Compliance with a WHO guideline for cardiovascular disease prevention. A population based cross-sectional study in Argentina

INTRODUCTION

Current recommendations for cardiovascular disease (CVD) prevention are guided CVD risk classification. This study aims to analyze the level of compliance with pharmacological and non-pharmacological recommendations outlined in the World Health Organization (WHO) CVD prevention clinical practice guideline within the general population of two cities in Argentina.

METHODS

We analyzed the compliance with preventive recommendations from the WHO 2007 Guidelines for Management of Cardiovascular Risk in two cities of Argentina participating in the CESCAS population-based study in the Southern Cone of Latin America.

RESULTS

3990 participants were included. Considering the WHO recommendations, the use of antiplatelet medication was 5.6% (95% CI 3.5, 8.9) in primary prevention and 20.5% (95%= CI 16.0, 25.9) in secondary prevention. Regarding lipid-lowering medication, it was 6.7% (CI 95%= 4.4, 10.1) and 15.4% (CI 95%= 11.6, 20.1), respectively. As per non-pharmacological recommendations in the general population: low intake of fruit and vegetables was 78.4% (CI 95%= 76.8, 79.9); low physical activity was 26.9% (CI 95%= 25.3, 28.5), current cigarette smoking was 28.3% (CI 95%= 26.6, 30.0), overweight/obesity was 73.9% (CI 95%= 72.3, 75.6), and excessive alcohol intake was 2.6% (CI 95%= 2.1, 3.4).

CONCLUSIONS

It was observed a significantly low compliance with pharmacological and non-pharmacological recommendations for CVD prevention in the general population of two cities in Argentina. Urgent efforts are needed to improve compliance to cardiovascular preventive recommendations promoted by CPG, especially in Low- and Middle- Income Countries.

Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: an application of the RE-AIM/PRISM extension for sustainability and health equity

BACKGROUND

The COVID-19 pandemic necessitated rapid changes in healthcare delivery in Guatemala's public primary care settings. A new hypertension program, implemented as part of a type 2 hybrid trial since 2019, exemplifies an implementation effort amidst a changing context in an under-resourced setting. We assessed the implementation of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care), raising implications for health equity and sustainability. We present innovative application of systems thinking visuals.

METHODS

Conducting a convergent mixed methods analysis, we assessed implementation in response to contextual changes across five Ministry of Health (MoH) districts at the pandemic's onset. Utilizing quantitative programmatic data and qualitative interviews with stakeholders (n=18; health providers, administrators, study staff), we evaluated dimensions of "Reach, Effectiveness, Adoption, Implementation and Maintenance," RE-AIM (Reach, Implementation delivery + adaptations), and "Practical Robust Implementation and Sustainability Model," PRISM (Organizational perspective on the EBI, Fit, Implementation and sustainability infrastructure) frameworks. We assessed representativeness by comparing participants to census data. To assess implementation delivery, we built behavior-over-time (BOT) graphs with quantitative programmatic data (July 2019-July 2021). To assess adaptations and contextual changes, we performed matrix-based thematic qualitative analysis. We converged quantitative implementation delivery data + qualitative adaptations data in joint displays. Finally, we analyzed qualitative and quantitative results across RE-AIM/PRISM and health districts to identify equity and sustainability considerations.

RESULTS

Contextual factors that facilitated program delivery included the perception that the EBI was beneficial, program champions, and staff communication. Key barriers to implementation delivery included competition with other primary care activities and limited implementation infrastructure (e.g., equipment, medications). Contextual changes related to COVID-19 hindered implementation delivery, threatened sustainability, and may have exacerbated inequities. However, adaptations that were planned enhanced implementation delivery and may have supported improved equity and sustainability.

CONCLUSIONS

Recognition of an EBI's benefits and program champions are important for supporting initial uptake. The ability to plan adaptations amid rapid contextual changes has potential advantages for sustainability and equitable delivery. Systems thinking tools and mixed methods approaches may shed light on the relations between context, adaptations, and equitable and sustainable implementation.

TRIAL REGISTRATION

NCT03504124.

Implementing integrated hypertension and diabetes management using the World Health Organization's HEARTS model: protocol for a pilot study in the Guatemalan national primary care system

BACKGROUND

The HEARTS technical package was developed by the World Health Organization to address the implementation gap in cardiovascular disease prevention in low- and middle-income countries. Guatemala is a middle-income country that is currently implementing HEARTS. National authorities in Guatemala are interested in exploring how hypertension and diabetes management can be integrated in HEARTS implementation. The objective of this study is to conduct a feasibility and acceptability pilot trial of integrated hypertension and diabetes management based on HEARTS in the publicly funded primary care system in Guatemala.

METHODS

A single-arm pilot trial for 6 months will be carried out in 11 Ministry of Health primary care facilities starting in September 2023. A planned sample of 100 adult patients diagnosed with diabetes (n = 45), hypertension (n = 45), or both (n = 10) will be enrolled. The intervention will consist of HEARTS-aligned components: Training health workers on healthy-lifestyle counseling and evidence-based treatment protocols, strengthening access to medications and diagnostics, training on risk-based cardiovascular disease management, team-based care and task sharing, and systems monitoring and feedback, including implementation of a facility-based electronic monitoring tool at the individual level. Co-primary outcomes of feasibility and acceptability will be assessed using an explanatory sequential mixed-methods design. Secondary outcomes include clinical effectiveness (treatment with medication, glycemic control, and blood pressure control), key implementation outcomes (adoption, fidelity, usability, and sustainability), and patient-reported outcome measures (diabetes distress, disability, and treatment burden). Using an implementation mapping approach, a Technical Advisory Committee will develop implementation strategies for subsequent scale-up planning.

DISCUSSION

This trial will produce evidence on implementing HEARTS-aligned hypertension and diabetes care in the MOH primary care system in Guatemala. Results also will inform future HEARTS projects in Guatemala and other low- and middle-income countries.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT06080451. The trial was prospectively registered on October 12, 2023.

Managing high cardiovascular disease risk among adults in Argentina using a multicomponent strategy linking key aspects of care: A two-arm cluster-randomized clinical trial (PRIMECare) protocol

BACKGROUND

Cardiovascular disease (CVD) imposes a significant burden on the Argentinian population. Management of its leading risk factors can significantly reduce the CVD burden in high-resource settings, but there is insufficient evidence for effective implementation of evidence-based interventions in lower-resource settings like Argentina.

METHODS

In this two-arm cluster-randomized trial we seek to compare the effective implementation, of a multicomponent intervention, versus usual care, to improve the management of high CVD risk across the care continuum in three provinces of Argentina. The multicomponent intervention strategy links five primary components of the CVD care continuum to improve its management: (1) a data management system linking a digital mHealth (mobile health) screening tool used by community health workers (CHWs), (2) an electronic appointment scheduler that is integrated with the primary care center electronic appointment system, (3) point of care testing for lipid profiles, (4) a clinical decision support (CDS) system for medication initiation, and (5) a text message (SMS) reminder system to improve treatment adherence and life-style changes. The primary outcome is the mean change in Framingham laboratory-based, 10-year absolute CVD risk score between the study arms from baseline to twelve months after enrollment.

CONCLUSIONS

This protocol describes the development of a multicomponent intervention to implement effective management of CVD, developed with partners at the National and provincial Departments of Health in Argentina, with the goal of understanding its effective implementation in a primary health care system strengthened by universal health coverage, provision of free health care services, and provision of free medication.

Global Effect of Modifiable Risk Factors on Cardiovascular Disease and Mortality

BACKGROUND

Five modifiable risk factors are associated with cardiovascular disease and death from any cause. Studies using individual-level data to evaluate the regional and sex-specific prevalence of the risk factors and their effect on these outcomes are lacking.

METHODS

We pooled and harmonized individual-level data from 112 cohort studies conducted in 34 countries and 8 geographic regions participating in the Global Cardiovascular Risk Consortium. We examined associations between the risk factors (body-mass index, systolic blood pressure, non-high-density lipoprotein cholesterol, current smoking, and diabetes) and incident cardiovascular disease and death from any cause using Cox regression analyses, stratified according to geographic region, age, and sex. Population-attributable fractions were estimated for the 10-year incidence of cardiovascular disease and 10-year all-cause mortality.

RESULTS

Among 1,518,028 participants (54.1% of whom were women) with a median age of 54.4 years, regional variations in the prevalence of the five modifiable risk factors were noted. Incident cardiovascular disease occurred in 80,596 participants during a median follow-up of 7.3 years (maximum, 47.3), and 177,369 participants died during a median follow-up of 8.7 years (maximum, 47.6). For all five risk factors combined, the aggregate global population-attributable fraction of the 10-year incidence of cardiovascular disease was 57.2% (95% confidence interval [CI], 52.4 to 62.1) among women and 52.6% (95% CI, 49.0 to 56.1) among men, and the corresponding values for 10-year all-cause mortality were 22.2% (95% CI, 16.8 to 27.5) and 19.1% (95% CI, 14.6 to 23.6).

CONCLUSIONS

Harmonized individual-level data from a global cohort showed that 57.2% and 52.6% of cases of incident cardiovascular disease among women and men, respectively, and 22.2% and 19.1% of deaths from any cause among women and men, respectively, may be attributable to five modifiable risk factors. (Funded by the German Center for Cardiovascular Research (DZHK); ClinicalTrials.gov number, NCT05466825.).

Effectiveness of peer mentoring and self-monitoring to improve blood pressure control in a vulnerable population in Argentina: Pragmatic randomized open-label controlled trial

OBJECTIVE

To evaluate the effectiveness of blood pressure (BP) self-monitoring and peer mentoring to improve the control of hypertension in clinical practice in primary care centers (PCCs) located in low-resource settings in Argentina.

METHODS

An individual randomized controlled trial was carried out to test two different approaches based on behavioral interventions in PCCs in Argentina. Hypertensive adults were randomly assigned to one of three arms: BP self-monitoring, peer mentoring, and usual care. The primary outcome was the change in BP values from baseline to the end of follow-up at 3 months. A qualitative approach of participants' experiences of the peer mentoring arm was also conducted.

RESULTS

A total of 442 participants with hypertension were included in the study. Self-monitoring and peer mentoring interventions did not show a significant difference in BP control compared to usual care. However, this trial showed an improvement regarding antihypertensive medication adherence among those assigned to the peer mentoring intervention compared to the control at the end of follow-up (p = 0.031).

DISCUSSION

Self-monitoring and peer mentoring interventions did not demonstrate to be effective in BP control compared to usual care. Implementing a peer support strategy was demonstrated to be feasible and effective in improving medication adherence in this population.

Quality improvement intervention to increase colorectal cancer screening at the primary care setting: a cluster-randomised controlled trial

BACKGROUND

Approximately 81% of deaths in Argentina are from chronic non-communicable diseases and 21% caused by cancer. Colorectal cancer (CRC) is the second most frequent cancer in Argentina. Even though CRC screening has been recommended for adults from 50 to 75 years old by using a faecal immunochemical test (FIT) annually, screening rates remain below 20% in the country.

METHODS

We conducted an 18-month, two-arm, pragmatic cluster-randomised controlled trial evaluating the effect of a quality improvement intervention, based on the Plan-Do-Study-Act cycles, considering barriers and catalysts to articulate theory and practice, to increase CRC screening rates using FITs at primary care level. The study involved ten public primary health centres in Mendoza province, Argentina. The primary outcome measure was the rate of effective CRC screening. Secondary outcomes were the rate of participants with a positive FIT, tests with invalid results and the rate of participants referred for colonoscopy.

RESULTS

Screening was effective in 75% of the participants in the intervention arm vs 54.2% in the control arm, OR 2.5 (95% CI 1.4 to 4.4, p=0.001). These results remained unchanged after adjusting for individual demographic and socioeconomic characteristics. Regarding secondary outcomes, the overall prevalence of positive tests was 17.7% (21.1% in the control arm and 14.7% in the intervention arm, p=0.3648). The overall proportion of participants with inadequate test results was 5.2% (4.9% in the control arm vs 5.5% in the intervention arm, p=0.8516). All the participants with positive tests were referred for colonoscopy in both groups.

CONCLUSIONS

An intervention based on quality improvement strategies proved to be highly successful in increasing effective CRC screening in Argentina's primary care setting within the public healthcare system.

TRIAL REGISTRATION NUMBER

NCT04293315.

Implementation outcomes and strategies for delivering evidence-based hypertension interventions in lower-middle-income countries: Evidence from a multi-country consortium for hypertension control

Guidance on contextually tailored implementation strategies for the prevention, treatment, and control of hypertension is limited in lower-middle income countries (Lower-MIC). To address this limitation, we compiled implementation strategies and accompanying outcomes of evidence-based hypertension interventions currently being implemented in five Lower-MIC. The Global Research on Implementation and Translation Science (GRIT) Coordinating Center (CC) (GRIT-CC) engaged its global network sites at Ghana, Guatemala, India, Kenya, and Vietnam. Purposively sampled implementation science experts completed an electronic survey assessing implementation outcomes, in addition to implementation strategies used in their ongoing hypertension interventions from among 73 strategies within the Expert Recommendations for Implementing Change (ERIC). Experts rated the strategies based on highest priority to their interventions. We analyzed the data by sorting implementation strategies utilized by sites into one of the nine domains in ERIC and summarized the data using frequencies, proportions, and means. Seventeen implementation experts (52.9% men) participated in the exercise. Of Proctor's implementation outcomes identified across sites, all outcomes except for appropriateness were broadly assessed by three or more countries. Overall, 59 out of 73 (81%) strategies were being utilized in the five countries. The highest priority implementation strategies utilized across all five countries focused on evaluative and iterative strategies (e.g., identification of context specific barriers and facilitators) to delivery of patient- and community-level interventions, while the lowest priority was use of financial and infrastructure change strategies. More capacity building strategies (developing stakeholder interrelationships, training and educating stakeholders, and supporting clinicians) were incorporated into interventions implemented in India and Vietnam than Ghana, Kenya, and Guatemala. Although robust implementation strategies are being used in Lower -MICs, there is minimum use of financial and infrastructure change strategies. Our study contributes to the growing literature that demonstrates the use of Expert Recommendations for Implementing Change (ERIC) implementation strategies to deliver evidence-based hypertension interventions in Lower-MICs and will inform future cross-country data harmonization activities in resource-constrained settings.

Blood Pressure Association with the 8-Item Morisky Medication Adherence Scale in Hypertensive Adults from Low-Resource Primary Care Settings: Results from a Prospective Cohort Nested within a Randomised Controlled Trial

INTRODUCTION

One of the self-report adherence scales most widely used is the 8-item Morisky Medication Adherence Scale (MMAS-8).

AIM

To evaluate construct validity and reliability of the MMAS-8 in hypertensive adults from low-resource settings within the public primary care level in Argentina.

METHODS

Prospective data from hypertensive adults under antihypertensive pharmacological treatment that participated in the "Hypertension Control Program in Argentina" study was analyzed. Participants were followed at baseline, 6, 12 and 18 months. Based on MMAS-8, adherence was defined as low (score < 6), medium (score 6 to < 8) and high (score of 8).

RESULTS

1214 participants were included in the analysis. In comparison to low adherence, high adherence category was associated with a reduction of - 5.6 mmHg (CI 95%: - 7.2; - 4.0) in systolic blood pressure (BP) and - 3.2 mmHg (CI 95%: - 4.2; - 2.2) in diastolic BP; and with a 56% higher likelihood to have controlled BP (p < .0001). Among those participants with baseline score ≤ 6, two points increase in MMAS-8 along follow-up showed a tendency to reduce BP in almost all-time points and a 34% higher likelihood of having controlled BP at the end of the follow-up (p = 0.0039). Cronbach's alpha total-item values in all time-points were higher than 0.70.

CONCLUSIONS

Higher MMAS-8 categories were positively associated with BP reduction and higher likelihood of BP control over time. Internal consistency was acceptable and in line with previous studies.

Risk factor clustering in men and women with CHD in the Southern Cone of Latin America

Background

Presence of multiple risk factors (RF) increases the risk for cardiovascular morbidity and mortality, and this is especially important in patients with coronary heart disease (CHD). The current study investigates sex differences in the presence of multiple cardiovascular RF in subjects with established CHD in the southern Cone of Latin America.

Methods

We analyzed cross-sectional data from the 634 participants aged 35-74 with CHD from the community-based CESCAS Study. We calculated the prevalence for counts of cardiometabolic (hypertension, dyslipidemia, obesity, diabetes) and lifestyle (current smoking, unhealthy diet, low physical activity, excessive alcohol consumption) RF. Differences in RF number between men and women were tested with age-adjusted Poisson regression. We identified the most common RF combinations among participants with ≥4 RF. We performed a subgroup analysis by educational level.

Results

The prevalence of cardiometabolic RF ranged from 76.3% (hypertension) to 26.8% (diabetes), and the prevalence of lifestyle RF from 81.9% (unhealthy diet) to 4.3% (excessive alcohol consumption). Obesity, central obesity, diabetes and low physical activity were more common in women, while excessive alcohol consumption and unhealthy diet were more common in men. Close to 85% of women and 81.5% of men presented with ≥4 RF. Women presented with a higher number of overall (relative risk (RR) 1.05, 95% CI 1.02-1.08) and cardiometabolic RF (1.17, 1.09-1.25). These sex differences were found in participants with primary education (RR women overall RF 1.08, 1.00-1.15, cardiometabolic RF 1.23, 1.09-1.39), but were diluted in those with higher educational attainment. The most common RF combination was hypertension/dyslipidemia/obesity/unhealthy diet.

Conclusion

Overall, women showed a higher burden of multiple cardiovascular RF. Sex differences persisted in participants with low educational attainment, and women with low educational level had the highest RF burden.

Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: An application of the RE-AIM/PRISM extension for sustainability and health equity

Background

The COVID-19 pandemic necessitated rapid changes in the delivery of care across public primary care settings in rural Guatemala in 2020. In response, a hypertension program implemented within the public primary care system required multiple adaptations, providing an illustrative example of dynamic implementation amidst changing context in an under-resourced setting. This study describes the evolvability of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care) during the COVID-19 pandemic and discusses implications for health equity and sustainability.

Methods

This convergent mixed methods analysis assessed implementation across five Ministry of Health districts during the initial phase of the pandemic. Qualitative and quantitative data were collected, analyzed, and integrated, informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation Maintenance) Framework's extension for sustainability, and its contextual enhancement, PRISM (Pragmatic, Robust, Implementation and Sustainability Model). For RE-AIM, we focused on the "Implementation" domain, operationalizing it qualitatively as continued delivery and adaptations to the EBI and implementation strategy, and quantitatively as the extent of delivery over time. We conducted 18 in-depth interviews with health providers / administrators (n=8) and study staff (n=10) and performed a matrix-based thematic-analysis. Qualitative results informed the selection of quantitative implementation summarized as behavior over time graphs. Quantitative implementation data and illustrative quotes are presented as joint displays.

Results

In relation to implementation, several organic adaptations hindered delivery, threatened sustainability, and may have exacerbated health inequities. Planned adaptations enhanced program delivery and may have supported improved equity and sustainability. Salient PRISM factors that influenced implementation included "Organizational perspective of the EBI", "Fit" and "Implementation and sustainability infrastructure". Facilitators to continued delivery included the perception that the EBI is beneficial, program champions, and healthcare team organization. Barriers included the perception that the EBI is complicated, competition with other primary care activities, and temporary suspension of services due to COVID-19.

Conclusions

Multi-level contextual changes led to numerous adaptations of the EBI and implementation strategy. Systems thinking approaches may shed light on how a program's sustainability and its equitable delivery are influenced by adaptations over time in response to dynamic, multi-level contextual factors.

Trial registration

NCT03504124.

Explanatory models of hypertension in Guatemala: recognizing the perspectives of patients, family members, health care providers and administrators, and national-level health system stakeholders

BACKGROUND

Uncontrolled hypertension is a major public health burden and the most common preventable risk factor for cardiovascular diseases in Guatemala and other low- and middle-income countries. Prior to an initial trial that evaluated a hypertension intervention in rural Guatemala, we collected qualitative information on the needs and knowledge gaps of hypertension care within Guatemala's public healthcare system. This analysis applied Kleinman's Explanatory Models of Illness to capture how patients, family members, community-, district-, and provincial-level health care providers and administrators, and national-level health system stakeholders understand hypertension.  METHODS: We conducted in-depth interviews with three types of participants: 1) national-level health system stakeholders (n = 17), 2) local health providers and administrators from district, and health post levels (25), and 3) patients and family members (19) in the departments of Sololá and Zacapa in Guatemala. All interviews were conducted in Spanish except for 6 Maya-Kaqchikel interviews. We also conducted focus group discussions with auxiliary nurses (3) and patients (3), one in Maya-Tz'utujil and the rest in Spanish. Through framework and matrix analysis, we compared understandings of hypertension by participant type using the Explanatory Model of Illness domains -etiology, symptoms, pathophysiology, course of illness, and treatment.

RESULTS

Health providers and administrators, and patients described hypertension as an illness that spurs from emotional states like sadness, anger, and worry; is inherited and related to advanced age; and produces symptoms that include a weakened body, nerves, pain, and headaches. Patients expressed concerns about hypertension treatment's long-term consequences, despite trying to comply with treatment. Patients stated that they combine biomedical treatment (when available) with natural remedies (teas and plants). Health providers and administrators and family members stated that once patients feel better, they often disengage from treatment. National-level health system stakeholders referred to lifestyle factors as important causes, considered patients to typically be non-compliant, and identified budget limitations as a key barrier to hypertension care. The three groups of participants identified structural barriers to limited hypertension care (e.g., limited access to healthy food and unaffordability of medications).

CONCLUSION

As understandings of hypertension vary between types of participants, it is important to describe their similarities and differences considering the role each has in the health system. Considering different perceptions of hypertension will enable better informed program planning and implementation efforts.

The Use of 2 e-Learning Modalities for Diabetes Education Using Facebook in 2 Cities of Argentina During the COVID-19 Pandemic: Qualitative Study

Background

The COVID-19 pandemic and the confinement that was implemented in Argentina generated a need to implement innovative tools for the strengthening of diabetes care. Diabetes self-management education (DSME) is a core element of diabetes care; however, because of COVID-19 restrictions, in-person diabetes educational activities were suspended. Social networks have played an instrumental role in this context to provide DSME in 2 cities of Argentina and help persons with diabetes in their daily self-management.

Objective

The aim of this study is to evaluate 2 diabetes education modalities (synchronous and asynchronous) using the social media platform Facebook through the content of posts on diabetes educational sessions in 2 cities of Argentina during the COVID-19 pandemic.

Methods

In this qualitative study, we explored 2 modalities of e-learning (synchronous and asynchronous) for diabetes education that used the Facebook pages of public health institutions in Chaco and La Rioja, Argentina, in the context of confinement. Social media metrics and the content of the messages posted by users were analyzed.

Results

A total of 332 messages were analyzed. We found that in the asynchronous modality, there was a higher number of visualizations, while in the synchronous modality, there were more posts and interactions between educators and users. We also observed that the number of views increased when primary care clinics were incorporated as disseminators, sharing educational videos from the sessions via social media. Positive aspects were observed in the posts, consisting of messages of thanks and, to a lesser extent, reaffirmations, reflections or personal experiences, and consultations related to the subject treated. Another relevant finding was that the educator/moderator role had a greater presence in the synchronous modality, where posts were based on motivation for participation, help to resolve connectivity problems, and answers to specific user queries.

Conclusions

Our findings show positive contributions of an educational intervention for diabetes care using the social media platform Facebook in the context of the COVID-19 pandemic. Although each modality (synchronous vs asynchronous) could have differential and particular advantages, we believe that these strategies have potential to be replicated and adapted to other contexts. However, more documented experiences are needed to explore their sustainability and long-term impact from the users' perspective.

[Implementation of the HEARTS Initiative in Argentina: initial resultsImplementação da Iniciativa HEARTS na Argentina: primeiros resultados]

Las enfermedades cardiovasculares son la principal causa de morbimortalidad, y la hipertensión es su principal factor de riesgo. En 2018, Argentina comenzó a implementar la Iniciativa HEARTS en 5 centros de atención primaria de salud a través del Plan Nacional de Prevención y Control de la Hipertensión Arterial. En este estudio se presenta el impacto de su implementación en los indicadores de cobertura efectiva, tratamiento, tratamiento combinado y control. La Iniciativa HEARTS incluye múltiples componentes; entre ellos se destacan la capacitación de los equipos de salud, la reorganización de las tareas basada en la transferencia de competencias clínicas, la provisión de dispositivos de medición de la presión arterial automáticos y clínicamente validados, y la utilización de un único protocolo de tratamiento estandarizado. Se utilizó un modelo de datos longitudinales del tipo ecuación de estimación generalizada, y se agrupó la información de los 5 centros de salud mediante promedios ponderados según el tamaño de la población bajo cobertura. El análisis de los resultados fue estratificado en dos períodos de tiempo delimitados por la irrupción de las restricciones debidas al COVID-19. Durante el primer período de 18 meses se observó una mejoría significativa en el tratamiento (5,9%; p<0,01) y el tratamiento combinado (13,4%; p<0,01), sin cambios significativos en la cobertura (8,4%; p=0,87) y con un descenso paradojal en el control (−3,3%; p=0,02). Durante las restricciones y respecto del período previo, se constató una reducción generalizada en todos los indicadores, principalmente en la cobertura (−23,6%; p<0,01) y el control (−12,5%; p<0,01). Sin embargo, los niveles de tratamiento y tratamiento combinado persistieron por encima de los valores basales (1,7%; p<0,01 y 5,4%; p<0,01, respectivamente).

Strengthening Capacity for Implementation Research Amid COVID-19 Pandemic: Learnings From the Global Alliance for Chronic Diseases Implementation Science School

Objective: To describe the design, delivery and evaluation of the 3rd Global Alliance for Chronic Diseases (GACD) Implementation Science School (ISS), delivered virtually in 2020 for the first time.

Methods: Since 2014, GACD has supported the delivery of more than ten Implementation Science Workshops for more than 500 international participants. It has also been conducting an annual ISS since 2018. In this study, we described the design, delivery and evaluation of the third ISS.

Results: Forty-six participants from 23 countries in five WHO regions attended the program. The virtual delivery was well-received and found to be efficient in program delivery, networking and for providing collaborative opportunities for trainees from many different countries. The recently developed GACD Implementation Science e-Hub was found to be an instrumental platform to support the program by providing a stand-alone, comprehensive online learning space for knowledge and skill development in implementation research.

Conclusion: The delivery of the virtual GACD ISS proved to be feasible, acceptable and effective and offers greater scalability and sustainability as part of a future strategy for capacity strengthening in implementation research globally.

¿Cuáles son las brechas de conocimiento y qué priorizar en investigación en salud mental del adulto mayor? Estudio cuali-cuantitativo utilizando la matriz de estrategias combinadas para Argentina (MECA)

INTRODUCCIÓN

el envejecimiento poblacional es un fenómeno mundial. Los problemas de salud mental, altamente prevalentes en este grupo, impactan en la vida de los individuos, sus familias y la sociedad en su conjunto.

OBJETIVO

identificar brechas de conocimiento y prioridades de investigación en salud mental del adulto mayor en Argentina.

MATERIAL Y MÉTODOS

diseño cuali-cuantitativo, en tres etapas: (1) diagnóstico de situación, (2) evaluación global de necesidades de investigación y (3) ejercicio de priorización basado en la Matriz de Estrategias Combinadas validada para Argentina (MECA).

RESULTADOS

con base en las primeras dos etapas del estudio se identificaron dos áreas temáticas investigar en el país y dimensiones priorizadas: (a) soledad-aislamiento y (b) deterioro cognitivo y demencia. Como resultado del ejercicio de priorización surgieron las siguientes dimensiones: en relación con soledad-aislamiento: 1. efecto de los programas, 2. falta de acceso a los recursos, 3. capacidad de adaptación a los contextos locales (integración social del adulto mayor) y 4. calidad de servicios. En relación con deterioro cognitivo y demencia: 1. impacto cuidadores y entorno, 2. barreras para la implementación de guías y capacitación, 3. estudios de costo-efectividad sobre intervenciones y calidad de vida, y 4. recolección y publicación de datos epidemiológicos.

CONCLUSIÓN

se debe enfatizar la importancia de fortalecer la investigación en Argentina sobre la implementación y difusión de intervenciones de promoción, prevención y prestación de servicios en la salud mental del adulto mayor.

[2021 World Health Organization guideline on pharmacological treatment of hypertension: Policy implications for the region of the AmericasDiretrizes de 2021 da Organização Mundial da Saúde sobre o tratamento medicamentoso da hipertensão arterial: repercussões para as políticas na região das Américas]

Las enfermedades cardiovasculares son la principal causa de muerte en la Región de las Américas y la hipertensión es la causa de más del 50% de ellas. En la Región, más de una cuarta parte de las mujeres adultas y cuatro de cada diez hombres adultos tienen hipertensión y su diagnóstico, tratamiento y control son deficientes. En el 2021, la Organización Mundial de la Salud (OMS) publicó directrices actualizadas sobre el tratamiento farmacológico de la hipertensión en personas adultas. En este artículo se destaca el papel facilitador de la iniciativa mundial HEARTS de la OMS y la iniciativa HEARTS en las Américas para catalizar la implementación de estas directrices, a la vez que se proporciona asesoramiento específico sobre políticas para dicha implementación y se destaca la necesidad de adoptar un enfoque estratégico general para el control de la hipertensión. Los autores instan a quienes abogan por la salud y a los responsables de las políticas a priorizar la prevención y el control de la hipertensión para mejorar la salud y el bienestar de la población, y a reducir las disparidades de salud en relación con las enfermedades cardiovasculares dentro de la población y entre las poblaciones de la Región de las Américas.

[2021 World Health Organization guideline on pharmacological treatment of hypertension: Policy implications for the Region of the AmericasDirectrices de la Organización Mundial de la Salud del 2021 sobre el tratamiento farmacológico de la hipertensión: implicaciones de política para la Región de las Américas]

A doença cardiovascular (DCV) é a principal causa de morte nas Américas, e a pressão arterial elevada é responsável por mais de 50% dos casos de DCV. Nas Américas, mais de um quarto das mulheres adultas e quatro de cada dez homens adultos têm hipertensão arterial, sendo que diagnóstico, tratamento e controle estão abaixo do ideal. Em 2021, a Organização Mundial da Saúde (OMS) divulgou uma atualização das diretrizes para o tratamento medicamentoso da hipertensão arterial em adultos. Esta publicação ressalta o papel facilitador da iniciativa Global HEARTS da OMS e da iniciativa HEARTS nas Américas para catalisar a implementação dessas diretrizes, oferece recomendações específicas de políticas para sua implementação e enfatiza a necessidade de uma abordagem estratégica abrangente para o controle da hipertensão arterial. Os autores clamam para que tanto as pessoas que advogam pela Saúde, quanto as autoridades responsáveis, priorizem a prevenção e o controle da hipertensão arterial como forma de melhorar a saúde e o bem-estar das populações e reduzir as disparidades de saúde cardiovascular dentro das populações das Américas e entre elas.

Prevalence of cardioprotective medication use in coronary heart disease patients in South America: systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Coronary heart disease (CHD) is the most common cause of death globally, and clinical guidelines recommend cardioprotective medications for patients with established CHD. Suboptimal use of these medications has been reported, but an overview from the South American region is lacking.

Purpose

Our aim is to summarize evidence on the prevalence of cardioprotective medication use for secondary prevention of CHD in South America. We also intend to explore time-trends, guideline compliance and factors associated with medication use.

Methods

We conducted a systematic review searching literature in PubMed, Embase, Cochrane, Lilacs and SciElo. We searched articles published from 2000 to 2021 that reported prevalence of secondary prevention medication use in South America. We pooled the prevalence estimates in a meta-analysis, described findings on guideline compliance, and used meta-regression models to analyse time-trends and identify factors associated with medication use.

Results

We identified 7388 publications, from which 73 were included in the review (Fig 1). Medication prevalence varied by class: beta-blockers 73.0%(95%CI 66.6%–79.1%), ACEI/ARBs 55.8% (95%CI 49.7%–61.8), antiplatelets 84.6% (95%CI 79.6%–88.5%), acetylsalicylic acid 85.1% (95%CI 79.7%–89.3%) and statins 78.5% (95%CI 70.7%–84.7%). Heterogeneity of the pooled estimates was high. Ten publications reported low medication use and nine reported adequate use. The use of beta-blockers, ACEI/ARBs and statins significantly increased from 1993 to 2020. Medication use was lower in community, public and rehabilitation settings compared to tertiary centres.

Conclusion

The use of most cardioprotective medication classes for secondary prevention of CHD in South America has increased over the last 20 years, but it could be further improved particularly in community settings.

2021 World Health Organization guideline on pharmacological treatment of hypertension: Policy implications for the region of the Americas

Cardiovascular disease (CVD) is the leading cause of death in the Americas and raised blood pressure accounts for over 50% of CVD. In the Americas over a quarter of adult women and four in ten adult men have hypertension and the diagnosis, treatment and control are suboptimal. In 2021, the World Health Organization (WHO) released an updated guideline for the pharmacological treatment of hypertension in adults. This policy paper highlights the facilitating role of the WHO Global HEARTS initiative and the HEARTS in the Americas initiative to catalyze the implementation of this guideline, provides specific policy advice for implementation, and emphasizes that an overarching strategic approach for hypertension control is needed. The authors urge health advocates and policymakers to prioritize the prevention and control of hypertension to improve the health and wellbeing of their populations and to reduce CVD health disparities within and between populations of the Americas.

Development of physical activity and food built environment quality indicators for chronic diseases in Argentina

Although obesity and non-communicable disease (NCD) prevention efforts to-date have focused mainly on individual level factors, the social and physical environments in which people live are now widely recognized as important social determinants of health. Obesogenic environments promote higher dietary energy intakes and sedentary behaviors, thus contributing to the obesity/NCD burden. To develop quality indicators (QIs) for measuring food and physical activity (PA)-built environments in municipalities. A literature review was conducted. Based on the best practices identified from this review, a draft set of candidate QI was retrieved. The initial 67 QIs were then evaluated by a modified Delphi panel of multidisciplinary health professionals (n = 40) to determine their relevance, validity, and feasibility in 3 rounds of voting and threaded discussion using a modified RAND/University of California, Los Angeles Appropriateness Methodology. Response rate for the panel was 89.4%. All final 42 QIs were rated as highly relevant, valid, and feasible (median rating ≥ 7 on a 1-9 scale), with no significant disagreement. The final QI set addresses for the PA domain: (i) promotion of PA; and (ii) improvements in the environment to strengthen the practice of PA; and for Food environment domain: (i) promotion of healthy eating; (ii) access to healthy foods; and (iii) promotion of responsible advertising. We generated a set of indicators to evaluate the PA and food built environment, which can be adapted for use in Latin American and other low- and middle-income countries.

Effectiveness of financial incentives and message framing to improve clinic visits of people with moderate-high cardiovascular risk in a vulnerable population in Argentina: A cluster randomized trial

In Argentina, cardiovascular disease (CVD) represents the first cause of mortality, but effective coverage for CVD prevention is low. Strategies based on behavioral economics are emerging worldwide as key pieces to increase the effectiveness of CVD prevention approaches. The aim of this study was to evaluate whether the implementation of two strategies based on financial incentives and framing increased attendance to clinical visits as proposed by the national program for CVD risk factors management among the uninsured and poor population with moderate or high CVD risk in Argentina. We conducted a cluster randomized trial in nine primary care clinics (PCCs) in Argentina. Three PCCs were assigned to financial incentives, 3 to framing-text messages (SMS) and 3 to usual care. The incentive scheme included a direct incentive for attending the first clinical visit and the opportunity to participate in a lottery when attending a second clinical visit. The framing-text messages group received messages with a gain-frame format. The main outcome was the proportion of participants who attended the clinical visits. A total of 918 individuals with a risk ≥10% of suffering a CVD event within the next 10 years were recruited to participate in the study. The financial incentive group had a significantly higher percentage of participants who attended the first (59.0% vs 33.9%, p˂ 0.001) and the follow up visit (34.4% and 16.6%, p˂ 0.001) compared to control group. However, the framing-SMS group did not show significant differences compared to the control group. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.govNCT03300154.

Monitoring Study Participants and Implementation with Phone Calls to Support Hypertension Control During the COVID-19 Pandemic: The Case of a Multicomponent Intervention Trial in Guatemala

Background

The COVID-19 pandemic presents a challenge to health care for patients with chronic diseases, especially hypertension, because of the important association and increased risk of these patients with a severe presentation of COVID-19 disease. The Guatemalan Ministry of Health has been implementing a multi-component program aimed at improving hypertension control in rural communities since 2019 as a part of an intervention research cluster randomized trial. When the first cases of COVID-19 were reported (March 13, 2020) in Guatemala, our study paused all study field activities, and began monitoring participants through phone calls. The objective of this paper is to describe the approach used to monitor study participants during the COVID-19 pandemic and compare data obtained during phone calls for intervention and control group participants.

Methods

We developed a cross-sectional study within the HyTREC (Hypertension Outcomes for T4 Research within Lower Middle-Income Countries) project 'Multicomponent Intervention to Improve Hypertension Control in Central America: Guatemala' in which phone calls were made to participants from both intervention and control groups to monitor measures important to the study: delivery of antihypertensive medications in both groups, receipt of coaching sessions and use of a home blood pressure monitor by intervention group participants, as well as reasons that they were not implemented.

Results

Regarding the delivery of antihypertensive drugs by the MoH to participants, those in the intervention group had a higher level of medication delivery (73%) than the control group (51%), p<0.001. Of the total participants in the intervention group, 62% had received at least one health coaching session in the previous three months and 81% used a digital home blood pressure monitor at least twice a week. Intervention activities were lower than expected due to restricted public transportation on top of decreased availability of health providers.

Conclusion

In Guatemala, specifically in rural settings, access to antihypertensive medications and health services during pandemic times was impaired and less than expected, even after accounting for the program's implementation activities and actions.

Attributes of the food and physical activity built environments from the Southern Cone of Latin America

Previous studies have shown the influence of the physical and social environments on the development of obesity and non-communicable diseases (NCD). An obesogenic environment promotes higher dietary energy intakes and sedentary behaviors while limiting opportunities or incentives for active living. This paper presents a dataset with key attributes of the food and physical activity built environment, including green spaces, quality of streets and sidewalks, and different types of food retail outlets in four cities of the Southern Cone of Latin America. A total of 139 representative neighborhoods randomly selected from: Marcos Paz and Bariloche (Argentina), Temuco (Chile) and Canelones-Barros Blancos (Uruguay) were evaluated, where standardized community walks were conducted for direct observation of the built environment. This dataset will contribute valuable data to the evaluation of obesogenic environments in the region, and could be linked to additional ecological information about risk factors for NCDs and socio-economic features from other sources. Understanding environmental influences on cardiovascular risk factors and individual habits may help explain NCD outcomes and plan urban policies.

Hypertension in Guatemala's Public Primary Care System: A Needs Assessment Using the Health System Building Blocks Framework

Background

Uncontrolled hypertension represents a substantial and growing burden in Guatemala and other low and middle-income countries. As a part of the formative phase of an implementation research study, we conducted a needs assessment to define short- and long-term needs and opportunities for hypertension services within the public health system.

Methods

We conducted a multi-method, multi-level assessment of needs related to hypertension within Guatemala’s public system using the World Health Organization’s health system building blocks framework. We conducted semi-structured interviews with stakeholders at national (n = 17), departmental (n = 7), district (n = 25), and community (n = 30) levels and focus groups with patients (3) and frontline auxiliary nurses (3). We visited and captured data about infrastructure, accessibility, human resources, reporting, medications and supplies at 124 health posts and 53 health centers in five departments of Guatemala. We conducted a thematic analysis of transcribed interviews and focus group discussions supported by matrix analysis. We summarized quantitative data observed during visits to health posts and centers.

Results

Major challenges for hypertension service delivery included: gaps in infrastructure, insufficient staffing and high turnover, limited training, inconsistent supply of medications, lack of reporting, low prioritization of hypertension, and a low level of funding in the public health system overall. Key opportunities included: prior experience caring for patients with chronic conditions, eagerness from providers to learn, and interest from patients to be involved in managing their health. The 5 departments differ in population served per health facility, accessibility, and staffing. All but 7 health posts had basic infrastructure in place. Enalapril was available in 74% of health posts whereas hydrochlorothiazide was available in only 1 of the 124 health posts. With the exception of one department, over 90% of health posts had a blood pressure monitor.

Conclusions

This multi-level multi-method needs assessment using the building blocks framework highlights contextual factors in Guatemala’s public health system that have been important in informing the implementation of a hypertension control trial. Long-term needs that are not addressed within the scope of this study will be important to address to enable sustained implementation and scale-up of the hypertension control approach.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06889-0.

Cost-effectiveness of a Multicomponent Intervention for Hypertension Control in Low-Income Settings in Argentina

IMPORTANCE

Hypertension is highly prevalent in low- and middle-income countries, and it is an important preventable risk factor for cardiovascular diseases (CVDs). Understanding the economic benefits of a hypertension control program is valuable to decision-makers.

OBJECTIVE

To evaluate the long-term cost-effectiveness of a multicomponent hypertension management program compared with usual care among patients with hypertension receiving care in public clinics in Argentina from a health care system perspective.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation used a Markov model to estimate the cost-effectiveness of a hypertension management program among adult patients with uncontrolled hypertension in a low-income setting. Patient-level data (743 individuals for multicomponent intervention; 689 for usual care) from the Hypertension Control Program in Argentina trial (HCPIA) were used to estimate treatment effects and the risk of CVD. Three health states were included in each strategy: (1) low risk of CVD, (2) high risk of CVD, and (3) death. The total time horizon was the lifetime, and each cycle lasted 6 months.

MAIN OUTCOMES AND MEASURES

Model inputs were based on trial data and other published sources. Cost and utilities were discounted at a rate of 5% annually. The incremental cost-effectiveness ratio (ICER) between the multicomponent intervention and usual care was calculated using the difference in costs in 2017 international dollars (INT $) divided by the difference in effectiveness in quality-adjusted life-years (QALYs). One-way sensitivity analysis and probabilistic sensitivity analysis were performed to assess the uncertainty and robustness of the results.

RESULTS

In the original trial, the 743 participants in the intervention group (349 [47.0%] men) had a mean (SD) age of 56.2 (12.0) years, and the 689 participants in the control group (311 [45.1%] men) had a mean (SD) age of 56.2 (11.7) years. In the base-case analysis, the HCPIA program yielded 8.42 discounted QALYs and accrued INT $3096 discounted costs, while usual care yielded 8.29 discounted QALYs and accrued INT $2473 discounted costs. The ICER for the HCPIA program was INT $4907/QALY gained. The model results remained robust in sensitivity analyses, and the model was most sensitive to parameters of program costs.

CONCLUSIONS AND RELEVANCE

In this study, the HCPIA multicomponent intervention vs usual care was a cost-effective strategy to improve hypertension management and reduce the risk of associated CVD among patients with hypertension who received services at public clinics in Argentina. This intervention program is likely transferable to other settings in Argentina or other lower- and middle-income countries.

Association between drinking patterns and cardiovascular risk: a population-based study in the Southern Cone of Latin America

BACKGROUND

Using data from general adult population, this study aims to describe epidemiology of alcohol consumption patterns and their association with cardiovascular risk.

METHODS

CESCAS I is a population-based study from four mid-sized cities in Argentina, Chile and Uruguay. Associations between diabetes, hypertension, dyslipidemia, cardiovascular disease (CVD) risk and history of CVD and drinking patterns were assessed using crude prevalence odds ratios (ORs) and adjusted OR.

RESULTS

A total of 37.2% of the studied population never drank and 18.3% reported to be former drinkers. Among current drinkers, moderate drinking was the most frequent pattern (24.2%). For women with light and moderate consumption, the odds of having >20% CVD risk was ~40% lower than that of never drinkers. The odds of having a history of CVD was 50% lower in those with moderate consumption. For men with heavy consumption, the odds of having >20% CVD risk was about twice as high as for never drinkers.

CONCLUSIONS

A harmful association was observed between heavy drinking and having >20% CVD risk for men. However, for women, an apparently protective association was observed between light and moderate drinking and having >20% CVD risk and between moderate drinking and having a history of CVD.

An innovative approach to improve the detection and treatment of risk factors in poor urban settings: a feasibility study in Argentina

BACKGROUND

The effective management of cardiovascular (CVD) prevention among the population with exclusive public health coverage in Argentina is low since less than 30% of the individuals with predicted 10-year CVD risk ≥10% attend a clinical visit for CVD risk factors control in the primary care clinics (PCCs).

METHODS

We conducted a non-controlled feasibility study using a mixed methods approach to evaluate acceptability, adoption and fidelity of a multi-component intervention implemented in the public healthcare system. The eligibility criteria were having exclusive public health coverage, age ≥ 40 years, residence in the PCC's catchment area and 10-year CVD risk ≥10%. The multi-component intervention addressed (1) system barriers through task shifting among the PCC's staff, protected medical appointments slots and a new CVD form and (2) Provider barriers through training for primary care physicians and CHW and individual barriers through a home-based intervention delivered by community health workers (CHWs).

RESULTS

A total of 185 participants were included in the study. Of the total number of eligible participants, 82.2% attended at least one clinical visit for risk factor control. Physicians intensified drug treatment in 77% of participants with BP ≥140/90 mmHg and 79.5% of participants with diabetes, increased the proportion of participants treated according to GCP from 21 to 32.6% in hypertensive participants, 7.4 to 33.3% in high CVD risk and 1.4 to 8.7% in very high CVD risk groups. Mean systolic and diastolic blood pressure were lower at the end of follow up (156.9 to 145.4 mmHg and 92.9 to 88.9 mmHg, respectively) and control of hypertension (BP < 140/90 mmHg) increased from 20.3 to 35.5%.

CONCLUSION

The proposed CHWs-led intervention was feasible and well accepted to improve the detection and treatment of risk factors in the poor population with exclusive public health coverage and with moderate or high CVD risk at the primary care setting in Argentina. Task sharing activities with CHWs did not only stimulate teamwork among PCC staff, but it also improved quality of care. This study showed that community health workers could have a more active role in the detection and clinical management of CVD risk factors in low-income communities.

Urban Retail Food Environments: Relative Availability and Prominence of Exhibition of Healthy vs. Unhealthy Foods at Supermarkets in Buenos Aires, Argentina

There is growing evidence that the food environment can influence diets. The present study aimed to assess the relative availability and prominence of healthy foods (HF) versus unhealthy products (UP) in supermarkets in Buenos Aires, Argentina and to explore differences by retail characteristics and neighborhood income level. We conducted store audits in 32 randomly selected food retails. Food availability (presence/absence, ratio of cumulative linear shelf length for HF vs. UP) and prominence inside the store (location visibility) were measured based on the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) protocol. On average, for every 1 m of shelf length for UP, there was about 25 cm of shelf length for HF (HF/UP ratio: 0.255, SD 0.130). UP were more frequently available in high-prominence store areas (31/32 retails) than HF (9/32 retails). Shelf length ratio differed across commercial chains (p = 0.0268), but not by store size or type. Retails in the lower-income neighborhoods had a lower HF/UP ratio than those in the higher-income neighborhoods (p = 0.0329). Availability of the selected HF was overcome largely by the UP, particularly in high prominence areas, and in neighborhoods with lower income level, which may pose an opportunity for public health interventions.

Translating instruments into multiple Mayan languages for a hypertension T4 study in Guatemala

Issue

Guatemala is a culturally and linguistically diverse country. Mayan languages are primarily spoken languages; few people know their written form. Health features and outcomes are difficult to assess due to the lack of validated instruments in these languages.

Description of the Problem

A cluster randomized trial to improve hypertension control is being conducted in 36 municipalities where Mayan languages are spoken in addition to Spanish. Instruments for measuring study outcomes were developed in Spanish and cross-culturally adapted into five Mayan languages following WHO's methodology. First, data were gathered on the proportion of people only fluent in a Mayan language in each district. We prioritized those Mayan languages spoken by more than 20% of the non-Spanish speaking population: Achí, K'iche', Kaqchikel, Tz'utujil and Mam. Second, forward translation to the Mayan languages was conducted by a local healthcare professional, who verbally recorded each instrument. The study team identified key words and concepts to guarantee content equivalence. Third, back-translation was conducted by two independent healthcare providers, who were blinded to the original instruments. The research team formally compared the original questionnaires with the back-translated versions to ensure they were conceptually equivalent and culturally adapted. Discrepancies were corrected as needed. Finally, local interviewers were trained on how to accurately use the written Spanish questionnaires and the Mayan language verbal recordings.

Results

By following this methodology, we achieved cross-culturally adapted instruments to improve the information-gathering process in communities where only Mayan languages are spoken.

Lessons

Having culturally adapted tools will allow researchers to reach a broader range of the target population, obtain more accurate information, and take into account participants' culture and cosmovision.

Key messages

Translating questionnaires to people’s native language allows researchers to obtain more accurate information in a standardized way and better understand participants’ culture and cosmovision. The described methodology is beneficial for conducting research in linguistically diverse countries. It promotes effective and inclusive communication among researchers and participants.

Barriers to hypertension and diabetes management in primary health care in Argentina: qualitative research based on a behavioral economics approach

Despite efforts to improve detection and treatment of adults with hypertension and diabetes in Argentina, many public healthcare system users remain undiagnosed or face barriers in managing these diseases. The purpose of this study is to identify health system, provider, and user-related factors that may hinder detection and treatment of hypertension and diabetes using a traditional and behavioral economics approach. We did qualitative research using in-depth semistructured interviews and focus groups with healthcare providers and adult users of Public Primary Care Clinics. Health system barriers included inadequate care accessibility; poor integration between primary care clinics and local hospitals; lack of resources; and gender bias and neglect of adult chronic disease. Healthcare provider-related barriers were inadequate training; lack of availability or reluctance to adopt Clinical Practice Guidelines; and lack of counseling prioritization. From a behavioral economics perspective, bottlenecks were related to inertia and a status quo, overconfidence, and optimism biases. User-related barriers for treatment adherence included lack of accurate information; resistance to adopt lifelong treatment; affordability; and medical advice mistrust. From a behavioral economics perspective, the most significant bottlenecks were overconfidence and optimism, limited attention, and present biases. Based on these findings, new interventions that aim to improve prevention and control of chronic conditions can be proposed. The study provides empirical evidence regarding the barriers and bottlenecks in managing chronic conditions in primary healthcare settings. Results may contribute to the design of behavioral interventions targeted towards healthcare provision for the affected population.

Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study

BACKGROUND

Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies.

METHODS

In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death.

FINDINGS

From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease.

INTERPRETATION

Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men.

FUNDING

Full funding sources are listed at the end of the paper (see Acknowledgments).

Evaluating a multicomponent program to improve hypertension control in Guatemala: study protocol for an effectiveness-implementation cluster randomized trial

BACKGROUND

Hypertension is a major risk factor for cardiovascular disease (CVD). Despite advances in hypertension prevention and treatment, the proportion of patients who are aware, treated and controlled is low, particularly in low-income and middle-income countries (LMICs). We will evaluate an adapted version of a multilevel and multicomponent hypertension control program in Guatemala, previously proven effective and feasible in Argentina. The program components are: protocol-based hypertension treatment using a standardized algorithm; team-based collaborative care; health provider education; health coaching sessions; home blood pressure monitoring; blood pressure audit; and feedback.

METHODS

Using a hybrid type 2 effectiveness-implementation design, we will evaluate clinical and implementation outcomes of the multicomponent program in Guatemala over an 18-month period. Through a cluster randomized trial, we will randomly assign 18 health districts to the intervention arm and 18 to enhanced usual care across five departments, enrolling 44 participants per health district and 1584 participants in total. The clinical outcomes are (1) the difference in the proportion of patients with controlled hypertension (< 130/80 mmHg) between the intervention and control groups at 18 months and (2) the net change in systolic and diastolic blood pressure from baseline to 18 months. The context-enhanced Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM)/Practical Robust Implementation and Sustainability Model (PRISM) framework will guide the evaluation of the implementation at the level of the patient, provider, and health system. Using a mixed-methods approach, we will evaluate the following implementation outcomes: acceptability, adoption, feasibility, fidelity, adaptation, reach, sustainability, and cost-effectiveness.

DISCUSSION

We will disseminate the study findings, and promote scale up and scale out of the program, if proven effective. This study will generate urgently needed data on effective, adoptable, and sustainable interventions and implementation strategies to improve hypertension control in Guatemala and other LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03504124. Registered on 20 April 2018.

The Moderate Alcohol and Cardiovascular Health Trial (MACH15): Design and methods for a randomized trial of moderate alcohol consumption and cardiometabolic risk

BACKGROUND

Observational studies have documented lower risks of coronary heart disease and diabetes among moderate alcohol consumers relative to abstainers, but only a randomized clinical trial can provide conclusive evidence for or against these associations.

AIM

The purpose of this study was to describe the rationale and design of the Moderate Alcohol and Cardiovascular Health Trial, aimed to assess the cardiometabolic effects of one alcoholic drink daily over an average of six years among adults 50 years or older.

METHODS

This multicenter, parallel-arm randomized trial was designed to compare the effects of one standard serving (∼11-15 g) daily of a preferred alcoholic beverage to abstention. The trial aimed to enroll 7800 people at high risk of cardiovascular disease. The primary composite endpoint comprised time to the first occurrence of non-fatal myocardial infarction, non-fatal ischemic stroke, hospitalized angina, coronary/carotid revascularization, or total mortality. The trial was designed to provide >80% power to detect a 15% reduction in the risk of the primary outcome. Secondary outcomes included diabetes. Adverse effects of special interest included injuries, congestive heart failure, alcohol use disorders, and cancer.

RESULTS

We describe the design, governance, masking issues, and data handling. In three months of field center activity until termination by the funder, the trial randomized 32 participants, successfully screened another 70, and identified ∼400 additional interested individuals.

CONCLUSIONS

We describe a feasible design for a long-term randomized trial of moderate alcohol consumption. Such a study will provide the highest level of evidence for the effects of moderate alcohol consumption on cardiovascular disease and diabetes, and will directly inform clinical and public health guidelines.

Stakeholder Engagement in the Translation of a Hypertension Control Program to Guatemala's Public Primary Health Care System: Lessons Learned, Challenges, and Opportunities

BACKGROUND

There is an urgent need to define appropriate intervention strategies to control blood pressure in low- and middle-income countries. In 2018, a program proven effective in Argentina was translated to Guatemala's public primary health care system in rural and primarily indigenous communities.

OBJECTIVES

This paper describes the stakeholder engagement process used to adapt the program to the Guatemalan rural context prior to implementing a type II hybrid effectiveness-implementation trial and shares lessons learned.

METHODS

We identified key differences in the 2 contexts that are relevant to translating the intervention to the Guatemalan context. Alongside interviews and focus group discussions, we conducted consultation workshops in July and August 2018, applying a participatory translation process involving patients, family members, community members, health care providers, and Ministry of Health officials. The process consisted of multiple meetings in Guatemala City, as well as meetings in each of the 5 departments where the study will be implemented, and 1 district per department. During the workshops, we presented the evidence-based experience from Argentina and then focused on the challenges and recommended solutions that the participants identified for each of the intervention's 6 components. The process concluded with a meeting in which the research team and Ministry of Health officials defined specific details of the intervention.

RESULTS

The outcome of the process is an adapted approach appropriate to integrate into Guatemala's public primary health care system in the trial phase. The approach considers the challenges and recommended strategies for each of the 6 intervention components.

CONCLUSIONS

We identified lessons learned, challenges, and opportunities during the adaptation process. Findings will inform ongoing stakeholder engagement during the study implementation and future scale-up and efforts to translate evidence-based hypertension control strategies to low- and middle-income countries globally.

[Reflections on translational health research and the COVID-19 case in Argentina]

CONICET's Translational Health Research Network is coordinating efforts to advance in translational medicine. Health researchers initiate and focus their research with the aim of improving the health and quality of life of the population. An efficient research system should address health problems relevant to the population resulting in interventions and outcomes important for patients and health professionals. Recommendations to achieve this involve large thematic areas like (a) to set research priorities; (b) to improve research methodology; (c) to make research management and regulation transparent; (d) to increase accessibility to all results; and (e) to improve research dissemination. The recent COVID-19 pandemic has been a clear demonstration of how the country's research system has united the most diverse disciplines to jointly provide solutions to address it. An active and transparent mechanism to identify priorities in the country and to unite funding and research efforts to provide solutions to those priorities is proposed. Translational health research means the joint work of the most diverse health research disciplines in order to jointly obtain efficient and effective interventions to improve the health and quality of life of the population.

Association between religiosity and depression varies with age and sex among adults in South America: Evidence from the CESCAS I study

Prior studies have suggest that religiosity mitigates symptoms of depression. However, population-based data in South America are limited. This study determines the prevalence of religiosity and explores its association with depression in four cities of the Southern cone of Latin-America. In the CESCAS I study 7524 participants aged between 35 and 74 years old were recruited between 2011 and 2012 from randomly selected samples in 4 cities (Bariloche and Marcos Paz, Argentina; Temuco, Chile; and Pando-Barros Blancos, Uruguay). Religiosity was assessed with a questionnaire from the Hispanic Community Health Study/Study of Latinos. Two dimensions were used: 1) recognition as belonging to a religion; and 2) frequency of participation in religious activities. Depression was measured using the PHQ-9. Prevalence of religiosity was described by sociodemographic characteristics. Association between religiosity and depression was examined through logistic regression models controlling for sex, age and other potential confounders. Weekly religious activities were reported by 32.3% (95% CI: 30.1, 33.6) of participants. Prevalence of major depressive episode (MDE) was 14.6% (95% CI: 13.6, 15.6). After controlling for confounders, older women (≥65 years) who reported religious affiliation had 70% lower likelihood of having MDE (OR: 0.3; 95% CI, 0.1, 0.8). Moreover, in this group, women participating in religious activities more than once per week compared with “never” had 50% lower likelihood of having a MDE (OR: 0.5; 95% CI: 0.3, 0.9). No association between religious activities and depression was found in men. Religiosity is highly prevalent among adults in four cities of South America. Our study found an inverse association between religiosity and depression only in women, stronger in olders. Although longitudinal studies are necessary to determine the true nature of these relationships, religiosity may be a relevant factor that health care providers could take into account when exploring depression in their patients.

The shift of obesity burden by socioeconomic status between 1998 and 2017 in Latin America and the Caribbean: a cross-sectional series study

BACKGROUND

The burden of obesity differs by socioeconomic status. We aimed to characterise the prevalence of obesity among adult men and women in Latin America and the Caribbean by socioeconomic measures and the shifting obesity burden over time.

METHODS

We did a cross-sectional series analysis of obesity prevalence by socioeconomic status by use of national health surveys done between 1998 and 2017 in 13 countries in Latin America and the Caribbean. We generated equiplots to display inequalities in, the primary outcome, obesity by wealth, education, and residence area. We measured obesity gaps as the difference in percentage points between the highest and lowest obesity prevalence within each socioeconomic measure, and described trends as well as changing patterns of the obesity burden over time.

FINDINGS

479 809 adult men and women were included in the analysis. Obesity prevalence across countries has increased over time, with distinct patterns emerging by wealth and education indices. In the most recent available surveys, obesity was most prevalent among women in Mexico in 2016, and the least prevalent among women in Haiti in 2016. The largest gap between the highest and lowest obesity estimates by wealth was observed in Honduras among women (21·6 percentage point gap), and in Peru among men (22·4 percentage point gap), compared with a 3·7 percentage point gap among women in Brazil and 3·3 percentage points among men in Argentina. Urban residents consistently had a larger burden than their rural counterparts in most countries, with obesity gaps ranging from 0·1 percentage points among women in Paraguay to 15·8 percentage points among men in Peru. The trend analysis done in five countries suggests a shifting of the obesity burden across socioeconomic groups and different patterns by gender. Obesity gaps by education in Mexico have reduced over time among women, but increased among men, whereas the gap has increased among women but remains relatively constant among men in Argentina.

INTERPRETATION

The increase in obesity prevalence in the Latin American and Caribbean region has been paralleled with an unequal distribution and a shifting burden across socioeconomic groups. Anticipation of the establishment of obesity among low socioeconomic groups could provide opportunities for societal gains in primordial prevention.

FUNDING

None.

Cluster Randomized Trial for Hypertension Control: Effect on Lifestyles and Body Weight

INTRODUCTION

Lifestyle modification, such as healthy diet habits, regular physical activity, and maintaining a normal body weight, must be prescribed to all hypertensive individuals. This study aims to test whether a multicomponent intervention is effective in improving lifestyle and body weight among low-income families.

STUDY DESIGN

Cluster randomized trial conducted between June 2013 and October 2016.

SETTING/PARTICIPANTS

A total of 1,954 uninsured adult patients were recruited in the study within 18 public primary healthcare centers of Argentina.

INTERVENTION

Components targeting the healthcare system, providers, and family groups were delivered by community health workers; tailored text messages were sent for 18 months.

MAIN OUTCOME MEASURES

Changes in the proportion of behavioral risk factors and body weight from baseline to end of follow-up. Data were analyzed in 2017.

RESULTS

Low fruit and vegetable consumption (fewer than 5 servings per day) decreased from 96.4% at baseline to 92.6% at 18 months in the intervention group, whereas in the control group it increased from 97.0% to 99.9% (p=0.0110). The proportion of low physical activity (<600 MET-minutes/week) decreased from 54.3% at baseline to 46.2% at 18 months in the intervention group and kept constant around 52% (p=0.0232) in the control group. The intervention had no effect on alcohol intake (p=0.7807), smoking (p=0.7607), addition of salt while cooking or at the table (p=0.7273), or body weight (p=0.4000).

CONCLUSIONS

The multicomponent intervention was effective for increasing fruit and vegetable intake and physical activity with no effect on alcohol consumption, smoking, addition of salt, or body weight among low-income families in Argentina.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01834131.

Validation and calibration of the patient health questionnaire (PHQ-9) in Argentina

BACKGROUND

The Patient Health Questionnaire-9 (PHQ-9) is a brief tool to assess the presence and severity of depressive symptoms. This study aimed to validate and calibrate the PHQ-9 to determine appropriate cut-off points for different degrees of severity of depression in Argentina.

METHODS

We conducted a cross-sectional study on an intentional sample of adult ambulatory care patients with different degrees of severity of depression. All patients who completed the PHQ-9 were further interviewed by a trained clinician with the Mini International Neuropsychiatric Interview (MINI) and the Beck Depression Inventory-II (BDI-II). Reliability and validity tests, including receiver operating curve analysis, were performed.

RESULTS

One hundred sixty-nine patients were recruited with a mean age of 47.4 years (SD = 14.8), of whom 102 were females (60.4%). The local PHQ-9 had high internal consistency (Cronbach's alpha = 0.87) and satisfactory convergent validity with the BDI-II scale [Pearson's correlation = 0.88 (p < 0.01)]. For the diagnosis of Major Depressive Episode (MDE) according to the MINI, a PHQ-9 ≥ 8 was the optimal cut-off point found (sensitivity 88.2%, specificity 86.6%, PPV 90.91%). The local version of PHQ-9 showed good ability to discriminate among depression severity categories according to the BDI-II scale. The best cut off points were 6-8 for mild cases, 9-14 for moderate and 15 or more for severe depressive symptoms respectively.

CONCLUSIONS

The Argentine version of the PHQ-9 questionnaire has shown acceptable validity and reliability for both screening and severity assessment of depressive symptoms.

A review of assessment indicators used by Healthy Municipalities and Communities Program in Latin America and the Caribbean region

The Healthy Municipalities and Communities Strategy (HMCS) was developed by the Pan American Health Organization in 1990. Evaluation and monitoring are fundamental components of health promotion policies. The aim of this study is to explore the indicators used in Latin America and the Caribbean (LAC) countries to assess the performance of HMCS. We searched MEDLINE, EMBASE, LILACS, BVSDE and Google Advanced Search for documents published between January 2000 and April 2016. We included only documents with assessment indicators of the strategy. All articles were independently assessed for eligibility by pairs of reviewers. We classified the indicators with a supporting framework proposed by O’Neill and Simard (Choosing indicators to evaluate Healthy Cities projects: a political task? Health Promot Int 2006, 21, 145–152.). Local level indicators figured far more prominently among countries and were distributed both in projects and specific activities. Regarding the evolution of the HMCS, indicators were reported in the five levels of analysis (local projects and activities, provincial, national and international networks). Empowerment was represented through the presence of active community organizations and different methods of community participation (forums, open hearing and participation maps). Public policies (such as for tobacco cessation) and bylaws adherence and changes in school’s curricula regarding healthy eating were frequently mentioned. However, this review demonstrated that impact indicators related to lifestyle changes or built environment are not clearly defined and there is a lack of indicators to measure progress in achieving change in long-term outcomes in LAC. We highlight the importance of designing validated indicators for measuring the impact of health promotion policies in partnership with each country involved.

An Educational Intervention to Improve Statin Use: Cluster RCT at the Primary Care Level in Argentina

INTRODUCTION

Statins are essential drugs for high cardiovascular disease (CVD) risk management; however, there is still low adherence to good clinical practice guidelines for statin use at the primary care level in low- and middle-income countries. This study aimed to test whether a complex intervention targeting physicians improves treatment and control of hypercholesterolemia among patients with moderate to high CVD risk in Argentina.

STUDY DESIGN

Cluster RCT.

SETTING/PARTICIPANTS

Ten primary care centers from the public healthcare system of Argentina.

INTERVENTION

Primary care physicians in the intervention group received an educational program with three main components: (1) an intensive 2-day training workshop; (2) educational outreach visits; and (3) a mobile health application installed on the physician's smartphones.

MAIN OUTCOME MEASURES

Reduction in mean low-density lipoprotein cholesterol level, reduction in mean Framingham risk score, proportion of patients receiving an appropriate statin dose, and mean annual number of primary care center visits.

RESULTS

Data were analyzed in 2017-2018. Between April 2015 and April 2016, a total of 357 participants were enrolled (179 patients in the intervention group and 178 in the control group). The global follow-up rate was 97.2%. At the end of the follow-up period, there was no difference in low-density lipoprotein cholesterol levels in any of the follow-up points among the groups. Mean CVD risk had a significant net difference in the first 6 months in the intervention group versus the control group (-4.0, 95% CI = -6.5, -1.5). At the end of follow-up, there was an absolute 41.5% higher rate of participants receiving an appropriate statin dose in the intervention group versus the control group.

CONCLUSIONS

Although the intervention did not reach a reduction in cholesterol levels, it had a significant positive impact on the promotion of adequate use of clinical practice guidelines.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02380911.

Socio-economic inequalities in smoking prevalence and involuntary exposure to tobacco smoke in Argentina: Analysis of three cross-sectional nationally representative surveys in 2005, 2009 and 2013

BACKGROUND

Understanding patterns of socio-economic inequalities in tobacco consumption is key to design targeted public health policies for tobacco control. This study examines socio-economic inequalities in smoking and involuntary exposure to tobacco smoke between 2005 and 2013.

METHODS

Data were derived from the Argentine National Risk Factors Surveys, conducted in 2005, 2009, and 2013. Two inequality measures were calculated: the age-adjusted prevalence ratio (PR) and the disparity index (DI). Educational level, household income per consumer unit and employment status were used as proxies for socio-economic status (SES). Generalized linear models were used in the analysis.

RESULTS

Prevalence of smoking decreased from 29.7% to 25.1% between 2005 and 2013, mainly in women (p<0.001). Despite the overall prevalence reduction, socio-economic inequalities in smoking persisted. For both men and women, the DI was moderately high for smoking (14.47%-33.06%) across the three surveys. In men, the PR indicated a higher smoking prevalence for lower educational levels and lower household income throughout the analyzed period. In women, unlike previous years, the 2013 survey showed disparity related to unemployment. Involuntary exposure to tobacco smoke in 2013 was associated with educational level and household income, with lower involuntary exposure among those with higher SES.

CONCLUSIONS

While overall smoking rates have decreased in Argentina, socio-economic disparities related to tobacco smoking persist. Comprehensive tobacco control programs targeted to address these inequalities are essential in developing strategies to reduce health disparities in tobacco-related diseases.

Omega 3 fatty acid supplementation after myocardial infarction: a systematic review and meta-analysis

BACKGROUND

The purpose of this review is to examine the effect of Omega-3 Fatty acids on mortality, morbidity, and adverse events in patients with acute myocardial infarction (AMI).

METHODS

Data Sources: MEDLINE, EMBASE, and the Cochrane Library through May 2018.

STUDY SELECTION

Randomized Controlled trials (RCT). Certainty of evidence was assessed with the GRADE system.

INTERVENTIONS

omega 3 fatty acids against placebo or no treatment. Primary and secondary outcomes: All-cause death, cardiovascular death, new AMI, stroke, need for therapeutic angioplasty or By-pass, new diagnosis of cancer and incidence of adverse events.

RESULTS

For the efficacy endpoints we included 10 RCT (24,414 patients). Omega 3 fatty acids probably make little or no difference to all-cause mortality (4 studies 9141 patients RR 1.06 - CI95% 0.90 to 1.27, moderate certainty), cardiovascular mortality (3 studies 4304 patients RR 0.93 - CI95% 0.63 to 1.37, moderate certainty), new AMI (RR 1.24 CI95% 0.71 to 2.14 - moderate certainty), any cardiovascular event (RR 0.95 95%CI 0.86 to 1.05; low certainty due to risk of bias and imprecision), and stroke (RR 1.2 95%CCI 0,66-2,19 - moderate certainty). Regarding adverse events, we are uncertain if Omega 3 fatty acids improve/reduce non severe adverse events (RR 1.39 95% CI 0.36 to 5.34; very low certainty). There is probably little or no difference in the outcome suspension due to adverse events (RR 1.19 CI 95% 0.97 to 1.47; moderate certainty).

CONCLUSIONS

For adult patients with AMI, omega 3 fatty-acids probably yield no benefit to patient important outcomes.

[Health impact assessment of the Program Healthy Centers in the Autonomous City of Buenos Aires, ArgentinaAvaliação do impacto na saúde do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires, Argentina]

Objective

To explore the motivations and expectations of the users of the Program for Healthy Centers in the Autonomous City of Buenos Aires and to evaluate its potential health impact.

Methods

In-depth interviews were conducted (n = 34) and a self-administered survey was sent to users of the program (n = 605). An epidemiological model was developed to estimate the impact of the program on cardiovascular events (CVE) and disability-adjusted life years (DALYs).

Results

The main motivating factors for using the healthy centers were geographic and economic accessibility (free services) and satisfaction with the care received. 14.4% (95% CI, 10.3-18.5%) of hypertensive users and 24.8% (95% CI, 17.6-32.0%) of diabetic users reported having learned of their altered values in the healthy center. More than half of the respondents reported some improvement in their knowledge about the benefits of physical activity and healthy eating; this was more frequent among those who were younger, of lower educational level, users of the public health system, users of a healthy center in the South zone and those who had a cardiometabolic risk factor (p<0.05). It was estimated that the healthy centers would prevent 12.5 cardiovascular and cerebrovascular events per year in the assisted population (4.75 events/100 000) and 47.75 DALYs due to these causes.

Conclusions

The healthy centers are a favorable space for the implementation of health promotion and prevention actions, contributing to the detection of and facilitating the monitoring of risk factors, with a potential to prevent cardiovascular events and its consequences.

Using mH ealth Tools to Improve Access and Coverage of People With Public Health Insurance and High Cardiovascular Disease Risk in Argentina: A Pragmatic Cluster Randomized Trial

Background Control of cardiovascular disease ( CVD ) risk factors is suboptimal in Argentina, despite the government's provision of free blood pressure and cholesterol-lowering medications for people without private insurance. We assessed whether community health workers' use of an integrated mH ealth tool encourages patients to attend visits at primary care clinics to improve CVD risk management in 2 provinces of Argentina. Methods and Results We conducted a pragmatic cluster randomized trial, with primary care clinics randomly assigned to intervention or control. Eligible people were aged 40 to 79 years, lived in the catchment area of primary care clinics, possessed a mobile phone for personal use, had public health coverage, and a 10-year CVD risk ≥10%. In the control arm, community health workers screened for CVD risk using a paper-based tool and encouraged high-risk people to present to the primary care clinics for care. In the intervention arm, community health workers used the mH ealth tool to calculate CVD risk and confirm a scheduled physician appointment. Primary outcomes were the proportion of participants who attended a baseline visit and completed at least 1 follow-up, respectively. We enrolled 755 people (376 interventions; 379 controls). Intervention participants were significantly more likely to complete baseline visits (49.4% versus 13.5%, P value 0.0008) and follow-up visits (31.9% versus 7.7%; P value 0.0041). The use of chronic medication and current smoking were significant predictors of primary outcomes. Conclusions Use of mH ealth tools identifies patients at high CVD risk in their home, increases the likelihood of participating in chronic CVD risk factor management, and strengthens referrals. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02913339.