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BackgroundLatin American youth have a high prevalence of mental health disorders and face major socioeconomic and public safety problems. This study assesses the association between stressful life events (SLEs) and depression, anxiety, and quality of life among adolescents and young adults from deprived neighbourhoods of Latin America.MethodsThe sample consisted of 2,402 participants, between adolescents (15–16 years) and young adults (20–24 years), from Bogotá (Colombia), Buenos Aires (Argentina), and Lima (Peru), assessed in 2021–2022 and recruited in education and community settings and social media. We evaluated the most frequent recent and distant SLEs (occurred in the previous year and more than a year ago, respectively), the relationship between SLEs and severity of depression (PHQ-8), anxiety (GAD-7), and quality of life (MANSA), and we tested for differences by gender and age group.ResultsThe most common recent and distant SLEs were related to public safety issues and financial distress. Accidents and school suspensions were more frequent among men, and sexual harassment and bullying among women. Every additional reported recent SLE increased the odds of mild, moderate, and severe depression (18, 17, and 25%, respectively) and anxiety (10, 17, and 21%, respectively) symptoms. Similar trends were found with distant SLEs and depression (8, 9, and 11% for mild, moderate, and severe symptoms, respectively) and anxiety (9, 11, and 12%, respectively). Furthermore, a higher number of recent and distant SLEs were associated with lower quality of life (β = −0.05, p

Aim: To describe the perceptions and experiences of key stakeholders to understand the use of telehealth in community mental health centers (CMHCs) during the COVID-19 pandemic in Lima and Callao, Peru. Methods: A qualitative study was carried out in four CMHCs in Lima and Callao, Peru. Forty-nine individual semi-structured interviews were conducted between September 2021 and March 2022, considering CMHCs' users and their relatives, health and administrative workers, directors, as well as local and national policymakers. Data was analyzed using thematic analysis. Results: Regarding the transition from in-person care to telehealth, CMHCs' directors and workers identified some of the regulations issued by the Government during the pandemic, such as the continuity of care through telehealth, especially for pregnant women and for people with comorbidities related to COVID-19. Regarding benefits, workers and users indicated that it allowed better communication, such as constant follow-ups. Directors and workers recognized that Google Drive facilitated access to user information, since they did not have an electronic medical record. Additionally, workers said they used social media to share educational information on mental health, and explained that some new users began their treatment this way. Regarding difficulties, participants reported a lack of devices and poor internet connection in CMHCs. Users mentioned that scheduling an appointment was difficult because the phone lines were usually saturated, and they could not find available appointments. Conclusion: Although the pandemic forced an immediate and disruptive change towards telehealth, CMHCs were able to adapt most of their services. This study reports the adaptations made by CMHCs to move from in-person to remote care, identifying the benefits and challenges faced, information that can be used for the nationwide implementation of telehealth in CMHCs. We recommend ensuring technological equipment and internet connection and adapt the telehealth system to make it responsive to the routine practices of CMHCs.

Objetivos. Comprender las experiencias de usuarios nuevos y continuadores de los Centros de Salud Mental Comunitaria (CSMC) de Lima y Callao, y de sus familiares, en relación a la atención en salud mental que recibieron durante la pandemia de la COVID-19. Materiales y métodos. Estudio cualitativo realizado entre septiembre del 2021 y febrero del 2022, en el que se entrevistó a 24 usuarios y familiares que interactuaron con los servicios brindados por tres CSMC de Lima y uno del Callao, durante la pandemia de la COVID-19. Se realizó un análisis temático de las entrevistas transcritas. Resultados. Los informantes percibieron que la pandemia exacerbó los síntomas de las personas con problemas de salud mental. Durante la pandemia, las atenciones de salud mental se apoyaron en el uso de tecnología, principalmente de llamadas telefónicas, las que sirvieron para monitorear el estado emocional y el tratamiento farmacológico de los usuarios, así como para programar y recordar citas. Los usuarios destacan que las llamadas telefónicas frecuentes les hicieron sentirse acompañados y resaltan el compromiso de los trabajadores de los CSMC. Como dificultades, reportan el incremento en la demanda de atención, problemas para acceder a videollamadas, y menor calidad en las atenciones virtuales. Conclusiones. La COVID-19 impactó emocionalmente a las personas con problemas de salud mental, a su vez, los servicios de los CSMC vieron afectada la modalidad (presencial o virtual), recursos, frecuencia, tiempo y calidad de la atención, encontrando limitaciones y beneficios en el uso de la tecnología.

Objetivos. Estimar la cantidad de bebidas y alimentos procesados y ultraprocesados que declaran información nutricional en su empaque y describir las características de esta información, así como determinar la presencia de información nutricional en los productos con octógonos. Materiales y métodos. Se tomaron fotografías del etiquetado de 4404 bebidas y alimentos procesados y ultraprocesados ofertados en supermercados de Lima Metropolitana. La información declarada en la etiqueta se recogió y se registró en la versión móvil y web del Programa de Información de Etiquetas de Alimentos (FLIP por sus siglas en inglés). Se analizaron las variables correspondientes a la declaración de información nutricional, la forma en que se declara dicha información y la declaración de la misma en bebidas y alimentos con octógonos. Resultados. De todos los productos recolectados solo el 71,4% declara algún tipo de información nutricional. De estos, el 13,8% declara la información nutricional en texto y no en tabla, además sólo 56,3% la declara por cada 100 gramos o mililitros. Del total de alimentos con el octógono «Contiene grasas trans», sólo 19,2% declara su contenido. Conclusiones. Más de la cuarta parte de bebidas y alimentos envasados expendidos en el mercado peruano no declaran información nutricional de ningún tipo, y de los que declaran, existe una que lo hace en diferentes formatos y unidades. Además, se halló que hay una proporción de bebidas y alimentos para cada tipo de octógono que no declaran la información del nutriente advertido en el mismo.

Abstract The SALURBAL (Urban Health in Latin America) Project is an interdisciplinary multinational network aimed at generating and disseminating actionable evidence on the drivers of health in cities of Latin America. We conducted a temporal multilayer network analysis where we measured cohesion over time using network structural properties and assessed diversity within and between different project activities according to participant attributes. Between 2017 and 2020 the SALURBAL network comprised 395 participants across 26 countries, 23 disciplines, and 181 institutions. While the cohesion of the SALURBAL network fluctuated over time, overall, an increase was observed from the first to the last time point of our analysis (clustering coefficient increased [0.83–0.91] and shortest path decreased [1.70–1.68]). SALURBAL also exhibited balanced overall diversity within project activities (0.5–0.6) by designing activities for different purposes such as capacity building, team-building, research, and dissemination. The network’s growth was facilitated by the creation of new diverse collaborations across a range of activities over time, while maintaining the diversity of existing collaborations (0.69–0.75 between activity diversity depending on the attribute). The SALURBAL experience can serve as an example for multinational research projects aiming to build cohesive networks while leveraging heterogeneity in countries, disciplines, career stage, and across sectors.

La venta de productos ultraprocesados y el sobrepeso y la obesidad han aumentado en América Latina en los últimos años. En el Perú, se aprobó la Ley N° 30021 en busca de reducir el sobrepeso y la obesidad en niños y adolescentes, sin embargo, el desarrollo de esta Ley se caracterizó por tener continuas modificaciones en los diversos documentos elaborados. El propósito de este artículo es identificar cambios esenciales en los documentos elaborados por el Gobierno y el Congreso en el marco de la Ley N° 30021, específicamente en los temas de regulación de la publicidad de alimentos y bebidas no alcohólicas, advertencias publicitarias y parámetros técnicos de nutrientes críticos. Los cambios identificados en los diferentes documentos muestran el dinamismo en el desarrollo de esta política donde la falta de evidencia científica oportuna, la oposición de la industria alimentaria y la falta de consenso político fueron los principales motivos.

Abstract Background Sugar-sweetened beverage consumption is associated with obesity and chronic disease. In 2018, Peru increased the tax on high-sugar beverages (≥6 g of sugar per 100 mL) from 17 to 25%, yet little is known about pre-existing beverage trends or demographic characteristics associated with purchases in the country. The aim of this study was to explore beverage purchasing trends from 2016 to 2017 and examine variation in purchase volume by sociodemographic characteristics among urban households in Peru. Methods This study used monthly household purchase data from a panel of 5145 households from January 2016–December 2017 from Kantar WorldPanel Peru. Beverage purchases were categorized by type and tax status under the 2018 regulation (untaxed, lower-sugar taxed, high-sugar taxed). To assess beverage purchasing trends, per-capita volume purchases were regressed on a linear time trend, with month dummies for seasonality and clustered standard errors. Mean volume purchases by beverage tax status (total liters purchased per month), overall and by key demographic characteristics (education, socioeconomic status, and geographic region), were calculated. Mean volume by beverage type was assessed to identify the largest contributors to total beverage volume. Results The trends analysis showed a decline in total beverage volume of − 52 mL/capita/month (95% CI: − 72, − 32) during the 24-month study period. Over 99% of households purchased untaxed beverages in a month, while > 92% purchased high-sugar taxed beverages. Less than half of all households purchased low-sugar taxed beverages in a month and purchase volume was low (0.3 L/capita/month). Untaxed beverage purchases averaged 9.4 L/capita/month, while households purchased 2.8 L/capita/month of high-sugar taxed beverages in 2017. Across tax categories, volume purchases were largest in the high education and high socioeconomic (SES) groups, with substantial variation by geographic region. The highest volume taxed beverage was soda (2.3 L/capita/month), while the highest volume untaxed beverages were milk and bottled water (1.9 and 1.7 L/capita/month, respectively). Conclusions Nearly all households purchased high-sugar taxed beverages, although volume purchases of taxed and untaxed beverages declined slightly from 2016 to 2017. Households with high SES and high education purchased the highest volume of taxed beverages, highlighting the need to consider possible differential impacts of the tax policy change by sub-population groups.

We sought to explore mental health and psychosocial impact among young people (18 to 24 years old) in Bogotá during the first months of the COVID-19 pandemic. Methods: We carried a cross sectional study using a web-based survey to assess mental health and personal impact among 18 to 24 years old living in Bogotá during the first 4 months of the 2020 COVID-19 pandemic lockdown. The depressive symptoms were measured with PHQ-8 and anxiety symptoms with (GAD-7). We also designed a questionnaire exploring changes in personal, family and social life. Results: Overall, 23% of the sample (n = 834) reported mild depressive symptoms (males 24% and females 23%); 29% reported moderate depressive symptoms (males 28%, females 30%); 22% moderate-severe symptoms (males 20%, females 23%) and 17% severe symptoms (males 15%, females 17%). Mild anxiety symptoms were reported by 29% of the sample (males 30%, females 29%); moderate anxiety symptoms by 29% (males 26%, females 30%); moderate-severe 18% (males 15%, females 20%) and severe anxiety by 6.0% (males 6.0% and females 6.0%). High symptoms of depression (PHQ-8 ≥ 10) were associated with being female, considering that the quarantine was stressful, having one member of the family losing their job, worsening of family relationships, decrease of physical activity and having a less nutritious diet. Having high anxiety symptoms (GAD-7 ≥ 10) were associated with sometimes not having enough money to buy food. Conclusions: The first months of the pandemic lockdown were associated with high depressive and anxiety symptoms among young persons living in Bogotá, Colombia. Increasing public health measures to provide support for young people is needed during lockdowns and it is necessary to further explore the long-term mental health impact due to personal, family and social changes brought by the COVID-19 pandemic.

ObjectiveThis study aimed to conduct a process evaluation of a salt substitute trial conducted in Peru.MethodsThrough semi-structured interviews of intervention participants, we documented and analyzed process evaluation variables as defined by the Medical Research Council Framework. This study was a stepped wedge trial conducted in Tumbes, Peru in 2014. The intervention was a community-wide replacement of regular salt (100% sodium) with “Salt Liz” (75% sodium and 25% potassium) using social marketing strategies to promote the adoption and continued use of the salt substitute in daily life. The components of the social marketing campaign included entertainment educational activities and local product promoters (“Amigas de Liz”). Another component of the intervention was the Salt Liz spoon to help guide the amount of salt that families should consume. The process evaluation variables measured were the context, mechanism of action, and implementation outcomes (acceptability, fidelity and adoption, perceptions, and feedback).ResultsIn total, 60 women were interviewed, 20 with hypertension and 40 without hypertension. Regarding context, common characteristics across the four villages included residents who primarily ate their meals at home and women who were responsible for household food preparation. As the mechanism of action, most participants did not notice a difference in the flavor between regular salt and Salt Liz; those that did notice a difference took around 2 weeks to become accustomed to the taste of the salt substitute. In terms of implementation outcomes, the Salt Liz was accepted by villagers and factors explaining this acceptability included that it was perceived as a “high quality” salt and as having a positive effect on one's health. Participants recognized that the Salt Liz is healthier than regular salt and that it can help prevent or control hypertension. However, most participants could not accurately recall how the compositions of the Salt Liz and regular salt differed and the role they play in hypertension. Although the use of the Salt Liz was far-reaching at the community level, the use of the Salt Liz spoon was poor. Educational entertainment activities were well-received, and most participants enjoyed them despite not always being active participants but rather sideline observers.ConclusionThis process evaluation identifies key intervention components that enabled a successful trial. Seeking and incorporating feedback from the target population helps deepen the understanding of contextual factors that influence an intervention's success. Furthermore, feedback received can aid the development of the intervention product. Some factors that can be improved for future interventions are acknowledged.Clinical trial registrationNCT01960972.

Se buscó caracterizar la satisfacción y percepciones de los residentes de Lima Metropolitana sobre distintos aspectos de la ciudad que pueden afectar su calidad de vida y salud, identificando diferencias por nivel socioeconómico (NSE) y cambios en el tiempo. Se realizó un análisis secundario de la Encuesta «Lima Cómo Vamos» entre 2010 y 2019, reportando los resultados mediante porcentajes, con diferencias entre NSE para cada año y entre años. En 2019 la satisfacción y percepciones eran mayoritariamente desfavorables, y han disminuido hasta en 30 puntos porcentuales con el tiempo. Las personas de NSE más bajos tenían valoraciones más desfavorables y con mayores reducciones en el tiempo. Esta insatisfacción y percepciones desfavorables revelan deficiencias en servicios públicos y condiciones urbanas que podrían afectar negativamente la calidad de vida y salud, haciendo necesarias políticas que reduzcan las brechas socioeconómicas y mejoren la salud de los ciudadanos de Lima Metropolitana.

Nutritional warnings are used as a public health strategy to address obesity. Peru approved in 2013 and implemented in 2019 a law requiring nutritional warnings on the marketing and packaging of processed foods high in sugar, sodium, saturated fat, and containing trans-fat. The complexity behind the design and approval of these policies over six years provides unique learnings, that inform the obesity prevention context, especially when proposed policies face strong opposition from powerful stakeholders. Our study aims to describe the milestones and key stakeholders' roles and stances during the nutritional warnings policy design in Peru, and to identify and analyze the main drivers of policy change that explain its approval. In 2021, interviews were conducted with 25 key informants closely involved in its design. Interviews were analyzed using the Kaleidoscope Model as a theoretical framework. Relevant policy documents and news were also analyzed. Milestones for this policy included the approval of the Law, Regulation, and Manual. Policy supporters were mainly from Congress, civil society advocates, and Health Ministers. Opponents came from Congress, ministries linked to the economic sector, the food industry, and media. Across the years, warnings evolved from a single text, to traffic lights, to the approved black octagons. Main challenges included the strong opposition of powerful stakeholders, the lack of agreement for defining the appropriate evidence supporting nutritional warning parameters and design, and the political instability of the country. Based on the Kaleidoscope Model, the policy successfully targeted a relevant problem (unhealthy eating decisions) and had powerful advocates who effectively used focusing events to reposition the warnings in the policy agenda across the years. Negotiations weakened the policy but led to its approval. Importantly, government veto players were mostly in favor of the policy, which enabled its final approval despite the strong opposition.

In June 2019, mandatory front-of-package warning labels (FOPL) were implemented in Peru. The aim of the study was to describe changes in marketing strategies on packaging: marketing techniques (MT), health claims (HC), and nutritional claims (NC) on the packaging of products frequently consumed by children before and after the FOPL implementation. Product photos were taken pre- (March 2019) and post-implementation (March-October 2020) in three supermarkets in Lima, Peru. Following INFORMAS protocols and Peruvian Technical Norms, the presence of MT, HC, and NC was assessed on all package sides. Products were classified as “high-in” and “not high-in” based on the regulation threshold for critical nutrients. Differences in the proportion of products with each strategy in both periods were evaluated. Also, a subsample of products was matched according to the barcode and exact McNemar test was used to compare proportions of strategies pre/post-implementation. We included 883 and 1,035 products in pre- and post-implementation, respectively. In both periods, MT appeared on almost 70% of all products. The presence of HC increased significantly only for beverages (24.5–38.1%, p < 0.001). In both phases, NC were commonly used on beverages (>80%). Overall, the prevalence of “high-in” products using MT increased (73.6–82.1%, p = 0.007), while use of HC increased among “not high-in” products (32.9–41.6%, p < 0.001). There is a high frequency of MT on all products and NC on beverages. The increase in MT in “high-in” products may be an industry response to minimize the impact of the FOPL on food choices and sales. New regulatory aspects regarding labeling should be implemented to strengthen the current policy.

Introduction Latin America has the second-highest adolescent birth rate (ABR) worldwide. Variation between urban and rural areas and evidence linking country development to ABR points towards upstream factors in the causal pathway. We investigated variation in ABR within and between cities, and whether different features of urban social environments are associated with ABR.Methods We included 363 cities in 9 Latin American countries. We collected data on social environment at country, city and subcity levels and birth rates among adolescents (ages 15–19). We investigated variation in ABR within and between countries and cities along with associations between social environment and ABR by fitting three-level negative binomial models (subcities nested within cities nested within countries).Results The median subcity ABR was 58.5 per 1000 women 15–19 (IQR 43.0–75.3). We found significant variability in subcity ABR between countries and cities (37% of variance between countries and 47% between cities within countries). Higher homicide rates and greater population growth in cities were associated with higher ABR (rate ratio (RR) 1.09; 95% CI 1.06 to 1.12 and RR 1.02; 95% CI 1.00 to 1.04, per SD, respectively), while better living conditions and educational attainment in subcities were associated with lower ABR after accounting for other social environment characteristics (RR 0.95; 95% CI 0.92 to 0.98 and 0.78; 95% CI 0.76 to 0.79, per SD, respectively).Conclusions The large heterogeneity of ABR found within countries and cities highlights the key role urban areas have in developing local policies. Holistic interventions targeting education inequalities and living conditions are likely important to reducing ABR in cities.

BackgroundDepression is one of the most prevalent mental disorders and a leading cause of disability, disproportionately affecting specific groups, such as patients with noncommunicable diseases. Over the past decade, digital interventions have been developed to provide treatment for these patients. CONEMO (Emotional Control in Spanish) is an 18-session psychoeducational digital intervention delivered through a smartphone app and minimally supported by a nurse. CONEMO demonstrated effectiveness in reducing depressive symptoms through a randomized controlled trial (RCT) among patients with diabetes, hypertension, or both, in Lima, Peru. However, in addition to clinical outcomes, it is important to explore users’ experiences, satisfaction, and perceptions of usability and acceptability, which can affect their engagement with the intervention. ObjectiveThis study aimed to explore the RCT participants’ experiences with CONEMO in Peru, complemented with information provided by the nurses who monitored them. MethodsIn 2018, semistructured interviews were conducted with a sample of 29 (13.4%) patients from the 217 patients who participated in the CONEMO intervention in Peru and the 3 hired nurses who supported its delivery. Interviewees were selected at random based on their adherence to the digital intervention (0-5, 10-14, and 15-18 sessions completed), to include different points of view. Content analysis was conducted to analyze the interviews. ResultsParticipants’ mean age was 64.4 (SD 8.5) years, and 79% (23/29) of them were women. Most of the interviewed participants (21/29, 72%) stated that CONEMO fulfilled their expectations and identified positive changes in their physical and mental health after using it. Some of these improvements were related to their thoughts and feelings (eg, think differently, be more optimistic, and feel calmer), whereas others were related to their routines (eg, go out more and improve health-related habits). Most participants (19/29, 66%) reported not having previous experience with using smartphones, and despite experiencing some initial difficulties, they managed to use CONEMO. The most valued features of the app were the videos and activities proposed for the participant to perform. Most participants (27/29, 93%) had a good opinion about the study nurses and reported feeling supported by them. A few participants provided suggestions to improve the intervention, which included adding more videos, making the sessions’ text simple, extending the length of the intervention, and improving the training session with long explanations. ConclusionsThe findings of this qualitative study provide further support and contextualize the positive results found in the CONEMO RCT, including insights into the key features that made the intervention effective and engaging. The participants’ experience with the smartphone and CONEMO app reveal that it is feasible to be used by people with little knowledge of technology. In addition, the study identified suggestions to improve the CONEMO intervention for its future scale-up. Trial RegistrationClinicalTrials.gov NCT03026426; https://clinicaltrials.gov/ct2/show/NCT03026426

Objective To explore which resources and activities help young people living in deprived urban environments in Latin America to recover from depression and/or anxiety.Design A multimethod, qualitative study with 18 online focus groups and 12 online structured group conversations embedded into arts workshops.Setting This study was conducted in Bogotá (Colombia), Buenos Aires (Argentina) and Lima (Peru).Participants Adolescents (15–16 years old) and young adults (20–24 years old) with capacity to provide assent/consent and professionals (older than 18 years of age) that had experience of professionally working with young people were willing to share personal experience within a group, and had capacity to provide consent.Results A total of 185 participants took part in this study: 111 participants (36 adolescents, 35 young adults and 40 professionals) attended the 18 focus groups and 74 young people (29 adolescents and 45 young adults) took part in the 12 arts workshops. Eight categories captured the resources and activities that were reported by young people as helpful to overcome mental distress: (1) personal resources, (2) personal development, (3) spirituality and religion, (4) social resources, (5) social media, (6) community resources, (7) activities (subcategorised into artistic, leisure, sports and outdoor activities) and (8) mental health professionals. Personal and social resources as well as artistic activities and sports were the most common resources identified that help adolescents and young adults to overcome depression and anxiety.Conclusion Despite the different contexts of the three cities, young people appear to use similar resources to overcome mental distress. Policies to improve the mental health of young people in deprived urban settings should address the need of community spaces, where young people can play sports, meet and engage in groups, and support community organisations that can enable and facilitate a range of social activities.

Complex interventions are needed to effectively tackle non-communicable diseases. However, complex interventions can contain a mix of effective and ineffective actions. Process evaluation (PE) in public health research is of great value as it could clarify the mechanisms and contextual factors associ­ated with variation in the outcomes, better identify effective components, and inform adaptation of the intervention. The aim of this paper is to demonstrate the value of PE through five case studies that span the research cycle. The interven­tions include using digital health, salt reduction strategies, use of fixed dose combinations, and task shifting. Insights of the methods used, and the implications of the PE findings to the project, were discussed. PE of complex interventions can refute or confirm the hypothesized mechanisms of action, thereby enabling intervention refinement, and identifying implementation strategies that can address local contextual needs, so as to improve service delivery and public health outcomes.

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

Background: Mental health is an important contributor to the global burden of disease, and depression is the most prevalent mental disorder in Latin America and the Caribbean (LAC). Informal jobs, often characterized by precarious working conditions, low wages, and limited employment benefits, are also highly prevalent in LAC and may be associated with poorer mental health. Our study tests the association between informal employment and major depressive symptoms in LAC cities. Methods: We used individual-level data collected by the Development Bank of Latin America via their “Encuesta CAF” (ECAF) 2016, a cross-sectional household survey of 11 LAC cities (N = 5430). Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Short Depression Scale with possible total score ranging from 0 to 30. Scores were dichotomized, with a score >‾ 16 indicating the presence of major depressive symptoms. Informal employment was defined based on self-reported lack of contribution to the social security system. We used generalized estimating equation (GEE) log-binomial models to estimate the association between informal employment and depressive symptoms overall and by gender. Models were adjusted for age, education, and household characteristics. Results: Overall, individuals employed in informal jobs had a 27% higher prevalence of major depressive symptoms (Prevalence Ratio [PR]: 1.27; 95% Confidence Interval [CI]: 1.00, 1.62) compared to those in formal jobs. The prevalence of depressive symptoms among individuals with informal jobs was higher compared to those with formal jobs in both women (PR: 1.36, 95% CI: 1.06, 1.74) and men (PR: 1.22; 95% CI: 0.90, 1.65). Conclusions: Informal employment in LAC was associated with a higher prevalence of major depressive symptoms. It is important to develop policies aiming at reducing informal jobs and increasing universal social protection for informal workers.

Objetivo. Describir la implementación del Programa de continuidad de cuidados y rehabilitación (PCC-R) en centros de salud mental comunitaria (CSMC) del Perú. Métodos. Estudio cualitativo sobre la implementación del PCC-R en cuatro CSMC de Lima y La Libertad, Perú. Se realizaron 42 entrevistas semiestructuradas individuales y un grupo focal con cinco participantes, para un total de 47 informantes entre usuarios, familiares y profesionales vinculados al diseño, la implementación y el monitoreo del PCC-R. Resultados. El PCC-R es un programa central de los servicios de salud mental comunitaria en Perú, goza de amplia aceptación y los prestadores y usuarios refieren estar satisfechos con sus resultados. Sin embargo, el programa carece de un documento normativo que detalle sus objetivos, organización y actividades, lo que explicaría la variabilidad en su aplicación. Existen limitaciones en la gestión de recursos financieros y humanos del PCC-R y necesidades de capacitación y supervisión, que deben ser mejoradas. Existe consenso sobre la necesidad, la utilidad y la viabilidad de desarrollar un sistema de monitoreo del PCC-R. Se recogen buenas prácticas y sugerencias para enfrentar estos retos. Conclusiones. El PCC-R es un programa insignia de los CSMC y de la reforma de la salud mental en Perú, y ha logrado amplia aceptación entre los prestadores y usuarios. Su implementación combina aciertos y dificultades, y revela tareas pendientes como desarrollar un documento normativo, mejorar la gestión de recursos, fortalecer la capacitación y acompañamiento, y aplicar un sistema de monitoreo para favorecer la mejora continua del programa.

Objective. Describe the implementation of the Continuity of Care and Rehabilitation Program (PCC-R) in community mental health centers (CSMCs, Spanish acronym) in Peru. Methods. Qualitative study of the implementation of the PCC-R in four CSMCs in Lima and La Libertad, Peru. Forty-two individual semi-structured interviews were conducted, as well as a focus group with five participants, for a total of 47 informants, including users, family members, and professionals involved in the design, implementation, and monitoring of the program. Results. The PCC-R is a key program for community mental health services in Peru and it enjoys broad acceptability. Providers and users report satisfaction with its results; however, the program lacks a policy document specifying its objectives, organization, and activities. This would explain the variability in its implementation. The PCC-R has limitations in terms of management of financial and human resources, and it is necessary to improve training and supervision. There is consensus on the need, usefulness, and viability of developing a system to monitor the PCC-R. Good practices and suggestions are presented with a view to addressing these challenges. Conclusions. The PCC-R is a flagship program for the CSMCs and for mental health reform in Peru. It has achieved broad acceptability among providers and users. Its implementation combines successes and difficulties, with pending tasks that include developing a policy document, improving resource management, strengthening training and supervision, and implementing a monitoring system for continuous improvement of the program.

Summary: Peru celebrates 200 years of independence in 2021. Over this period of independent life, and despite the turbulent socio-political scenarios, from internal armed conflict to economic crisis to political instability over the last 40 years, Peru has experienced major changes on its epidemiological and population health profile. Major advancements in maternal and child health as well as in communicable diseases have been achieved in recent decades, and today Peru faces an increasing burden of non-communicable diseases including mental health conditions. In terms of the configuration of the public health system, Peru has also strived to secure country-wide optimal health care, struggling in particular to improve primary health care and intercultural services. The science and technology infrastructure has also evolved, although the need for substantial investments remains if advancing science is to be a national priority. Climate change will also bring significant challenges to population health given Peru's geographical and microclimates diversity. Looking back over the 200-years of independence, we present a summary of key advances in selected health-related fields, thus serving as the basis for reflections on pending agendas and future challenges, in order to look forward to ensuring the future health and wellbeing of the Peruvian population. Resumen (translated abstract): El Perú cumple 200 años de independencia en 2021. Durante estos dos siglos de vida independiente, junto con periodos sociales y políticos turbulentos, incluyendo un conflicto armado interno, hiperinflación y la inestabilidad política de los últimos 40 años, el Perú ha experimentado importantes cambios en su perfil epidemiológico con repercusiones directas en la salud de la población. En las últimas décadas, los indicadores de salud materno-infantil y de las enfermedades transmisibles muestran mejoría importante, pero el país se enfrenta de manera simultánea a una carga cada vez mayor de enfermedades no transmisibles y de salud mental. En cuanto a los sistemas de salud pública, se han realizado esfuerzos por aumentar la cobertura y calidad de la atención de salud en todo el país, apostándose en particular por mejorar la atención primaria. La ciencia y tecnología relacionadas con la salud también han mejorado, aunque si se quiere que la ciencia sea una prioridad nacional, son necesarias inversiones sustanciales. El cambio climático traerá importantes desafíos para la salud de la población, dada la diversidad geográfica y de microclimas del país. Para conmemorar los 200 años de vida independiente del Perú, presentamos un resumen de avances clave en diversas áreas y temas relacionados con la salud. Este repaso sirve como base para reflexionar sobre agendas y desafíos pendientes y futuros, con el fin de asegurar la salud y el bienestar de la población peruana en las próximas décadas.

El objetivo del estudio fue describir la oferta y la publicidad de alimentos y bebidas en instituciones educativas y entornos escolares de 15 colegios públicos y privados de Lima en 2019. Se realizaron observaciones inopinadas y se registraron los alimentos ofrecidos, la presencia de advertencias publicitarias, octógonos y la publicidad en quioscos y cafeterías. A la hora de salida se observó la venta ambulatoria de alimentos. Todas las escuelas ofrecían productos ultraprocesados, el 73,3% vendía alimentos con octógonos y el 60% tenía publicidad de alimentos procesados y ultraprocesados. En el 86,7% de los colegios había vendedores ambulantes de alimentos, varios de los alimentos eran productos ultraprocesados. Los resultados sugieren un ambiente alimentario no saludable dentro y alrededor de las escuelas, y el incumplimiento de la regulación actual. Resulta necesario mejorar la difusión y supervisión de la política alimentaria, y construir con las escuelas estrategias para promover una alimentación saludable.

Patients diagnosed with type 2 diabetes mellitus, who then become infected with SARS-CoV-2, are at greater risk of developing complications from COVID-19, which may even lead to death. Diabetes is a chronic condition that requires continuous contact with healthcare facilities; therefore, this type of patients should have regular access to medicines, tests and appointments with healthcare personnel. In Peru, care and treatment continuity have been affected since the national state of emergency due to COVID-19 began; because many healthcare facilities suspended outpatient consultations. The strategies presented in this study were developed by different Peruvian health providers in the pandemic context to ensure care continuity for people with diabetes. This article provides recommendations to strengthen primary healthcare, because it is the first level of healthcare contact for patients with diabetes.

Background The global burden of mental health conditions has led to the implementation of new models of care for persons with mental illness. Recent mental health reforms in Peru include the implementation of a community mental health model (CMHM) that, among its core objectives, aims to provide care in the community through specialized facilities, the community mental health centers (CMHCs). Community involvement is a key component of this model. This study aims to describe perceptions of community engagement activities in the current model of care in three CMHCs and identify barriers and potential solutions to implementation. Methods A qualitative research study using in-depth semi-structured interviews with clinicians from three CMHCs and with policy-makers involved in the implementation of the mental health reforms was conducted in two regions of Peru. The interviews, conducted in Spanish, were digitally recorded with consent, transcribed and analyzed using principles of grounded theory applying a framework approach. Community engagement activities are described at different stages of patient care. Results Twenty-five full-time employees (17 women, 8 men) were interviewed, of which 21 were clinicians (diverse health professions) from CMHCs, and 4 were policy-makers. Interviews elucidated community engagement activities currently being utilized including: (1) employing community mental health workers (CMHWs); (2) home visits; (3) psychosocial clubs; (4) mental health workshops and campaigns; and (5) peer support groups. Inadequate infrastructure and financial resources, lack of knowledge about the CMHM, poorly defined catchment areas, stigma, and inadequate productivity approach were identified as barriers to program implementation. Solutions suggested by participants included increasing knowledge and awareness about mental health and the new model, implementation of peer-training, and improving productivity evaluation and research initiatives. Conclusion Community engagement activities are being conducted in Peru as part of a new model of care. However, their structure, frequency, and content are perceived by clinicians and policy-makers as highly variable due to a lack of consistent training and resources across CMHCs. Barriers to implementation should be quickly addressed and potential solutions executed, so that scale-up best optimizes the utilization of resources in the implementation process.

BackgroundMobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development. ObjectiveThis paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both. MethodsThe economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in São Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top–down and bottom–up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds. ResultsThe economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. ConclusionsWe expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries. Trial RegistrationClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426 International Registered Report Identifier (IRRID)DERR1-10.2196/26164

Background: Financial incentives may improve the initiation and engagement of behaviour change that reduce the negative outcomes associated with non-communicable diseases. There is still a paucity in guidelines or recommendations that help define key aspects of incentive-oriented interventions, including the type of incentive (e.g. cash rewards, vouchers), the frequency and magnitude of the incentive, and its mode of delivery. We aimed to systematically review the literature on financial incentives that promote healthy lifestyle behaviours or improve health profiles, and focused on the methodological approach to define the incentive intervention and its delivery. The protocol was registered at PROSPERO on 26 July 2018 (CRD42018102556). Methods: We sought studies in which a financial incentive was delivered to improve a health-related lifestyle behaviour (e.g., physical activity) or a health profile (e.g., HbA1c in people with diabetes). The search (which took place on March 3rd 2018) was conducted using OVID (MEDLINE and Embase), CINAHL and Scopus. Results: The search yielded 7,575 results and 37 were included for synthesis. Of the total, 83.8% (31/37) of the studies were conducted in the US, and 40.5% (15/37) were randomised controlled trials. Only one study reported the background and rationale followed to develop the incentive and conducted a focus group to understand what sort of incentives would be acceptable for their study population. There was a degree of consistency across the studies in terms of the direction, form, certainty, and recipient of the financial incentives used, but the magnitude and immediacy of the incentives were heterogeneous. Conclusions: The available literature on financial incentives to improve health-related lifestyles rarely reports on the rationale or background that defines the incentive approach, the magnitude of the incentive and other relevant details of the intervention, and the reporting of this information is essential to foster its use as potential effective interventions.

Introduction Improving the mental health of young people is a global public health priority. In Latin America, young people living in deprived urban areas face various risk factors for mental distress. However, most either do not develop mental distress in the form of depression and anxiety, or recover within a year without treatment from mental health services. This research programme seeks to identify the personal and social resources that help young people to prevent and recover from mental distress.Methods and analysis A cross-sectional study will compare personal and social resources used by 1020 young people (aged 15–16 and 20–24 years) with symptoms of depression and/or anxiety and 1020 without. A longitudinal cohort study will follow-up young people with mental distress after 6 months and 1 year and compare resource use in those who do and do not recover. An experience sampling method study will intensively assess activities, experiences and mental distress in subgroups over short time periods. Finally, we will develop case studies highlighting existing initiatives that effectively support young people to prevent and recover from mental distress. The analysis will assess differences between young people with and without distress at baseline using t-tests and χ2 tests. Within the groups with mental distress, multivariate logistic regression analyses using a random effects model will assess the relationship between predictor variables and recovery.Ethics and dissemination Ethics approvals are received from Ethics Committee in Biomedical Research, Faculty of Medicine, University of Buenos Aires; Faculty of Medicine-Research and Ethics Committee of the Pontificia Universidad Javeriana, Bogotá; Institutional Ethics Committee of Research of the Universidad Peruana Cayetano Heredia and Queen Mary Ethics of Research Committee. Dissemination will include arts-based methods and target different audiences such as national stakeholders, researchers from different disciplines and the general public.Trial registration number ISRCTN72241383.

Background Mental, neurological, and substance (MNS) use disorders are a leading cause of disability worldwide; specifically in Peru, MNS affect 1 in 5 persons. However, the great majority of people suffering from these disorders do not access care, thereby making necessary the improvement of existing conditions including a major rearranging of current health system structures beyond care delivery strategies. This paper reviews and examines recent developments in mental health policies in Peru, presenting an overview of the initiatives currently being introduced and the main implementation challenges they face. Methods Key documents issued by Peruvian governmental entities regarding mental health were reviewed to identify and describe the path that led to the beginning of the reform; how the ongoing reform is taking place; and, the plan and scope for scale-up. Results Since 2004, mental health has gained importance in policies and regulations, resulting in the promotion of a mental health reform within the national healthcare system. These efforts crystallized in 2012 with the passing of Law 29889 which introduced several changes to the delivery of mental healthcare, including a restructuring of mental health service delivery to occur at the primary and secondary care levels and the introduction of supporting services to aid in patient recovery and reintegration into society. In addition, a performance-based budget was approved to guarantee the implementation of these changes. Some of the main challenges faced by this reform are related to the diversity of the implementation settings, eg, isolated rural areas, and the limitations of the existing specialized mental health institutes to substantially grow in parallel to the scaling-up efforts in order to be able to provide training and clinical support to every region of Peru. Conclusion Although the true success of the mental healthcare reform will be determined in the coming years, thus far, Peru has achieved a number of legal, policy and fiscal milestones, thereby presenting a unique and fertile environment for the expansion of mental health services.

Introduction: Understanding local complexities and challenges of stroke-related caregiving are essential to develop appropriate interventions. Our study aimed to characterize the impact of post-stroke care among informal caregivers in a setting of transitioning economy. Materials and methods: Qualitative study based on in-depth interviews with primary caregivers of stroke survivors in Lima, Peru. Transcribed data was organized around the following themes: emotional impact of caregiving, main stress factors and coping mechanisms to deal with the caregiving role, as well as the unmet needs of caregivers. Results: We interviewed twelve caregivers, mean age 52.5 years. Eight were females, who were either the spouse or child of the stroke survivor. Stroke patients had a median age of 70 years, range 53–85 years. All participants reported having experienced emotional stress and depressive symptoms as a result of caregiving. Although most had family support, reduced social activities and added unanticipated financial burdens increased caregiver's stress. None of the caregivers had received training in post-stroke care tasks after the patient's discharge and only a few had received some psychological support. Almost all expressed the need to see a professional to improve their mental health. Keeping a positive attitude towards their relative's physical post-stroke condition was a key coping mechanism. Conclusions: In the absence of structured institutional responses, family members are responsible of providing care for stroke survivors, a task escorted by major emotional, financial, and social strains. This burden could be prevented or curtailed if caregivers were to be targeted by interventions providing psychological and financial support, together with basic training on post-stroke care.

In recent decades, overweight or obesity have increased dramatically in middle- and low-income countries; a situation which consolidates chronic non-communicable diseases (NCD) as one of the leading causes of mortality and disability worldwide. Currently, half the people in Peru over the age of 15 years are overweight, and one fifth suffer from obesity. The situation is worsening and increasingly affects people in poverty, who frequently benefit from food supplement programs designed to combat food insecurity and malnutrition. There is an urgent worldwide need to find policies and programs that help fight the problem of obesity at the population level, a task that is still pending. In this article, we review the current epidemic of overweight and obesity in Peru and the world and its most significant consequences and causes, with an emphasis on access to and availability of foods. We describe the largest food supplement programs and synthesize the research on interventions in order to reflect on how their findings might help social programs work as a platform to reduce obesity and prevent NCD in Peru.

Community Kitchens (CKs) are one of the main food providers to low-income families in Peru and may encourage healthier diets. We aimed to determine the prevalence of fruit and vegetable consumption and associated sociodemographic and behavioral factors among CKs customers. A cross-sectional study enrolling customers of 48 CKs in two areas of Lima, Peru, was performed. The self-reported amount of fruits and vegetables consumed (

Background: Incentives play a role in introducing health-related benefits, but no interventions using mixed incentives, i.e. a combination of individual and group incentives, have been tested in individuals with type 2 diabetes mellitus (T2DM). We evaluated the feasibility of implementing individual- and mixed-incentives, with and without a supportive partner, on glycated haemoglobin (HbA1c) control and weight loss among patients with T2DM. Methods: This is a feasibility, sex-stratified, single-blinded, randomized controlled study in individuals with T2DM. All participants received diabetes education and tailored goal setting for weight and glycated haemoglobin (HbA1c). Participants were randomly assigned into three arms: individual incentives (Arm 1), mixed incentives-altruism (Arm 2), and mixed incentives-cooperation (Arm 3). Participants were accompanied by a diabetes educator every other week to monitor targets, and the intervention period lasted 3 months. The primary outcome was the change in HbA1c at 3 months from baseline. Weight and change body mass index (BMI) were considered as secondary outcomes. Results: Out of 783 patients screened, a total of 54 participants, 18 per study arm, were enrolled and 44 (82%) completed the 3-month follow-up. Mean baseline HbA1c values were 8.5%, 7.9% and 8.2% in Arm 1, Arm 2, and Arm 3, respectively. At 3 months, participants in all three study arms showed reductions in HbA1c ranging from -0.9% in Arm 2 to -1.4% in Arm 1. Weight and BMI also showed reductions. Conclusions: Individual and mixed cash incentives show important reductions in HbA1c, weight and BMI in patients with type 2 diabetes mellitus after 3 months. Recruitment and uptake of the intervention were successfully accomplished demonstrating feasibility to conduct larger effectiveness studies to test individual and mixed economic incentives for diabetes management. Registration: ClinicalTrials.gov Identifier NCT02891382

Background: Incentives play a role in introducing health-related benefits, but no interventions using mixed incentives, i.e. a combination of individual and group incentives, have been tested in individuals with type 2 diabetes mellitus (T2DM). We evaluated the feasibility of implementing individual- and mixed-incentives, with and without a supportive partner, on glycated haemoglobin (HbA1c) control and weight loss among patients with T2DM. Methods: This is a feasibility, sex-stratified, single-blinded, randomized controlled study in individuals with T2DM. All participants received diabetes education and tailored goal setting for weight and glycated haemoglobin (HbA1c). Participants were randomly assigned into three arms: individual incentives (Arm 1), mixed incentives-altruism (Arm 2), and mixed incentives-cooperation (Arm 3). Participants were accompanied by a diabetes educator every other week to monitor targets, and the intervention period lasted 3 months. The primary outcome was the change in HbA1c at 3 months from baseline. Weight and change body mass index (BMI) were considered as secondary outcomes. Results: Out of 783 patients screened, a total of 54 participants, 18 per study arm, were enrolled and 44 (82%) completed the 3-month follow-up. Mean baseline HbA1c values were 8.5%, 7.9% and 8.2% in Arm 1, Arm 2, and Arm 3, respectively. At 3 months, participants in all three study arms showed reductions in HbA1c ranging from -0.9% in Arm 2 to -1.4% in Arm 1. Weight and BMI also showed reductions. Conclusions: Individual and mixed cash incentives show important reductions in HbA1c, weight and BMI in patients with type 2 diabetes mellitus after 3 months. Recruitment and uptake of the intervention were successfully accomplished demonstrating feasibility to conduct larger effectiveness studies to test individual and mixed economic incentives for diabetes management. Registration: ClinicalTrials.gov Identifier NCT02891382

Background: Weight loss is important for the control of type 2 diabetes mellitus but is difficult to achieve and sustain. Programmes employing financial incentives have been successful in areas such as smoking cessation. However, the optimum design for an incentivised programme for weight loss is undetermined, and may depend on social, cultural and demographic factors. Methods: An original questionnaire was designed whose items addressed respondent personal and health characteristics, and preferences for a hypothetical incentivised weight loss programme. One hundred people with type 2 diabetes mellitus were recruited to complete the questionnaire from the endocrinology clinic of a public hospital in Lima, Peru. A descriptive analysis of responses was performed. Results: Ninety-five percent of subjects who had previously attempted to lose weight had found this either 'difficult' or 'very difficult'. Eighty-five percent of subjects would participate in an incentivised weight loss programme. Median suggested incentive for 1 kg weight loss every 2 weeks over 9 months was PEN 100 (~USD $30). Cash was preferred by 70% as payment method. Only 56% of subjects would participate in a deposit-contract scheme, and the median suggested deposit amount was PEN 20 (~USD $6). Eighty percent of subjects would share the incentive with a helper, and family members were the most common choice of helper. Conclusions: The challenge of achieving and sustaining weight loss is confirmed in this setting. Direct cash payments of PEN 100 were generally preferred, with substantial scope for involving a co-participant with whom the incentive could be shared. Employing direct financial incentives in future weight loss programmes appears to be widely acceptable among people with type 2 diabetes mellitus.

Background: This study aimed to understand the offer of mental health care at the primary care level, collecting the views of psychologists, primary health care providers (PHCPs), and patients, with a focus on health services in which patients attend regularly and who present a higher prevalence of mental disorders. Methods: A qualitative study was conducted in antenatal care, tuberculosis, HIV/AIDS, and chronic diseases services from six primary health care centers. Semi-structured interviews were conducted with psychologists, PHCPs, and patients working in or attending the selected facilities. Results: A total of 4 psychologists, 22 PHCPs, and 37 patients were interviewed. A high perceived need for mental health care was noted. PHCPs acknowledged the emotional impact physical health conditions have on their patients and mentioned that referral to psychologists was reserved only for serious problems. Their approach to emotional problems was providing emotional support (includes listening, talk about their patients’ feelings, provide advice). PHCPs identified system-level barriers about the specialized mental health care, including a shortage of psychologists and an overwhelming demand, which results in brief consultations and lack in continuity of care. Psychologists focus their work on individual consultations; however, consultations were brief, did not follow a standardized model of care, and most patients attend only once. Psychologists also mentioned the lack of collaborative work among other healthcare providers. Despite these limitations, interviewed patients declared that they were willing to seek specialized care if advised and considered the psychologist's care provided as helpful; however, they recognized the stigmatization related to seeking mental health care. Conclusions: There is a perceived need of mental health care for primary care patients. To attend these needs, PHCPs provide emotional support and refer to psychology the most severe cases, while psychologists provide one-to-one consultations. Significant limitations in the care provided are discussed.

Background: This study aimed to understand the offer of mental health care at the primary care level, collecting the views of psychologists, primary health care providers (PHCPs), and patients, with a focus on health services in which patients attend regularly and who present a higher prevalence of mental disorders. Methods: A qualitative study was conducted in antenatal care, tuberculosis, HIV/AIDS, and chronic diseases services from six primary health care centers. Semi-structured interviews were conducted with psychologists, PHCPs, and patients working in or attending the selected facilities. Results: A total of 4 psychologists, 22 PHCPs, and 37 patients were interviewed. A high perceived need for mental health care was noted. PHCPs acknowledged the emotional impact physical health conditions have on their patients and mentioned that referral to psychologists was reserved only for serious problems. Their approach to emotional problems was providing emotional support (includes listening, talk about their patients’ feelings, provide advice). PHCPs identified system-level barriers about the specialized mental health care, including a shortage of psychologists and an overwhelming demand, which results in brief consultations and lack in continuity of care. Psychologists focus their work on individual consultations; however, consultations were brief, did not follow a standardized model of care, and most patients attend only once. Psychologists also mentioned the lack of collaborative work among other healthcare providers. Despite these limitations, interviewed patients declared that they were willing to seek specialized care if advised and considered the psychologist's care provided as helpful; however, they recognized the stigmatization related to seeking mental health care. Conclusions: There is a perceived need of mental health care for primary care patients. To attend these needs, PHCPs provide emotional support and refer to psychology the most severe cases, while psychologists provide one-to-one consultations. Significant limitations in the care provided are discussed.

Objectives. To evaluate the acceptability and feasibility of an intervention based on mobile health, for the adoption of healthy lifestyles in prehypertensive people living in low-income urban areas in Argentina, Guatemala and Peru. Materials and methods. Prehypertensive people aged 30-60 years were recruited for a pilot study. The intervention included two counseling calls made by a nutritionist followed by a weekly customized text message. An internet-based platform offered support for the implementation of the intervention. Using semi-structured interviews, we evaluated the reach and acceptability of the intervention in the participants and ease of use for the nutritionists. Results. It was possible to contact 43 of the 45 participants (95%). The average number of calls to contact a subject was two, with a range of 1-9 calls. Two participants could not be reached on their cell phone; five did not receive complete exposure to the intervention. Based on semi-structured interviews, the results showed good acceptability for the intervention by the participants. Nutritionists perceived the platform as friendly and easy to use. Barriers to deliver this intervention were related to difficulties in obtaining an adequate cellular signal. Conclusions. Given the high penetration of mobile phones in developing countries, it is concluded that it is feasible and acceptable to offer a mobile health based intervention oriented towards lifestyle modification in people with prehypertension or high risk of chronic disease intervention.

In resourced-constrained settings, daily cooking practices are still the norm. Replacing sodium in regular salt to produce potassium-enriched salts are potential alternative routes to reduce sodium intake, paired with the benefit associated with potassium intake. This change would likely have effects on palatability and taste of prepared foods, yet a threshold to discriminate sensorial changes can be determined. The main goal of this study was to assess if the use of potassium-enriched salt substitutes lead to perceived differences in taste utilizing a sensory discrimination test.A triangle taste test was conducted and participants were offered samples of cooked rice prepared with different salts. The only ingredient that differed in the preparation was the salt used: 100%NaCl (regular salt) and salts where sodium was replaced by 50%, 33% or 25% KCl (potassium-enriched salt). Comparisons were carried out according to the minimum number of correct judgments. A total of 156 subjects, 49% males, mean age 41.0 years (SD±15.5) years, participated in the study. Samples using 25% potassium-enrichment were indistinguishable in terms of taste from regular salt, whereas samples with 33% and 50% potassium-enrichment were distinguishable. Results were consistent when stratified by sex and age. Less than 10% of participants attributed the differences to bitterness or metallic flavor.The 25% potassium-enriched salt is indistinguishable from regular salt. These findings suggest a potential to achieve sodium intake reduction strategies in cooking practices by substituting regular salt with potassium-enriched salt without affecting palatability.

Interventions to promote behaviors to reduce sodium intake require messages tailored to local understandings of the relationship between what we eat and our health. We studied local explanations about hypertension, the relationship between local diet, salt intake, and health status, and participants’ opinions about changing food habits. This study provided inputs for a social marketing campaign in Peru promoting the use of a salt substitute containing less sodium than regular salt. Qualitative methods (focus groups and in-depth interviews) were utilized with local populations, people with hypertension, and health personnel in six rural villages. Participants were 18–65 years old, 41% men. Participants established a direct relationship between emotions and hypertension, regardless of age, gender, and hypertension status. Those without hypertension established a connection between eating too much/eating fried food and health status but not between salt consumption and hypertension. Participants rejected dietary changes. Economic barriers and high appreciation of local culinary traditions were the main reasons for this. It is the conclusion of this paper that introducing and promoting salt substitutes require creative strategies that need to acknowledge local explanatory disease models such as the strong association between emotional wellbeing and hypertension, give a positive spin to changing food habits, and resist the “common sense” strategy of information provision around the causal connection between salt consumption and hypertension.

In this article, the relationship between mental health and chronic non-communicable diseases is discussed as well as the possibility to address them in a comprehensive manner in the Peruvian health system. First, the prevalence estimates and the burden of chronic non-communicable diseases and mental disorders worldwide and in Peru are reviewed. Then, the detrimental impact of depression in the early stages as well as the progress of diabetes and cardiovascular diseases is described. Additionally, the gap between access to mental health care in Peru is analyzed. Lastly, the alternatives to reduce the gap are explored. Of these alternatives, the integration of mental health into primary care services is emphasized; as a feasible way to meet the care needs of the general population, and people with chronic diseases in particular, in the Peruvian context.

To characterize adherence to pharmacological medication and beliefs towards medication in a group of patients with hypertension in a large national hospital.Cross-sectional survey among patients with hypertension attending the outpatient clinic of a large national hospital. Exposure of interest was the patient's beliefs towards general medication and antihypertensive drugs, i.e. beliefs of harm, overuse, necessity and concern, measured using the Beliefs about Medication questionnaire. Main outcome was adherence measured using the Morisky Medication Adherence Scale-8. Multivariate analysis was conducted using Poisson distribution logistic regression, prevalence ratios and 95% confidence intervals were calculated.Data from 115 participants, 67% females and mean age 62.7 years were analyzed. Low adherence was found in 57.4%. Highest scores were on the ideas of necessity and one of the most rated statements was "physicians would prescribe less medication if they spent more time with patients". Beliefs of harm about medications and concerns about antihypertensive drugs were higher in the low adherence group (p

ObjectiveThis study aimed to compare self-reported weight and body mass index (BMI) in order to determine discrepancies between subjective and objective obesity-related markers, and possible explanatory factors of overweight and obesity underestimation, in urban, rural and migrant populations.Materials and methodsData from the PERU MIGRANT study, a cross-sectional study, in low-income settings, of urban, migrant (rural-to-urban), and rural groups, including BMI, self-reported weight and socio-demographic indicators were analyzed. Percentage of concurrences between BMI and self-reported weight and Kappa coefficients for inter-rater agreement were calculated. Univariate and standardized descriptive analyses were performed to identify potential explanatory variables for weight underestimation in only overweight and obese individuals, using established BMI and waist circumference cut offs.Results983 Participants-199 urban, 583 migrants and 201 rural-were analyzed. Based on BMI, overall prevalence of obesity was 20.1% (95% CI 17.6%-22.6%), and overweight was 38.3% (95% CI 35.2%-41.2%), with differences between study groups (pDiscussionOverall, high levels of overweight, obesity, and underestimation of BMI status were found, with poor agreement between BMI and self-reported weight, showing the unawareness of weight status severity in this low-income setting.

Robust evidence on interventions to improve the shortage of health workers in rural areas is needed. We assessed stated factors that would attract short-term contract nurses and midwives to work in a rural area of Peru.A discrete choice experiment (DCE) was conducted to evaluate the job preferences of nurses and midwives currently working on a short-term contract in the public sector in Ayacucho, Peru. Job attributes, and their levels, were based on literature review, qualitative interviews and focus groups of local health personnel and policy makers. A labelled design with two choices, rural community or Ayacucho city, was used. Job attributes were tailored to these settings. Multiple conditional logistic regressions were used to assess the determinants of job preferences. Then we used the best-fitting estimated model to predict the impact of potential policy incentives on the probability of choosing a rural job or a job in Ayacucho city. We studied 205 nurses and midwives. The odds of choosing an urban post was 14.74 times than that of choosing a rural one. Salary increase, health center-type of facility and scholarship for specialization were preferred attributes for choosing a rural job. Increased number of years before securing a permanent contract acted as a disincentive for both rural and urban jobs. Policy simulations showed that the most effective attraction package to uptake a rural job included a 75% increase in salary plus scholarship for a specialization, which would increase the proportion of health workers taking a rural job from 36.4% up to 60%.Urban jobs were more strongly preferred than rural ones. However, combined financial and non-financial incentives could almost double rural job uptake by nurses and midwifes. These packages may provide meaningful attraction strategies to rural areas and should be considered by policy makers for implementation.

Doctors' scarcity in rural areas remains a serious problem in Latin America and Peru. Few studies have explored job preferences of doctors working in underserved areas. We aimed to investigate doctors' stated preferences for rural jobs.A labelled discrete choice experiment (DCE) was performed in Ayacucho, an underserved department of Peru. Preferences were assessed for three locations: rural community, Ayacucho city (Ayacucho's capital) and other provincial capital city. Policy simulations were run to assess the effect of job attributes on uptake of a rural post. Multiple conditional logistic regressions were used to assess the relative importance of job attributes and of individual characteristics. A total of 102 doctors participated. They were five times more likely to choose a job post in Ayacucho city over a rural community (OR 4.97, 95%CI 1.2; 20.54). Salary increases and bonus points for specialization acted as incentives to choose a rural area, while increase in the number of years needed to get a permanent post acted as a disincentive. Being male and working in a hospital reduced considerably chances of choosing a rural job, while not living with a partner increased them. Policy simulations showed that a package of 75% salary increase, getting a permanent contract after two years in rural settings, and getting bonus points for further specialisation increased rural job uptake from 21% to 77%. A package of 50% salary increase plus bonus points for further specialisation would also increase the rural uptake from 21% to 52%.Doctors are five times more likely to favour a job in urban areas over rural settings. This strong preference needs to be overcome by future policies aimed at improving the scarcity of rural doctors. Some incentives, alone or combined, seem feasible and sustainable, whilst others may pose a high fiscal burden.

Objetivos. Evaluar la aceptabilidad y factibilidad de una intervención basada en salud móvil, para la adopción de estilos de vida saludables en personas prehipertensas que viven en zonas urbanas de bajos recursos en Argentina, Guatemala y Perú. Materiales y métodos. Se reclutaron prehipertensos entre 30 a 60 años para un estudio piloto. La intervención incluyó dos llamadas de consejería realizadas por una nutricionista, seguidas de un mensaje de texto customizado semanal. Una plataforma basada en Internet ofreció el soporte para la implementación de la intervención. Utilizando entrevistas semiestructuradas se evaluó el alcance y la aceptabilidad de esta intervención en los participantes, y la facilidad de uso en las nutricionistas. Resultados. Se logró contactar a 43 de los 45 participantes (95%). El número promedio de llamadas para contactar a un sujeto fue de dos, con un rango de 1-9 llamadas. Dos participantes pudieron ser contactados en su teléfono celular y cinco no recibieron una exposición completa a la intervención. Basados en las entrevistas semiestructuradas, los resultados mostraron una buena aceptabilidad a la intervención en los participantes. Las nutricionistas percibieron a la plataforma como amigable y de fácil manejo. Las barreras para ofrecer esta intervención se relacionaron con dificultades para obtener una señal de telefonía celular adecuada. Conclusiones. Dada la alta penetración de la telefonía celular en países en desarrollo, se concluye que una intervención basada en salud móvil es factible y aceptable para ofrecer una intervención orientada a la modificación del estilo de vida en prehipertensos o personas de alto riesgo de enfermedades crónicas.

Objetivos. Evaluar la aceptabilidad y factibilidad de una intervención basada en salud móvil, para la adopción de estilos de vida saludables en personas prehipertensas que viven en zonas urbanas de bajos recursos en Argentina, Guatemala y Perú. Materiales y métodos. Se reclutaron prehipertensos entre 30 a 60 años para un estudio piloto. La intervención incluyó dos llamadas de consejería realizadas por una nutricionista, seguidas de un mensaje de texto customizado semanal. Una plataforma basada en Internet ofreció el soporte para la implementación de la intervención. Utilizando entrevistas semiestructuradas se evaluó el alcance y la aceptabilidad de esta intervención en los participantes, y la facilidad de uso en las nutricionistas. Resultados. Se logró contactar a 43 de los 45 participantes (95%). El número promedio de llamadas para contactar a un sujeto fue de dos, con un rango de 1-9 llamadas. Dos participantes pudieron ser contactados en su teléfono celular y cinco no recibieron una exposición completa a la intervención. Basados en las entrevistas semiestructuradas, los resultados mostraron una buena aceptabilidad a la intervención en los participantes. Las nutricionistas percibieron a la plataforma como amigable y de fácil manejo. Las barreras para ofrecer esta intervención se relacionaron con dificultades para obtener una señal de telefonía celular adecuada. Conclusiones. Dada la alta penetración de la telefonía celular en países en desarrollo, se concluye que una intervención basada en salud móvil es factible y aceptable para ofrecer una intervención orientada a la modificación del estilo de vida en prehipertensos o personas de alto riesgo de enfermedades crónicas.