Co-creation process of an intervention to implement a multiparameter point-of-care testing device in a primary healthcare setting for non-communicable diseases in Peru.

BACKGROUND: Point-of-care testing (POCT) devices are diagnostic tools that can provide quick and accurate results within minutes, making them suitable for diagnosing non-communicable diseases (NCDs). However, these devices are not widely implemented in healthcare systems and for this reason is relevant to understand the implementation process. AIM: To describe the process and define a strategy to implement a multiparameter POCT device for diagnosing and managing NCDs in one region of Peru. METHODS: A descriptive and non-experimental study, using the participatory methodologies of co-creation process. It was conducted in one region of Peru (Tumbes) to design an intervention for implementing a multiparameter POCT device. Two co-creation sessions were conducted involving five groups: community members, primary healthcare workers, these groups in both rural and urban settings, and regional decision-makers. These sessions included activities to understand patient journeys in receiving care for NCDs, identify facilitators and barriers to POCT devices usage, and define an implementation strategy for POCT devices in both rural and urban settings of Tumbes. The research team analysed the data and summarized key topics for discussion after each session. RESULTS: A total of 78 participants were enrolled across the five groups. Among community members: 22.2% had only diabetes, 24.1% had only hypertension, and 18.5% had both diagnoses. In the patient journey, community members mentioned that it took at least three days to receive a diagnosis and treatment for an NCD. Most of the participants agreed that the POCT devices would be beneficial for their communities, but they also identified some concerns. The strategy for POCT devices implementation included healthcare workers training, POCT devices must be placed in the laboratory area and must be able to perform tests for glucose, glycated haemoglobin, cholesterol, and creatinine. Advertising about POCT devices should be displayed at the healthcare centres and the municipality using billboards and flyers. CONCLUSIONS: The co-creation process was useful to develop strategies for the implementation of multiparameter POCT devices for NCDs, involving the participation of different groups of stakeholders guided by moderators in both, rural and urban, settings in Peru.

User requirements for non-invasive and minimally invasive glucose self-monitoring devices in low-income and middle-income countries: a qualitative study in Kyrgyzstan, Mali, Peru and Tanzania.

AIMS: Development of non-invasive and minimally invasive glucose monitoring devices (NI-MI-GMDs) generally takes place in high-income countries (HICs), with HIC's attributes guiding product characteristics. However, people living with diabetes (PLWD) in low-income and middle-income countries (LMICs) encounter different challenges to those in HICs. This study aimed to define requirements for NI-MI-GMDs in LMICs to inform a target product profile to guide development and selection of suitable devices. METHODS: This was a multiple-methods, exploratory, qualitative study conducted in Kyrgyzstan, Mali, Peru and Tanzania. Interviews and group discussions/activities were conducted with healthcare workers (HCWs), adults living with type 1 (PLWD1) or type 2 diabetes (PLWD2), adolescents living with diabetes and caregivers. RESULTS: Among 383 informants (90 HCW, 100 PLWD1, 92 PLWD2, 24 adolescents, 77 caregivers), a range of differing user requirements were reported, including preferences for area of glucose measurement, device attachment, data display, alert type and temperature sensitivity. Willingness to pay varied across countries; common requirements included ease of use, a range of guiding functions, the possibility to attach to a body part of choice and a cost lower than or equal to current glucose self-monitoring. CONCLUSIONS: Ease-of-use and affordability were consistently prioritised, with broad functionality required for alarms, measurements and attachment possibilities. Perspectives of PLWD are crucial in developing a target product profile to inform characteristics of NI-MI-GMDs in LMICs. Stakeholders must consider these requirements to guide development and selection of NI-MI-GMDs at country level, so that devices are fit for purpose and encourage frequent glucose monitoring among PLWD in these settings.

Health equity: access to quality services and caring for underserved populations.

Barriers to access to quality services and caring for underserved populations are a call to action for researchers and other key partners to achieve health equity. In order to accomplish this, several key partners play important roles. More participation of younger generations, women and people of color from different contexts should be encouraged and facilitated. This editorial serves to present this journal issue that includes the articles of young women from low- and middle-income countries. Different methodologies are used to demonstrate the problem of access to quality services and care in a comprehensive way. After understanding the public health problems using an equity lens, we need to implement evidence-based interventions to improve the health system response.

Implementation of a salt substitute intervention using social marketing in resourced-limited communities in Peru: a process evaluation study.

Objective: This study aimed to conduct a process evaluation of a salt substitute trial conducted in Peru. Methods: Through semi-structured interviews of intervention participants, we documented and analyzed process evaluation variables as defined by the Medical Research Council Framework. This study was a stepped wedge trial conducted in Tumbes, Peru in 2014. The intervention was a community-wide replacement of regular salt (100% sodium) with "Salt Liz" (75% sodium and 25% potassium) using social marketing strategies to promote the adoption and continued use of the salt substitute in daily life. The components of the social marketing campaign included entertainment educational activities and local product promoters ("Amigas de Liz"). Another component of the intervention was the Salt Liz spoon to help guide the amount of salt that families should consume. The process evaluation variables measured were the context, mechanism of action, and implementation outcomes (acceptability, fidelity and adoption, perceptions, and feedback). Results: In total, 60 women were interviewed, 20 with hypertension and 40 without hypertension. Regarding context, common characteristics across the four villages included residents who primarily ate their meals at home and women who were responsible for household food preparation. As the mechanism of action, most participants did not notice a difference in the flavor between regular salt and Salt Liz; those that did notice a difference took around 2 weeks to become accustomed to the taste of the salt substitute. In terms of implementation outcomes, the Salt Liz was accepted by villagers and factors explaining this acceptability included that it was perceived as a "high quality" salt and as having a positive effect on one's health. Participants recognized that the Salt Liz is healthier than regular salt and that it can help prevent or control hypertension. However, most participants could not accurately recall how the compositions of the Salt Liz and regular salt differed and the role they play in hypertension. Although the use of the Salt Liz was far-reaching at the community level, the use of the Salt Liz spoon was poor. Educational entertainment activities were well-received, and most participants enjoyed them despite not always being active participants but rather sideline observers. Conclusion: This process evaluation identifies key intervention components that enabled a successful trial. Seeking and incorporating feedback from the target population helps deepen the understanding of contextual factors that influence an intervention's success. Furthermore, feedback received can aid the development of the intervention product. Some factors that can be improved for future interventions are acknowledged. Clinical trial registration: NCT01960972.

Facilitators and barriers of the implementation of point-of-care devices for cardiometabolic diseases: a scoping review.

BACKGROUND: Point-of-care testing (POCT) devices may facilitate the delivery of rapid and timely results, providing a clinically important advantage in patient management. The challenges and constraints in the implementation process, considering different levels of actors have not been much explored. This scoping review aimed to assess literature pertaining to implementation facilitators and barriers of POCT devices for the diagnosis or monitoring of cardiometabolic diseases. METHODS: A scoping review of the literature was conducted. The inclusion criteria were studies on the inception, planning, or implementation of interventions with POCT devices for the diagnosis or monitoring of cardiometabolic diseases defined as dyslipidemia, cardiovascular diseases, type 2 diabetes, and chronic kidney disease. We searched MEDLINE, Embase, and Global Health databases using the OVID searching engine until May 2022. The Consolidated Framework of Implementation Research (CFIR) was used to classify implementation barriers and facilitators in five constructs. Also, patient, healthcare professional (HCP), and organization level was used. RESULTS: Twenty studies met the eligibility criteria for data extraction. All studies except two were conducted in high-income countries. Some findings are: 1) Intervention: the most widely recognized facilitator was the quick turnaround time with which results are obtained. 2) Outer setting: at the organizational level, the lack of clear regulatory and accreditation mechanisms has hindered the adoption and sustainability of the use of POCT. 3) Inner setting: for HCP, performing POCT during the consultation was both a facilitator and a barrier in terms of time, personnel, and service delivery. 4) Individuals: the implementation of POCT may generate stress and discomfort in some HCP in terms of training and new responsibilities. 5) Process: for patients, it is highly appreciated that obtaining the sample was simple and more comfortable if venipuncture was not used. CONCLUSION: This scoping review has described the facilitators and barriers of implementing a POCT device for cardiometabolic conditions using the CFIR. The information can be used to design better strategies to implement these devices and benefit more populations that have low access to cardiometabolic tests.

Use of continuous glucose monitors in low- and middle-income countries: A scoping review.

AIMS: The use of continuous glucose monitors (CGMs) has been shown to have positive impact on diabetes management for people with type 1 diabetes (T1DM), type 2 diabetes (T2DM) and gestational diabetes (GDM) in high-income countries. However, as useful as CGMs are, the experience in low- and middle-income countries (LMICs) is limited and has not been summarized. METHODS: A scoping review of the scientific literature was conducted. Medline, Embase, Global Health and Scopus were used to seek original research conducted in LMICs. The search results were screened by two reviewers independently. We included studies assessing health outcomes following the use of CGMs at the individual level (e.g. glycaemic control or complications) and at the health system level (e.g. barriers, facilitators and cost-effectiveness) in English, Portuguese, Spanish and French. Results were summarized narratively. RESULTS: From 4772 records found in database search, 27 reports were included; most of them from China (n = 7), Colombia (n = 5) and India (n = 4). Thirteen reports studied T1DM, five T2DM, seven both T1DM and T2DM and two GDM. Seven reports presented results of experimental studies (five randomized trials and two quasi-experimental); two on cost-effective analysis and the remaining 18 were observational. Studies showed that CGMs improved surrogate glycaemic outcomes (HbA1c reduction), hard endpoints (lower hospitalization rates and diabetes complications) and patient-oriented outcomes (quality of life). However, several caveats were identified: mostly observational studies, few participants in trials, short follow-up and focused on surrogate outcomes. CONCLUSIONS: The scoping review identified that studies about CGMs in LMICs have several limitations. Stronger study designs, appropriate sample sizes and the inclusion of patient-important outcomes should be considered to inform the evidence about CGMs for the management of people with diabetes in LMICs.

Perceptions of acceptance and reluctance to COVID-19 vaccination in Peru. / Percepciones de aceptabilidad y reticencia a las vacunas contra la COVID-19 en el Perú.

OBJECTIVES.: To explore factors that influence the acceptance or reluctance to COVID-19 vaccination using qualitative methods. MATERIALS AND METHODS.: Descriptive qualitative study conducted between April and June 2021. A semi-structured interview guide was used to explore the perceptions of participants from different regions of Peru regarding COVID-19 vaccination. The Health Belief Model was used as theoretical framework and its dimensions are: susceptibility, severity, benefits, barriers, and cues to action. RESULTS.: We interviewed 30 people, mostly were women. For the participants, the efficacy of vaccines is related to the country of origin of the vaccines; in addition, they consider that it is important to know the long-term effects on health after vaccination. The information received by governmental and health authorities can be a decisive factor for vaccination. People with the intention of not being vaccinated feel that vaccination promotion strategies violate their human rights. CONCLUSIONS.: There is a group of people undecided or unsure about receiving COVID-19 vaccines who need to be encouraged according to their concerns and needs. Governmental and health authorities should work together to improve the confidence of the population and provide messages to clarify doubts about the efficacy and adverse reactions of vaccines.

OBJETIVOS.: Explorar los factores que predisponen la aceptabilidad o reticencia a la vacunación contra la COVID-19 utilizando métodos cualitativos. MATERIALES Y MÉTODOS.: Estudio cualitativo descriptivo realizado entre abril y junio del 2021. Se utilizó una guía de entrevista semiestructurada que exploró las percepciones de los participantes de diferentes regiones del Perú con relación a la aplicación de la vacuna para la COVID-19, tomando como marco teórico el modelo de creencias en salud, cuyas dimensiones son: susceptibilidad, severidad, beneficios, barreras y estímulos asociados para ejecutar la acción. RESULTADOS.: Se entrevistó a treinta personas, en su mayoría mujeres. Para los participantes la eficacia de las vacunas se relaciona con el país de procedencia, además, consideran que es importante conocer los efectos a largo plazo en la salud luego de la aplicación de la vacuna. La información recibida por las autoridades gubernamentales y sanitarias puede ser un factor decisivo para la aplicación de la vacuna. Las personas con la intención de no vacunarse sienten que las estrategias de promoción de la vacunación vulneran sus derechos humanos. CONCLUSIONES.: Existe un grupo de personas indecisas o inseguras de recibir las vacunas contra la COVID-19 en quienes es necesario fomentar estímulos de acuerdo con sus preocupaciones y necesidades. Las autoridades gubernamentales y sanitarias deben trabajar conjuntamente para mejorar la confianza de la población y brindar mensajes que despejen las principales dudas sobre la eficacia y las reacciones adversas de las vacunas.

Process evaluation of complex interventions in non-communicable and neglected tropical diseases in low- and middle-income countries: a scoping review.

OBJECTIVES: The aim of this review is to map out the use of process evaluation (PE) in complex interventions that address non-communicable diseases (NCDs) and neglected tropical diseases (NTDs) to identify gaps in the design and conduct, as well as strengths, limitations and implications, of this type of research in low- and middle-income countries (LMICs). DESIGN: Scoping review of PE studies of complex interventions implemented in LMICs. Six databases were searched focused on studies published since 2008. DATA SOURCES: Embase, PubMed, EbscoHost, Web of Science (WOS), Virtual Health Library (VHL) Regional Portal and Global Index Medicus: Regional Indexes AIM (AFRO), LILACS (AMRO/PAHO), IMEMR (EMRO), IMSEAR (SEARO), WPRIM (WPRO) Global Index Regional Indexes, MEDLINE, SciELO. ELIGIBILITY CRITERIA: Studies conducted in LMICs on PEs of randomised controlled trials (RCTs) and non-RCTs published between January 2008 and January 2020. Other criteria were studies of interventions for people at risk or having physical and mental NCDs, and/or NTDs, and/or their healthcare providers and/or others related to achieve better health for these two disease groups. Studies were excluded if they were not reported in English or Spanish or Portuguese or French, not peer-reviewed articles, not empirical research and not human research. DATA EXTRACTION AND SYNTHESIS: Data extracted to be evaluated were: available evidence in the utilisation of PE in the areas of NCDs and NTDs, including frameworks and theories used; methods applied to conduct PEs; and in a subsample, the barriers and facilitators to implement complex interventions identified through the PE. Variables were extracted and categorised. The information was synthesised through quantitative analysis by reporting frequencies and percentages. Qualitative analysis was also performed to understand facilitators and barriers presented in these studies. The implications for PEs, and how the information from the PE was used by researchers or other stakeholders were also assessed in this approach. RESULTS: 303 studies were identified, 79% were for NCDs, 12% used the label 'PE', 27% described a theory or framework for the PE, and 42% used mixed methods to analyse their findings. Acceptability, barriers and facilitators to implement the interventions, experiences and perceptions, and feasibility were the outcomes most frequently evaluated as part of the PEs. Barriers and facilitators themes identified were contextual factors, health system factors, human resources, attitudes and policy factors. CONCLUSIONS: PEs in NCDs and NTDs are used in LMICs with a wide variety of methods. This review identified many PEs that were not labelled by the authors as such, as well as a limited application of PE-related theories and frameworks, and heterogeneous reporting of this type of study.

Using government data to understand the use and availability of medicines for hypertension and diabetes: lessons from Peru.

BACKGROUND: Regular measurement of the availability and use of key medicines for non-communicable diseases allows the tracking of progress to achieve equitable access to medicines. Using a country-level public sector monitoring system for medicine supply, we aim to evaluate the availability and use of losartan 50 mg tablets and metformin 850 mg tablets between 2015 and 2020 investigating the impact of different policy changes and the COVID-19 pandemic. METHODS: Data from the Peruvian National System of Medicine Supply were analyzed using an interrupted time series analysis with known and unknown structural breaks. The outcomes assessed were medicine use (monthly doses dispensed at facilities over time) and medicine availability (proportion of facilities that reported having the medicine available). RESULTS: The use of losartan and metformin at the primary level of care had a linear increasing trend over the period of analysis. In secondary and tertiary levels of care, there were no increases but some significant level and trend changes of doses dispensed at different times between 2017 to 2019, but none were related to the change of procurement procedures. At all levels of care, the COVID-19 onset in April 2020 caused an abrupt drop in doses dispensed especially at the primary level. Regarding availability, we found an increasing linear trend in the primary level of care for both medicines. In secondary and tertiary levels of care, the availability fluctuated between 40 and 95%. The onset of the COVID-19 pandemic did not significantly impact medicine availability, except for losartan in the tertiary level of care. CONCLUSION: The availability and proper dispensing of first-line medicines for hypertension and diabetes is an essential factor for sustainable and equitable treatment. Health care systems need to be prepared for forecasting the increasing demand of medicines for chronic diseases, but also to maintain effective medicine supply chains during humanitarian crisis like pandemics.

Anxiety, Depression, and Post-Traumatic Stress Disorder (PTSD) Symptomatology According to Gender in Health-Care Workers during the COVID-19 Pandemic in Peru Shortened Title: "Psychological Impact of the Pandemic on Women".

OBJECTIVE: The current study will evaluate the association that the COVID-19 pandemic has had with health-care workers and identify the factors that influenced the female gender being more affected. METHODS: This is a cross-sectional study conducted in two hospitals in Arequipa (a Peruvian city). The participants were health-care workers. We applied a questionnaire with sociodemographic information and three scales: the Generalized Anxiety Disorder-7, the Patient Health Questionnaire-9, and the Primary Care Post-Traumatic Stress Disorder (PTSD) Screen for DSM-5. The main outcomes were anxiety, depression, and PTSD scores. The exposure of interest was gender. The scores of the scales were estimated by medians and percentiles 25-75 (p25-p75), and we used linear regression to estimate the crude and adjusted coefficients and their respective confidence intervals at 95% (CI 95%). RESULTS: There were 109 participants, and 43.1% were women. The anxiety, depression, and PTSD median (p25-p75) scores in the study population were 6 (2-11), 6 (2-10), and 1 (0-3), respectively. The adjusted analysis showed that the female sex had 4.48 (CI 95% 2.95-6.00), 4.50 (CI 95% 2.39-6.62), and 1.13 (CI 95% 0.50-1.76) higher points on average for the scales of anxiety, depression, and PTSD symptoms in comparison to males, respectively. CONCLUSIONS: Female health-care workers showed increased scores of mental health issues in comparison to male health-care workers.

Pilot Feasibility Assessment of a Tailored Physical Activity Prescription in Overweight and Obese People in a Public Hospital.

We aimed to evaluate the feasibility of a tailored physical activity (PA) prescription in overweight and obese people in a tertiary hospital in Lima, Peru. A feasibility pre-post-pilot study was conducted using mixed methods. Participants received a tailored prescription scheme for PA that lasted twelve weeks. It included two prescription sessions, three follow-up phone calls, and three evaluations. Primary feasibility outcomes were recruitment, visits, and phone call adherence. Primary intervention outcomes were self-reported PA levels and the 6 min walk test. Out of 228 people invited to participate, 30 were enrolled and received the first session of prescription, 11 went to the second session, and 21 went to the final evaluation; phone call participation decreased progressively during follow-up. There were no differences in the 6th week and the 12th week compared to the baseline for all the measures, except in the 6 min walk test. The participants considered the intervention was well designed, but they suggested complementing it with dietary instructions. The prescription of PA in overweight and obese people is feasible for promoting PA, but its implementation requires refinements to anticipate possible barriers to changing behavior.

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

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

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.

Percepciones de aceptabilidad y reticencia a las vacunas contra la COVID-19 en el Perú / Perceptions of acceptance and reluctance to COVID-19 vaccination in Peru

RESUMEN Objetivos. Explorar los factores que predisponen la aceptabilidad o reticencia a la vacunación contra la COVID-19 utilizando métodos cualitativos. Materiales y métodos. Estudio cualitativo descriptivo realizado entre abril y junio del 2021. Se utilizó una guía de entrevista semiestructurada que exploró las percepciones de los participantes de diferentes regiones del Perú con relación a la aplicación de la vacuna para la COVID-19, tomando como marco teórico el modelo de creencias en salud, cuyas dimensiones son: susceptibilidad, severidad, beneficios, barreras y estímulos asociados para ejecutar la acción. Resultados. Se entrevistó a treinta personas, en su mayoría mujeres. Para los participantes la eficacia de las vacunas se relaciona con el país de procedencia, además, consideran que es importante conocer los efectos a largo plazo en la salud luego de la aplicación de la vacuna. La información recibida por las autoridades gubernamentales y sanitarias puede ser un factor decisivo para la aplicación de la vacuna. Las personas con la intención de no vacunarse sienten que las estrategias de promoción de la vacunación vulneran sus derechos humanos. Conclusiones. Existe un grupo de personas indecisas o inseguras de recibir las vacunas contra la COVID-19 en quienes es necesario fomentar estímulos de acuerdo con sus preocupaciones y necesidades. Las autoridades gubernamentales y sanitarias deben trabajar conjuntamente para mejorar la confianza de la población y brindar mensajes que despejen las principales dudas sobre la eficacia y las reacciones adversas de las vacunas.

ABSTRACT Objectives. To explore factors that influence the acceptance or reluctance to COVID-19 vaccination using qualitative methods. Materials and methods. Descriptive qualitative study conducted between April and June 2021. A semi-structured interview guide was used to explore the perceptions of participants from different regions of Peru regarding COVID-19 vaccination. The Health Belief Model was used as theoretical framework and its dimensions are: susceptibility, severity, benefits, barriers, and cues to action. Results. We interviewed 30 people, mostly were women. For the participants, the efficacy of vaccines is related to the country of origin of the vaccines; in addition, they consider that it is important to know the long-term effects on health after vaccination. The information received by governmental and health authorities can be a decisive factor for vaccination. People with the intention of not being vaccinated feel that vaccination promotion strategies violate their human rights. Conclusions. There is a group of people undecided or unsure about receiving COVID-19 vaccines who need to be encouraged according to their concerns and needs. Governmental and health authorities should work together to improve the confidence of the population and provide messages to clarify doubts about the efficacy and adverse reactions of vaccines.

COVID-19's impact on type 1 diabetes management: A mixed-methods study exploring the Peruvian experience.

INTRODUCTION: The COVID-19 pandemic has negatively impacted health services, especially in low-and-middle-income countries, where care for chronic conditions such as diabetes was disrupted. Our study aims to describe the challenges faced by people living with Type 1 diabetes mellitus (T1DM) to access care during the COVID-19 pandemic in Peru. METHODS: A sequential explanatory mixed-method study was conducted between May and September 2020 including health professionals involved in T1DM care, people with T1DM and their caregivers. The study consisted of a quantitative strand to gather general information through electronic surveys and a qualitative strand that involved in-depth interviews. RESULTS: For the quantitative study, we included 105 people with T1DM, 50 caregivers and 76 health professionals. The qualitative study included a total of 31 interviews; 16 people with T1DM, 14 health care professionals, and one representative from the Peruvian Ministry of Health (MoH). People with T1DM faced difficulties accessing consultations, insulin, monitoring devices and laboratory testing during the pandemic. Different phases of the Peruvian health system response were found. Firstly, an initial informal response to addressing T1DM care during the pandemic characterised by local initiatives to ensure continuity of care for people with T1DM. Following from this, a formal response was implemented by the MoH which focussed on reinforcing the primary level of care. Measures included teleconsultations and delivery of medicines, although these were not implemented in all health care establishments. Throughout the pandemic patient associations played an important role in organising and helping to counteract the impact of COVID-19 on people with T1DM. CONCLUSIONS: The Peruvian health care system slowly adapted to the COVID-19 pandemic to provide care for people with T1DM. However, people with T1DM had difficulties to access care. Thus, reinforcement of interventions such as communication between levels of care, teleconsultations and delivery of medicines was urgently needed. Patient associations' capacity to respond should be considered by local authorities and civil society should be part of the health system response.

Factors Influencing the Implementation of Remote Delivery Strategies for Non-Communicable Disease Care in Low- and Middle-Income Countries: A Narrative Review.

Objectives: The COVID-19 pandemic has disrupted health care for non-communicable diseases (NCDs) and necessitated strategies to minimize contact with facilities. We aimed to examine factors influencing implementation of remote (non-facility-based) delivery approaches for people with hypertension and/or diabetes in low- and middle-income countries (LMICs), to inform NCD care delivery during health service disruption, including humanitarian crises. Methods: Our narrative review used a hermeneutic and purposive approach, including primary studies conducted in LMICs, which assessed implementation factors influencing remote NCD care delivery. Results were analyzed using the Consolidated Framework for Implementation Research. Results: Twenty-eight included studies revealed the strong influence of both internal organizational and broader contextual factors, such as community health worker policies or technological environment. Addressing patients' specific characteristics, needs and resources was important for implementation success. Conclusion: This review highlighted the multiple, complex, interdependent factors influencing implementation of remote NCD care in LMICs. Our findings may inform actors designing NCD care delivery in contexts where facility-based access is challenging. Implementation research is needed to evaluate context-adapted e-Health, community-based, and simplified clinical management strategies to facilitate remote NCD care.

Analysis of medical appointments for patients with overweight and obesity in a public hospital of Lima, Peru: a cross-sectional study of audio-recorded consultations.

OBJECTIVE: To describe the content of overweight and obesity counseling performed in a public Peruvian hospital. METHODS: We audio-recorded 40 visits of patients with overweight or obesity from the internal medicine, cardiology, endocrinology, and family medicine services at Cayetano Heredia Hospital. Fragments of the recordings in which counseling was performed were transcribed and codified. We established a checklist to score each counseling session and performed descriptive analyses. RESULTS: Complete counseling (including weight, nutrition, and physical activity) was performed in 32.5% of consultations. The average time spent in counseling was 1.72 minutes. Counseling on weight loss was performed in 65% of consultations, nutrition in 65%, and physical activity in 35%. On average, 8 of 26 checklist items were fulfilled per appointment. Weight loss goals were established in 15% of visits. The most frequent diet recommendations were eating more fruits and vegetables (32.5%) and eating fewer carbohydrates (30.0%). Suggested physical activities were walking (10.0%), running (7.5%), and playing any sport (7.5%). CONCLUSIONS: Complete counseling was only addressed in one-third of the appointments, and most counseling was superficial without considering therapeutic goals. This suggests the need to include lifestyle counseling in consultations, regardless of the medical specialty or patient's background condition.

Management of type 1 diabetes in low- and middle-income countries: Comparative health system assessments in Kyrgyzstan, Mali, Peru and Tanzania.

AIMS: To describe and compare the health system responses for type 1 diabetes in Kyrgyzstan, Mali, Peru and Tanzania. METHODS: The Rapid Assessment Protocol for Insulin Access, a multi-level assessment of the health system, was implemented in Kyrgyzstan, Mali, Peru and Tanzania using document reviews, site visits and interviews to assess the delivery of care and access to insulin. RESULTS: Despite the existence of noncommunicable or diabetes strategies and Universal Health Coverage policies including diabetes-related supplies, this has not necessarily translated into access to insulin or diabetes care for all. Insulin and related supplies were often unavailable and unaffordable. Across the four countries test strips and insulin, when paid for by the individual, represented respectively 48-82% and 25-36% of total costs. Care was mainly delivered at tertiary-level hospitals by specialists. Only Kyrgyzstan had data collection systems integrated into the Ministry of Health structure. In addition, issues with healthcare worker training and education and empowerment of people with diabetes were present in these health systems. CONCLUSIONS: People with type 1 diabetes in these countries face different barriers, including the cost of insulin and care. Given the renewed attention to diabetes on the global health agenda tailored health system responses for type 1 diabetes are needed. Insulin should be prioritized as it is the foundation of type 1 diabetes care, but other elements of care and support need to be fostered by different actors.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Population-based stroke incidence estimates in Peru: Exploratory results from the CRONICAS cohort study.

BACKGROUND: Limited information exists about the incidence of first-ever stroke at the population level, particularly in low- and middle-income countries (LMIC). Longitudinal data from the CRONICAS Cohort Study includes both altitude and urbanization and allows a detailed assessment of stroke incidence in resource constrained settings. The aim of this study was to estimate the incidence and explore risk factors of first-ever stroke at the population level in Peru. METHODS: Stroke was defined using a standardised approach based on information from cohort participants or family members. This information was adjudicated centrally by trained physicians using common definitions. Time of follow-up was calculated as the difference between date of enrolment and the reported date of the stroke event. Unstandardised and age-standardised, first-ever stroke incidence rate and 95% confidence intervals (95% CI) were calculated. Generalized linear models, assuming Poisson distribution and link log, were utilized to determine potential factors to develop stroke. FINDINGS: 3,601 individuals were originally enrolled in the cohort and 2,471 provided data for the longitudinal analysis. The median time of follow-up was 7.0 (range: 1 - 9) years, accruing a total of 17,308 person-years. During followup, there were 25 incident cases of stroke, resulting in an age-standardised incidence of stroke of 98.8 (95% CI: 63.8 - 154.0) per 100,000 person-years. After adjustment by age and sex, stroke incidence was higher among people with hypertension (incidence risk ratio (IRR) = 5.18; 95% CI: 1.89 - 14.16), but lower among people living at high altitude (IRR = 0.09; 95% CI: 0.01 - 0.63). INTERPRETATION: Our results indicate a high incidence of first-ever strokes in Peruvian general population. These results are consistent with the estimates found in previous LMIC reports. Our study also found a contributing role of hypertension, increasing the risk of having a first-ever stroke. This work further advances the field of stroke epidemiology by identifying high altitude as a factor related to lower incidence of stroke in a longitudinal study. However, this information needs to be considered with cautions because of the study limitations.

DISCLAIMER: This translation in Spanish was submitted by the authors and we reproduce it as supplied. It has not been peer reviewed. Our editorial processes have only been applied to the original abstract in English, which should serve as reference for this manuscript. ANTECEDENTES: Existe información limitada sobre la incidencia del accidente cerebrovascular (ACV) a nivel poblacional, especialmente en los países de ingresos bajos y medios (PIBM). Los datos longitudinales del estudio de cohorte CRONICAS incluyen tanto la altitud como la urbanización y permiten una evaluación detallada de la incidencia de ACV en entornos con recursos limitados. El objetivo de este estudio fue estimar la incidencia y explorar los factores de riesgo del primer ACV a nivel poblacional en Perú. MÉTODOS: El accidente cerebrovascular se definió utilizando un método estandarizado basado en la información de los participantes de la cohorte o de familiares. Esta información fue adjudicada centralmente por médicos entrenados usando definiciones estándar. El tiempo de seguimiento se calculó como la diferencia entre la fecha de enrolamiento y la fecha reportada del evento de ACV. Se calculó la tasa de incidencia del primer ACV no estandarizada y estandarizada por edad y los intervalos de confianza al 95% (IC 95%). Se utilizaron modelos lineales generalizados, asumiendo la distribución de Poisson y el link log, para determinar los factores potenciales para desarrollar un accidente cerebrovascular. RESULTADOS: 3.601 individuos se reclutaron originalmente en la cohorte y 2.471 proporcionaron datos para el análisis longitudinal. La mediana del tiempo de seguimiento fue de 7,0 (rango 1 - 9) años, haciendo un total de 17 308 personas-año. Durante el seguimiento, se produjeron 25 casos incidentes de ACV, lo que dio lugar a una incidencia estandarizada por edad de 98,8 (IC 95%: 63,8-154,0) por 100.000 personas-año. Tras el ajuste por edad y sexo, la incidencia de ACV fue mayor entre las personas con hipertensión (riesgo relativo (RR) = 5,18; IC 95%: 1,89 ­ 14,16), pero menor entre las que vivían a nivel de altura (RR = 0,09; 95% CI: 0,01 ­ 0,63). INTERPRETACIÓN: Los resultados indican una alta incidencia de ACV en la población general. Estos resultados son consistentes con las estimaciones encontradas en informes anteriores de PIBM. En consonancia con la literatura publicada, nuestro estudio también encontró un papel contribuyente de la hipertensión, aumentando el riesgo de tener un primer ACV. Nuestro estudio supone un avance en el campo de la epidemiología del ACV al identificar la altitud como un factor relacionado con una menor incidencia en un estudio longitudinal. Sin embargo, esta información debe de tomarse con precaución debido a las limitaciones del estudio.