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

The consequences of early childhood growth failure over the life course:

This paper examines the impact over the life course of early childhood growth failure as measured by achieved height at 36 months. It uses data collected on individuals who participated in a nutritional supplementation trial between 1969 and 1977 in rural Guatemala and who were subsequently reinterviewed between 2002 and 2004. It finds that individuals who did not suffer growth failure in the first three years of life complete more schooling, score higher on tests of cognitive skill in adulthood, have better outcomes in the marriage market, earn higher wages and are more likely to be employed in higher-paying skilled labor and white-collar jobs, are less likely to live in poor households, and, for women, fewer pregnancies and smaller risk of miscarriages and stillbirths. Growth failure has adverse impacts on body size and several dimensions of physical fitness in adulthood but does not have marked effects on risk indicators of cardiovascular and related chronic diseases. These results provide a powerful rationale for investments that reduce early-life growth failure.Chronic disease, early life growth failure, fertility, Human capital, Poverty, Undernutrition, Wages,

What Determines Adult Cognitive Skills? Impacts of Pre-Schooling, Schooling and Post-Schooling Experiences in Guatemala

Most investigations of the importance of and the determinants of adult cognitive skills assume that (a) they are produced primarily by schooling and (b) schooling is statistically predetermined. But these assumptions may lead to misleading inferences about impacts of schooling and of pre-schooling and post-schooling experiences on adult cognitive skills. This study uses an unusually rich longitudinal data set collected over 35 years in Guatemala to investigate production functions for adult (i) reading-comprehension and (ii) nonverbal cognitive skills as dependent on behaviorally-determined pre-schooling, schooling and post-schooling experiences. Major results are: (1) Schooling has significant and substantial impact on adult reading comprehension (but not on adult nonverbal cognitive skills)—but estimates of this impact are biased upwards substantially if there are no controls for behavioral determinants of schooling in the presence of persistent unobserved factors such as genetic endowments and/or if family background factors that appear to be correlated with genetic endowments are included among the first-stage instruments. (2) Both pre-schooling and post-schooling experiences have substantial significant impacts on one or both of the adult cognitive skill measures that tend to be underestimated if these pre- and post-schooling experiences are treated as statistically predetermined—in contrast to the upward bias for schooling, which suggests that the underlying physical and job-related components of genetic endowments are negatively correlated with those for cognitive skills. (3) The failure in most studies to incorporate pre- and post-schooling experiences in the analysis of adult cognitive skills or outcomes affected by adult cognitive skills is likely to lead to misleading over-emphasis on schooling relative to these pre-and post-schooling experiences. (4) Gender differences in the coefficients of the adult cognitive skills production functions are not significant, suggesting that most of the fairly substantial differences in adult cognitive skills favoring males on average originate from gender differences in schooling attainment and in experience in skilled jobs favoring males. These four sets of findings are of substantial interest in themselves. But they also have important implications for broader literatures, reinforcing the importance of early life investments in disadvantaged children in determining adult skills and options, pointing to limitations in the cross-country growth literature of using schooling of adults to represent human capital, supporting hypotheses about the importance of childhood nutrition and work complexity in explaining the “Flynn effect” of substantial increases in measured cognitive skills over time, and questioning the interpretation of studies that report productivity impacts of cognitive skills without controlling for the endogeneity of such skills.

Formative research to develop a community-based intervention for chronic disease prevention in Guatemalan school-age children

BACKGROUND: Noncommunicable diseases (NCD) are the most common causes of morbidity and mortality worldwide, even in low- and middle-income countries (LMIC). Recent trends in health promotion emphasize community-based interventions as an important strategy for improving health outcomes. The aim of this study was to conduct formative research regarding the perceptions of NCD risk factors, their influencing factors, and community resources available to aid the development and implementation of a community-based intervention with school-age children. METHODS: Focus group discussions (n = 18), home visits (n = 30), and individual semi-structured interviews (n = 26) were conducted in three urban communities in Guatemala with school-age children (10–12 years of age), teachers, parents, and local community members (i.e., school principals, school food kiosk vendors, religious leaders, authority representatives). All focus groups and interviews were transcribed verbatim for thematic analysis. RESULTS: Children, parents, and teachers have general knowledge about modifiable risk factors. Adults worried more about tobacco use, as compared to unhealthy diet and physical inactivity in children. Participants identified features at the intrapersonal (e.g., negative emotional state), interpersonal (e.g., peers as role models), and organizational and community levels (e.g., high levels of crime) that influence these risk factors in children. School committees, religious leaders, and government programs and activities were among the positive community resources identified. CONCLUSIONS: These findings should help researchers in Guatemala and similar LMIC to develop community-based interventions for NCD prevention in school-age children that are effective, feasible, and culturally acceptable

Activities contributing to energy expenditure among Guatemalan adults

<p>Abstract</p> <p>Background</p> <p>Guatemala has experienced a substantial increase in overweight and obesity in recent years, yet physical activity patterns and consequent energy expenditure are largely unexplored in this population.</p> <p>Methods</p> <p>To describe overall physical activity levels (PAL) and activities contributing to daily energy expenditure, we analyzed time spent in daily activities as reported by 985 women and 819 men, living in rural and urban areas of Guatemala in 2002–04.</p> <p>Results</p> <p>Physical activity levels recommended to prevent obesity (PAL ≥ 1.70) differed by residence/occupation among men (agricultural-rural: 77%; nonagricultural-rural: 36%; urban: 24%; P < 0.01), but not women (rural: 2%; urban: 3%; P = 0.5). Median energy expenditure was higher among agricultural-rural men (44 MET*h/d; MET = metabolic equivalent) compared to nonagricultural-rural (37 MET*h/d) and urban men (35 MET*h/d; P < 0.01); energy expenditure was slightly lower among rural compared to urban women (34 MET*h/d vs. 35 MET*h/d; P < 0.01). Occupation was the largest contributor to energy expenditure (19–24 MET*h/d); among women and nonagricultural-rural and urban men this was primarily of a light intensity. Energy expenditure in sedentary activities ranged from 2 MET*h/d among rural women to 6 MET*h/d among agricultural-rural men. Any sports/exercise time was reported by 35% and 5% of men and women, respectively. Nevertheless, the majority of participants believed they were significantly active to stay healthy.</p> <p>Conclusion</p> <p>Overall, energy expenditure was low in the population not dedicated to agricultural occupations; an increased focus on active leisure-time behaviors may be needed to counterbalance reductions in energy expenditure consequent to sedentarization of primary occupations.</p

What Determines Adult Cognitive Skills? Impacts of Pre-Schooling, Schooling and Post-Schooling Experiences in Guatemala

Most investigations of the importance of and the determinants of adult cognitive skills assume that (a) they are produced primarily by schooling and (b) schooling is statistically predetermined. But these assumptions may lead to misleading inferences about impacts of schooling and of pre-schooling and post-schooling experiences on adult cognitive skills. This study uses an unusually rich longitudinal data set collected over 35 years in Guatemala to investigate production functions for adult (i) reading-comprehension and (ii) non-verbal cognitive skills as dependent on behaviorally-determined pre-schooling, schooling and post-schooling experiences. Major results are: (1) Schooling has significant and substantial impact on adult reading comprehension (but not on adult non-verbal cognitive skills) —but estimates of this impact are biased upwards substantially if there is not control for behavioral determinants of schooling in the presence of persistent unobserved factors such as genetic endowments and/or if family background factors that appear to be correlated with genetic endowments are included among the first-stage instruments. (2) Both pre-schooling and post-schooling experiences have substantial significant impacts on one or both of the adult cognitive skill measures that tend to be underestimated if these pre- and post-schooling experiences are treated as statistically predetermined—in contrast to the upward bias for schooling, which suggests that the underlying physical and job-related components of genetic endowments are negatively correlated with those for cognitive skills. (3) The failure in most studies to incorporate pre- and post-schooling experiences in the analysis of adult cognitive skills or outcomes affected by adult skills is likely to lead to misleading over-emphasis on schooling relative to these pre-and post-schooling experiences. (4) Gender differences in the coefficients of the adult cognitive skills production functions are not significant, suggesting that most of the fairly substantial differences in adult cognitive skills favoring males on average originate from gender differences in completed grades of schooling and in experience in skilled jobs favoring males. These four sets of findings are of substantial interest in themselves. But they also have important implications for broader literatures, pointing to limitations in the cross-country growth literature of using schooling of adults to represent human capital, supporting hypotheses about the importance of childhood nutrition and work complexity in explaining the “Flynn effect” of substantial increases in measured cognitive skills over time, and questioning the interpretation of studies that report productivity impacts of cognitive skills without controlling for the endogeneity of such skills

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.Fil: Hernández Galdamez, Diego. Institute Of Nutrition Of Central America And Panama Guatemala; GuatemalaFil: Mansilla, Kristyne. Institute Of Nutrition Of Central America And Panama Guatemala; GuatemalaFil: Peralta, Ana Lucía. Institute Of Nutrition Of Central America And Panama Guatemala; GuatemalaFil: Rodríguez Szaszdi, Javier. Institute Of Nutrition Of Central America And Panama Guatemala; GuatemalaFil: Ramírez, Juan Manuel. Institute Of Nutrition Of Central America And Panama Guatemala; GuatemalaFil: Roche, Dina. Institute Of Nutrition Of Central America And Panama Guatemala; GuatemalaFil: Gulayin, Pablo Elías. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Ramirez Zea, Manuel. Institute Of Nutrition Of Central America And Panama Guatemala; GuatemalaFil: He, Jiang. Tulane University School of Public Health and Tropical Medicine; Estados UnidosFil: 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: Fort, Meredith P.. Colorado School of Public Health; Estados Unido

What Determines Adult Cognitive Skills? Influences of Pre-Schooling, Schooling, and Post-Schooling Experiences in Guatemala

Most empirical investigations of the effects of cognitive skills assume that they are produced by schooling, and that schooling is exogenous. Drawing on a rich longitudinal data set to estimate production functions for adult reading-comprehension cognitive skills and adult nonverbal cognitive skills, we find that (1) Schooling attainment has a significant and substantial effect on adult reading-comprehension cognitive skills but not on adult nonverbal cognitive skills; and (2) Pre-schooling and post-schooling experiences have substantial positive significant effects on adult cognitive skills. Pre-schooling experiences that increase height for age at age six years substantially and significantly increase adult reading-comprehension and nonverbal cognitive skills, even after controlling for schooling attainment and post-school skilled job tenure. Post-schooling tenure in skilled jobs also has a significant positive effect on adult reading-comprehension and nonverbal cognitive skills, although the latter estimate is sensitive to how we treat gender. Age also has significant positive effect but with diminishing returns on adult reading-comprehension cognitive skills. The findings (1) reinforce the importance of early life investments; (2) support the importance of childhood nutrition (“Flynn effect”) and work complexity in explaining increases in cognitive skills; (3) question interpretations of studies reporting productivity impacts of cognitive skills without controlling for endogeneity; and (4) point to limitations in using adult schooling alone to represent human capital

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

Dietary patterns and cardio-metabolic risk in a population of Guatemalan young adults

Abstract Background Latin America is facing an increasing burden of nutrition-related non-communicable disease. Little is known about dietary patterns in Guatemalan adults and how dietary patterns are associated with cardio-metabolic disease (CMD) risk. Methods This analysis is based on data from a 2002–04 follow-up study of the INCAP Nutrition Supplementation Trial Longitudinal Cohort. Diet data were collected using a validated, semi-quantitative food frequency questionnaire. We derived dietary patterns using principal components analysis. CMD risk was assessed by anthropometry (body mass index, waist circumference), biochemistry (fasting blood glucose and lipids), and clinical (blood pressure) measures. We used sex-stratified multivariable log binomial models to test associations between dietary pattern tertile and CMD risk factors. The sample included 1428 participants (681 men and 747 women) ages 25–43 years. Results We derived three dietary patterns (traditional, meat-based modern, and starch-based modern), collectively explaining 24.2% of variance in the diet. Dietary patterns were not associated with most CMD risk factors; however, higher starch-based modern tertiles were associated with increased prevalence of low highdensity lipoprotein cholesterol (HDL-c) in men (Prevalence Ratio (PR) 1.17, 95% Confidence Interval (CI) 1.01, 1.20 for tertile 2; PR 1.20, 95% CI 1.00, 1.44 for tertile 3; p trend 0.04). Higher traditional tertiles were associated with increased prevalence of abdominal obesity in women (PR 1.24, 95% CI 1.07, 1.43 for tertile 2; PR 1.19, 95% CI 1.02, 1.39 for tertile 3; p trend 0.02) but marginally significant reduced prevalence of low HDL-c in men (PR 0.88, 95% CI 0.76, 1.00 for tertile 2; PR 0.85, 95% CI 0.72, 1.00 for tertile 3; p trend 0.05). Conclusion Our findings suggest the presence of two ‘modern' dietary patterns in Guatemala – one of which was associated with increased prevalence of low HDL-c in men. The association between the traditional dietary pattern and some CMD risk factors may vary by sex.https://deepblue.lib.umich.edu/bitstream/2027.42/137709/1/40795_2017_Article_188.pd