Use of m-Health Technology for Preventive Interventions to Tackle Cardiometabolic Conditions and Other Non-Communicable Diseases in Latin America- Challenges and Opportunities

In Latin America, cardiovascular disease (CVD) mortality rates will increase by an estimated 145% from 1990 to 2020. Several challenges related to social strains, inadequate public health infrastructure, and underfinanced healthcare systems make cardiometabolic conditions and non-communicable diseases (NCDs) difficult to prevent and control. On the other hand, the region has high mobile phone coverage, making mobile health (mHealth) particularly attractive to complement and improve strategies toward prevention and control of these conditions in low- and middle-income countries. In this article, we describe the experiences of three Centers of Excellence for prevention and control of NCDs sponsored by the National Heart, Lung, and Blood Institute with mHealth interventions to address cardiometabolic conditions and other NCDs in Argentina, Guatemala, and Peru. The nine studies described involved the design and implementation of complex interventions targeting providers, patients and the public. The rationale, design of the interventions, and evaluation of processes and outcomes of each of these studies are described, together with barriers and enabling factors associated with their implementation.Fil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Diez Canseco, Francisco. Universidad Peruana Cayetano Heredia; PerúFil: Irazola, Vilma. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Miranda, Jaime. Universidad Peruana Cayetano Heredia; PerúFil: Ramirez Zea, Manuel. Institute of Nutrition of Central America and Panama; GuatemalaFil: Rubinstein, Adolfo Luis. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Cost-Effectiveness of a Comprehensive Approach for Hypertension Control in Low-Income Settings in Argentina: Trial-Based Analysis of the Hypertension Control Program in Argentina

Background: A recent cluster randomized trial evaluating a multicomponent intervention showed significant reductions in blood pressure in low-income hypertensive subjects in Argentina. Objectives: To assess the cost-effectiveness of this intervention. Methods: A total of 1432 hypertensive participants were recruited from 18 primary health care centers. The intervention included home visits led by community health workers, physician education, and text messaging. Resource use and quality of life data using the three-level EuroQol five-dimensional questionnaire were prospectively collected. The study perspective was that of the public health care system, and the time horizon was 18 months. Intention-to-treat analysis was used to analyze cost and health outcomes (systolic blood pressure [SBP] change and quality-adjusted life-years [QALYs]). A 1 time gross domestic product per capita per QALY was used as the cost-effectiveness threshold (US $14,062). Results: Baseline characteristics were similar in the two arms. QALYs significantly increased by 0.06 (95$304 in the intervention group and US $154 in the control group (adjusted difference of US$140.18; 95% CI US $75.41–US$204.94). The incremental cost-effectiveness ratio was $3299 per QALY (95$26 per mm Hg of SBP (95% credible interval 13–46). Subgroup analysis showed that the intervention was cost-effective in all prespecified subgroups (age, sex, cardiovascular risk, and body mass index). Conclusions: The multicomponent intervention was cost-effective for blood pressure control among low-income hypertensive patients.Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Chaparro, Martin. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Palacios, Alfredo. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Shi, Lizheng. University of Tulane; Estados UnidosFil: Beratarrechea, Andrea Gabriela. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Irazola, Vilma. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Rubinstein, Adolfo Luis. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Mills, Katherine. University of Tulane; Estados UnidosFil: He, Jiang. University of Tulane; Estados UnidosFil: Pichón-Riviere, Andrés. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Potential reach of mHealth versus traditional mass media for prevention of chronic diseases : evidence from a nationally representative survey in a middle-income country in Africa.

BACKGROUND: Public radio and television announcements have a long tradition in public health education. With the global rise of computer and mobile device ownership, short message service (SMS) and email-based health services (mHealth) are promising new tools for health promotion. OBJECTIVE: Our objectives were to examine 1) self-reported exposure to programs related to noncommunicable diseases (NCDs) on national public television and radio during the 12 months preceding the survey (2013-2014), 2) current ownership of a mobile phone, smartphone, computer, or tablet, and use of the Internet, and 3) willingness of individuals to receive SMS or emails with information on health, with a focus on distribution of these variables across different demographic, socioeconomic status (SES), and NCD risk groups. METHODS: We obtained data in a population survey of 1240 participants aged 25-64 years conducted in 2013-2014 in the Seychelles, a rapidly developing small island state in the African region. We administered a structured questionnaire and measured NCD risk factors. Univariate and multivariate analyses explored the relationships between outcomes and sociodemographic variables. RESULTS: Of 1240 participants, 1037 (83.62%) reported exposure to NCD-related programs on public television, while a lower proportion of 740 adults (59.67%), reported exposure via public radio (P<.001). Exposure to NCD-related programs on public television was associated with older age (P<.001) and female sex (P<.001), but not with SES, while exposure to NCD-related programs on public radio was associated with older age (P<.001) and lower SES (P<.001). A total of 1156 (93.22%) owned a mobile phone and ownership was positively associated with female sex (P<.001), younger age (P<.001), and higher SES (P<.001). Only 396 adults (31.93%) owned a smartphone and 244 adults (19.67%) used their smartphone to access the Internet. A total of 1048 adults (84.51%) reported willingness to receive health-related SMS, which was positively associated with female sex (P<.001), younger age (P<.001), and higher SES (P<.001). Controlling for SES, exposure to NCD-related programs on public television or radio and willingness to receive health-related SMS were not independently associated with a person's NCD risk. CONCLUSIONS: Broadcasting health programs through traditional mass media (national public radio and television) reached the majority of the population under study, including older adults and those in lower socioeconomic groups. With a high penetration of mobile phones and willingness to receive health-related SMS, mHealth presents an opportunity for health programs, especially when targeted SMS messages are intended for younger adults and those in higher socioeconomic groups. By contrast, due to reduced Internet access, email-based programs had a more limited reach for health promotion programs. These findings emphasize the different reach of interventions using SMS or email versus traditional mass media, according to demographic and socioeconomic categories, for health education programs in a developing country

Educational intervention to improve effectiveness in treatment and control of patients with high cardiovascular risk in low-resource settings in Argentina: study protocol of a cluster randomised controlled trial

INTRODUCTION:Hypercholesterolaemia is estimated to cause 2.6 million deaths annually and one-third of the cases of ischaemic heart disease. In Argentina, the prevalence of hypercholesterolaemia increased between 2005 and 2013 from 27.9% to 29.8%. Only one out of four subjects with a self-reported diagnosis of coronary heart disease is taking statins. Since 2014, statins (simvastatin 20 mg) are part of the package of drugs provided free-of-charge for patients according to cardiovascular disease (CVD) risk stratification. The goal of this study is to test whether a complex intervention targeting physicians and pharmacist assistants improves treatment and control of hypercholesterolaemia among patients with moderate-to-high cardiovascular risk in Argentina.METHODS AND ANALYSIS:This is a cluster trial of 350 patients from 10 public primary care centres in Argentina to be randomised to either the intervention or usual care. The study is designed to have 90% statistical power to detect a 0.7 mmol/L reduction in low-density lipoproteins cholesterol from baseline to 12 months. The physician education programme consists of a 2-day initial intensive training and certification workshop followed by educational outreach visits (EOVs) conducted at 3, 6 and 9 months from the outset of the study. An on-site training to pharmacist assistants during the first EOV is performed at each intervention clinic. In addition, two intervention support tools are used: an app installed in physician´s smartphones to serve as a decision aid to improve prescription of statins according to patient´s CVD risk and a web-based platform tailored to send individualised SMS messages to patients.ETHICS AND DISSEMINATION:Ethical approval was obtained from an independent ethics committee. Results of this study will be presented to the Ministry of Health of Argentina for potential dissemination and scale-up of the intervention programme to the entire national public primary care network in Argentina.TRIAL REGISTRATION NUMBER:NCT02380911.Fil: Gulayin, Pablo. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Irazola, Vilma. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Lozada, Alfredo. Universidad Austral; ArgentinaFil: Chaparro, Raul Martin. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Santero, Marilina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Gutierrez, Laura. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Poggio, Rosana. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Beratarrechea, Andrea Gabriela. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Rubinstein, Adolfo Luis. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentin

Quality of life in type 2 diabetes mellitus patients requiring insulin treatment in Buenos Aires, Argentina: a cross-sectional study

Background: Decision-makers have begun to recognize Health-Related Quality of Life (HRQoL) as an important and measurable outcome of healthcare interventions; and HRQoL data is increasingly being used by policy-makers to prioritize health resources. Our objective was to measure HRQoL in a group of Type 2 Diabetes Mellitus (T2DM) patients receiving insulin treatment in Buenos Aires, Argentina. Methods: We conducted a cross-sectional study of patients with T2DM over 21 years of age, treated with either Neutral Protamine Hagedorn (NPH) insulin or Insulin Glargine (IG), who had not changed their baseline schedule in the last 6 months. The recruitment was during 2006–7 in nine private diabetes specialists’ offices in Buenos Aires, Argentina. A standardized diabetes-specific HRQoL questionnaire, the Audit of Diabetes Dependent Quality of Life (ADDQoL), was used. Results: A total of 183 patients were included (93 receiving NPH and 90 receiving IG). The mean QoL score was: 0.98 (SD: 0.89) and the diabetes specific QoL was: -1.49 (SD: 0.90). T2DM had a negative impact on HRQoL with a mean Average Weighted Impact (AWI) score on QoL of -1.77 (SD: 1.58). The greatest negative impact was observed for domains: ‘ worries about the future’ , ‘ freedom to eat’ , ‘ living conditions ’, ‘ sex life’ , and ‘ family life’ . The mean AWI score was -1.71 (SD: 1.48) in patients treated with IG and -1.85 (SD: 1.68) in patients receiving NPH, this difference was not statistically significant. Conclusion: The ADDQoL questionnaire is a tool that can be used in Argentina to measure the QoL of patients with diabetes when evaluating diabetes care programs. The scores of QoL in our selected population did not differ from those reported in high-income countries. We expect that the results of this study will increase healthcare providers’ awareness of patients’ perceived QoL and help to overcome the barriers that delay insulin treatment; mainly clinical inertia and patient resistanc

Acceptability of short message service (SMS) as a tool for malaria treatment adherence in the Brazilian Amazon: a qualitative study

Background: Malaria is one of the leading causes of morbidity worldwide, and patient adherence to prescribed antimalarials is essential for effective treatment. Methods: This cross-sectional study, with in-depth telephone interviews, analyzed participants’ perceptions of short message service (SMS) in adherence to treatment. Results: Five thematic categories emerged: decreased forgetfulness, the novelty of the tool, easy-to-understand language, the impact of SMS messages during treatment, and suggestions for improvement and complaints. Conclusions: SMS could assist patients in adhering to prescribed antimalarials.Fil: Rodovalho, Sheila. Universidade do Estado do Amazonas; BrasilFil: Dias, Ádila Liliane Barros. Universidade do Estado do Amazonas; BrasilFil: Paz Ade, Maria. Pan American Health Organization; ArgentinaFil: Saint Gerons, Diego Macias. Pan American Health Organization; ArgentinaFil: Castro, Jose Luis. Pan American Health Organization; ArgentinaFil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Murta, Felipe Leão Gomes. Universidade do Estado do Amazonas; BrasilFil: dos Santos, Alicia Cacau Patrine. Universidade do Estado do Amazonas; BrasilFil: Marques, Leonardo Lincoln Gomes. Universidade do Estado do Amazonas; BrasilFil: Sampaio, Vanderson Souza. Universidade do Estado do Amazonas; BrasilFil: Baia da Silva, Djane Clarys. Fundación Oswaldo Cruz; Brasil. Universidade do Estado do Amazonas; BrasilFil: Monteiro, Wuelton Marcelo. Universidade do Estado do Amazonas; Brasi

Supporting self-management for people with hypertension:a meta-review of quantitative and qualitative systematic reviews

OBJECTIVES: Globally, healthcare policy promotes supported self-management as a strategy for people with long-term conditions. This meta-review aimed to explore how people with hypertension make sense of their condition, to assess the effectiveness of supported self-management in hypertension, and to identify effective components of support. METHODS: From a search of eight databases (January 1993-October 2012; update June 2017) we included systematic syntheses of qualitative studies of patients' experiences, and systematic reviews of randomized controlled trials evaluating the impact of supported self-management on blood pressure and medication adherence. We used meta-ethnography, meta-Forest plots and narrative analysis to synthesise the data. RESULTS: Six qualitative and 29 quantitative reviews provided data from 98 and 446 unique studies, respectively. Self-management support consistently reduced SBP (by between 2 and 6 mmHg), and DBP (by between 1 and 5 mmHg). Information about hypertension and treatment, home BP monitoring (HBPM) and feedback (including telehealth) were widely used in effective interventions. Patients' perceptions of a disease with multiple symptoms contrasted with the professional view of an asymptomatic condition. HBPM, in the context of a supportive patient-professional relationship, changed perceptions of the significance of symptoms and fostered confidence in ability to self-manage hypertension. CONCLUSION: Our systematic qualitative and quantitative meta-reviews tell complementary stories. Supported self-management can improve blood pressure control. Interventions are complex and encompass a broad range of support strategies. HBPM (with or without telehealth) within the context of a supportive patient-professional partnership can bridge the gap between medical and lay perspectives of hypertension and enable effective self-management.The PRISMS meta-review was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project numbers 11/1014/04). H.P. was supported by a Primary Care Research Career Award from the Chief Scientist’s Office of the Scottish Government at the time of the PRISMS study. D.D. and S.J.C.T. are also supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care North Thames at Bart’s Health NHS Trust (NIHR CLAHRC North Thames)

Implementation tells us more beyond pooled estimates: Secondary analysis of a multicountry mHealth trial to reduce blood pressure

Background: The uptake of an intervention aimed at improving health-related lifestyles may be influenced by the participant’s stage of readiness to change behaviors. Objective: We conducted secondary analysis of the Grupo de Investigación en Salud Móvil en América Latina (GISMAL) trial according to levels of uptake of intervention (dose-response) to explore outcomes by country, in order to verify the consistency of the trial’s pooled results, and by each participant’s stage of readiness to change a given lifestyle at baseline. The rationale for this secondary analysis is motivated by the original design of the GISMAL study that was independently powered for the primary outcome—blood pressure—for each country. Methods: We conducted a secondary analysis of a mobile health (mHealth) multicountry trial conducted in Argentina, Guatemala, and Peru. The intervention consisted of monthly motivational phone calls by a trained nutritionist and weekly tailored text messages (short message service), over a 12-month period, aimed to enact change on 4 health-related behaviors: salt added to foods when cooking, consumption of high-fat and high-sugar foods, consumption of fruits or vegetables, and practice of physical activity. Results were stratified by country and by participants’ stage of readiness to change (precontemplation or contemplation; preparation or action; or maintenance) at baseline. Exposure (intervention uptake) was the level of intervention (<50%, 50%-74%, and ≥75%) received by the participant in terms of phone calls. Linear regressions were performed to model the outcomes of interest, presented as standardized mean values of the following: blood pressure, body weight, body mass index, waist circumference, physical activity, and the 4 health-related behaviors. Results: For each outcome of interest, considering the intervention uptake, the magnitude and direction of the intervention effect differed by country and by participants’ stage of readiness to change at baseline. Among those in the high intervention uptake category, reductions in systolic blood pressure were only achieved in Peru, whereas fruit and vegetable consumption also showed reductions among those who were at the maintenance stage at baseline in Argentina and Guatemala. Conclusions: Designing interventions oriented toward improving health-related lifestyle behaviors may benefit from recognizing baseline readiness to change and issues in implementation uptake. Trial Registration: ClinicalTrials.gov NCT01295216; http://clinicaltrials.gov/ct2/show/NCT01295216 (Archived by WebCite at http://www.webcitation.org/72tMF0B7B)

Strengthening therapeutic adherence and pharmacovigilance to antimalarial treatment in Manaus, Brazil: a multicomponent strategy using mHealth

Background: Public health initiatives for improving adherence to primaquine based regimens and enhancing effective pharmacovigilance are needed to support the efforts for malaria elimination in real world conditions. Methods: A multicomponent patient-oriented strategy using a Smart Safety Surveillance (3S) approach including: (1) educational materials for treatment counselling and identification of warning symptoms of haemolytic anaemia; (2) an mHealth component using Short Message Service (SMS) treatment reminders and (3) development and implementation of follow-up phone surveys three days after treatment completion, using a web-based platform linked to the local information system of malaria. Adherence was measured using the Morisky Medication Adherence Scale. Self-reported events were registered using a structured questionnaire and communicated to the Brazilian Health Regulatory Agency. Results: Educational materials were disseminated to 5594 patients, of whom 1512 voluntarily entered the mHealth component through the local information system; 7323 SMS were sent, and 1062 participants completed a follow-up survey after treatment. The mean age of patients was 37.36 years (SD 13.65), 61.24% were male, 98.54% were infected with. Plasmodium vivax and 95.90% received a short regimen of chloroquine plus primaquine (CQ + PQ 7 days), as per malaria case management guidelines in Brazil. From the 1062 surveyed participants 93.31% were considered adherent to the treatment. Most of the patients (95.20%) reported at least one adverse event. Headache, lack of appetite and nausea/vomiting were the most frequently reported adverse events by 77.31%, 70.90% and 56.78% of the patients respectively. A quarter of the patients reported anxiety or depression symptoms; 57 (5.37%) patients reported 5 to 6 warning symptoms of haemolytic anaemia including jaundice and dark urine in 44 (4.14%). Overall, three patients presenting symptoms of haemolytic anaemia attended a hospital and were diagnosed with G6PD deficiency, and one had haemolysis. All of them recovered. Conclusions: Under real world conditions, a multicomponent patient-oriented strategy using information and communication technologies allowed health care providers to reinforce treatment adherence and enhance safety surveillance of adverse events associated with regimens using primaquine. Active monitoring through phone surveys also reduced under-reporting of ADRs. This approach is low-cost, scalable and able to support prioritized activities of the national malaria programme.Fil: Macías Saint Gerons, Diego. Universidad de Valencia; EspañaFil: Rodovalho, Sheila. Universidad Federal del Amazonas.; BrasilFil: Barros Dias, Ádila Liliane. Universidad Federal del Amazonas.; BrasilFil: Lacerda Ulysses de Carvalho, André. Pan American Health Organization; BrasilFil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Monteiro, Wuelton Marcelo. Universidad Federal del Amazonas.; BrasilFil: Barata Machado, Myrna. State of Amazonas Health Surveillance Foundation; BrasilFil: Fernandes da Costa, Cristiano. State of Amazonas Health Surveillance Foundation; BrasilFil: Yoshito Wada, Marcelo. No especifíca;Fil: Maximiano Faria de Almeida, Márcia Helena. No especifíca;Fil: Silva de Matos Fonseca, Rayanne. Fundação de Medicina Tropical Dr. Heitor Vieira Dourado; BrasilFil: Mota Cordeiro, Jady Shayenne. Fundação de Medicina Tropical Dr. Heitor Vieira Dourado; BrasilFil: Rodrigues Antolini, Alinne Paula. No especifíca;Fil: Nepomuceno, João Altecir. No especifíca;Fil: Fleck, Karen. Brazilian Health Regulatory Agency; BrasilFil: Simioni Gasparotto, Fernanda. Brazilian Health Regulatory Agency; BrasilFil: Lacerda, Marcus. Fundação de Medicina Tropical Dr. Heitor Vieira Dourado; BrasilFil: Rojas Cortés, Robin. Pan American Health Organization; Estados UnidosFil: Pal, Shanthi Narayan. No especifíca;Fil: Porrás, Analía I.. Pan American Health Organization; Estados UnidosFil: Ade, María de la Paz. Pan American Health Organization; Estados UnidosFil: Castro, José Luis. Pan American Health Organization; Estados Unido

Behaviour change strategies for reducing blood pressure-related disease burden: findings from a global implementation research programme.

The Global Alliance for Chronic Diseases comprises the majority of the world's public research funding agencies. It is focussed on implementation research to tackle the burden of chronic diseases in low- and middle-income countries and amongst vulnerable populations in high-income countries. In its inaugural research call, 15 projects were funded, focussing on lowering blood pressure-related disease burden. In this study, we describe a reflexive mapping exercise to identify the behaviour change strategies undertaken in each of these projects.Using the Behaviour Change Wheel framework, each team rated the capability, opportunity and motivation of the various actors who were integral to each project (e.g. community members, non-physician health workers and doctors in projects focussed on service delivery). Teams then mapped the interventions they were implementing and determined the principal policy categories in which those interventions were operating. Guidance was provided on the use of Behaviour Change Wheel to support consistency in responses across teams. Ratings were iteratively discussed and refined at several group meetings.There was marked variation in the perceived capabilities, opportunities and motivation of the various actors who were being targeted for behaviour change strategies. Despite this variation, there was a high degree of synergy in interventions functions with most teams utilising complex interventions involving education, training, enablement, environmental restructuring and persuasion oriented strategies. Similar policy categories were also targeted across teams particularly in the areas of guidelines, communication/marketing and service provision with few teams focussing on fiscal measures, regulation and legislation.The large variation in preparedness to change behaviour amongst the principal actors across these projects suggests that the interventions themselves will be variably taken up, despite the similarity in approaches taken. The findings highlight the importance of contextual factors in driving success and failure of research programmes. Forthcoming outcome and process evaluations from each project will build on this exploratory work and provide a greater understanding of factors that might influence scale-up of intervention strategies