Showing papers by "J. Jaime Miranda published in 2022"

Discriminative Accuracy of Chronic Obstructive Pulmonary Disease Screening Instruments in 3 Low- and Middle-Income Country Settings.

Abstract: Importance Most of the global morbidity and mortality in chronic obstructive pulmonary disease (COPD) occurs in low- and middle-income countries (LMICs), with significant economic effects. Objective To assess the discriminative accuracy of 3 instruments using questionnaires and peak expiratory flow (PEF) to screen for COPD in 3 LMIC settings. Design, Setting, and Participants A cross-sectional analysis of discriminative accuracy, conducted between January 2018 and March 2020 in semiurban Bhaktapur, Nepal; urban Lima, Peru; and rural Nakaseke, Uganda, using a random age- and sex-stratified sample of the population 40 years or older. Exposures Three screening tools, the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE; range, 0-6; high risk indicated by a score of 5 or more or score 2-5 with low PEF [<250 L/min for females and <350 L/min for males]), the COPD in LMICs Assessment questionnaire (COLA-6; range, 0-5; high risk indicated by a score of 4 or more), and the Lung Function Questionnaire (LFQ; range, 0-25; high risk indicated by a score of 18 or less) were assessed against a reference standard diagnosis of COPD using quality-assured postbronchodilator spirometry. CAPTURE and COLA-6 include a measure of PEF. Main Outcomes and Measures The primary outcome was discriminative accuracy of the tools in identifying COPD as measured by area under receiver operating characteristic curves (AUCs) with 95% CIs. Secondary outcomes included sensitivity, specificity, positive predictive value, and negative predictive value. Results Among 10 709 adults who consented to participate in the study (mean age, 56.3 years (SD, 11.7); 50% female), 35% had ever smoked, and 30% were currently exposed to biomass smoke. The unweighted prevalence of COPD at the 3 sites was 18.2% (642/3534 participants) in Nepal, 2.7% (97/3550) in Peru, and 7.4% (264/3580) in Uganda. Among 1000 COPD cases, 49.3% had clinically important disease (Global Initiative for Chronic Obstructive Lung Disease classification B-D), 16.4% had severe or very severe airflow obstruction (forced expiratory volume in 1 second <50% predicted), and 95.3% of cases were previously undiagnosed. The AUC for the screening instruments ranged from 0.717 (95% CI, 0.677-0.774) for LFQ in Peru to 0.791 (95% CI, 0.770-0.809) for COLA-6 in Nepal. The sensitivity ranged from 34.8% (95% CI, 25.3%-45.2%) for COLA-6 in Nepal to 64.2% (95% CI, 60.3%-67.9%) for CAPTURE in Nepal. The mean time to administer the instruments was 7.6 minutes (SD 1.11), and data completeness was 99.5%. Conclusions and Relevance This study demonstrated that screening instruments for COPD were feasible to administer in 3 low- and middle-income settings. Further research is needed to assess instrument performance in other low- and middle-income settings and to determine whether implementation is associated with improved clinical outcomes.

Multimorbidity matters in low and middle-income countries

Abstract: Multimorbidity is a complex challenge affecting individuals, families, caregivers, and health systems worldwide. The burden of multimorbidity is remarkable in low- and middle-income countries (LMICs) given the many existing challenges in these settings. Investigating multimorbidity in LMICs poses many challenges including the different conditions studied, and the restriction of data sources to relatively few countries, limiting comparability and representativeness. This has led to a paucity of evidence on multimorbidity prevalence and trends, disease clusters, and health outcomes, particularly longitudinal outcomes. In this paper, based on our experience of investigating multimorbidity in LMICs contexts, we discuss how the structure of the health system does not favor addressing multimorbidity, and how this is amplified by social and economic disparities and, more recently, by the COVID-19 pandemic. We argue that generating epidemiologic data around multimorbidity with similar methods and definition is essential to improve comparability, guide clinical decision-making and inform policies, research priorities, and local responses. We call for action on policy to refinance and prioritize primary care and integrated care as the center of multimorbidity.

Effects of salt substitutes on clinical outcomes: a systematic review and meta-analysis

Abstract: Objectives The Salt Substitute and Stroke Study (SSaSS) recently reported blood pressure-mediated benefits of a potassium-enriched salt substitute on cardiovascular outcomes and death. This study assessed the effects of salt substitutes on a breadth of outcomes to quantify the consistency of the findings and understand the likely generalisability of the SSaSS results. Methods We searched PubMed, Embase and the Cochrane Library up to 31 August 2021. Parallel group, step-wedge or cluster randomised controlled trials reporting the effect of salt substitute on blood pressure or clinical outcomes were included. Meta-analyses and metaregressions were used to define the consistency of findings across trials, geographies and patient groups. Results There were 21 trials and 31 949 participants included, with 19 reporting effects on blood pressure and 5 reporting effects on clinical outcomes. Overall reduction of systolic blood pressure (SBP) was −4.61 mm Hg (95% CI −6.07 to −3.14) and of diastolic blood pressure (DBP) was −1.61 mm Hg (95% CI −2.42 to −0.79). Reductions in blood pressure appeared to be consistent across geographical regions and population subgroups defined by age, sex, history of hypertension, body mass index, baseline blood pressure, baseline 24-hour urinary sodium and baseline 24-hour urinary potassium (all p homogeneity >0.05). Metaregression showed that each 10% lower proportion of sodium choloride in the salt substitute was associated with a −1.53 mm Hg (95% CI −3.02 to −0.03, p=0.045) greater reduction in SBP and a −0.95 mm Hg (95% CI −1.78 to −0.12, p=0.025) greater reduction in DBP. There were clear protective effects of salt substitute on total mortality (risk ratio (RR) 0.89, 95% CI 0.85 to 0.94), cardiovascular mortality (RR 0.87, 95% CI 0. 81 to 0.94) and cardiovascular events (RR 0.89, 95% CI 0.85 to 0.94). Conclusions The beneficial effects of salt substitutes on blood pressure across geographies and populations were consistent. Blood pressure-mediated protective effects on clinical outcomes are likely to be generalisable across population subgroups and to countries worldwide. Trial registration number CRD42020161077.

The potential scalability of salt substitutes as an intervention to lower population sodium levels.

Abstract: Reducing salt intake is one of the most cost-effective interventions to improve population health due to the subsequent reductions in blood pressure. Countries are introducing programs to lower salt consumption. Such programs usually focus on reducing salt in packaged foods and meals alongside campaigns to change consumer behavior. Thus, this paper provides an overview of the rationale for and evidence supporting the use of salt substitutes. Cur-rent approaches to salt reduction are insufficient, and more innovative solutions need to be identified. There is good evidence that salt substitutes, where some of the sodium is replaced with potassium, are effective to lower sodium total intake. The main challenge is to understand the pathways to market for salt substitutes. How do we implement programs to promote salt substitutes in different countries? What levels of government intervention are required? With more research and government investment, salt substitutes could be a game changer for increasing the impact of strategies to reduce population salt intake.

Implementation and scalability of a digital intervention to reduce depressive symptoms in people with diabetes, hypertension or both in Brazil and Peru: a qualitative study of health system’s stakeholders’ perspectives

Abstract: Two randomized controlled trials (RCTs) in Brazil and Peru demonstrated the effectiveness of CONEMO, a digital intervention supported by trained nurses or nurse assistants (NAs), to reduce depressive symptoms in people with diabetes and/or hypertension. This paper extends the RCTs findings by reflecting on the conditions needed for its wider implementation in routine care services. A qualitative study using semi-structured interviews and content analysis was conducted with nurses/NAs, clinicians, healthcare administrators, and policymakers. Informants reported that CONEMO would be feasible to implement in their health services, but some conditions could be improved before its scale-up: reducing workloads of healthcare workers; raising mental health awareness among clinicians and administrators; being able to inform, deliver and accompany the intervention; assuring appropriate training and supervision of nurses/NAs; and supporting the use of technology in public health services and by patients, especially older ones. We discuss some suggestions on how to overcome these challenges.

Sex Differences in the Etiology and Burden of Heart Failure across Country Income Level: Analysis of 204 Countries and Territories 1990-2019.

Abstract: BACKGROUND Heart failure (HF) is a global epidemic. OBJECTIVE To assess global sex differences in HF epidemiology across country income levels. METHODS Using Global Burden of Disease (GBD) data from 204 countries and territories 1990-2019, we assessed sex differences in HF prevalence, etiology, morbidity, and temporal trends across country sociodemographic index or gross national income. We derived age-standardized rates. RESULTS Of 56.2 million (95% uncertainty interval [UI] 46.4-67.8 million) people with HF in 2019, 50.3% were females and 69.2% lived in low- and middle-income countries; age-standardized prevalence was greater in males and in high-income countries. Ischemic and hypertensive heart disease were top causes of HF in males and females, respectively. There were 5.1 million (95% UI 3.3-7.3 million) years lived with disability, distributed equally between sexes. Between 1990-2019, there was an increase in HF cases, but a decrease in age-standardized rates/100,000 in males (9.1%, from 864.2 to 785.7) and females (5.8%, from 686.0 to 646.1). High-income regions experienced a 16.0% decrease in age-standardized rates (from 877.5 to 736.8), while low-income regions experienced a 3.9% increase (from 612.1 to 636.0), largely consistent across sexes. There was a temporal increase in age-standardized HF from hypertensive, rheumatic and calcific aortic valvular heart disease, and a decrease from ischemic heart disease, with regional and sex differences. CONCLUSIONS Age-standardized HF rates have decreased over time, with larger decreases in males than females; and with large decreases in high-income and small increases in low-income regions. Sex and regional differences offer targets for intervention.

The environment and kidney health: challenges and opportunities.

Abstract: The accelerating environmental degradation as a result of modernisation and climate change is an urgent threat to human health. Environment change can impact kidney health in a variety of ways such as water scarcity, global heating and changing biodiversity. Ever increasing industrialization of health care has a large carbon footprint, with dialysis being a major contributor. There have been calls for all stakeholders to adopt a 'one health approach' and develop mitigation and adaptation strategies to combat this challenge. Because of its exquisite sensitivity to various elements of environment change, kidney health can be a risk marker and a therapeutic target for such interventions. In this narrative review, we discuss the various mechanisms through which environmental change is linked to kidney health and the ways that the global kidney health communities can respond to environmental change.

Isolation facilities for covid-19: towards a person centred approach

Abstract: Chuan De Foo and colleagues argue that isolation facilities have the potential to interrupt the transmission of infectious agents, particularly in the earlier stages of infectious disease outbreaks, but they must deliver person centred care

Measurement of physical activity and sedentary behavior in national health surveys, South America

Abstract: ABSTRACT Objectives. To characterize how physical activity and sedentary behavior have been measured in national health surveys in South American countries. Methods. An extensive search was made for national health surveys from all 12 South American countries through health websites, national statistical offices, and contact with researchers and policy-makers. The following eligibility criteria were used to select surveys: conducted in a South American country; used a nationally representative sample ≥ 18 years; coordinated by the public, private or mixed private–public sector; and assessed physical activity and/or sedentary behavior. Data were extracted on general information about the surveys, specific details about the physical activity and sedentary behavior assessment, and additional questions related to activity behavior. Results. In total, 36 surveys were included, two of which were multicountry surveys; all surveys assessed physical activity and 27 assessed sedentary behavior. Most surveys (23/36; 64%) were based on previously validated international questionnaires, but 13 (57%) of these deviated from the reference tools, introducing changes and adaptations. Sedentary behavior was assessed mostly through questions on screen time and/or daily sitting time in the same physical activity questionnaires. No survey used device-based measures to generate data on these behaviors. Conclusions. Differences between instruments used and modifications limit the comparability of data across countries. This highlights the importance of standardizing assessment within South America for physical activity and sedentary behavior sections in national surveys, with the broader aim of contributing to establishing a standardized strategy for the surveillance of physical activity and sedentary behavior in South America.

Stroke care and collaborative academic research in Latin America.

Abstract: OBJECTIVE A narrative overview of regional academic research collaborations to address the increasing burden and gaps in care for patients at risk of, and who suffer from, stroke in Latin America (LA). MATERIALS AND METHODS A summary of experiences and knowledge of the local situation is presented. No systematic literature review was performed. RESULTS The rapidly increasing burden of stroke poses immense challenges in LA, where prevention and manage-ment strategies are highly uneven and inadequate. Clinical research is increasing through various academic consortia and networks formed to overcome structural, funding and skill barriers. However, strengthening the ability to generate, analyze and interpret randomized evidence is central to further develop effective therapies and healthcare systems in LA. CONCLUSIONS Regional networks foster the conduct of multicenter studies -particularly randomized controlled trials-, even in resource-poor regions. They also contribute to the external validity of international studies and strengthen systems of care, clinical skills, critical thinking, and international knowledge exchange.

Design and approval of the nutritional warnings’ policy in Peru: Milestones, key stakeholders, and policy drivers for its approval

Abstract: Background : Nutritional warnings are used as a public health strategy to prevent increases in obesity prevalence. Peru approved in 2013 and implemented in 2019 a Law requiring nutritional warnings on the marketing and packaging of processed foods high in sugar, sodium, saturated fat, and containing trans-fat. The complexity behind the implementation of this set of policies over six years provide unique learnings, essential to inform the obesity prevention context, especially when facing strong opposition from powerful stakeholders such as the food industry. Aims : Describe milestones and key stakeholders roles and stances during the nutritional warnings policy design in Peru; and identify and analyze the main drivers of policy change that explain its approval. Methodology : In 2021, interviews were conducted with 25 key informants, advocates and opponents of the policy, closely involved in its design. Interviews were analyzed using the Kaleidoscope Model as a theoretical framework. Relevant policy documents and news were also analyzed. Results : Milestones for this policy were the approval of the Law, Regulation, and Manual. Policy supporters were mainly from the Congress, civil society organizations, and Health Ministers; whereas opponents came from other parties in the Congress, ministries linked to the economic sector, the food industry, and media. Across the years, warnings evolved from a single text, to traffic lights, to the approved black octagons. Main challenges included the strong opposition of powerful stakeholders; the lack of agreement for defining the appropriate evidence for nutritional warning parameters and design; and the political instability of the country. Based on the Kaleidoscope Model, the policy successfully targeted a relevant problem (unhealthy eating decisions) and had powerful advocates who effectively used focusing events to reposition the warnings in the policy agenda across the years. Negotiations weakened the policy but led to its approval. Importantly, government veto players were mostly in favor of the policy, which enabled its final approval despite the strong opposition. Conclusions : Despite the strong opposition faced and technical and political difficulties to define the best parameters and warnings design, Perus nutritional warnings policy was approved. Lessons learned are essential to inform similar and related prevention policies in Peru and elsewhere.

Burden of treatment as a measure of healthcare quality: An innovative approach to addressing global inequities in multimorbidity

Abstract: Global evidence shows that system quality failures are responsible for more deaths than those caused by HIV, tuberculosis, and malaria combined [1]. In low- and middle-income countries (LMICs), the effects of poor quality care are particularly profound. Nearly 60% of the 8 million preventable deaths that occur yearly in LMICs are due to quality deficits [2]. These span many sectors of healthcare, including primary care, where deficiencies in disease prevention, care coordination, and continuity of care result in inadequate management of both communicable and non-communicable diseases (NCDs) [2]. As the burden of NCDs rises, the push for quality is imperative [3]. The presence of multimorbidity, defined as the occurrence of two or more chronic conditions including those of infectious etiology, compounds this need. In this commentary, we argue that novel methods to evaluate the quality of primary healthcare, such as burden of treatment, must be developed and tailored for use in order for LMICs to achieve equitable outcomes in patients with multimorbidity.

Maternal internal migration and child growth and nutritional health in Peru: an analysis of the demographic and health surveys from 1991 to 2017

Abstract: Peru has historically experienced high rural-to-urban migration. Despite large reductions in undernutrition, overweight is increasing. Elsewhere, internal migration has been associated with differences in children's growth and nutritional health. We investigated how child growth and nutritional status in Peru varied over time and in association with maternal internal migration.Using data from Demographic & Health Surveys from 1991 to 2017, we assessed trends in child growth (height-for-age [HAZ], weight-for-age [WAZ], weight-for-height [WHZ] z scores) and nutritional health (stunting, underweight, overweight) by maternal adult internal migration (urban [UNM] or rural non-migrant [RNM], or urban-urban [UUM], rural-urban [RUM], rural-rural [RRM], or urban-rural migrant [URM]). Using 2017 data, we ran regression analyses, adjusting for confounders, to investigate associations of maternal migration with child outcomes and the maternal and child double burden of malnutrition. We further stratified by timing of migration, child timing of birth and, for urban residents, type of area of residence. Results are given as adjusted predictive margins (mean z score or %) and associated regression p-values [p].In 1991-2017, child growth improved, and undernutrition decreased, but large differences by maternal migration persisted. In 2017, within urban areas, being the child of a migrant woman was associated with lower WHZ (UUM = 0.6/RUM = 0.5 vs UNM = 0.7; p = 0.009 and p < 0.001 respectively) and overweight prevalence ((RUM 7% vs UNM = 11% [p = 0.002]). Results however varied both by child timing of birth (birth after migration meant greater overweight prevalence) and type of area of residence (better linear growth in children of migrants [vs non-migrants] in capital/large cities and towns but not small cities). In rural areas, compared to RNM, children of URM had higher HAZ (- 1.0 vs - 1.2; p < 0.001) and WAZ (- 0.3 vs - 0.4; p = 0.001) and lower stunting (14% vs 21%; [p < 0.001]). There were no differences by timing of birth in rural children, nor by time since migration across all children. The mother and child double burden of malnutrition was higher in rural than urban areas but no differences were found by maternal internal migration.Migration creates a unique profile of child nutritional health that is not explained by maternal ethnic and early life factors, but which varies depending on the pathway of migration, the child timing of birth in relation to migration and, for urban dwellers, the size of the place of destination. Interventions to improve child nutritional health should take into consideration maternal health and migration history.

Epigenetic biomarkers of autoimmune risk and protective antioxidant signaling in methylmercury-exposed adults

Abstract: Background Methylmercury (MeHg) is an environmental pollutant of global public health concern. MeHg is associated with immune dysfunction but the underlying mechanisms are unclear. The most common route of MeHg exposure is through consumption of fatty fish that contain beneficial n-3 polyunsaturated fatty acids (PUFA) that may protect against MeHg toxicity. Objectives To better inform individual costs and benefits of fish consumption, we aimed to identify candidate epigenetic biomarkers of biological responses that reflect MeHg toxicity and PUFA protection. Methods We profiled genome-wide DNA methylation using Illumina Infinium MethylationEPIC BeadChip in whole blood from N=32 individuals from Madre de Dios, Peru. Madre de Dios has high artisanal and small-scale gold mining activity, which results in high MeHg exposure to nearby residents. We compared DNA methylation in N=16 individuals with high (>10 µg/g) vs. N=16 individuals with low (<1 µg/g) total hair mercury (a proxy for methylmercury exposure), matched on age and sex. Results We identified hypomethylated (i.e., likely activated) genes and promoters in high vs. low MeHg-exposed participants linked to Th1/Th2 immune imbalance, decreased IL-7 signaling, and increased marginal zone B cells. These three pathways are feasible mechanisms for MeHg-induced autoimmunity. In addition, we identified candidate epigenetic biomarkers of PUFA-mediated protection: hypomethylated enhancer binding sites for retinoid X receptor (RXR) and retinoic acid receptor α (RARα). Last, we observed hypomethylated enhancer and promoter binding sites for glucocorticoid receptor (GR), which is associated with developmental neurotoxicity, and transcription factor 7-like 2 (TCF7L2), which is associated with type 2 diabetes (T2D) risk. Discussion Here, we identify a set of candidate epigenetic biomarkers for assessing individualized risk of autoimmune response and protection against neurotoxicity due to MeHg exposure and fish consumption. In addition, our results may inform surrogate tissue biomarkers of early MeHg exposure-related neurotoxicity and T2D risk.

The urban built environment and adult BMI, obesity, and diabetes in Latin American cities

Abstract: Abstract Latin America is the world’s most urbanized region and its heterogeneous urban development may impact chronic diseases. Here, we evaluated the association of built environment characteristics at the sub-city —intersection density, greenness, and population density— and city-level —fragmentation and isolation— with body mass index (BMI), obesity, and type 2 diabetes (T2D). Data from 93,280 (BMI and obesity) and 122,211 individuals (T2D) was analysed across 10 countries. Living in areas with higher intersection density was positively associated with BMI and obesity, whereas living in more fragmented and greener areas were negatively associated. T2D was positively associated with intersection density, but negatively associated with greenness and population density. The rapid urban expansion experienced by Latin America provides unique insights and vastly expand opportunities for population-wide urban interventions aimed at reducing obesity and T2D burden.

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

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

Addressing the challenges of noncommunicable diseases and injuries in Latin America and Asia-Pacific countries.

Abstract: Not available.

Does food biodiversity protect against malnutrition and favour the resilience to climate change-related events in Amazon Indigenous communities? A protocol for a mixed methods study

Abstract: Background: Undernutrition is projected to be a major consequence of climate change. Biodiversity could enhance climate change resilience by improving nutritional outcomes and providing healthy food resources during and/or after climate-related events. For Indigenous populations who currently base their diet on local biodiversity, rapid climate changes may affect their ability to produce, access or gather food and consequently impact their nutritional status. There is a knowledge gap regarding whether nutritional status among Indigenous populations is better among those who consume a diet with greater biodiversity than those who have a diet with low biodiversity. Objective: This study aims to investigate the role of food biodiversity (FBD) in nutritional resilience to extreme flooding events of Shawi Amazon Indigenous adults living in Peruvian communities that have experienced extreme floods in the past five years. Methods: This study will use a mixed-method sequential explanatory design. The quantitative component includes a cross-sectional survey to assess the association between food biodiversity (FBD) and the prevalence of anaemia in adults aged 15 to 60 years old (n=365). Anaemia will be evaluated using blood hemoglobin and serum ferritin. FBD will be measured with a food frequency questionnaire and a 24-hour dietary recall. Soil-transmitted helminth infections, malaria, and inflammatory biomarkers will also be evaluated. Qualitative component will include a community-based participatory approach to investigate the role of FBD in the responses to extreme floods. Male (n=14) and female (n=14) participants, previously identified in the quantitative phase with high and low levels of FBD, will be invited to participate in a Photovoice activity and semi-structured interviews. A analytical framework for climate change resilience will be used to integrate the data. Discussion: Findings will be integrated to identify features of diet quality to suggest nutritional interventions that are resilient to changing climatic conditions in the Amazon and respect Indigenous views.

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

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

Leisure-Time and Transport-Related Physical Activity and the Risk of Mortality: The CRONICAS Cohort Study.

Abstract: BACKGROUND The long-term health association of the leisure-time and transport-related physical activity domains of the International Physical Activity Questionnaire have not been established in Latin American settings. The authors aimed to quantify the 7-year all-cause mortality risk associated with levels of leisure-time and transport-related physical activity. METHODS Ongoing prospective cohort study conducted in 4 sites in Peru. People ≥35 years were randomly selected from the general population in each study site. The exposures were leisure-time and transport-related physical activity (International Physical Activity Questionnaire) at baseline. The outcome was all-cause mortality based on information retrieved from national records. Cox regression and sensitivity analyses were conducted. RESULTS There were 3601 people (mean age 55.8 y, 51.5% women). Greater levels of physical activity were associated with lower risk of all-cause mortality, an observation confirmed in sensitivity analyses. Compared with those with low levels of physical activity, leisure-time (≥500 metabolic equivalent of task minutes per week) and transport-related (500-1499 and ≥1500 metabolic equivalent of task minutes per week) physical activity were associated with 70% (95% confidence interval, 3%-90%), 43% (95% confidence interval, 18%-61%), and 42% (95% confidence interval, 8%-63%) lower all-cause mortality, respectively. CONCLUSIONS Greater levels of leisure-time and transport-related physical activity were associated with a strong reduction in the risk of all-cause mortality across different geographical sites.

Challenges of design, implementation, acceptability, and potential for, biomedical technologies in the Peruvian Amazon

Abstract: Biomedical technologies have the potential to be advantageous in remote communities. However, information about barriers faced by users of technology in general and in remote Indigenous communities is scarce. The purpose of this study was to characterize the leading challenges faced by researchers who have used biomedical technologies in the Peruvian Amazon.This exploratory, qualitative study with a phenomenological approach depicts the lived experience of participants who were researchers with experience working with biomedical technologies in the Peruvian Amazon in the past five years. Analysis was based on three core themes: design, implementation, and acceptability. Sub-themes included environment, community, and culture. Of the 24 potential participants identified and contacted, 14 agreed to participate, and 13 met inclusion criteria and completed semi-structured interviews. Results were sent to each participant with the opportunity to provide feedback and partake in a 30-minute validation meeting. Five participants consented to a follow-up meeting to validate the results and provide further understanding.Participants recognized significant challenges, including technologies designed out-of-context, difficulty transporting the technologies through the Amazon, the impact of the physical environment (e.g., humidity, flooding), and limited existing infrastructure, such as electricity and appropriately trained health personnel. Participants also identified cultural factors, including the need to address past experiences with technology and health interventions, understand and appropriately communicate community benefits, and understand the effect of demographics (e.g., age, education) on the acceptance and uptake of technology. Complementary challenges, such as corruption in authority and waste disposal, and recommendations for technological and health interventions such as co-design were also identified.This study proposes that technological and health interventions without efforts to respect local cultures and health priorities, or understand and anticipate contextual challenges, will not meet its goal of improving access to healthcare in remote Amazon communities. Furthermore, the implications of corruption on health services, and improper waste disposal on the environment may lead to more detrimental health inequities.