Tobacco use and access among 13 to 15 year olds in Kuna Yala, an indigenous region of Panama.

BACKGROUND: Panama has the lowest overall prevalence of tobacco use in the Americas, however rates are almost three times higher in the indigenous territory of Kuna Yala compared with the national average. Most people who smoke started during adolescence, making this a key period for tobacco control efforts. OBJECTIVE: We aimed to examine tobacco access and use among adolescents (13 to 15 years old) in Kuna Yala compared with nationwide Panama using data from the 2017 Global Youth Tobacco Survey, a standardised international tool for assessing key tobacco control indicators among adolescents. RESULTS: The prevalence of current tobacco use among 13 to 15 year olds in Kuna Yala was 14.0% (95% CI: 11.6% to 16.9%)-almost twice the national average of 7.8% (95% CI: 6.3% to 9.4%). Half of all adolescents in Kuna Yala estimated the cost of a 20-cigarette pack as less than US$0.75, compared with 16.2% of adolescents across of Panama (p value <0.01). CONCLUSIONS: Kuna Yala is one of the few indigenous territories in Spanish-speaking countries where key tobacco control indicators have recently been assessed. Higher tobacco use and lower reported cigarette prices in that region may be linked with the presence of barter economy which may give adolescents more ready access to cigarettes than in other parts of Panama. There is a need for more indigenous-specific data to help build the evidence base to improve tobacco control and reduce commercial tobacco use among indigenous peoples.

Malnutrition among Children under Age Five in Panama: Results of the ENSPA 2019.

Background: Malnutrition has important short- and long-term consequences in children under age five. Malnutrition encompasses undernutrition, overnutrition, and the coexistence of both of them, known as the double burden of malnutrition (DBM). Objective: The aim of this study was to estimate the prevalence of undernutrition, overnutrition, and the DBM among these children at the national level and by living area in Panama. Methods: Data from the National Health Survey of Panama (ENSPA, Spanish acronym), a population-based, cross-sectional study carried out in 2019 were used. Stunting, wasting, overweight, and obesity were defined according to the cut-off points of the World Health Organization Growth Standards. Undernutrition was defined as being stunted only, wasted only or both; overnutrition was defined as being overweight only or obese only; and the DBM was defined as the co-occurence of stunting and overweight/obesity in the same child. Prevalence and general characteristics at the national level and by living area were weighted. Findings: The prevalence of undernutrition was 15.3% (95% confidence interval (CI) 13.4-17.3) at the national level and 36.6% (CI: 30.1-43.5) in indigenous areas. The prevalence of overnutrition was 10.2% (8.2-12.6) at the national level and 11.9% (CI: 8.5-16.3), 8.4% (CI: 6.5-10.7) and 8.7% (CI: 5.2-14.3) in urban, rural and indigenous areas, respectively. The DBM prevalence was 1.4% (CI: 1.0-2.1) at the national level and 2.7% (CI: 1.4-5.1) in indigenous areas. Conclusions: Undernutrition is still the most prevalent malnutrition condition in our country. Panama has the highest prevalence of overnutrition in Central America. The highest prevalence of undernutrition and DBM was found among children living in indigenous areas.

Physical Inactivity and Sedentary Behaviour among Panamanian Adults: Results from the National Health Survey of Panama (ENSPA) 2019.

Physical inactivity (PI) has been described as an independent risk factor for a large number of major non-communicable diseases and is associated with an increased risk of premature death. Additionally, sedentary behaviour has been associated with increased overall mortality. We estimated the national prevalence of PI and sedentary behaviour using the Global Physical Activity Questionnaire version 2. Using unconditional logistic regressions, the possible risk factors for PI were assessed. Over half of the people included in this study (54.9%; 95% CI: 54.1-57.3%) were physically inactive, with the median time spent engaged in sedentary behaviour being 120 min per day. Statistically significant associations with PI were observed with regard to sex, living area, and alcohol consumption. PI prevalence in Panama was elevated and showed a sex difference (women: 64.7%, 95% CI: 63.7-66.7%; men: 43.4%, 95% CI: 41.5-47.5%). According to our analysis of three-domain-related physical activities, the main contribution to the total estimated energy expenditure of physical activity/week came from the transport domain, followed by the work/household domain, and the least significant contributor was consistently the domain of exercise- and sports-related physical activities.

Diabetes mellitus, its prevalence, awareness, and control in Panama: Data from ENSPA 2019, a national cross-sectional study.

Diabetes mellitus (DM) represents an important global burden of disease. In Panama, DM was investigated in 1 study utilizing questionnaires and in another using biomarkers, but at subnational level. Using data from a recent cross-sectional country-wide population-based study that included biomarkers, we estimated the prevalence of DM, its awareness, and control; evaluating possible risk factors. We used data from 4400 participants aged 18 years or older from the National Health Study of Panama (ENSPA) study conducted in 2019 at a national level. Weighted prevalence and 95% confidence intervals for DM, awareness, and control were estimated by sociodemographic factors, family history of DM, tobacco and alcohol use, nutritional status, and hypertension. Odds ratios (ORs) and 95% confidence intervals were calculated using logistic regression models to assess the possible risk factors associated with DM prevalence and awareness. We generated OR estimates by pooling ENSPA data with a previous regional study, prevalence of cardiovascular risk factors. The prevalence of DM was estimated to be 12.4% (10.9%-14.05%). In both men and women, age, family history of diabetes (OR in men: 4.0 ([2.4-6.7]; OR in women 3.5 [2.5-4.8]), and obesity (OR in men: 2.6 [1.4-5.1]; OR in women: 2.0 [0.9-4.5]) were associated with DM. Diagnosed and controlled hypertension was associated with DM only in women (OR: 2.1 [1.2-3.6]). DM awareness was estimated to be 62.6% (56.3%-68.9%). In both men and women, DM awareness was associated with age and a family history of diabetes (OR in men: 6.6 [2.4-18.4]; OR in women 1.9 ([1.1-3.6]). In women, having secondary education (OR: 1.9 [0.9-3.9]) and being diagnosed with uncontrolled hypertension (OR: 3.3 [1.2-9.5]) was also associated to DM awareness. Men in the ENSPA study were less likely to be aware of DM than those in the prevalence of cardiovascular risk factors (OR: 0.2 [0.0-0.7]). Less than half of the individuals diagnosed with DM had their condition controlled (39.6% [31.4%-47.8%]). This study revealed that the prevalence, awareness, and control of DM were similar to recent estimates reported in other Latin American countries. It also provides a baseline regarding DM and associated risk factors in Panama at a country-level knowledge that is essential for health policy development and useful in clinical practice.

History of the National Cancer Registry of Panama.

Background: The National Cancer Registry of Panama (NCRP) was established in 1974. In 1984, histological confirmation became mandatory. The now pathology-based registry has evolved and has been a population-based cancer registry (PBCR) since 2012 with cancer-specific Web-based reporting software. Herein, we characterize the main features in its development that may help readers understand its evolution and improvements that are needed to be in line with international standards. Methods: We describe the major components of the NCRP using its structure, processes, and a results framework for 3 major periods since its inception: 1974-1999, 2000-2011, and 2012 to present. Results: The NCRP has always been linked to the Ministry of Health of Panama. Until the end of its second period, it operated as a pathology-based registry and all staff worked part time. Currently, the NCRP is based on passive reporting through a Web-based system set up for both public and private health institutions, covering 77% of the existing health-care institutions in the nation. The number of cases with unknown age were less than 10 per year and primary tumors with unknown origin were at most 3%. The proportion of death certificate only (DCO) cases decreased 5% in 18 years. Men are more likely to have DCO than women (odds ratio, 1.53; 95% CI, 1.48-1.58). Discussion: The NCRP has evolved, achieving significant improvements and progress over the years. Yet, much remains to be done. To provide internationally comparable, valid, and timely cancer incidence data, the NCRP should continue to improve its quality and coverage and provide continuous staff training on cancer registry procedures.

Prevalence of hypertension and possible risk factors of hypertension unawareness among individuals aged 30-75 years from two Panamanian provinces: Results from population-based cross-sectional studies, 2010 and 2019.

BACKGROUND: Recent estimates of hypertension in Panama remain unknown. We aim to describe the variation in prevalence and unawareness of hypertension in two Panamanian provinces using two different cross-sectional population-based studies and to investigate risk factors associated with hypertension unawareness. METHODS: Data were derived from a sub-national study conducted in the provinces of Panama and Colon (PREFREC-2010 [2,733 participants]) and from a nationally representative study (ENSPA-2019), in which we restricted our analyses to the same provinces (4,653 participants). Individuals aged 30-75 years who had (a) self-reported history of hypertension or (b) blood pressure (BP) ≥140/90mmHg or (c) a combination or both were classified as hypertensive. Participants with BP≥140/90mmHg who denied a history of hypertension were considered unaware of the condition. Multivariable logistic regression models were used to estimate the association between risk factors and unawareness, expressed as odds ratios (OR) and 95% confidence interval (CI). FINDINGS: In 2010, the prevalence and unawareness of hypertension in men were 51.6% (95% CI: 45.7-57.5) and 32.3% (25.4-40.1), respectively, and in women 46.0% (42.1-49.9) and 16.1% (12.6-20.4), respectively. In 2019, the prevalence and unawareness of hypertension in men were 46.5% (42.1-51.0) and 52.3% (45.9-58.6), and in women 42.1% (39.6-44.7) and 33.3% (29.8-37.0). Men (2010 and 2019), age <50 years (2010 and 2019), having no/primary education (2010), and living in a non-urban region (2019) were positively associated with hypertension unawareness, whereas obesity (2010), physical inactivity (2010), family history of hypertension (2019), and BP assessment in the year before study enrollment (2010 and 2019) were inversely associated with hypertension unawareness. INTERPRETATION: Benefits of a decrease in the prevalence of hypertension are being undermined by an increase in hypertension unawareness. Actions should be encouraged to strengthen the implementation of the existing healthcare program for cardiovascular risk factor control.

Tobacco advertisement, promotion and sponsorship ban enforcement index at sales points in Panama, 2017.

INTRODUCTION: We assess the tobacco advertisement, promotion and sponsorship (TAPS) ban enforcement in sales points in Panama in 2017. METHODS: A nationwide observational survey to assess TAPS ban enforcement in sales points was conducted and involved retail sale in non-specialized stores with food, beverages or tobacco predominating according to the International Standard Industrial Classification of All Economic Activities Rev. 4. A TAPS ban enforcement index was developed from factorial analysis by principal component with a polychoric correlation matrix to calculate the mean national index value. RESULTS: The national TAPS ban enforcement index value was found to be 3.03. The index value in sales points according to the tobacco products advertisement was 1.98, which was significantly lower where the advertisement was present and 3.09 where it was absent (t=7.57, p<0.05). Each of the three health regions corresponding to Indigenous Territories had an index below the national mean: Emberá-Wounáan (2.52), Guna-Yala (2.65), and Ngäbe-Buglé (2.91). Similar findings were observed among health regions with a west national border: Chiriquí (2.80) and Bocas Del Toro (2.93). On the other hand, the top indices were observed in Panama Metro (3.25), Darién (3.53) and Coclé (3.63). CONCLUSIONS: There is a high level of enforcement of the TAPS ban as a consequence of the full implementation of the FCTC as a law in Panama. However, indigenous territories and west national border areas had the lowest TAPS ban enforcement, making these populations vulnerable. A fertile ground for future research includes the identification of possible vulnerable targets for tobacco products advertisement, particularly in urban areas.

Assessing the knowledge, attitudes and perceptions of tobacco-associated diseases and how it is influenced by tobacco products advertisement, promotion and sponsorship while enforcing a strong and comprehensive ban in Panama: a cross-sectional study.

OBJECTIVES: Assessing the knowledge, attitudes and perceptions (KAP) of tobacco-associated diseases, and how it is influenced by tobacco products' advertisement, promotion and sponsorship (TAPS) while enforcing a strong and comprehensive ban. DESIGN: The Panamanian implementation of the Global Adult Tobacco Survey: an international standardised cross-sectional survey study. SETTING: National Panamanian population aged between 15 years and 29 years old. PARTICIPANTS: There were 4796 responding participants (n=905 830 in the expanded sample). PRIMARY AND SECONDARY OUTCOMES: An index was developed using factorial analysis using TAPS and KAP variables. The primary outcomes were: (1) The national median index value. (2) The index value stratified by sex, age, occupation, income quintile and geographical areas. (3) The first and second factor loadings (FFL and SFL, respectively) for variables included in the KAP index. RESULTS: Fifteen out of the 16 variables comprising the index were variables related to KAP and one variable was related to TAPS. The top three variables according to their FFL were 'KAP that cigarette is associated to …': (1) '… bladder cancer'. (2) '… breast cancer'. (3) '… stomach cancer'. The top three variables according to the SFL were 'KAP that cigarette is associated to …': (1)'… chronic bronchitis'. (2) '… myocardial infarction'. (3) '… lung cancer'. Illegal tobacco advertisement in posters was the only TAPS variable included in the index. The national KAP index value was 0.26. Our results show that current smokers, teens, men, people with the lowest income quintile, and those living in Guna Yala Indigenous Territory (health region with the highest smoking prevalence) had a lower median value than the national median. CONCLUSIONS: Men, young adults and deprived youth had the lowest median KAP index. Illegal TAPS had no influence on the KAP of tobacco-associated diseases when a strong and comprehensive ban is enforced.

Seguir avanzando en las Américas: el control del tabaco fomenta el desarrollo sostenible*

[EXTRACTO]. el presente número especial de la Revista Panamericana de Salud Pública aporta datos relevantes y actuali- zados de la Región de las Américas, abriendo camino por una senda en la que aún queda mucho trabajo por hacer para mejo- rar las medidas de control del tabaco. Además, las múltiples iniciativas de investigación descritas en este número demues- tran la enorme capacidad y colaboración presentes en la Región. Este número especial ha sido posible gracias a la cooperación de investigadores, organizaciones nacionales e internacionales, organismos intergubernamentales, puntos focales de control del tabaco en los ministerios de salud y diferentes especialistas en el control del tabaco que colaboran de forma continua para lograr los objetivos de salud.

Moving forward in the Americas: tobacco control fosters sustainable development

[EXTRACT]. This special issue applies this lens, bringing an equity focus to tobacco control measures, with particular attention paid to vulnerable groups (e.g., youth and low-income quintiles) and including a gender perspective. Further, one analysis empha- sizes the extent of environmental damage posed across the tobacco production chain, including the economic cost of tobacco products waste, and proposes policies to address this.

Seguir avanzando en las Américas: el control del tabaco fomenta el desarrollo sostenible

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The association of tobacco control policies and the risk of acute myocardial infarction using hospital admissions data.

OBJECTIVE: To evaluate the association of a nationwide comprehensive smoking ban (CSB) and tobacco tax increase (TTI) on the risk of acute myocardial infarctions (AMI) in Panama for the period of 2006 - 2010 using hospital admissions data. METHODS: Data of AMI cases was gathered from public and private hospitals in the country for the period of January 1, 2006 to December 31, 2010. The number of AMI cases was calculated on a monthly basis. The risk of AMI was estimated for the pre-CSB period (January 2006 to April 2008) and was used as a reference point. Three post-intervention periods were examined: (1) post-CSB from May 2008 to April 2009 (12 months); (2) post-CSB from May 2009 to November 2009 (7 months); and (3) post-TTI from December 2009 to December 2010 (13 months). Relative risks (RR) of AMI were estimated for each post intervention periods by using a Poisson regression model. Mortality registries for the country attributed to myocardial infarction (MI) were obtained from January 2001 to December 2012. The annual percentage change (APC) of the number of deaths from MI was calculated using Joinpoint regression analysis. RESULTS: A total sample size of 2191 AMI cases was selected (monthly mean number of cases 36.52 ± 8.24 SD). Using the pre-CSB as a reference point (RR = 1.00), the relative risk of AMI during the first CSB period, the second CSB period and post-TTI were 0.982, 1.049, and 0.985, respectively. The APC of deaths from MI from January 2001 to April 2008 was 0.5%. From January 2001 to June 2010 the APC trend was 0.47% and from July 2010 to December 2012 the APC was -0.3%. CONCLUSIONS: The implementation of a CSB and TTI in Panama were associated with a decrease in tobacco consumption and a reduction of the RR of AMI.

Exposición al humo de tabaco en mujeres y menores entre 3 meses y 10 años: Ciudad de Panamá: año: 2005 / Exhibition to the tobacco smoke in women and minors between 3 months and 10 years: City of Panama: year: 2005

El humo ambiental de tabaco es una compleja mezcla de partículas y compuestos en fase gaseosa y de vapor. Su concentración se relaciona directamente con el número de fumadores en un espacio dado y es inversa al tamaña y ventilación del lugar. Los hogares son fuente de exposición al humo ambiental de tabaco de segunda mano (HTSM) y por sus particularidades no cuentan con una normativa que regule el consumo de tabaco en estos espacios. No se dispone de evidencia de esta situación en los hogares. Con diseño multicéntrico descriptivo utilizando protocolo único, se evaluó en el 2005 la exposición al HTSM en mujeres no fumadoras y menores entre tres meses y diez años, según criterio de inclusión, previo consentimiento informado. Mediante muestreo de conveniencia en instalaciones de salud de primer y tercer nivel de atención, localizadas en la ciudad de Panamá, se seleccionaron 40 familias, donde en ocho de cada diez el padre o un varon mayor de diez años era fumador activo. Las mediciones de cotinina en el cabello de los menores fueron superiores a las mujeres no fumadoras. Se destacaron valores de cotinina en cabellos de menores similares a los reportados en bares y restaurantes de la ciudad de Panamá.

Exposición al humo de tabaco en mujeres y menores entre 3 meses y 10 años: Ciudad de Panamá: año: 2005 / Exhibition to the tobacco smoke in women and minors between 3 months and 10 years: City of Panama: year: 2005

El humo ambiental de tabaco es una compleja mezcla de partículas y compuestos en fase gaseosa y de vapor. Su concentración se relaciona directamente con el número de fumadores en un espacio dado y es inversa al tamaña y ventilación del lugar. Los hogares son fuente de exposición al humo ambiental de tabaco de segunda mano (HTSM) y por sus particularidades no cuentan con una normativa que regule el consumo de tabaco en estos espacios. No se dispone de evidencia de esta situación en los hogares. Con diseño multicéntrico descriptivo utilizando protocolo único, se evaluó en el 2005 la exposición al HTSM en mujeres no fumadoras y menores entre tres meses y diez años, según criterio de inclusión, previo consentimiento informado. Mediante muestreo de conveniencia en instalaciones de salud de primer y tercer nivel de atención, localizadas en la ciudad de Panamá, se seleccionaron 40 familias, donde en ocho de cada diez el padre o un varon mayor de diez años era fumador activo. Las mediciones de cotinina en el cabello de los menores fueron superiores a las mujeres no fumadoras. Se destacaron valores de cotinina en cabellos de menores similares a los reportados en bares y restaurantes de la ciudad de Panamá.