Showing papers by "J. Jaime Miranda published in 2019"

The epidemiological burden of obesity in childhood: a worldwide epidemic requiring urgent action

Abstract: In recent decades, the prevalence of obesity in children has increased dramatically. This worldwide epidemic has important consequences, including psychiatric, psychological and psychosocial disorders in childhood and increased risk of developing non-communicable diseases (NCDs) later in life. Treatment of obesity is difficult and children with excess weight are likely to become adults with obesity. These trends have led member states of the World Health Organization (WHO) to endorse a target of no increase in obesity in childhood by 2025. Estimates of overweight in children aged under 5 years are available jointly from the United Nations Children’s Fund (UNICEF), WHO and the World Bank. The Institute for Health Metrics and Evaluation (IHME) has published country-level estimates of obesity in children aged 2–4 years. For children aged 5–19 years, obesity estimates are available from the NCD Risk Factor Collaboration. The global prevalence of overweight in children aged 5 years or under has increased modestly, but with heterogeneous trends in low and middle-income regions, while the prevalence of obesity in children aged 2–4 years has increased moderately. In 1975, obesity in children aged 5–19 years was relatively rare, but was much more common in 2016. It is recognised that the key drivers of this epidemic form an obesogenic environment, which includes changing food systems and reduced physical activity. Although cost-effective interventions such as WHO ‘best buys’ have been identified, political will and implementation have so far been limited. There is therefore a need to implement effective programmes and policies in multiple sectors to address overnutrition, undernutrition, mobility and physical activity. To be successful, the obesity epidemic must be a political priority, with these issues addressed both locally and globally. Work by governments, civil society, private corporations and other key stakeholders must be coordinated.

Rising rural body-mass index is the main driver of the global obesity epidemic in adults

Abstract: Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities1,2. This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity3,4,5,6. Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017—and more than 80% in some low- and middle-income regions—was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing—and in some countries reversal—of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.

Understanding the rise of cardiometabolic diseases in low- and middle-income countries

Abstract: Increases in the prevalence of noncommunicable diseases (NCDs), particularly cardiometabolic diseases such as cardiovascular disease, stroke and diabetes, and their major risk factors have not been uniform across settings: for example, cardiovascular disease mortality has declined over recent decades in high-income countries but increased in low- and middle-income countries (LMICs). The factors contributing to this rise are varied and are influenced by environmental, social, political and commercial determinants of health, among other factors. This Review focuses on understanding the rise of cardiometabolic diseases in LMICs, with particular emphasis on obesity and its drivers, together with broader environmental and macro determinants of health, as well as LMIC-based responses to counteract cardiometabolic diseases. The rise of cardiometabolic diseases in low- and middle-income countries is tied to a multitude of environmental, social and commercial determinants, which are discussed in this Review along with a strategy to counteract those factors.

Building a Data Platform for Cross-Country Urban Health Studies: the SALURBAL Study

Abstract: Studies examining urban health and the environment must ensure comparability of measures across cities and countries. We describe a data platform and process that integrates health outcomes together with physical and social environment data to examine multilevel aspects of health across cities in 11 Latin American countries. We used two complementary sources to identify cities with ≥ 100,000 inhabitants as of 2010 in Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico, Nicaragua, Panama, and Peru. We defined cities in three ways: administratively, quantitatively from satellite imagery, and based on country-defined metropolitan areas. In addition to “cities,” we identified sub-city units and smaller neighborhoods within them using census hierarchies. Selected physical environment (e.g., urban form, air pollution and transport) and social environment (e.g., income, education, safety) data were compiled for cities, sub-city units, and neighborhoods whenever possible using a range of sources. Harmonized mortality and health survey data were linked to city and sub-city units. Finer georeferencing is underway. We identified 371 cities and 1436 sub-city units in the 11 countries. The median city population was 234,553 inhabitants (IQR 141,942; 500,398). The systematic organization of cities, the initial task of this platform, was accomplished and further ongoing developments include the harmonization of mortality and survey measures using available sources for between country comparisons. A range of physical and social environment indicators can be created using available data. The flexible multilevel data structure accommodates heterogeneity in the data available and allows for varied multilevel research questions related to the associations of physical and social environment variables with variability in health outcomes within and across cities. The creation of such data platforms holds great promise to support researching with greater granularity the field of urban health in Latin America as well as serving as a resource for the evaluation of policies oriented to improve the health and environmental sustainability of cities.

A Novel International Partnership for Actionable Evidence on Urban Health in Latin America: LAC‐Urban Health and SALURBAL

Abstract: This article describes the origins and characteristics of an interdisciplinary multinational collaboration aimed at promoting and disseminating actionable evidence on the drivers of health in cities in Latin America and the Caribbean: The Network for Urban Health in Latin America and the Caribbean and the Wellcome Trust funded SALURBAL (Salud Urbana en America Latina, or Urban Health in Latin America) Project. Both initiatives have the goals of supporting urban policies that promote health and health equity in cities of the region while at the same time generating generalizable knowledge for urban areas across the globe. The processes, challenges, as well as the lessons learned to date in launching and implementing these collaborations, are described. By leveraging the unique features of the Latin American region (one of the most urbanized areas of the world with some of the most innovative urban policies), the aim is to produce generalizable knowledge about the links between urbanization, health, and environments and to identify effective ways to organize, design, and govern cities to improve health, reduce health inequalities, and maximize environmental sustainability in cities all over the world.

Prevalence, awareness, treatment and control of hypertension in rural and urban communities in Latin American countries.

Abstract: Objectives:The objective is to describe hypertension (HTN) prevalence, awareness, treatment and control in urban and rural communities in Latin America to inform public and policy-makers.Methods:Cross-sectional analysis from urban (n = 111) and rural (n = 93) communities including 33 276 participant

The process of prioritization of non-communicable diseases in the global health policy arena.

Abstract: Although non-communicable diseases (NCDs) are the leading cause of morbidity and mortality worldwide, the global policy response has not been commensurate with their health, economic and social burden. This study examined factors facilitating and hampering the prioritization of NCDs on the United Nations (UN) health agenda. Shiffman and Smith's (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. The Lancet 370: 1370-9.) political priority framework served as a structure for analysis of a review of NCD policy documents identified through the World Health Organization's (WHO) NCD Global Action Plan 2013-20, and complemented by 11 semi-structured interviews with key informants from different sectors. The results show that a cohesive policy community exists, and leaders are present, however, actor power does not extend beyond the health sector and the role of guiding institutions and civil society have only recently gained momentum. The framing of NCDs as four risk factors and four diseases does not necessarily resonate with experts from the larger policy community, but the economic argument seems to have enabled some traction to be gained. While many policy windows have occurred, their impact has been limited by the institutional constraints of the WHO. Credible indicators and effective interventions exist, but their applicability globally, especially in low- and middle-income countries, is questionable. To be effective, the NCD movement needs to expand beyond global health experts, foster civil society and develop a broader and more inclusive global governance structure. Applying the Shiffman and Smith framework for NCDs enabled different elements of how NCDs were able to get on the UN policy agenda to be disentangled. Much work has been done to frame the challenges and solutions, but implementation processes and their applicability remain challenging globally. NCD responses need to be adapted to local contexts, focus sufficiently on both prevention and management of disease, and have a stronger global governance structure.

Physical activity and sedentary behavior patterns and sociodemographic correlates in 116,982 adults from six South American countries: the South American physical activity and sedentary behavior network (SAPASEN).

Abstract: Physical inactivity and sedentary behavior are major concerns for public health. Although global initiatives have been successful in monitoring physical activity (PA) worldwide, there is no systematic action for the monitoring of correlates of these behaviors, especially in low- and middle-income countries. Here we describe the prevalence and distribution of PA domains and sitting time in population sub-groups of six south American countries. Data from the South American Physical Activity and Sedentary Behavior Network (SAPASEN) were used, which includes representative data from Argentina (n = 26,932), Brazil (n = 52,490), Chile (n = 3719), Ecuador (n = 19,851), Peru (n = 8820), and Suriname (n = 5170). Self-reported leisure time (≥150 min/week), (≥150 min/week), transport (≥10 min/week), and occupational PA total (≥10 min/week), as well as sitting time (≥4 h/day) were captured in each national survey. Sex, age, income, and educational status were exposures. Descriptive statistics and harmonized random effect meta-analyses were conducted. The prevalence of PA during leisure (Argentina: 29.2% to Peru: 8.6%), transport (Peru: 69.7% to Ecuador: 8.8%), and occupation (Chile: 60.4 to Brazil 18.3%), and ≥4 h/day of sitting time (Peru: 78.8% to Brazil: 14.8%) differed widely between countries. Moreover, total PA ranged between 60.4% (Brazil) and 82.9% (Chile) among men, and between 49.4% (Ecuador) and 74.9% (Chile) among women. Women (low leisure and occupational PA) and those with a higher educational level (low transportation and occupational PA as well as high sitting time) were less active. Concerning total PA, men, young and middle-aged adults of high educational status (college or more) were, respectively, 47% [OR = 0.53 (95% CI = 0.36–0.78), I2 = 76.6%], 25% [OR = 0.75 (95% CI = 0.61-0.93), I2 = 30.4%] and 32% [OR = 0.68 (95% CI = 0.47-1.00), I2 = 80.3%] less likely to be active. PA and sitting time present great ranges and tend to vary across sex and educational status in South American countries. Country-specific exploration of trends and population-specific interventions may be warranted.

Epidemiology and risk factors of asthma-chronic obstructive pulmonary disease overlap in low- and middle-income countries.

Abstract: Background Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) represents the confluence of bronchial airway hyperreactivity and chronic airflow limitation and has been described as leading to worse lung function and quality of life than found with either singular disease process. Objective We aimed to describe the prevalence and risk factors for ACO among adults across 6 low- and middle-income countries (LMICs). Methods We compiled cross-sectional data for 11,923 participants aged 35 to 92 years from 4 population-based studies in 12 settings. We defined COPD as postbronchodilator FEV1/forced vital capacity ratio below the lower limit of normal, asthma as wheeze or medication use in 12 months or self-reported physician diagnosis, and ACO as having both. Results The prevalence of ACO was 3.8% (0% in rural Puno, Peru, to 7.8% in Matlab, Bangladesh). The odds of having ACO were higher with household exposure to biomass fuel smoke (odds ratio [OR], 1.48; 95% CI, 0.98-2.23), smoking tobacco (OR, 1.28 per 10 pack-years; 95% CI, 1.22-1.34), and having primary or less education (OR, 1.35; 95% CI, 1.07-1.70) as compared to nonobstructed nonasthma individuals. ACO was associated with severe obstruction (FEV1 %, Conclusions ACO may be as prevalent and more severe in LMICs than has been reported in high-income settings. Exposure to biomass fuel smoke may be an overlooked risk factor, and we favor diagnostic criteria for ACO that include environmental exposures common to LMICs.

Effect of low-sodium salt substitutes on blood pressure, detected hypertension, stroke and mortality.

Abstract: Objective A systematic review and meta-analysis was conducted to assess the efficacy of low-sodium salt substitutes (LSSS) as a potential intervention to reduce cardiovascular (CV) diseases. Methods Five engines and ClinicalTrials.gov were searched from inception to May 2018. Randomised controlled trials (RCTs) enrolling adult hypertensive or general populations that compared detected hypertension, systolic blood pressure (SBP), diastolic blood pressure (DBP), overall mortality, stroke and other CV risk factors in those receiving LSSS versus regular salt were included. Effects were expressed as risk ratios or mean differences (MD) and their 95% CIs. Quality of evidence assessment followed GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. Results 21 RCTs (15 in hypertensive (n=2016), 2 in normotensive (n=163) and 4 in mixed populations (n=5224)) were evaluated. LSSS formulations were heterogeneous. Effects were similar across hypertensive, normotensive and mixed populations. LSSS decreased SBP (MD −7.81 mm Hg, 95% CI −9.47 to –6.15, p Conclusions LSSS significantly decreased SBP and DBP. There was no effect for detected hypertension, overall mortality and intermediate outcomes. Large, long-term RCTs are necessary to clarify salt substitute effects on clinical outcomes.

Use of a mobile phone app to treat depression comorbid with hypertension or diabetes: A Pilot Study in Brazil and Peru

Abstract: Background: Depression is underdiagnosed and undertreated in primary health care. When associated with chronic physical disorders, it worsens outcomes. There is a clear gap in the treatment of depression in low- and middle-income countries (LMICs), where specialists and funds are scarce. Interventions supported by mobile health (mHealth) technologies may help to reduce this gap. Mobile phones are widely used in LMICs, offering potentially feasible and affordable alternatives for the management of depression among individuals with chronic disorders. Objective: This study aimed to explore the potential effectiveness of an mHealth intervention to help people with depressive symptoms and comorbid hypertension or diabetes and explore the feasibility of conducting large randomized controlled trials (RCTs). Methods: Emotional Control (CONEMO) is a low-intensity psychoeducational 6-week intervention delivered via mobile phones and assisted by a nurse for reducing depressive symptoms among individuals with diabetes or hypertension. CONEMO was tested in 3 pilot studies, 1 in Sao Paulo, Brazil, and 2 in Lima, Peru. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at enrollment and at 6-week follow-up. Results: The 3 pilot studies included a total of 66 people. Most participants were females aged between 41 and 60 years. There was a reduction in depressive symptoms as measured by PHQ-9 in all pilot studies. In total, 58% (38/66) of the participants reached treatment success rate (PHQ-9 <10), with 62% (13/21) from Sao Paulo, 62% (13/21) from the first Lima pilot, and 50% (12/24) from the second Lima pilot study. The intervention, the app, and the support offered by the nurse and nurse assistants were well received by participants in both settings. Conclusions: The intervention was feasible in both settings. Clinical data suggested that CONEMO may help in decreasing participants’ depressive symptoms. The findings also indicated that it was possible to conduct RCTs in these settings.

Combating non-communicable diseases: potentials and challenges for community health workers in a digital age, a narrative review of the literature.

Abstract: The use of community health workers (CHWs) has been explored as a viable option to provide home health education, counselling and basic health care, notwithstanding their challenges in training and retention. In this manuscript, we review the evidence and discuss how the digitalization affects the CHWs programmes for tackling non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). We conducted a review of literature covering two databases: PubMED and Embase. A total of 97 articles were abstracted for full text review of which 26 are included in the analysis. Existing theories were used to construct a conceptual framework for understanding how digitalization affects the prospects of CHW programmes for NCDs. The results are divided into two themes: (1) the benefits of digitalization and (2) the challenges to the prospects of digitalization. We also conducted supplemental search in non-peer reviewed literature to identify and map the digital platforms currently in use in CHW programmes. We identified three benefits and three challenges of digitalization. Firstly, it will help improve the access and quality of services, notwithstanding its higher establishment and maintenance costs. Secondly, it will add efficiency in training and personnel management. Thirdly, it will leverage the use of data generated across grass-roots platforms to further research and evaluation. The challenges posed are related to funding, health literacy of CHWs and systemic challenges related to motivating CHWs. Several dozens of digital platforms were mapped, including mobile-based networking devices (used for behavioural change communication), Web-applications (used for contact tracking, reminder system, adherence tracing, data collection and decision support), videoconference (used for decision support) and mobile applications (used for reminder system, supervision, patients' management, hearing screening and tele-consultation). The digitalization efforts of CHW programmes are afflicted by many challenges, yet the rapid technological penetration and acceptability coupled with the gradual fall in costs constitute encouraging signals for the LMICs. Both CHWs interventions and digital technologies are not inexpensive, but they may provide better value for the money when applied at the right place and time.

Process evaluation in the field: global learnings from seven implementation research hypertension projects in low-and middle-income countries

Abstract: Process evaluation is increasingly recognized as an important component of effective implementation research and yet, there has been surprisingly little work to understand what constitutes best practice. Researchers use different methodologies describing causal pathways and understanding barriers and facilitators to implementation of interventions in diverse contexts and settings. We report on challenges and lessons learned from undertaking process evaluation of seven hypertension intervention trials funded through the Global Alliance of Chronic Diseases (GACD). Preliminary data collected from the GACD hypertension teams in 2015 were used to inform a template for data collection. Case study themes included: (1) description of the intervention, (2) objectives of the process evaluation, (3) methods including theoretical basis, (4) main findings of the study and the process evaluation, (5) implications for the project, policy and research practice and (6) lessons for future process evaluations. The information was summarized and reported descriptively and narratively and key lessons were identified. The case studies were from low- and middle-income countries and Indigenous communities in Canada. They were implementation research projects with intervention arm. Six theoretical approaches were used but most comprised of mixed-methods approaches. Each of the process evaluations generated findings on whether interventions were implemented with fidelity, the extent of capacity building, contextual factors and the extent to which relationships between researchers and community impacted on intervention implementation. The most important learning was that although process evaluation is time consuming, it enhances understanding of factors affecting implementation of complex interventions. The research highlighted the need to initiate process evaluations early on in the project, to help guide design of the intervention; and the importance of effective communication between researchers responsible for trial implementation, process evaluation and outcome evaluation. This research demonstrates the important role of process evaluation in understanding implementation process of complex interventions. This can help to highlight a broad range of system requirements such as new policies and capacity building to support implementation. Process evaluation is crucial in understanding contextual factors that may impact intervention implementation which is important in considering whether or not the intervention can be translated to other contexts.

La inmigración venezolana en el Perú: desafíos y oportunidades desde la perspectiva de la salud

Abstract: As a result of the political, social, and economic crisis in the Bolivarian Republic of Venezuela, more than 700,000 people have immigrated to Peru since the second semester of 2017. In the year following the 2017 census, Peru's population grew by nearly one million, some 300,000 of them Peruvian, the rest being predominantly young Venezuelan immigrants. This article describes and analyzes the situation and health implications stemming from the fact that Peru became a migratory destination. To this end, a secondary analysis of surveys applied to the Venezuelan population in Peru was carried out. The main challenges arise from limited access to healthcare. Sexual and reproductive healthcare shows the largest deficits, below Peru's urban populations. The vulnerabilities of the Venezuelan migrant population are not detached from those already faced by Peru's poorest urban populations, whose services do not meet their needs and demands, neither in terms of coverage nor quality. However, immigration also generates opportunities, such as that represented by health professionals and technicians, who could contribute to offset the deficit generated by the emigration of thousands of Peruvian health professionals in recent decades. It is also an opportunity not to lose sight of the fact that inequalities in the right to healthcare are still challenges to inclusive development.

Addressing Depression Comorbid With Diabetes or Hypertension in Resource-Poor Settings: A Qualitative Study About User Perception of a Nurse-Supported Smartphone App in Peru

Abstract: Background: Smartphone apps could constitute a cost-effective strategy to overcome health care system access barriers to mental health services for people in low- and middle-income countries. Objective: The aim of this paper was to explore the patients’ perspectives of CONEMO (Emotional Control, in Spanish: Control Emocional), a technology-driven, psychoeducational, and nurse-supported intervention delivered via a smartphone app aimed at reducing depressive symptoms in people with diabetes, hypertension or both who attend public health care centers, as well as the nurses’ feedback about their role and its feasibility to be scaled up. Methods: This study combines data from 2 pilot studies performed in Lima, Peru, between 2015 and 2016, to test the feasibility of CONEMO. Interviews were conducted with 29 patients with diabetes, hypertension or both with comorbid depressive symptoms who used CONEMO and 6 staff nurses who accompanied the intervention. Using a content analysis approach, interview notes from patient interviews were transferred to a digital format, coded, and categorized into 6 main domains: the perceived health benefit, usability, adherence, user satisfaction with the app, nurse’s support, and suggestions to improve the intervention. Interviews with nurses were analyzed by the same approach and categorized into 4 domains: general feedback, evaluation of training, evaluation of study activities, and feasibility of implementing this intervention within the existing structures of health system. Results: Patients perceived improvement in their emotional health because of CONEMO, whereas some also reported better physical health. Many encountered some difficulties with using CONEMO, but resolved them with time and practice. However, the interactive elements of the app, such as short message service, android notifications, and pop-up messages were mostly perceived as challenging. Satisfaction with CONEMO was high, as was the self-reported adherence. Overall, patients evaluated the nurse accompaniment positively, but they suggested improvements in the technological training and an increase in the amount of contact. Nurses reported some difficulties in completing their tasks and explained that the CONEMO intervention activities competed with their everyday work routine. Conclusions: Using a nurse-supported smartphone app to reduce depressive symptoms among people with chronic diseases is possible and mostly perceived beneficial by the patients, but it requires context-specific adaptations regarding the implementation of a task shifting approach within the public health care system. These results provide valuable information about user feedback for those building mobile health interventions for depression.

Low Body Mass Index Is Associated with Higher Odds of COPD and Lower Lung Function in Low- and Middle-Income Countries

Abstract: The relationship of body mass index (BMI) with lung function and COPD has been previously described in several high-income settings. However, few studies have examined this relationship in resource...

Multimorbidity at sea level and high-altitude urban and rural settings: The CRONICAS Cohort Study:

Abstract: Objective:To characterize the prevalence and clustering of multimorbidity in four diverse geographical settings in Peru.Methods:Multimorbidity, defined as having ≥2 chronic conditions, was studied ...

¿Qué representa cambiar el umbral diagnóstico de la hipertensión arterial? Guías ACC/AHA 2017 y su aplicación en Perú

Abstract: Introduction and objective There is little evidence in Latin America about the impact of the ACC/AHA 2017 guideline. Taking as reference the JNC 7 guideline, the objective of our study is to estimate changes in the prevalence of arterial hypertension (HBP) according to socio-demographic characteristics and geographic regions, applying the criteria of the new ACC / AHA guide 2017. Methods Cross-sectional study of the Demographic and Family Health Survey conducted in Peru in 2017. Standardized weighted hypertension prevalence's were estimated for the WHO population according to both guidelines, and absolute differences with 95% CI. Results We included 30,682 people aged 18 years and over, with an average age of 42.3 years, 51.1% women. The standardized prevalence of HBP for 2017 according to JNC 7 was 14.4% (95% CI: 13.8-15.1) and according to ACC / AHA 2017 it was 32.9% (95% CI: 32.0-33.7), so the prevalence increase is 18.5 percentage points, being higher in males than females (24.2 vs 12.9 respectively). In people with obesity and / or who consume tobacco, the increases were higher (24.3 and 24.1 percentage points respectively). In the regions of Tacna, Ica and Metropolitan Lima, the increase, in comparison with the JNC 7 guidelines, overcome the national average (22.4, 20.7 and 20.4, percentage points, respectively). Conclusions Considering the context of a Latin American country and knowing the epidemiology of hypertension in Peru, the potential adoption of the ACC/AHA 2017 guidelines for the prevention, detection, evaluation, and management of hypertension should be accompanied by an evaluation of the impact at the individual, system and social level.

Cardiovascular Disease Prognostic Models in Latin America and the Caribbean: A Systematic Review

Abstract: Background: Cardiovascular prognostic models guide treatment allocation and support clinical decisions. Whether there are valid models for Latin American and Caribbean (LAC) populations is unknown. Objective: This study sought to identify and critically appraise cardiovascular prognostic models developed, tested, or recalibrated in LAC populations. Methods: The systematic review followed the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies) framework (PROSPERO [International Prospective Register of Systemic Reviews]: CRD42018096553). Reports were included if they followed a prospective design and presented a multivariable prognostic model; reports were excluded if they studied symptomatic individuals or patients. The following search engines were used: EMBASE, MEDLINE, Scopus, SciELO, and LILACS. Risk of bias assessment was conducted with PROBAST (Prediction model Risk Of Bias ASsessment Tool). No quantitative summary was conducted due to large heterogeneity. Results: From 2,506 search results, 8 studies (N = 130,482 participants) were included for qualitative synthesis. We could not identify any cardiovascular prognostic model developed for LAC populations; reviewed reports evaluated available models or conducted a recalibration analysis. Only 1 study included a Caribbean population (Puerto Rico); 3 studies were retrieved from Chile; 2 from Argentina, Brazil, Colombia, and Uruguay; and 1 from Mexico. Four studies included population-based samples, and the other 4 included people affiliated to a health facility (e.g., prevention clinics). Most studied participants were older than 50 years, and there were more women in 5 reports. The Framingham model was assessed 6 times, and the American College of Cardiology/American Heart Association pooled equation was assessed twice. Across the prognostic models assessed, calibration varied widely from one population to another, showing great overestimation particularly in some subgroups (e.g., highest risk). Discrimination (e.g., C-statistic) was acceptable for most models; for Framingham it ranged from 0.66 to 0.76. The American College of Cardiology/American Heart Association pooled equation showed the best discrimination (0.78). That there were few outcome events was the most important methodological limitation of the identified studies. Conclusions: No cardiovascular prognostic models have been developed in LAC, hampering key evidence to inform public health and clinical practice. Validation studies need to improve methodological issues. Highlights There has never been a cardiovascular prognostic model developed in LAC. Few studies have tested available models, but they have methodological limitations. Discrimination estimates were acceptable across studies. Calibration estimates showed important overestimation across studies. Many countries in Latin America do not have tools for cardiovascular prevention.

Compensating control participants when the intervention is of significant value: experience in Guatemala, India, Peru and Rwanda.

Abstract: The Household Air Pollution Intervention Network (HAPIN) trial is a randomised controlled trial in Guatemala, India, Peru and Rwanda to assess the health impact of a clean cooking intervention in households using solid biomass for cooking. The HAPIN intervention—a liquefied petroleum gas (LPG) stove and 18-month supply of LPG—has significant value in these communities, irrespective of potential health benefits. For control households, it was necessary to develop a compensation strategy that would be comparable across four settings and would address concerns about differential loss to follow-up, fairness and potential effects on household economics. Each site developed slightly different, contextually appropriate compensation packages by combining a set of uniform principles with local community input. In Guatemala, control compensation consists of coupons equivalent to the LPG stove’s value that can be redeemed for the participant’s choice of household items, which could include an LPG stove. In Peru, control households receive several small items during the trial, plus the intervention stove and 1 month of fuel at the trial’s conclusion. Rwandan participants are given small items during the trial and a choice of a solar kit, LPG stove and four fuel refills, or cash equivalent at the end. India is the only setting in which control participants receive the intervention (LPG stove and 18 months of fuel) at the trial’s end while also being compensated for their time during the trial, in accordance with local ethics committee requirements. The approaches presented here could inform compensation strategy development in future multi-country trials.

Forty years since Alma-Ata: do we need a new model for noncommunicable diseases?

Abstract: www.jogh.org • doi: 10.7189/jogh.09.010316 1 June 2019 • Vol. 9 No. 1 • 010316 Last year marked the 40 th Anniversary of the Alma-Ata Declaration which stated that Primary Health Care (PHC) was “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community.” [1] The Declaration mentioned the need for PHC to evolve with changing disease and socio-economic conditions, focus on the main health problems by providing health promotion, prevention, care and rehabilitation, involving the community resources at large for health, empowering communities and adequate human resources.

Million Migrants study of healthcare and mortality outcomes in non-EU migrants and refugees to England: Analysis protocol for a linked population-based cohort study of 1.5 million migrants.

Abstract: Background: In 2017, 15.6% of the people living in England were born abroad, yet we have a limited understanding of their use of health services and subsequent health conditions. This linked population-based cohort study aims to describe the hospital-based healthcare and mortality outcomes of 1.5 million non-European Union (EU) migrants and refugees in England. Methods and analysis: We will link four data sources: first, non-EU migrant tuberculosis pre-entry screening data; second, refugee pre-entry health assessment data; third, national hospital episode statistics; and fourth, Office of National Statistics death records. Using this linked dataset, we will then generate a population-based cohort to examine hospital-based events and mortality outcomes in England between Jan 1, 2006, and Dec 31, 2017. We will compare outcomes across three groups in our analyses: 1) non-EU international migrants, 2) refugees, and 3) general population of England. Ethics and dissemination: We will obtain approval to use unconsented patient identifiable data from the Secretary of State for Health through the Confidentiality Advisory Group and the National Health Service Research Ethics Committee. After data linkage, we will destroy identifying data and undertake all analyses using the pseudonymised dataset. The results will provide policy makers and civil society with detailed information about the health needs of non-EU international migrants and refugees in England.

It is not easy living with this illness: A syndemic approach to medication adherence and lifestyle change among low-income diabetes patients in Lima, Peru

Abstract: This study analyzes the experiences of low-income people living with type 2 diabetes in Lima, Peru. We use a syndemic approach to describe and discuss their challenges in following physicians' reco...

Within-country migration and obesity dynamics: analysis of 94,783 women from the Peruvian demographic and health surveys

Abstract: Rural-to-urban migration is associated with increased obesity, yet it remains unknown whether this association exist, and to what extent, with other types of internal migration. We conducted a secondary analysis of the Peruvian Demographic and Health Surveys (2005 to 2012) on data collected from women aged 15–49 years. Participants were classified as rural stayers, urban stayers, rural-to-urban migrants, intra-rural migrants, intra-urban migrants, and urban-to-rural migrants. Marginal effects from a logit regression model were used to assess the probabilities of being and becoming obese given both the length of time in current place of residence and women’s migration status. Analysis of cross-sectional survey data generated between 2005 and 2012. Data from 94,783 participants was analyzed. Intra-urban migrants and rural-to-urban migrants had the highest rates of obesity (21% in 2012). A steady increase in obesity is observed across all migration statuses. Relative to rural non-migrants, participants exposed to urban environments had greater odds, two- to three-fold higher, of obesity. The intra-rural migrant group also shows higher odds relative to rural stayers (42% higher obesity odds). The length of exposure to urban settings shows a steady effect over time. Both exposure to urban environments and migration are associated with higher odds of obesity. Expanding the characterization of within-country migration dynamics provides a better insight into the relationship between duration of exposure to urban settings and obesity.

Lack of an Association Between Household Air Pollution Exposure and Previous Pulmonary Tuberculosis

Abstract: Observational studies investigating household air pollution (HAP) exposure to biomass fuel smoke as a risk factor for pulmonary tuberculosis have reported inconsistent results. To evaluate the association between HAP exposure and the prevalence of self-reported previous pulmonary tuberculosis. We analyzed pooled data including 12,592 individuals from five population-based studies conducted in Latin America, East Africa, and Southeast Asia from 2010 to 2015. We used multivariable logistic regression to model the association between HAP exposure and self-reported previous pulmonary tuberculosis adjusted for age, sex, tobacco smoking, body mass index, secondary education, site and country of residence. Mean age was 54.6 years (range of mean age across settings 43.8–59.6 years) and 48.6% were women (range of % women 38.3–54.5%). The proportion of participants reporting HAP exposure was 38.8% (range in % HAP exposure 0.48–99.4%). Prevalence of previous pulmonary tuberculosis was 2.7% (range of prevalence 0.6–6.9%). While participants with previous pulmonary tuberculosis had a lower pre-bronchodilator FEV1 (mean − 0.7 SDs, 95% CI − 0.92 to − 0.57), FVC (− 0.52 SDs, 95% CI − 0.69 to − 0.33) and FEV1/FVC (− 0.59 SDs, 95% CI − 0.76 to − 0.43) as compared to those who did not, we did not find an association between HAP exposure and previous pulmonary tuberculosis (adjusted odds ratio = 0.86; 95% CI 0.56–1.32). There was no association between HAP exposure and self-reported previous pulmonary tuberculosis in five population-based studies conducted worldwide.