Protocol for a controlled before-after quasi-experimental study to evaluate the effectiveness of a multi-component intervention to reduce gaps in hypertension care and control in low-income communes of Medellin, Colombia.

INTRODUCTION: Research on public health interventions to improve hypertension care and control in low-income and middle-income countries remains scarce. This study aims to evaluate the effectiveness and assess the process and fidelity of implementation of a multi-component intervention to reduce the gaps in hypertension care and control at a population level in low-income communes of Medellin, Colombia. METHODS AND ANALYSIS: A multi-component intervention was designed based on international guidelines, cross-sectional population survey results and consultation with the community and institutional stakeholders. Three main intervention components integrate activities related to (1) health services redesign, (2) clinical staff training and (3) patient and community engagement. The effectiveness of the intervention will be evaluated in a controlled before-after quasi-experimental study, with two deprived communes of the city selected as intervention and control arms. We will conduct a baseline and an endline survey 2 years after the start of the intervention. The primary outcomes will be the gaps in hypertension diagnosis, treatment, follow-up and control. Effectiveness will be evaluated with the difference-in-difference measures. Generalised estimation equation models will be fitted considering the clustered nature of data and adjusting for potential confounding variables. The implementation process will be studied with mixed methods. Implementation fidelity will be documented to assess to which degree the intervention components were implemented as intended. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Research Committee of Metrosalud in Colombia (reference 1400/5.2), the Medical Ethics Committee of the Antwerp University Hospital (reference 18/40/424) and the Institutional Review Board of the Antwerp Institute of Tropical Medicine (reference 1294/19). We will share and discuss the study results with the community, institutional stakeholders and national health policymakers. We will publish them in national and international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: NCT05011838.

'Where are the dead flies!': perceptions of local communities towards the deployment of Tiny Targets to control tsetse in the Democratic Republic of the Congo.

The National Programme for the control of human African trypanosomiasis in Democratic Republic of Congo includes a large-scale vector control operation using Tiny Targets. These are small panels of insecticide-impregnated cloth that are deployed in riverine habitat where tsetse flies concentrate. The effectiveness of Tiny Targets depends partly on acceptance by local communities. In 2018, we conducted research to explore the perception and acceptability of Tiny Targets in two different village clusters where Tiny Targets had been deployed by the local community or external teams. We conducted fourteen focus group discussions and seven semistructured interviews in three villages from each cluster in the Yasa Bonga health zone. Our findings showed that acceptability was better in the cluster where communities were involved in the deployment of Tiny Targets. Also in this cluster, awareness about Tiny Targets was satisfactory and the project was implemented within local customs, which promoted a positive perception of Tiny Targets and their benefits. In the cluster where external teams deployed Tiny Targets, a lack of information and communication, stereotypes applied by communities towards the deployment teams and the impression of inadequate respect for local customs led to anxiety and a misleading interpretation of the purpose of Tiny Targets and negatively influenced acceptability. This study highlights the importance of involving communities for programme acceptance. Our research underlined how awareness campaigns and communication are essential, but also how working within the scope of community social norms and customs are equally important. Prospects for the successful use of Tiny Targets are greater when communities are involved because the use can be adapted to social norms.

'I did not get this disease on the street; it was brought home as a gift': Gender, violence and HIV vulnerability among Cuban women.

While gay, bisexual and other men who have sex with men are most affected by HIV in Cuba, infections among women have increased over time, but there has been little research to contextualise their vulnerability to HIV. The purpose of this study was to explore the role of gender and violence in shaping vulnerability to HIV among Cuban women. Qualitative in-depth interviews were conducted with women living with HIV at an outpatient HIV clinic in Havana. Narrative and thematic technique were used to systematically analyse the data. Participants described negotiating sexual relationships in a context where traditional gender norms merge with the paradox of increasing professional opportunities for women alongside growing economic precarity. Interconnected economic and emotional dependence along with violence influenced the acceptance of certain behaviours that heightened vulnerability to HIV, including inconsistent condom use and infidelity. Gender transformative approaches that recognise the complex interplay between gender norms, economic precarity and violence are needed to address women's vulnerability to HIV in the Cuban context. Such efforts can reinforce existing strategies to promote behaviourally focused prevention while creating an enabling environment for the integration and expansion of biomedical innovation in HIV prevention.

Sterile Insect Technique: Successful Suppression of an Aedes aegypti Field Population in Cuba.

Dengue virus infections are a serious public health problem worldwide. Aedes aegypti is the primary vector of dengue in Cuba. As there is no vaccine or specific treatment, the control efforts are directed to the reduction of mosquito populations. The indiscriminate use of insecticides can lead to adverse effects on ecosystems, including human health. The sterile insect technique is a species-specific and environment-friendly method of insect population control based on the release of large numbers of sterile insects, ideally males only. The success of this technique for the sustainable management of agricultural pests has encouraged its evaluation for the population suppression of mosquito vector species. Here, we describe an open field trial to evaluate the effect of the release of irradiated male Ae. aegypti on a wild population. The pilot trial was carried out in a suburb of Havana and compared the mosquito population density before and after the intervention, in both untreated control and release areas. The wild population was monitored by an ovitrap network, recording frequency and density of eggs as well as their hatch rate. A significant amount of sterility was induced in the field population of the release area, as compared with the untreated control area. The ovitrap index and the mean number of eggs/trap declined dramatically after 12 and 5 weeks of releases, respectively. For the last 3 weeks, no eggs were collected in the treatment area, clearly indicating a significant suppression of the wild target population. We conclude that the sterile males released competed successfully and induced enough sterility to suppress the local Ae. aegypti population.

A Realist Synthesis of Community-Based Interventions in Vector-Borne Diseases.

Randomized control trials have provided evidence that some community-based interventions (CBIs) work in vector-borne diseases (VBDs). Conversely, there is limited evidence on how well those CBIs succeed in producing specific outcomes in different contexts. To conduct a realist synthesis for knowledge translation on this topic, we examined the extent to which realist concepts (context, mechanisms, and outcomes) and their relationships are present in the existing literature on CBIs for VBDs. Articles on CBIs were identified from prior scoping reviews of health interventions for VBDs. Content of the articles was extracted verbatim if it referred either to realist concepts or CBI features. The number of articles and the average number of words extracted per category per CBI were quantified. Content of the articles was scrutinized to inductively gather qualitative evidence on the interactions between realist concepts. We reviewed 41 articles on 17 CBIs from 12 countries. The average number of words used for mechanisms was much lower than those used for outcomes and context (309,474, and 836, respectively). The average number of words used for mechanisms increased when a CBI was described in three or more articles. There were more extensive accounts on CBI features than on mechanisms. It was difficult to gather evidence on the interactions among realist concepts from the content of the articles. Scarce reporting on mechanisms in published articles limits conducting a realist synthesis of CBIs in VBDs. More transdisciplinary research that goes beyond the biomedical paradigm is needed to boost the development of intervention mechanisms in this field.

Towards a better integration of social sciences in arbovirus research and decision-making: an experience from scientific collaboration between Cuban and Quebec institutions.

In 2017, the Institute of Tropical Medicine Pedro Kourí, University of Montreal Public Health Research Institute, and McGill University joined efforts to provide scenarios for scientific exchange and knowledge dissemination about the social science contribution on arboviral research. This commentary describes the scientific collaboration between Cuban and Canadian (Quebec) institutions, illustrating the need and opportunities to facilitate research and effective decision-making processes for arboviral prevention and control, going beyond traditional biomedical aspects. We organized a set of scientific activities within three international events conducted in Cuba between 2017 and 2018. Given the collaborating institutions' expertise and the knowledge gaps in arboviral research, we selected three main thematic areas: social determinants and equity, community-based interventions and use of evidence for decision-making. The partnership shows that interdisciplinary collaboration and the use and integration of quantitative and qualitative methods from the social sciences is essential to face the current challenges in arbovirus research.

Prevalencia del síndrome de fragilidad y factores asociados en adultos mayores / Prevalence of Frailty Syndrome and Associated Factors in Elderly Adults

Introducción: En Latinoamérica, la prevalencia del síndrome de fragilidad en adultos mayores no institucionalizados de 60 años a más oscila entre 7,7 y 39,3 por ciento. En Perú, pocos estudios han abordado este tema y sus factores asociados en poblaciones similares. Objetivo: Identificar la prevalencia de fragilidad y los factores asociados en adultos mayores pertenecientes a siete centros de atención primaria. Métodos: Estudio transversal analítico cuya variable desenlace fue la presencia de fragilidad, según criterios de Fried. Se incluyeron también datos sociodemográficos (para la ocupación se usó la clasificación SEE y Sem FyC), tamizaje de depresión (con la escala de Yesavage), grado de funcionalidad (con el índice de Barthel) y las comorbilidades (usando el índice Geriátrico de Comorbilidad y el índice de severidad de Greenfield). Resultados: Se evaluaron 116 adultos mayores, la prevalencia de fragilidad fue de 20,7 por ciento. Los factores asociados fueron tener dos o más enfermedades (RPa = 3,33; IC 95 por ciento: 1,04 - 10,68), tener depresión moderada (RPa = 6,50; IC 95 por ciento: 2,52 - 16,75) y dependencia moderada para la realización de AVD (RPa = 2,63; IC 95 por ciento: 2,63 - 14,15). Los factores protectores fueron haber tenido una ocupación clase III (RPa = 0,11; IC 95 por ciento: 0,02 - 0,54), IV (RPa = 0,07; IC 95 por ciento: 0,01 - 0,35) o V (RPa = 0,24; IC 95 por ciento: 0,09 - 0,60) y el vivir con algún familiar (RPa = 0,25; IC 95 por ciento: 0,08 - 0,74). Conclusión: Uno de cada cinco adultos mayores fue frágil. Los síntomas depresivos, tener dos o más comorbilidades y el ser dependiente para las actividades de la vida diaria fueron factores asociados a la fragilidad. Por su parte, trabajar en cargos no directivos y el vivir acompañado de algún familiar fueron factores protectores(AU)

Introduction: In Latin America, the prevalence of frailty syndrome in non-institutionalized elderly adults aged 60 years and older ranges from 7.7 to 39.3 percent. In Peru, few studies have addressed this topic and its associated factors in similar populations. Objective: To identify the prevalence of frailty and the associated factors in elderly adults from seven primary care centers. Methods: Analytical and cross-sectional study whose outcome variable was the presence of frailty, according to the Fried criteria. We also included sociodemographic data (for occupation, the classifications of the Spanish Society of Epidemiology [SEE in Spanish] and the Spanish Society of Family and Community Medicine [SEMFyC in Spanish] were used), depression screening (using the Yesavage scale), degree of functionality (using the Barthel index), and comorbidities (using the Geriatric Index of Comorbidity and Greenfield's severity index). Results: 116 older adults were evaluated. The prevalence of frailty was 20.7 percent. The associated factors were having two or more illnesses (RPa=3.33; 95 percent CI: 1.04-10.68), having moderate depression (RPa=6.50; 95 percent CI: 2.52-16.75), and moderate dependence for performing daily-life activities (RPa=2.63; 95 percent CI: 2.63-14.15). Protective factors were having had a class III occupation (RPa=0.11; 95 percent CI: 0.02-0.54), class IV (RPa=0.07; 95 percent CI: 0.01-0.35), or class V (RPa=0.24; 95 percent CI: 0.09-0.60), and living with a relative (RPa=0.25; 95 percent CI: 0.08-0.74). Conclusion: One in five elderly adults was frail. Depressive symptoms, having two or more comorbidities, and being dependent for daily-life activities were factors associated with frailty. On the other hand, working in non-managerial positions and living with a family member were protective factors(AU)

Using implementation science theories and frameworks in global health.

In global health, researchers and decision makers, many of whom have medical, epidemiology or biostatistics background, are increasingly interested in evaluating the implementation of health interventions. Implementation science, particularly for the study of public policies, has existed since at least the 1930s. This science makes compelling use of explicit theories and analytic frameworks that ensure research quality and rigour. Our objective is to inform researchers and decision makers who are not familiar with this research branch about these theories and analytic frameworks. We define four models of causation used in implementation science: intervention theory, frameworks, middle-range theory and grand theory. We then explain how scientists apply these models for three main implementation studies: fidelity assessment, process evaluation and complex evaluation. For each study, we provide concrete examples from research in Cuba and Africa to better understand the implementation of health interventions in global health context. Global health researchers and decision makers with a quantitative background will not become implementation scientists after reading this article. However, we believe they will be more aware of the need for rigorous implementation evaluations of global health interventions, alongside impact evaluations, and in collaboration with social scientists.

To the bone: Comment on "I wanted a skeleton they brought a prince": A qualitative investigation of factors mediating the implementation of a Performance Based Incentive program in Malawi.

Recently, McMahon and colleagues set out to build on a widely-used fidelity framework, assessing the role of moderating factors during the implementation of performance-based financing programs in Malawi. Their attempt draws again the attention to the importance of approaching real word implementation issues from a theoretical perspective. It also highlights the importance of fidelity assessment within process evaluation of health programs. In this comment we argue that theoretical developments in the field of implementation science in global health would benefit from an accurate understanding of existing conceptual frameworks as well as from taking into account all contemporary contributions.

Comunicación para la prevención de arbovirosis: adecuación de iniciativas de la OPS al contexto cubano

[RESUMEN]. El presente trabajo tiene como objetivo describir las oportunidades y los desafíos de los procesos de capacitación en la articulación de iniciativas regionales y nacionales de comunicación para la prevención de arbovirosis, usando como ejemplo las lecciones aprendidas en el contexto cubano. En febrero de 2016 y diciembre de 2017 profesionales del Instituto de Medicina Tropical Pedro Kourí participaron en la realización de talleres de fortalecimiento de capacidades de comunicación para la prevención de arbovirosis en la Atención Primaria de Salud con la incorporación paulatina de los más recientes enfoques promovidos por la Organización Panamericana de la Salud sobre el tema. Se capacitaron especialistas de diferentes perfiles profesionales a nivel nacional, provincial, municipal y de áreas de salud, se formaron y consolidaron equipos multidisciplinarios en los diferentes niveles, se asignaron y articularon tareas concretas a cada nivel, y se establecieron sitios de demostración de los enfoques de comunicación promovidos en los talleres. Asimismo, se identificaron necesidades de aprendizaje en comunicación social y se incorporaron a la estrategia nacional 2018-2021 actividades de capacitación del personal técnico y de monitoreo y evaluación con el objetivo de garantizar la implementación de acciones de comunicación y su sostenibilidad. No obstante, las instituciones participantes tendrán que afrontar desafíos propios de la comunicación en la prevención de las arbovirosis como, por ejemplo, la fluctuación del personal entrenado, la movilización de recursos para la comunicación, y la identificación de indicadores adecuados de evaluación.

[ABSTRACT]. The purpose of this paper is to describe the opportunities and challenges of training processes in the coordination of regional and national communication initiatives for arboviral disease prevention, using the lessons learned in the Cuban context as an example. In February 2016 and December 2017, professional staff from the Pedro Kourí Institute of Tropical Medicine attended workshops for strengthening communication capacities for arboviral disease prevention in primary health care settings through gradual introduction of the most recent approaches promoted by the Pan American Health Organization in this regard. National, provincial, municipal, and health area specialists with diverse professional profiles were trained; multidisciplinary teams were strengthened at the different levels; specific tasks were assigned and coordinated at each level; and demonstration sites were established for the communication approaches promoted in the workshops. Learning needs in the field of mass communication were also identified, and activities for training technical staff and for monitoring and evaluation were introduced in the national strategy 2018-2021 to guarantee the implementation and sustainability of communication activities. Notwithstanding, participating institutions will have to address the challenges characteristic of communication for arboviral disease prevention, which include the rotation of trained personnel, the mobilization of resources for communication, and the identification of appropriate evaluation indicators.

[RESUMO]. O presente trabalho tem o objetivo de descrever as oportunidades e os desafios da capacitação em articulação de iniciativas regionais e nacionais de comunicação para prevenção de arboviroses, a partir dos ensinamentos tirados com a experiência cubana. Em fevereiro de 2016 e em dezembro de 2017, profissionais do Instituto de Medicina Tropical Pedro Kourí, em Cuba, participaram de um seminário sobre o fortalecimento da capacidade de comunicação para prevenção de arboviroses na atenção primária à saúde com a incorporação gradual dos enfoques mais recentes promovidos pela Organização Pan-Americana da Saúde (OPAS). Especialistas com diferentes perfis profissionais foram capacitados ao nível nacional, de província, do município e de áreas de saúde. Equipes multidisciplinares foram formadas e consolidadas nos diferentes níveis e elas receberam a incumbência de tarefas concretas coordenadas em cada nível e participaram da demonstração dos enfoques de comunicação apresentados nos seminários. Além disso, as necessidades de aprendizagem em comunicação social foram identificadas e atividades de capacitação do pessoal técnico e atividades de monitoramento e avaliação foram incorporadas à estratégia nacional 2018–2021 com o objetivo de garantir a implementação e a sustentabilidade das ações de comunicação. Porém, as instituições participantes terão de enfrentar os próprios desafios de comunicação na prevenção das arboviroses, por exemplo, rotatividade do pessoal capacitado, captação de recursos para comunicação e identificação dos indicadores adequados de avaliação.

Community-based dengue control intervention in Ouagadougou: intervention theory and implementation fidelity.

BACKGROUND: While malaria control is the primary health focus in Burkina Faso, the recent dengue epidemic calls for new interventions. This paper examines the implementation fidelity of an innovative intervention to control dengue in the capital Ouagadougou. METHODS: First we describe the content of the intervention and its theory. We then assess the fidelity of the implementation. This step is essential as preparation for subsequent evaluation of the intervention's effectiveness. Observations (n = 62), analysis of documents related to the intervention (n = 8), and semi-structured interviews with stakeholders (n = 18) were conducted. The collected data were organized and analyzed using QDA Miner. The theory of the intervention, grounded in reported good practices of community-based interventions, was developed and discussed with key stakeholders. RESULTS: The theory of the intervention included four components: mobilization and organization, operational planning, community action, and monitoring/evaluation. The interactions among these components were intended to improve people's knowledge about dengue and enhance the community's capacity for vector control, which in turn would reduce the burden of the disease. The majority of the planned activities were conducted according to the intervention's original theory. Adaptations pertained to implementation and monitoring of activities. CONCLUSIONS: Despite certain difficulties, some of which were foreseeable and others not, this experience showed the feasibility of developing community-based interventions for vector-borne diseases in Africa.

Insecticide treated curtains and residual insecticide treatment to control Aedes aegypti: An acceptability study in Santiago de Cuba.

BACKGROUND: Within the context of a field trial conducted by the Cuban vector control program (AaCP), we assessed acceptability of insecticide-treated curtains (ITCs) and residual insecticide treatment (RIT) with deltamethrin by the community. We also assessed the potential influence of interviewees' risk perceptions for getting dengue and disease severity. METHODOLOGY/PRINCIPAL FINDINGS: We embedded a qualitative study using in-depth interviews in a cluster randomized trial (CRT) testing the effectiveness of ITCs and RIT in Santiago de Cuba. In-depth interviews (N = 38) were conducted four and twelve months after deployment of the tools with people who accepted the tools, who stopped using them and who did not accept the tools. Data analysis was deductive. Main reasons for accepting ITCs at the start of the trial were perceived efficacy and not being harmful to health. Constraints linked to manufacturer instructions were the main reason for not using ITCs. People stopped using the ITCs due to perceived allergy, toxicity and low efficacy. Few heads of households refused RIT despite the noting reasons for rejection, such as allergy, health hazard and toxicity. Positive opinions of the vector control program influenced acceptability of both tools. However, frequent insecticide fogging as part of routine AaCP vector control actions diminished perceived efficacy of both tools and, therefore, acceptability. Fifty percent of interviewees did feel at risk for getting dengue and considered dengue a severe disease. However, this did not appear to influence acceptability of ITCs or RIT. CONCLUSION/SIGNIFICANCE: Acceptability of ITCs and RIT was linked to acceptability of AaCP routine vector control activities. However, uptake and use were not always an indication of acceptability. Factors leading to acceptability may be best identified using qualitative methods, but more research is needed on the concept of acceptability and its measurement.

[Communication for arboviral disease prevention: tailoring PAHO initiatives to the Cuban contextComunicação para prevenção de arboviroses: adequação das iniciativas da OPAS ao contexto cubano]. / Comunicación para la prevención de arbovirosis: adecuación de iniciativas de la OPS al contexto cubano.

The purpose of this paper is to describe the opportunities and challenges of training processes in the coordination of regional and national communication initiatives for arboviral disease prevention, using the lessons learned in the Cuban context as an example. In February 2016 and December 2017, professional staff from the Pedro Kourí Institute of Tropical Medicine attended workshops for strengthening communication capacities for arboviral disease prevention in primary health care settings through gradual introduction of the most recent approaches promoted by the Pan American Health Organization in this regard. National, provincial, municipal, and health area specialists with diverse professional profiles were trained; multidisciplinary teams were strengthened at the different levels; specific tasks were assigned and coordinated at each level; and demonstration sites were established for the communication approaches promoted in the workshops. Learning needs in the field of mass communication were also identified, and activities for training technical staff and for monitoring and evaluation were introduced in the national strategy 2018-2021 to guarantee the implementation and sustainability of communication activities. Notwithstanding, participating institutions will have to address the challenges characteristic of communication for arboviral disease prevention, which include the rotation of trained personnel, the mobilization of resources for communication, and the identification of appropriate evaluation indicators.

O presente trabalho tem o objetivo de descrever as oportunidades e os desafios da capacitação em articulação de iniciativas regionais e nacionais de comunicação para prevenção de arboviroses, a partir dos ensinamentos tirados com a experiência cubana. Em fevereiro de 2016 e em dezembro de 2017, profissionais do Instituto de Medicina Tropical Pedro Kourí, em Cuba, participaram de um seminário sobre o fortalecimento da capacidade de comunicação para prevenção de arboviroses na atenção primária à saúde com a incorporação gradual dos enfoques mais recentes promovidos pela Organização Pan-Americana da Saúde (OPAS). Especialistas com diferentes perfis profissionais foram capacitados ao nível nacional, de província, do município e de áreas de saúde. Equipes multidisciplinares foram formadas e consolidadas nos diferentes níveis e elas receberam a incumbência de tarefas concretas coordenadas em cada nível e participaram da demonstração dos enfoques de comunicação apresentados nos seminários. Além disso, as necessidades de aprendizagem em comunicação social foram identificadas e atividades de capacitação do pessoal técnico e atividades de monitoramento e avaliação foram incorporadas à estratégia nacional 2018­2021 com o objetivo de garantir a implementação e a sustentabilidade das ações de comunicação. Porém, as instituições participantes terão de enfrentar os próprios desafios de comunicação na prevenção das arboviroses, por exemplo, rotatividade do pessoal capacitado, captação de recursos para comunicação e identificação dos indicadores adequados de avaliação.

Comunicación para la prevención de arbovirosis: adecuación de iniciativas de la OPS al contexto cubano / Communication for arboviral disease prevention: tailoring PAHO initiatives to the Cuban context / Comunicação para prevenção de arboviroses: adequação das iniciativas da OPAS ao contexto cubano

RESUMEN El presente trabajo tiene como objetivo describir las oportunidades y los desafíos de los procesos de capacitación en la articulación de iniciativas regionales y nacionales de comunicación para la prevención de arbovirosis, usando como ejemplo las lecciones aprendidas en el contexto cubano. En febrero de 2016 y diciembre de 2017 profesionales del Instituto de Medicina Tropical Pedro Kourí participaron en la realización de talleres de fortalecimiento de capacidades de comunicación para la prevención de arbovirosis en la Atención Primaria de Salud con la incorporación paulatina de los más recientes enfoques promovidos por la Organización Panamericana de la Salud sobre el tema. Se capacitaron especialistas de diferentes perfiles profesionales a nivel nacional, provincial, municipal y de áreas de salud, se formaron y consolidaron equipos multidisciplinarios en los diferentes niveles, se asignaron y articularon tareas concretas a cada nivel, y se establecieron sitios de demostración de los enfoques de comunicación promovidos en los talleres. Asimismo, se identificaron necesidades de aprendizaje en comunicación social y se incorporaron a la estrategia nacional 2018-2021 actividades de capacitación del personal técnico y de monitoreo y evaluación con el objetivo de garantizar la implementación de acciones de comunicación y su sostenibilidad. No obstante, las instituciones participantes tendrán que afrontar desafíos propios de la comunicación en la prevención de las arbovirosis como, por ejemplo, la fluctuación del personal entrenado, la movilización de recursos para la comunicación, y la identificación de indicadores adecuados de evaluación.

ABSTRACT The purpose of this paper is to describe the opportunities and challenges of training processes in the coordination of regional and national communication initiatives for arboviral disease prevention, using the lessons learned in the Cuban context as an example. In February 2016 and December 2017, professional staff from the Pedro Kourí Institute of Tropical Medicine attended workshops for strengthening communication capacities for arboviral disease prevention in primary health care settings through gradual introduction of the most recent approaches promoted by the Pan American Health Organization in this regard. National, provincial, municipal, and health area specialists with diverse professional profiles were trained; multidisciplinary teams were strengthened at the different levels; specific tasks were assigned and coordinated at each level; and demonstration sites were established for the communication approaches promoted in the workshops. Learning needs in the field of mass communication were also identified, and activities for training technical staff and for monitoring and evaluation were introduced in the national strategy 2018-2021 to guarantee the implementation and sustainability of communication activities. Notwithstanding, participating institutions will have to address the challenges characteristic of communication for arboviral disease prevention, which include the rotation of trained personnel, the mobilization of resources for communication, and the identification of appropriate evaluation indicators.

RESUMO O presente trabalho tem o objetivo de descrever as oportunidades e os desafios da capacitação em articulação de iniciativas regionais e nacionais de comunicação para prevenção de arboviroses, a partir dos ensinamentos tirados com a experiência cubana. Em fevereiro de 2016 e em dezembro de 2017, profissionais do Instituto de Medicina Tropical Pedro Kourí, em Cuba, participaram de um seminário sobre o fortalecimento da capacidade de comunicação para prevenção de arboviroses na atenção primária à saúde com a incorporação gradual dos enfoques mais recentes promovidos pela Organização Pan-Americana da Saúde (OPAS). Especialistas com diferentes perfis profissionais foram capacitados ao nível nacional, de província, do município e de áreas de saúde. Equipes multidisciplinares foram formadas e consolidadas nos diferentes níveis e elas receberam a incumbência de tarefas concretas coordenadas em cada nível e participaram da demonstração dos enfoques de comunicação apresentados nos seminários. Além disso, as necessidades de aprendizagem em comunicação social foram identificadas e atividades de capacitação do pessoal técnico e atividades de monitoramento e avaliação foram incorporadas à estratégia nacional 2018-2021 com o objetivo de garantir a implementação e a sustentabilidade das ações de comunicação. Porém, as instituições participantes terão de enfrentar os próprios desafios de comunicação na prevenção das arboviroses, por exemplo, rotatividade do pessoal capacitado, captação de recursos para comunicação e identificação dos indicadores adequados de avaliação.

Why Did Zika Not Explode in Cuba? The Role of Active Community Participation to Sustain Control of Vector-Borne Diseases.

As the global public health community develops strategies for sustainable Zika prevention and control, assessment of the Cuban response to Zika provides critical lessons learned. Cuba's early and successful response to Zika, grounded in the country's long-standing dengue prevention and control program, serves as a model of rapid mobilization of intersectoral efforts. Sustaining this response requires applying the evidence generated within the Cuban dengue program that active community participation improves outcomes and is sustainable and cost-effective. There is also a need for implementation science efforts to assess the transferability of lessons learned from Zika prevention and control to other pathogens and from one context to another in addition to how to take these efforts to scale.

[Translation into practice of empowerment strategies for dengue prevention: facilitators and barriers]. / Traslación a la práctica de estrategias de empoderamiento en la prevención del dengue: facilitadores y barreras.

Objective To identify facilitators and barriers to the process of translating community empowerment strategies into the practice of the national Aedes aegypti control program in Cuba. Methods A case study of the process was conducted from 2005 to 2009 at national and provincial levels of the control program. Data from participant observation, in-depth interviews, and document analysis were triangulated and analyzed inductively and deductively. Results The main facilitators identified included a proposal for an empowerment strategy effective in reducing Aedes aegypti infestation, which was explained in such a way that it could be implemented by program staff; and a control program with national coverage capable of implementing the proposal. The principal barriers were the complexity of the strategy and the absence of organizational changes needed to facilitate its insertion into the control program. Each barrier or facilitator identified was either static or dynamic in nature. Dynamic factors are those that offer signals for action. Conclusions Multiple barriers and facilitators influence the process of translating community empowerment strategies into the practice of the Cuban Aedes aegypti control program. The analysis of these factors as either static or dynamic makes it possible to design more appropriate and effective strategies that can promote the process and increase the likelihood of success.

A modified theoretical framework to assess implementation fidelity of adaptive public health interventions.

BACKGROUND: One of the major debates in implementation research turns around fidelity and adaptation. Fidelity is the degree to which an intervention is implemented as intended by its developers. It is meant to ensure that the intervention maintains its intended effects. Adaptation is the process of implementers or users bringing changes to the original design of an intervention. Depending on the nature of the modifications brought, adaptation could either be potentially positive or could carry the risk of threatening the theoretical basis of the intervention, resulting in a negative effect on expected outcomes. Adaptive interventions are those for which adaptation is allowed or even encouraged. Classical fidelity dimensions and conceptual frameworks do not address the issue of how to adapt an intervention while still maintaining its effectiveness. DISCUSSION: We support the idea that fidelity and adaptation co-exist and that adaptations can impact either positively or negatively on the intervention's effectiveness. For adaptive interventions, research should answer the question how an adequate fidelity-adaptation balance can be reached. One way to address this issue is by looking systematically at the aspects of an intervention that are being adapted. We conducted fidelity research on the implementation of an empowerment strategy for dengue prevention in Cuba. In view of the adaptive nature of the strategy, we anticipated that the classical fidelity dimensions would be of limited use for assessing adaptations. The typology we used in the assessment-implemented, not-implemented, modified, or added components of the strategy-also had limitations. It did not allow us to answer the question which of the modifications introduced in the strategy contributed to or distracted from outcomes. We confronted our empirical research with existing literature on fidelity, and as a result, considered that the framework for implementation fidelity proposed by Carroll et al. in 2007 could potentially meet our concerns. We propose modifications to the framework to assess both fidelity and adaptation. The modified Carroll et al.'s framework we propose may permit a comprehensive assessment of the implementation fidelity-adaptation balance required when implementing adaptive interventions, but more empirical research is needed to validate it.