULTS: Forty physicians from 10 countries in Latin America have completed training. In addition, there are currently 13 fellows from five countries in training. Of the graduates, 39 (98%) are now practicing in pediatric hematology/oncology in Latin America. Moreover, many of them have leadership positions within their institutions and participate in research, advocacy, and policy making. Graduates from the UNOP program contribute to institutions by providing care for an increasing number of patients with pediatric cancer. The UNOP program is the first pediatric hematology/oncology fellowship program in the world to be accredited by Accreditation Council for Graduate Medical Education-International, an international body accrediting clinical training programs. CONCLUSION: The UNOP program has trained specialists to increase the available care for children with cancer in Latin America. This regional approach to specialist training can maximize resources and serve as a model for other programs and regions.

Stigma in Pediatric Cancer: An Exploratory Study of Osteosarcoma and Retinoblastoma in Guatemala, Jordan, and Zimbabwe.

PURPOSE: Stigma is an understudied barrier to health care acceptance in pediatric oncology. We sought to explore the stigma experience, including its impact on cancer treatment decision making, and identify strategies to mitigate stigma for patients with osteosarcoma and retinoblastoma in Guatemala, Jordan, and Zimbabwe. METHODS: Participants included caregivers, adolescent patients (age 12-19 years), and health care clinicians. A semistructured interview guide based on The Health Stigma and Discrimination Framework (HSDF) was adapted for use at each site. Interviews were conducted in English, Spanish, Arabic, or Shona, audio-recorded, translated, and transcribed. Thematic analysis focused on stigma practices, experiences, outcomes, drivers, mitigators, and interventions. RESULTS: We conducted 56 interviews (28 caregivers, 19 health care clinicians, nine patients; 20 in Guatemala, 21 in Jordan, 15 in Zimbabwe). Major themes were organized into categories used to adapt the HSDF to global pediatric cancer care. Themes were described similarly across all sites, ages, and diagnoses, with specific cultural nuances noted. Pediatric cancer stigma was depicted as an isolating and emotional experience beginning at diagnosis and including internalized and associative stigma. Stigma affected decision making and contributed to negative outcomes including delayed diagnosis, treatment abandonment, regret, and psychosocial fragility. Overcoming stigma led to positive outcomes including resilience, treatment adherence, pride, and advocacy. Identified stigma drivers and mitigators were linked to potential interventions. CONCLUSION: Participants describe a shared stigma experience that transcends geography, cultural context, age, and diagnosis. Stigma manifestations have the potential to impact medical decision making and affect long-term psychological outcomes. Stigma assessment tools and interventions aimed at stigma mitigation including educational initiatives and support groups specific to pediatric cancer should be the focus of future research.

Factores pronósticos de mortalidad a 30 días en neumonía por SARS-CoV-2 / Prognostic Factors for 30-day Mortality in SARS-CoV-2 Pneumonia

Introducción: SARS-CoV-2 ha causado millones de muertes a nivel global desde su primer caso reportado en China. En Guatemala existen pocos estudios que describan los factores pronósticos. Nuestro objetivo fue determinar los factores asociados de mortalidad a 30 días en pacientes con neumonía (Nm) por SARS-CoV-2 y construir un modelo predictor. Material y Métodos: Estudio retrospectivo en 144 sujetos en el Hospital Roosevelt de marzo a diciembre 2020 con criterios de Nm por SARS-CoV-2. Se revisó el expediente médico para datos clínicos y de laboratorio desde ingreso hasta alta hospitalaria o muerte. Resultados: Se evaluaron 105 hombres y 39 mujeres con media de edad 53 años. El 47% tenía comorbilidades como diabetes mellitus 2 e hipertensión arterial sistémica. Promedio de días de hospitalización: 13. Cuadros leves a moderados de Síndrome de Distrés Respiratorio Agudo (SDRA): 92%. Se indicó ventilación mecánica invasiva (VMI) a 46 pacientes. La mortalidad general fue 35%. Factores asociados a mortalidad a 30 días: edad ≥50 años, inicio de síntomas ≥7 días, SDRA severo, radio NL >4,4, recibir VMI, alteración en LDH y procalcitonina. Nuestro modelo mostró que los mejores predictores de mortalidad eran alteración en procalcitonina (OR: 4,45), recibir VMI (OR: 112) y días de estancia hospitalaria (OR: 1,12) con precisión de 91,5% y área bajo la curva de 94,4%. Conclusiones: Los factores pronósticos de mortalidad en pacientes guatemaltecos con Nm por SARS-CoV-2 son múltiples e incluyen rasgos demográficos, clínicos y serológicos; identificarlos y contar con un modelo pronóstico ayudará a brindar atención médica de precisión.

Introduction: SARS-CoV-2 has caused millions of deaths globally since its first case was reported in China. In Guatemala, few studies describe prognostic factors. Our objective was to determine the factors associated with 30 day mortality in patients with Pneumonia (Nm) due to SARS-CoV-2 and to build a predictor model. Material and Methods: Retrospective study in 144 subjects at Roosevelt Hospital from March to December 2020 with Nm criteria for SARS-CoV-2. The medical record was rviewed, obtaining clinical and laboratory data from admission to hospital discharge or death. Results: 105 men and 39 women with an average age of 53 years were evaluated. 47% had comorbidities, with type 2 diabetes mellitus and systemic arterial hypertension being common. The average number of days of hospitalization was 13. 92% had mild to moderate acute respiratory distress syndrome (ARDS). Invasive mechanical ventila-tion (IMV) was indicated for 46 patients. Overall mortality was 35%. The factors asso-ciated with 30-day mortality were age ≥50 years, the onset of symptoms ≥7 days, severe ARDS, N/L ratio >4.4, receiving IMV, alterations in LDH, and procalcitonin. Our model showed that the best predictors of mortality were altered procalcitonin (OR: 4.45), receiving IMV (OR: 112), and days of hospital stay (OR: 1.12) with precision of 91.5% and area under the curve of 94.4%. Conclusions: The prognostic factors of mortality in Guatemalan patients with Nm due to SARS-CoV-2 are multiple and include demographic, clinical and serological features; identifying them and having a prognostic model will help provide precision medical care.

Factors associated with hand hygiene adherence among healthcare workers in Guatemala during the COVID-19 pandemic.

BACKGROUND: Healthcare-associated infections are prevalent in low- and middle-income countries and may be reduced through proper hand hygiene (HH) adherence during patient care. AIM: We produced and distributed alcohol-based hand rub (ABHR) to 19 public primary- and secondary-level healthcare facilities in Quetzaltenango, Guatemala, and carried out HH observations to assess healthcare workers' (HCWs) HH adherence, and to identify factors associated with this practice. HH adherence was defined as washing hands with soap and water or using ABHR. METHODS: Observations were conducted before (2021, baseline) and after (2022, follow-up) ABHR distribution to evaluate the evolution of HH practices over time. Bivariate comparisons and mixed-effects logistic regression models were used to explore associations between HH adherence and the following independent variables: healthcare facility level, type of contact performed, timing of HH performance, occupational category of HCW and materials present (e.g., water, soap, ABHR). FINDINGS: We observed 243 and 300 patient interactions among 67 and 82 HCWs at each time point, respectively. HH adherence was low for both observation periods (40% at baseline and 35% at follow-up). HCWs were more likely to adhere to HH during invasive contacts, after patient contact, and if the HCW was a physician. CONCLUSION: HH adherence varied by scenario, which underscores the importance of addressing multiple determinants of behaviour change to improve adherence. This requires interventions implemented with a multi-modal approach that includes both increasing access to HH materials and infrastructure, as well as HH education and training, monitoring and feedback, reminders, and promoting a HH safety culture.

Methodology for adapting a co-created early childhood development intervention and implementation strategies for use by frontline workers in India and Guatemala: a systematic application of the FRAME-IS framework.

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021-2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies.

Main findings: The International Guide for Monitoring Child Development, an early childhood development support and monitoring tool, was successfully adapted for use by frontline workers in rural India and Guatemala.Added knowledge: Our Methods Forum paper uses a detailed framework to document the collaborative, co-creating process used and the adaptive decisions taken.Global health impact for policy and action: Evidence on how best to adapt and optimize early childhood interventions for frontline workers will be useful or scaling up support for children globally.

HLA-DRB1 and HLA-DQB1 genes in patients diagnosed with systemic lupus erythematosus in Guatemala.

Systemic lupus erythematosus (SLE) is an autoimmune disorder that impacts connective tissue and can affect various organs and systems within the body. One important aspect of this disease is the role of the human leukocyte antigen (HLA) system, a protein complex that plays a role in the immune response. Specifically, the HLA-DRB1 and HLA-DQB1 genes have been implicated in the development of SLE. In order to better understand this relationship in the Guatemalan population, a study was conducted with the objective of characterizing the allelic and haplotype profiles of the HLA-DQB1 and HLA-DRB1 loci in 50 patients diagnosed with SLE who were receiving treatment at a hospital in Guatemala. Allele and haplotype frequencies were determined and compared to 127 healthy Guatemalan subjects as a control group. The results of the analysis showed a reduction in the frequencies of HLA-DQB1*03 and HLA-DRB1*14 in SLE patients, which could suggest a protective effect on the development of the disease. In contrast, a risk association was found between HLA-DRB1*07, HLA-DRB1*08, HLA-DQB1*02 and HLA-DQB1*06 in SLE patients. Finally, we observed an additional protective associated of haplotype HLA-DRB1*04∼DQB1*03 with SLE patients, while haplotypes HLA-DRB1*07∼DQB1*02 and DRB1*08-DQB1*06 showed a risk association.

A biosocial analysis of perinatal and late neonatal mortality among Indigenous Maya Kaqchikel communities in Tecpán, Guatemala: a mixed-methods study.

INTRODUCTION: Neonatal mortality is a global public health challenge. Guatemala has the fifth highest neonatal mortality rate in Latin America, and Indigenous communities are particularly impacted. This study aims to understand factors driving neonatal mortality rates among Maya Kaqchikel communities. METHODS: We used sequential explanatory mixed methods. The quantitative phase was a secondary analysis of 2014-2016 data from the Global Maternal and Newborn Health Registry from Chimaltenango, Guatemala. Multivariate logistic regression models identified factors associated with perinatal and late neonatal mortality. A number of 33 in-depth interviews were conducted with mothers, traditional Maya midwives and local healthcare professionals to explain quantitative findings. RESULTS: Of 33 759 observations, 351 were lost to follow-up. There were 32 559 live births, 670 stillbirths (20/1000 births), 1265 (38/1000 births) perinatal deaths and 409 (12/1000 live births) late neonatal deaths. Factors identified to have statistically significant associations with a higher risk of perinatal or late neonatal mortality include lack of maternal education, maternal height <140 cm, maternal age under 20 or above 35, attending less than four antenatal visits, delivering without a skilled attendant, delivering at a health facility, preterm birth, congenital anomalies and presence of other obstetrical complications. Qualitative participants linked severe mental and emotional distress and inadequate maternal nutrition to heightened neonatal vulnerability. They also highlighted that mistrust in the healthcare system-fueled by language barriers and healthcare workers' use of coercive authority-delayed hospital presentations. They provided examples of cooperative relationships between traditional midwives and healthcare staff that resulted in positive outcomes. CONCLUSION: Structural social forces influence neonatal vulnerability in rural Guatemala. When coupled with healthcare system shortcomings, these forces increase mistrust and mortality. Collaborative relationships among healthcare staff, traditional midwives and families may disrupt this cycle.

Junk food use and neurodevelopmental and growth outcomes in infants in low-resource settings.

Introduction: Feeding infants a sub-optimal diet deprives them of critical nutrients for their physical and cognitive development. The objective of this study is to describe the intake of foods of low nutritional value (junk foods) and identify the association with growth and developmental outcomes in infants up to 18 months in low-resource settings. Methods: This is a secondary analysis of data from an iron-rich complementary foods (meat versus fortified cereal) randomized clinical trial on nutrition conducted in low-resource settings in four low- and middle-income countries (Democratic Republic of the Congo, Guatemala, Pakistan, and Zambia). Mothers in both study arms received nutritional messages on the importance of exclusive breastfeeding up to 6 months with continued breastfeeding up to at least 12 months. This study was designed to identify the socio-demographic predictors of feeding infants' complementary foods of low nutritional value (junk foods) and to assess the associations between prevalence of junk food use with neurodevelopment (assessed with the Bayley Scales of Infant Development II) and growth at 18 months. Results: 1,231 infants were enrolled, and 1,062 (86%) completed the study. Junk food feeding was more common in Guatemala, Pakistan, and Zambia than in the Democratic Republic of Congo. 7% of the infants were fed junk foods at 6 months which increased to 70% at 12 months. Non-exclusive breastfeeding at 6 months, higher maternal body mass index, more years of maternal and paternal education, and higher socioeconomic status were associated with feeding junk food. Prevalence of junk foods use was not associated with adverse neurodevelopmental or growth outcomes. Conclusion: The frequency of consumption of junk food was high in these low-resource settings but was not associated with adverse neurodevelopment or growth over the study period.