Cognitive and motor improvement by tummy time practice in preemies from low-income settings: a randomized clinical trial.

Introduction: Early intervention and parental education for preemies are limited in some low-income countries. Thus, this study aimed to assess whether daily tummy time (TT) associated with usual care (UC) enhances motor and cognitive development in preemies from low-income countries. The main and secondary aim was to assess prone head elevation (PHE) and motor and cognitive functions, respectively. Methods: Thirty-one preemies with a mean gestational age at birth of 33.3 ± 1.6 weeks and weighing <2,500 g were included and 18 completed all assessments. Parents from the TT group were asked to perform TT with their preemies for at least 20 min during daily activities and playtime. Motor and cognitive functions were assessed by a blinded examiner using the motor and cognitive composite scores of Bayley-III after two and four months of corrected age. PHE was given by the angle from the tragus of the ear to the supporting surface of the infant; measurements were obtained using the Kinovea® software at baseline, after two, three, and four months of corrected age. Results: The Bayley-III motor composite score of the TT group was higher than the UC group after two and four months of corrected age. The PHE angle increased over time but did not differ between groups. Discussion: Nevertheless, TT expanded the perspective of preemies to explore their bodies and environment, favoring the stimuli for motor and cognitive patterns. The loss of participants (31%) was one of the limitations of the study, illustrating the challenge of providing continued early interventions to preemies from low-income countries. In this sense, TT practice is a home intervention that may improve motor and cognitive function of preemies immediately after hospital discharge.

Acute kidney injury developed in the intensive care unit: a population-based prospective cohort study in the Brazilian Amazon.

The Brazilian Amazon is a vast area with limited health care resources. To assess the epidemiology of critically ill acute kidney injury (AKI) patients in this area, a prospective cohort study of 1029 adult patients of the three intensive care units (ICUs) of Rio Branco city, the capital of Acre state, were evaluated from February 2014 to February 2016. The incidence of AKI was 53.3%. Risk factors for AKI included higher age, nonsurgical patients, admission to the ICU from the ward, higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores at ICU admission, and positive fluid balance > 1500 ml/24 hours in the days before AKI development in the ICU, with aOR of 1.3 (95% CI 1.03-1.23), 1.47 (95% CI 1.07-2.03), 1.96 (95% CI 1.40-2.74), 1.05 (95% CI 1.03-1.08) for each unit increase, and 1.62 (95% CI 1.16-2.26), respectively. AKI was associated with higher ICU mortality (aOR 2.03, 95% CI 1.29-3.18). AKI mortality was independently associated with higher age, nonsurgical patients, sepsis at ICU admission, presence of shock or use of vasoactive drugs, mechanical ventilation and mean positive fluid balance in the ICU > 1500 ml/24 hours, both during ICU follow-up, with aOR 1.27 (95% CI 1.14-1.43) for each 10-year increase, 1.64 (95% CI 1.07-2.52), 2.35 (95% CI 1.14-4.83), 1.88 (95% CI 1.03-3.44), 6.73 (95% CI 4.08-11.09), 2.31 (95% CI 1.52-3.53), respectively. Adjusted hazard ratios for AKI mortality 30 and 31-180 days after ICU discharge were 3.13 (95% CI 1.84-5.31) and 1.69 (95% CI 0.99-2.90), respectively. AKI incidence was strikingly high among critically ill patients in the Brazilian Amazon. The AKI etiology, risk factors and outcomes were similar to those described in high-income countries, but mortality rates were higher.

Heart Failure Care Facilitators and Barriers in Rural Haiti: A Qualitative Study.

Background: Heart failure (HF) is a leading cause of hospitalizations in Haiti. However, few patients return for outpatient care. The factors contributing to chronic HF care access are poorly understood. Objective: The purpose of this study is to investigate the facilitators and barriers to accessing care for chronic HF from the patients' perspectives. Methods: We conducted a qualitative descriptive study of 13 patients with HF participating in three group interviews and one individual interview. We recruited patients after discharge from a nongovernmental organization-supported academic hospital in rural Haiti. We employed thematic analysis using emergent coding and categorized themes using the socioecological model. Findings: Facilitators of chronic care included participants' knowledge about the importance of treatment for HF and engagement with health systems to manage symptoms. Social support networks helped participants access clinics. Participants reported low cost of care at this subsidized hospital, good medication accessibility, and trust in the healthcare system. Participants expressedstrong spiritual beliefs, with the view that the healthcare system is an extension of God's influence. Barriers to chronic care included misconceptions about the importance of adherence to medications when symptoms improve and remembering follow-up appointments. Unexpectedly, participants believed they should take their HF medications with food and that food insecurity resulted in missed doses. Lack of social support networks limited clinic access. The nonhealthcare costs associated with clinic visits were prohibitive for many participants. Participants expressed low satisfaction regarding the clinic experience. A barrier to healthcare was the belief that heart disease caused by mystical and supernatural spirits is incurable. Conclusions: We identified several facilitators and barriers to chronic HF care with meaningful implications for HF management in rural Haiti. Future interventions to improve chronic HF care should emphasize addressing misconceptions about HF management and fostering patient support systems for visit and medication adherence. Leveraging local spiritual beliefs may also promote care engagement.

Estimating time-varying cholera transmission and oral cholera vaccine effectiveness in Haiti and Cameroon, 2021-2023.

In 2023, cholera affected approximately 1 million people and caused more than 5000 deaths globally, predominantly in low-income and conflict settings. In recent years, the number of new cholera outbreaks has grown rapidly. Further, ongoing cholera outbreaks have been exacerbated by conflict, climate change, and poor infrastructure, resulting in prolonged crises. As a result, the demand for treatment and intervention is quickly outpacing existing resource availability. Prior to improved water and sanitation systems, cholera, a disease primarily transmitted via contaminated water sources, also routinely ravaged high-income countries. Crumbling infrastructure and climate change are now putting new locations at risk - even in high-income countries. Thus, understanding the transmission and prevention of cholera is critical. Combating cholera requires multiple interventions, the two most common being behavioral education and water treatment. Two-dose oral cholera vaccination (OCV) is often used as a complement to these interventions. Due to limited supply, countries have recently switched to single-dose vaccines (OCV1). One challenge lies in understanding where to allocate OCV1 in a timely manner, especially in settings lacking well-resourced public health surveillance systems. As cholera occurs and propagates in such locations, timely, accurate, and openly accessible outbreak data are typically inaccessible for disease modeling and subsequent decision-making. In this study, we demonstrated the value of open-access data to rapidly estimate cholera transmission and vaccine effectiveness. Specifically, we obtained non-machine readable (NMR) epidemic curves for recent cholera outbreaks in two countries, Haiti and Cameroon, from figures published in situation and disease outbreak news reports. We used computational digitization techniques to derive weekly counts of cholera cases, resulting in nominal differences when compared against the reported cumulative case counts (i.e., a relative error rate of 5.67% in Haiti and 0.54% in Cameroon). Given these digitized time series, we leveraged EpiEstim-an open-source modeling platform-to derive rapid estimates of time-varying disease transmission via the effective reproduction number ( R t ). To compare OCV1 effectiveness in the two considered countries, we additionally used VaxEstim, a recent extension of EpiEstim that facilitates the estimation of vaccine effectiveness via the relation among three inputs: the basic reproduction number ( R 0 ), R t , and vaccine coverage. Here, with Haiti and Cameroon as case studies, we demonstrated the first implementation of VaxEstim in low-resource settings. Importantly, we are the first to use VaxEstim with digitized data rather than traditional epidemic surveillance data. In the initial phase of the outbreak, weekly rolling average estimates of R t were elevated in both countries: 2.60 in Haiti [95% credible interval: 2.42-2.79] and 1.90 in Cameroon [1.14-2.95]. These values are largely consistent with previous estimates of R 0 in Haiti, where average values have ranged from 1.06 to 3.72, and in Cameroon, where average values have ranged from 1.10 to 3.50. In both Haiti and Cameroon, this initial period of high transmission preceded a longer period during which R t oscillated around the critical threshold of 1. Our results derived from VaxEstim suggest that Haiti had higher OCV1 effectiveness than Cameroon (75.32% effective [54.00-86.39%] vs. 54.88% [18.94-84.90%]). These estimates of OCV1 effectiveness are generally aligned with those derived from field studies conducted in other countries. Thus, our case study reinforces the validity of VaxEstim as an alternative to costly, time-consuming field studies of OCV1 effectiveness. Indeed, prior work in South Sudan, Bangladesh, and the Democratic Republic of the Congo reported OCV1 effectiveness ranging from approximately 40% to 80%. This work underscores the value of combining NMR sources of outbreak case data with computational techniques and the utility of VaxEstim for rapid, inexpensive estimation of vaccine effectiveness in data-poor outbreak settings.

Evaluation of the potential impact and cost-effectiveness of respiratory syncytial virus (RSV) prevention strategies for infants in Argentina.

BACKGROUND: New interventions are available for the prevention of respiratory syncytial virus (RSV) disease in young infants. We aimed to assess the potential impact and cost-effectiveness of using a long-acting monoclonal antibody (RSV mAb) or maternal RSV vaccine in the Argentine context. METHODS: We used a static proportionate outcomes model to calculate the costs and consequences of using RSV mAb or maternal RSV vaccine over a ten-year period (2025-2034) in Argentina, assuming both year-round and seasonal administration. We compared each intervention to no pharmaceutical RSV intervention. The primary outcome was the discounted cost per disability-adjusted life year (DALY) averted from a societal perspective. We assumed willingness-to-pay of US$ 12,285 per DALY averted (0.9 times the national gross domestic product per capita). We used population study data on costs and disease burden and the efficacy of clinical trials of both interventions as inputs. We ran deterministic and probabilistic uncertainty analyses. FINDINGS: Either strategy (RSV mAb or maternal RSV vaccine) could prevent >25% of RSV deaths aged <5 years and âˆ¼30% aged <6 months (the age group where most intervention impact occurs). With a dose price of $US 50, both products have a 100% probability of being cost-effective compared to no intervention (US$ 5283 [95%CI $5203-$5363] and US$ 5522 [95%CI $5427 - $5617] per DALY averted for year-round use of RSV mAb and maternal RSV vaccine, respectively). Similar health impact could be achieved by a six-month seasonal strategy, which could improve cost-effectiveness by around 45% (assuming the dose price is unchanged). INTERPRETATION: Either RSV mAb or maternal RSV vaccine are worth consideration in Argentina when priced at ≤US$ 50 per dose. A seasonal strategy could improve cost-effectiveness.

Do behavioral drivers matter for healthcare decision-making during crises? A study of low-income women in El Salvador during the COVID-19 pandemic.

Understanding health-seeking behaviors and their drivers is key for governments to manage health policies. A growing body of research explores the role of cognitive biases and heuristics in health and care-seeking behaviors, but little is known about how a context of heightened anxiety and uncertainty might influence these behavioral drivers. This study analyzes the association between four behavioral predictors-internal locus of control, impatience, optimism bias, and aspirations-and healthcare decisions among low-income women in El Salvador, controlling for other factors. We find positive associations between internal locus of control and preventive health behaviors during the COVID-19 pandemic. For instance, a one standard deviation increase in locus of control is associated with a 10% increase in an index measuring the use of masks, distancing, hand washing, and vaccination. Locus of control was also associated with women's use of preventive health services (one standard deviation improves the likelihood of having a hypertension test in the last six months by 5.8 percentage points). In a sub-sample of mothers, we find significant relationships between the four behavioral drivers and the decisions the mothers make for their children. However, we find these associations are less robust compared to the decisions they make for themselves. Some associations were stronger during the pandemic, suggesting that feelings of uncertainty and stress could amplify behavioral drivers' influence on health-related behaviors. This novel finding is relevant for designing policy responses for future shocks. JEL CODES: I12, D10, D91, I30.

Development of Automated Triggers in Ambulatory Settings in Brazil: Protocol for a Machine Learning-Based Design Thinking Study.

BACKGROUND: The use of technologies has had a significant impact on patient safety and the quality of care and has increased globally. In the literature, it has been reported that people die annually due to adverse events (AEs), and various methods exist for investigating and measuring AEs. However, some methods have a limited scope, data extraction, and the need for data standardization. In Brazil, there are few studies on the application of trigger tools, and this study is the first to create automated triggers in ambulatory care. OBJECTIVE: This study aims to develop a machine learning (ML)-based automated trigger for outpatient health care settings in Brazil. METHODS: A mixed methods research will be conducted within a design thinking framework and the principles will be applied in creating the automated triggers, following the stages of (1) empathize and define the problem, involving observations and inquiries to comprehend both the user and the challenge at hand; (2) ideation, where various solutions to the problem are generated; (3) prototyping, involving the construction of a minimal representation of the best solutions; (4) testing, where user feedback is obtained to refine the solution; and (5) implementation, where the refined solution is tested, changes are assessed, and scaling is considered. Furthermore, ML methods will be adopted to develop automated triggers, tailored to the local context in collaboration with an expert in the field. RESULTS: This protocol describes a research study in its preliminary stages, prior to any data gathering and analysis. The study was approved by the members of the organizations within the institution in January 2024 and by the ethics board of the University of São Paulo and the institution where the study will take place. in May 2024. As of June 2024, stage 1 commenced with data gathering for qualitative research. A separate paper focused on explaining the method of ML will be considered after the outcomes of stages 1 and 2 in this study. CONCLUSIONS: After the development of automated triggers in the outpatient setting, it will be possible to prevent and identify potential risks of AEs more promptly, providing valuable information. This technological innovation not only promotes advances in clinical practice but also contributes to the dissemination of techniques and knowledge related to patient safety. Additionally, health care professionals can adopt evidence-based preventive measures, reducing costs associated with AEs and hospital readmissions, enhancing productivity in outpatient care, and contributing to the safety, quality, and effectiveness of care provided. Additionally, in the future, if the outcome is successful, there is the potential to apply it in all units, as planned by the institutional organization. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/55466.

Integrity at stake: confronting "publish or perish" in the developing world and emerging economies.

The scientific community faces significant ethical challenges due to the "publish or perish" culture, particularly in developing and emerging economies. This paper explores the widespread unethical practices in scientific publishing, including the sale of authorships, the proliferation of "paper mills," and the misuse of artificial intelligence to produce fraudulent research. These practices undermine the integrity of scientific research, skew publication metrics, and distort academic rankings. This study examines various instances of academic fraud, emphasizing the impact on low-income countries, with specific cases from Latin America. Recommendations include stricter verification of authorship, disciplinary measures for scientific fraud, and policies promoting transparency and accountability in research. Addressing these challenges is crucial for maintaining the integrity and credibility of scientific endeavors globally.

Improvements in habitability and housing satisfaction after dwelling regeneration in social housing complexes. The RUCAS study.

Housing is a pressing problem worldwide and a key determinant of health and wellbeing. The right to adequate housing, as a pillar of the right to an adequate standard of living, means more than a roof to live under. Adequate means the dwelling must fulfill material functions and psychosocial functions, thus contributing to dwellers health and wellbeing. Social housing policies aim to fulfill the right to housing, but frequently fail in fulfilling the right to it being adequate. This study capitalizes on the implementation of a national urban regeneration program in two social housing villas in central Chile (one in Santiago, in the central valley, the other in Viña del Mar, a coastal city) to run a natural experiment assessing the impact of dwelling renovation on several dimensions of perceived habitability and housing satisfaction among the -mostly female-household homemakers. We use 5 waves of survey data collected with a step-wedge design to estimate the association between a time-varying exposure status (the intervention) and 7 binary outcomes for habitability and 5 for housing dissatisfaction, including overall housing satisfaction. We use Poisson regression models with robust variance and a random intercept at the respondent level. At baseline, reports of poor habitability and dissatisfaction across all features were markedly high, the highest levels of dissatisfaction being with acoustic insulation and dwelling size in both villas, and with indoor temperature in Santiago. The intervention resulted in statistically significant and markedly large improvements in reported habitability and dissatisfaction relative to those housing components targeted by the intervention, as well as with overall dwelling satisfaction in both study cases. Implications are, first, that the policy response to quantitative housing deficits must not overlook housing quality; second, that housing renovation appears as a promising intervention for qualitative housing crises; third, that while improvements in habitability and satisfaction are specific to the interventions in place, overall housing satisfaction can improve in more limited, tailored, dwelling renovation interventions. Social housing renovation in Latin America appears as a promising intervention to improve quality of life among the urban poor dwellers and reduce inequalities in health related to housing conditions.

An update on the mechanisms and risk factors for anesthesia-related cardiac arrest in children: a narrative review.

The relation between surgery and anesthesia safety in children and a country's Human Development Index (HDI) value has been described previously. The aim of this narrative review was to provide an update on the mechanisms and risk factors of Anesthesia-Related Cardiac Arrest (ARCA) in pediatric surgical patients in countries with different HDI values and over time (pre-2001 vs. 2001‒2024). Electronic databases were searched up to March 2024 for studies reporting ARCA events in children. HDI values range from 0 to 1 (very-high-HDI countries: ≥ 0.800, high-HDI countries: 0.700‒0.799, medium-HDI countries: 0.550‒0.699, and low-HDI countries: < 0.550). Independent of time, the proportion of children who suffered perioperative Cardiac Arrest (CA) attributed to anesthesia-related causes was higher in very-high-HDI countries (50%) than in countries with HDI values less than 0.8 (15‒36%), but ARCA rates were higher in countries with HDI values less than 0.8 than in very-high-HDI countries. Regardless of the HDI value, medication-related factors were the most common mechanism causing ARCA before 2001, while cardiovascular-related factors, mainly hypovolemia, and respiratory-related factors, including difficulty maintaining patent airways and adequate ventilation, were the major mechanisms in the present century. Independent of HDI value and time, a higher number of ARCA events occurred in children with heart disease and/or a history of cardiac surgery, those aged younger than one year, those with ASA physical status III‒V, and those who underwent emergency surgery. Many ARCA events were determined to be preventable. The implementation of specialized pediatric anesthesiology and training programs is crucial for anesthesia safety in children.

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.

Type and timing of ultra-processed foods consumption and its association with dietary intake and physical activity in women with obesity living in poverty.

BACKGROUND: The present study aimed to investigate the type and timing of ultra-processed foods (UPF) consumption and its association with dietary intake (DI) and physical activity (PA) in women with obesity living in poverty. METHODS: A cross-sectional study was employed. Obesity was defined by at least two criteria (body mass index, waist circumference or % fat mass). Poverty was defined as the three lowest classes of the Brazilian Economic Classification Criterion. PA was measured with triaxial accelerometers and DI was assessed with three 24-h dietary recalls. Foods were categorised according to the NOVA classification, with UPF classified into five subgroups, as well as the timing of consumption into six meals. RESULTS: In total, 56 adult women were included. Overall energy intake was 1653.21 (503.22) kcal/day. UPF intake was 21.62% (11.94%) kcal/day, being higher at breakfast (4.91% kcal/day), afternoon snack (5.39% kcal/day) and dinner (5.01% kcal/day). Only UPF subgroup 4 (sandwich biscuits, sweets, or treats) showed a positive association with energy intake (ß = 54.40 [27.6, 81.10] kcal/day) and a negative association with protein intake (ß = -0.31% [-0.48%, -0.14%] kcal/day). UPF consumption in morning (ß = -0.41% [-0.79%, -0.02%] kcal/day) and afternoon (ß = -0.18% [-0.33%, -0.04%] kcal/day) snacks was associated with lower protein intake. Furthermore, lunchtime UPF consumption was positively associated with walking time (ß = 0.16% [0.02%; 0.30%]) and steps/hour (ß = 8.72 [1.50; 15.94] steps/h). CONCLUSIONS: Women with obesity living in poverty consume more UPF during breakfast, afternoon snack and dinner. Physical activity is positively associated with UPF consumption at lunch. UPF, such as sandwich biscuits, sweets or treats, contribute to increasing energy intake and reducing protein intake.

Continuing Professional Development at Two Rural Hospitals in Ecuador.

Background: E-learning Continuing Professional Development (CPD) is an activity demonstrated to improve the quality of healthcare delivery. The CPD of medical and nursing staff in high income countries (HICs) is commonplace. CPD of administrative staff is less common, but increasingly frequent. In low- and middle-income countries (LMICs), CPD of any kind is infrequent, particularly in rural and remote areas. Objective: The aim of this study was to describe a hospital-based e-learning CPD program for clinical and non-clinical personnel as a unique example of a successful, ongoing educational pilot, quality improvement program involving a broad cohort of employees, in a country that does not require such activities. Methods: Using the online educational platform Chamilo, e-learning modules were created for eight groups including clinical and non-clinical employees. Upon completion of each module, one to two paragraph discussions were provided for each incorrect answer submitted. Two additional chances were offered for the employee to achieve a passing score of 70%. This study reports on the first 10-month period of the program. Findings: All participants achieved the 70% passing threshold after the first or second attempt. There was 100% participation by the employees required to complete the e-learning modules. Employee feedback suggested the modules were good for continuing education, but some felt the CPD was imposed on them. Conclusion: E-learning CPD is an important and emerging element for CPD and may provide opportunities for healthcare service quality improvement as part of broader pedagogical modalities, such as conferences and directed readings, in rural and remote areas of LMICs. These pilot programs could provide important information to develop Spanish-language e-learning CPD programs across a broader region, promote collaboration with regional professional societies, and possibly contribute to the establishment of national health program CPD standards.

The Importance of Conducting Practice-oriented Research with Underserved Populations.

There has been a growing emphasis on dissemination of empirically supported treatments. Dissemination, however, should not be restricted to treatment. It can and, in the spirit of the scientific-practitioner model, should also involve research. Because it focuses on the investigation of clinical routine as it takes place in local settings and because it can involve the collaboration of several stakeholders, practice-oriented research (POR) can be viewed as an optimal research method to be disseminated. POR has the potential of addressing particularly relevant gaps of knowledge and action when implemented in regions of the world that have limited resources for or experiences with empirical research, and/or in clinical settings that are serving clinical populations who are not typically receiving optimal mental care services - specifically, individuals in rural and inner cities that have limited economic and social resources. The establishment and maintenance of POR in such regions and/or settings, however, come with specific obstacles and challenges. Integrating the experiences acquired from research conducted in various continents (Africa, Europe, Latin America, and North America), the goal of this paper is to describe some of these challenges, strategies that have been implemented to address them, as well as new possible directions to facilitate the creation and growth of POR. It also describes how these challenges and ways to deal with them can provide helpful lessons for already existing POR infrastructures.

Digital Support Systems to Improve Child Health and Development in Peru: Protocol for a Randomized Controlled Trial.

BACKGROUND: Children living in low and middle-income countries (LMICs) are at greater risk for experiencing adversities that can undermine their health and early development. Recently launched digital early childhood development (ECD) programs attempt to support families with young children in their home environments using digital technologies. However, relatively little is known regarding the effectiveness of these new technologies. OBJECTIVE: The goal of this study is to rigorously assess the reach, effectiveness, and cost-effectiveness of a newly developed digital ECD platform called Afini. The Afini platform was designed to support parents of young children in low-resource settings to improve ECD and interact with caregivers through messenger services and a chatbot. METHODS: This is a 3-arm cluster randomized controlled trial. In total, 2471 caregivers and their 3- to 9-month-old children were enrolled in the study across 164 study clusters in the San Marcos, Cajabamba, and Cajamarca provinces of Peru. Clusters of participants were randomly assigned to 1 of 3 groups: a control group (72 community clusters and 980 caregiver-child dyads), a home visit intervention group (20 community clusters and 316 caregiver-child dyads), and an Afini intervention group (72 community clusters and 1175 caregiver-child dyads). Families in the control group receive no focused ECD intervention. The home visit group is receiving biweekly home visits by a trained field staff following the national ECD program (Programa Nacional Cuna Más) curriculum and training guidelines. Caregivers in the Afini group are receiving ECD activities and advice through the digital platform. The primary study outcome is children's overall development at the age of 2.5 years, using the internationally validated long form of the Global Scales for Early Development. Secondary outcomes include caregiver engagement; caregiver mental health; screen time; as well as caregiver reports of children's motor, cognitive, language, and socioemotional development measured through locally piloted and validated tools. RESULTS: Enrollment started in September 2021 and ended in March 2023. Endline assessments will take place between August 2023 and September 2024. CONCLUSIONS: This study is, to our knowledge, the first to rigorously assess the effectiveness and cost-effectiveness of digital ECD technologies in LMICs. Given the large number of children in LMICs currently receiving only limited external support, the evaluated platform has the potential to improve the short- and long-term well-being of millions of children and their parents globally. TRIAL REGISTRATION: ClinicalTrials.gov NCT05202106; https://clinicaltrials.gov/ct2/show/NCT05202106. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50371.

Demanda de servicios de salud de la población adulta mayor de bajos ingresos en Colombia

Objetivo: Analizar los determinantes de la demanda de servicios de salud del adulto mayor entre los segmentos más pobres de Colombia. Materiales y métodos: Estudio de datos panel a partir de datos de riesgo individualizado de una aseguradora del régimen subsidiado en Colombia. Se elaboraron modelos de regresión lineal para determinar la demanda de salud bajo dos escenarios. Resultados: El hacinamiento, la exposición al humo y roedores mantienen una relación positiva con la demanda de servicios de salud. Por el contrario, la educación, ocupación, realizar actividad física y el no consumo de alcohol son factores protectores. Conclusión: La transición demográfica y epidemiológica que experimenta Colombia trae consigo retos para el sistema de salud. La identificación de determinantes de la demanda contribuye al establecimiento de estrategias para el mejoramiento del sistema de salud vigente y futuro.

Objective: To analyze the determinants of the demand for health services of the elderly among the poorest segments in Colombia. Materials and methods: Panel data study based on individualized risk data from an insurer of the subsidized regime in Colombia. Linear regression models were developed to determine health demand under two scenarios. Results: Overcrowding, exposure to smoke and rodents maintain a positive relationship with the demand for health services. On the contrary, education, occupation, physical activity, and non-alcohol consumption are protective factors. Conclusion: The demographic and epidemiological transition that Colombia is experiencing brings challenges to the health system. The identification of determinants of demand contributes to the implementation of strategies to improve the current and future health system.

Rabies outbreak in Brazil: first case series in children from an indigenous village.

BACKGROUND: Human rabies outbreak transmitted by bats continues to be a relevant public health problem not only in the Amazon region. The disease has affected one of the areas with the greatest poverty in southeastern Brazil, a region inhabited by the Maxakali indigenous people. CASE PRESENTATION: We describe four cases of rabies among indigenous children that occurred in the indigenous village of Pradinho, municipality of Bertópolis, Minas Gerais, Brazil. Cases were notified between April and May 2022, all of whom died on average eight days after the first symptoms. All cases were observed in rural residents under 12 years of age. The probable form of exposure was through bat bites. The predominant symptoms were prostration, fever, dyspnea, sialorrhea, tachycardia, and altered level of consciousness. Half of the cases underwent late and/or incomplete post-exposure rabies prophylaxis, however, the other half underwent pre-exposure rabies prophylaxis, with only one case completing the scheme and another undergoing the adapted Milwaukee Protocol (Recife Protocol). All cases ended in death. CONCLUSIONS: This was the first rabies outbreak among indigenous people in Brazil. Among the manifested clinical forms in the series, there was a disease atypical presentation in at least one case. We suggest active surveillance and an intercultural educational campaign to prevent new cases.