Publications

Decentralized agricultural systems (DAS) are essential to food security for millions of people in low-resource settings, yet most existing contaminant monitoring frameworks have been designed for centralized supply chains. This paper proposes a structured framework for integrating contaminant monitoring into DAS by (1) mapping the diverse supply chain structures and stakeholders that constitute these systems; (2) analyzing stakeholder motivations, constraints, and value propositions for monitoring adoption; and (3) identifying efficient monitoring points where these value propositions align with product quality improvement. The framework is organized around four core principles: tiered monitoring matched to supply chain position and stakeholder capacity, monitoring at stakeholder handoff points rather than within individual segments, incentive structures that make monitoring self-sustaining, and capacity building and governance as durable infrastructure. The framework is illustrated through the case of maize and aflatoxin contamination in Guatemala. It remains a conceptual framework, however, and its principles are intended to be generalizable across crops, contaminants, and geographies rather than demonstrated to be so. Empirical validation across these dimensions remains a necessary next step. The central argument is that through this framework, small, strategically placed incentives at high-leverage points in decentralized supply chains can shift system-wide quality outcomes. This can occur without requiring top-down regulatory enforcement, which is often neither feasible nor effective in these contexts.

Background: Stunting is a pervasive issue in low‑ and middle‑income countries, reflecting biological processes that adversely affect childhood cognitive development and increase the risk of chronic disease in adulthood. Nutritional intake is an important causative factor in stunting. Understanding the nutritional intake patterns of children with stunting can help inform nutrition program development. Objective: To characterize breastfeeding and dietary patterns from a clinical cohort of children with stunting in Guatemala and identify factors associated with linear growth. Methods: We included children with at least one diet record and one length/height‑for‑age z‑score below -2 from ages 0-5 years. We excluded children enrolled in complex care for severe non‑nutritional illness and records from prior to 6 months of age. We described adherence to World Health Organization infant and young child feeding indicators upon program enrollment. We longitudinally characterized breastfeeding and complementary feeding patterns of the cohort using generalized additive mixed modeling. We identified and quantified associations between various nutritional factors and linear growth using linear mixed effects models. Results: The final analytical dataset included 19,476 patient encounters from 2,352 children. Most children did not meet World Health Organization standards for dietary adequacy upon enrollment in the program. Dietary intakes were predominantly carbohydrate‑based. The factors most strongly associated with linear growth were food insecurity (negatively associated), portion size, and continued breastfeeding from 12 to 23 months. Adherence to the infant and young child feeding indicators was positively associated with linear growth. The intake of most food groups was also positively associated with linear growth. Conclusions: These findings suggest that the nutritional focus of interventions should be on adequate dietary diversity, earlier introduction and higher frequency of the less frequently consumed food groups, age‑appropriate portion sizes, and breastfeeding through 2 years of age. Public policy measures to address food insecurity are also necessary.

Elevated low-density lipoprotein cholesterol (LDL-C) is a modifiable risk factor for cardiovascular disease, the leading cause of premature death worldwide. Assessing the LDL-C-related burden is critical for guiding prevention and treatment strategies. To estimate the global, regional, and national burden of ischemic heart disease and ischemic stroke attributable to elevated LDL-C (relative to 35-54 mg/dL) from 1990 to 2023 and to quantify the contributions of population growth, aging, risk-deleted burden, and exposure changes to burden trends. This comparative risk assessment, part of the Global Burden of Disease Study 2023, estimated population-level LDL-C exposure and associated health loss in 204 countries and territories. Mean LDL-C levels were estimated using spatiotemporal gaussian process regression based on 806 studies across 161 countries. Relative risks were derived from meta-analyses of 38 randomized clinical trials. Population-attributable fractions for deaths and disability-adjusted life-years (DALYs) were estimated by age and sex for adults aged 25 years or older from 1990 to 2023, with 95% uncertainty intervals. Population-level LDL-C concentrations. Population-attributable fractions, counts, and rates (all ages and age standardized per 100 000) of LDL-C-attributable deaths and DALYs from ischemic heart disease and ischemic stroke, with uncertainty intervals. In 2023, elevated LDL-C accounted for 3.6 million deaths (95% uncertainty interval, 2.2-5.4 million; 6.0% of global mortality) and 90.7 million DALYs (95% uncertainty interval, 58.9-123.3 million; 3.2% of DALYs). Although global all-ages rates remained stable, age-standardized death and DALY rates decreased by 45.6% and 39.5%, respectively, since 1990. In 2023, age-standardized LDL-C-attributable DALY rates were highest in Eastern Europe and lowest in high-income Asia-Pacific. One-third of the global LDL-C burden occurred in India and China. Population growth and aging drove the increasing burden, with notable regional disparities in LDL-C exposure and risk-deleted DALY rates shifting toward middle-sociodemographic settings. Despite declining age-standardized rates, the absolute LDL-C burden has increased since 1990 due to demographic changes and has shifted toward middle-sociodemographic countries. Measurement and surveillance gaps persist. Strengthened prevention, diagnosis, and treatment access strategies are essential to mitigate the health burden of LDL-C.

Management of debridement-eligible thermal burns requires accurate removal of devitalized tissue. Tangential excision remains limited by imprecise depth assessment beneath opaque eschar, risking unintended dermal sacrifice. Bromelain-based enzymatic debridement (BBD) has emerged as an alternative; however, its impact on patient-level surgical outcomes has not been rigorously quantified in randomized trials. A systematic review and meta-analysis of randomized trials compared BBD with standard of care (SOC) in acute deep thermal burns. The primary outcome was the proportion requiring surgical excision. Random-effects models pooled effects. A prespecified sensitivity analysis evaluated a wound-level trial. Risk of bias was assessed using the Cochrane RoB 2 tool. Five randomized trials met criteria. Four reporting per-patient outcomes contributed to the primary meta-analysis (n = 336). BBD reduced surgical excision versus SOC (RR, 0.11; 95% CI, 0.06-0.23; I² = 0%), corresponding to an absolute risk reduction of 65% and a number needed to treat of 1.5. BBD was also associated with reduced autograft use, shorter time to debridement, and comparable or improved blinded scar assessments at 12 months. Open-label design was the principal source of potential bias. Sensitivity analysis including the wound-level trial preserved effect direction with increased heterogeneity. Randomized evidence demonstrates that, in early-treated debridement-eligible burns with limited total body surface area burned (TBSA), BBD reduces operative and graft burden without compromising wound closure or long-term remodeling. Future trials incorporating blinded operative endpoint adjudication, objective assessment of dermal preservation and broader clinical outcomes will further clarify treatment effect and optimize patient selection.

The HEARTS model (Healthy-lifestyle counseling, Evidence-based treatment protocols, Access to essential medicines and technologies, Risk-based management, Team-based care, and Systems for monitoring) is recommended by the World Health Organization and the Pan American Health Organization to improve primary care management of hypertension, diabetes, and other cardiovascular disease risk factors in national health systems. The objective of this study is to evaluate HEARTS implementation in the Ministry of Health primary care system in Guatemala, where a scale-up project covering approximately 10% of the country began in 2024. This is a prospective, observational evaluation using a hybrid type 3 effectiveness-implementation design with three sequential periods: pre-implementation, implementation, and maintenance. The six HEARTS-aligned multilevel implementation strategies are: (1) training and supportive supervision for health workers, (2) standardized treatment protocols, (3) strengthening availability of medications and diagnostics, (4) task sharing with non-physician health workers, (5) quality monitoring systems, and (6) patient engagement and community outreach. The evaluation is guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Co-primary outcomes are hypertension and diabetes treatment rates (Reach), estimated from MOH administrative data using a difference-in-differences approach comparing intervention districts with non-HEARTS comparator districts. Additional quantitative outcomes include treatment intensity and retention (Reach), disease control (Effectiveness), district-level uptake (Adoption), strategy-specific fidelity (Implementation), and sustainment of outcomes after external support concludes (Maintenance). To explain variation in quantitative outcomes, semi-structured interviews will be conducted with MOH staff, government officials, international advisors, and civil society stakeholders using an explanatory sequential mixed methods design. The study will include a cost-effectiveness analysis and budget impact analysis to inform policy decisions on scale-up and sustainability. This study will provide evidence on HEARTS implementation in Guatemala. Findings will inform decisions about national scale-up and contribute to the global evidence base on implementation of hypertension and diabetes management in primary care health systems. This study is registered on the Open Science Framework (https://osf.io/easm9).

To test the feasibility of a smartphone app, BebeApp, that provides evidence-based early childhood development (ECD) guidance in rural Guatemala and pilot procedures for an adequately powered randomised controlled trial. We conducted an individually randomised pilot feasibility trial to compare BebeApp to printed ECD guidance. This trial was conducted in Tecpán, Chimaltenango, a semi-rural community that is 95% Kaqchikel Indigenous Maya. First-time primary caregiver-infant (0-28 days) dyads. BebeApp provides age-dependent, evidence-based caregiver guidance for breastfeeding and complementary feeding, sleep and developmental support. A mixed-methods evaluation of BebeApp's implementation and acceptability using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. App usability, usefulness and satisfaction were assessed via questionnaires, semi-structured interviews and app interaction data. 41 infant-caregiver dyads were enrolled with 40 completing the study. Engagement was high with caregivers opening BebeApp a median (IQR) 11 (6-21) times per month. Usability was found to be acceptable but no difference was found between pre-measurements and post-measurements. In interviews, caregivers expressed some initial difficulty using BebeApp but were able to gain confidence with a training session. App usefulness and satisfaction responses were positive. Caregivers often noted that BebeApp was their only source of ECD information outside of their family. We found that caregivers in rural Guatemala responded positively to a smartphone ECD app and engaged with it throughout the trial. Given the urgent need for ECD programmes in low- and middle-income settings, smartphone apps may be a method to deliver services directly to caregivers.

(1) To compare the ability of body mass index (BMI), waist-to-height ratio and visceral fat, as measured by bioelectrical impedance analysis (BIA), to predict hypertension and diabetes in men and women and (2) to determine whether the correlation between BMI and visceral fat varies by height quantile. We conducted a cross-sectional analysis of a representative survey that included data on anthropometrics, body composition, glycosylated haemoglobin and blood pressure. We used receiver operating characteristic analysis and DeLong CIs to compare the ability of each adiposity measure to predict diabetes and hypertension in each gender. Tecpán and San Antonio Suchitepéquez, Guatemala. 806 non-pregnant adults from 347 households, primarily of Indigenous ethnicity. Diabetes, defined as a haemoglobin A1c of greater than 6.5% or self-reported history and hypertension, defined as a systolic blood pressure over 140 or a diastolic blood pressure over 90. Among the three adiposity measures, visceral fat was the best predictor of diabetes (area under the curve; AUC 0.73 (95% CI 0.66 to 0.81) (men); AUC 0.75 (95% CI 0.7 to 0.8) (women)) and hypertension (AUC 0.7 (95% CI 0.61 to 0.79) (men); AUC 0.76 (95% CI 0.7 to 0.82) (women)), followed by waist-to-height ratio followed by BMI. All three measures better predicted hypertension in women than in men. In sensitivity analysis, visceral fat and waist-to-height ratio better predicted hypertension and diabetes when BMI was below 30 kg/m2. The correlation between BMI and visceral fat did not vary appreciably by height. Of the three adiposity measures studied, BIA-derived visceral fat best predicted cardiometabolic disease in the population. In clinical practice, alternative techniques beyond BMI need to be considered when assessing adiposity, screening for cardiometabolic disease and diagnosing clinical obesity.

Most countries in Latin America have committed to adopting HEARTS, PAHO's recommended approach for managing hypertension and diabetes in national primary care health systems. This study aimed to understand and refine a HEARTS pilot for scale-up in Guatemala. Team members conducted semi-structured interviews with 30 patients and health workers participating in a HEARTS pilot across 10 primary care facilities in Guatemala's Ministry of Health system. Researchers analyzed interviews using a combined inductive-deductive approach alongside the Tailored Implementation in Chronic Diseases framework and used convergent mixed methods to generate meta-inferences. Despite high feasibility and acceptability scores, health workers described tensions between HEARTS and competing responsibilities. Patients described rational navigation of an unreliable system, a more fitting explanation for low retention than noncompliance. Both patients and health workers understood HEARTS as another externally funded project with uncertain sustainability. Medication availability improved during the pilot, but district and facility-level incentive structures perpetuated supply unreliability. Greater absolute treatment gains for hypertension than for diabetes likely reflected health worker comfort and preexisting access to blood pressure monitoring supplies. Both patients and health workers identified education gaps. Integration of qualitative and quantitative findings suggested concrete scale-up refinements, including simplifying treatment protocols, strengthening diabetes components, focusing training on nurses, reforming central-level pharmaceutical supply policies, and securing high-level Ministry of Health commitments. A HEARTS pilot trial in Guatemala met pre-specified quantitative outcomes, but qualitative and mixed-methods approaches revealed key barriers. These findings will assist in refining HEARTS in Guatemala for planned national scale-up. ClinicalTrials.gov (NCT06080451).

To assess the cost of co-creating an adaptation of the International Guide for Monitoring Child Development (intervention for use by community health workers (CHWs)) in rural Guatemala and India. We developed survey instruments to capture the costs, from health-system and societal perspectives, of adapting the guide with local partners and international experts in the two sites. We included the costs of human resources, information technology, and infrastructure and logistic support. To improve the transparency and comparability of cost estimates, we reported the required resources for adaptation, such as time and expertise of human resources, and the quantity, function and usage time of the resources used. Adaptation of the guide took 14 months in India and 18 months in Guatemala during 2021-2022. Total costs by site were 38 174.57 United States dollars (US$) in Guatemala, US$ 39 287.15 in India and US$ 81 846.59 for international consultants. International consultants accounted for about half of the costs, and the Guatemala and India sites each accounted for about a quarter of the costs. Human resources were the largest contributor to the adaptation costs in both sites (90.1%; 34 398.20/38 174.57 in Guatemala and 94.8%; 37 262.74/39 287.15 in India) followed by infrastructure support and information technology. Since most of the required steps to adapt the guide for use by CHWs have now been done by our study, we expect future adaptation costs to be lower. The methods used in this study provide an example of how to cost intervention adaptations in the future. Évaluer le coût de la création conjointe d'une adaptation du Guide international d’observation du développement de l’enfant (intervention destinée aux agents de santé communautaire) dans les zones rurales du Guatemala et de l’Inde. Nous avons mis au point des outils d’enquête afin de recenser les coûts, d’un point de vue sociétal et du système de santé, liés à l’adaptation du guide en collaboration avec des partenaires locaux et des experts internationaux dans les deux pays. Nous avons pris en compte le coût des ressources humaines, de l’équipement informatique, de l’infrastructure et du soutien logistique. Afin d’améliorer la transparence et la comparabilité des estimations de coûts, nous avons énuméré les ressources nécessaires à l’adaptation, telles que le temps mis et l’expertise des ressources humaines, ainsi que la quantité, la fonction et la durée d’utilisation des ressources mobilisées. L’adaptation du guide a nécessité 14 mois en Inde et 18 mois au Guatemala sur la période 2021–2022. Les coûts totaux par pays étaient de 38 174,57 dollars américains (USD) au Guatemala, de 39 287,15 USD en Inde et de 81 846,59 USD pour les consultants internationaux. Ceux-ci représentaient environ la moitié des coûts, tandis que l’Inde et le Guatemala représentaient chacun environ un quart des coûts. Les ressources humaines représentaient le poste de dépenses principal dans les coûts d’adaptation dans les deux pays (90,1%; 34 398,20 / 38 174,57 au Guatemala et 94,8%; 37 262,74 / 39 287,15 en Inde), suivies de l’infrastructure et de l’équipement informatique. Dans la mesure où la plupart des étapes nécessaires à l’adaptation du guide à l’usage des agents de santé communautaire ont déjà été réalisées dans le cadre de notre étude, les futurs coûts d’adaptation devraient être inférieurs. Les méthodes appliquées dans la présente étude offrent un exemple de la façon de chiffrer le coût des adaptations d’interventions dans le futur. Evaluar el coste de la cocreación de una adaptación de la Guía Internacional para el Seguimiento del Desarrollo Infantil (intervención para su uso por trabajadores comunitarios de salud [TCS ]) en zonas rurales de Guatemala e India. Se desarrollaron instrumentos de encuesta para estimar los costes, desde las perspectivas del sistema sanitario y de la sociedad, de la adaptación de la guía con socios locales y expertos internacionales en ambos emplazamientos. Se incluyeron los costes de recursos humanos, tecnologías de la información y apoyo de infraestructura y logístico. Para mejorar la transparencia y la comparabilidad de las estimaciones de costes, se describieron los recursos necesarios para la adaptación, como el tiempo y la experiencia del personal, así como la cantidad, la función y el tiempo de uso de los recursos utilizados. La adaptación de la guía requirió 14 meses en India y 18 meses en Guatemala durante el periodo 2021-2022. Los costes totales por emplazamiento fueron de 38 174,57 dólares de los Estados Unidos (US$) en Guatemala, US$ 39 287,15 en India y US$ 81 846,59 correspondientes a consultores internacionales. Los consultores internacionales representaron aproximadamente la mitad de los costes, mientras que los emplazamientos de Guatemala e India representaron cada uno alrededor de una cuarta parte. Los recursos humanos constituyeron el principal componente de los costes de adaptación en ambos emplazamientos (90,1%; 34 398,20/38 174,57 en Guatemala y 94,8%; 37 262,74/39 287,15 en India), seguidos del apoyo a la infraestructura y de las tecnologías de la información. Dado que la mayoría de las etapas necesarias para adaptar la guía para su uso por trabajadores comunitarios de salud ya se han llevado a cabo en este estudio, se espera que los costes de adaptación futuros sean menores. Los métodos utilizados en este estudio proporcionan un ejemplo de cómo estimar los costes de adaptaciones de intervenciones en el futuro. تقييم تكلفة المشاركة في إنشاء نسخة مُعدّلة من الدليل الدولي لرصد نمو الطفل (تدخل لاستخدامها بواسطة العاملين في مجال الصحة المجتمعية (CHW) في المناطق الريفية في غواتيمالا والهند. قمنا بتطوير أدوات للمسح لرصد تكاليف تكييف الدليل، من منظور النظام الصحي والمنظور المجتمعي، بالتعاون مع شركاء محليين وخبراء دوليين في الموقعين. وقمنا بتضمين تكاليف الموارد البشرية، وتكنولوجيا المعلومات، والبنية التحتية، والدعم اللوجستي. ولتحسين شفافية تقديرات التكلفة وقابلية مقارنتها، قمنا بإعداد تقارير عن الموارد المطلوبة للتكييف، مثل وقت وخبرة الموارد البشرية، وكمية الموارد المستخدمة ووظيفتها ومدة استخدامها. استغرق تكييف الدليل 14 شهرًا في الهند و18 شهرًا في غواتيمالا خلال الفترة من 2021 إلى 2022. وبلغت التكاليف الإجمالية حسب الموقع 38174.57 دولارًا أمريكيًا في غواتيمالا، و39287.15 دولارًا أمريكيًا في الهند، و81846.59 دولارًا أمريكيًا للاستشاريين الدوليين. شكل الاستشاريون الدوليون حوالي نصف التكاليف، بينما شكلت تكاليف كل من غواتيمالا والهند حوالي ربع التكاليف. كانت الموارد البشرية المساهم الأكبر في تكاليف التكييف في كلا الموقعين (%90.1؛ 34398.20/38174.57 في غواتيمالا، و%94.8؛ 37262.74/39287.15 في الهند)، يليها دعم البنية التحتية وتكنولوجيا المعلومات. نظرًا لأن معظم الخطوات المطلوبة لتكييف الدليل لاستخدامه بواسطة العاملين في مجال الصحة المجتمعية، قد تم إنجازها في دراستنا، فإننا نتوقع انخفاض تكاليف التكييف المستقبلية. تقدم الأساليب المستخدمة في هذه الدراسة مثالًا على كيفية حساب تكاليف تكييف التدخلات في المستقبل. 旨在评估共同制定《儿童发展监测国际指南》改编版本【供危地马拉和印度农村地区的社区卫生工作者 (CHW) 采取干预措施时使用】所需成本。. 我们开发了调查工具，以从卫生系统和社会的角度计算在这两个国家聘请当地合作伙伴和国际专家改编指南所需成本。我们将人力资源成本、信息技术成本以及基础设施和后勤支助成本全部计算在内。为了提升成本估计的透明度和可比性，我们报告了改编指南所需资源（例如人力资源方面的时间投入和专门知识投入）以及所用资源的数量、功能和使用时间。. 在 2021-2022 年期间，印度和危地马拉分别历时 14 个月和 18 个月完成了指南改编工作。按现场划分算得的总成本分别为 38,174.57 美元（危地马拉）、39287.15 美元（印度）和 81846.59 美元（聘请国际顾问的花费）。聘请国际顾问的花费约占成本的一半，而危地马拉和印度两个现场的支出分别约占成本的四分之一。在两国改编成本中，占比最大的都是人力资源支出（在危地马拉占 90.1%，即 34398.20/38174.57；在印度占 94.8%，即 37262.74/39287.15），其次是在基础设施支助和信息技术方面的支出。. 由于我们现已在开展研究的过程中完成了大部分指南改编（以供 CHW 使用）相关必要步骤，我们预计未来的改编成本将会降低。我们在本次研究中所用方法为未来如何计算干预措施改编成本提供了范例。. Оценить затраты на совместное создание адаптированной версии Международного руководства по мониторингу развития детей (предназначенного для использования общинными медико-санитарными работниками (ОМСР) в сельских районах Гватемалы и Индии). Авторы разработали опросники, чтобы определить затраты (с точки зрения системы здравоохранения и общества) на адаптацию руководства с привлечением местных партнеров и международных экспертов в двух странах. В расчет включались затраты на кадровые ресурсы, информационные технологии, инфраструктуру и материально-техническую поддержку. Чтобы повысить прозрачность и обеспечить сравнимость оценок затрат, авторы представили данные о требуемых для адаптации ресурсах, таких как время, квалификация кадровых ресурсов, количество, функциональное назначение и время использования каждого из ресурсов. Адаптация руководства заняла 14 месяцев в Индии и 18 месяцев в Гватемале на протяжении 2021–2022 годов. Общие затраты составили 38 174,57 доллара США для Гватемалы, 39 287,15 доллара США для Индии и 81 846,59 доллара США на международных консультантов. Почти половина расходов пришлась на международных консультантов, а расходы на местах в Гватемале и Индии составили примерно по четверти от общей суммы. Наибольшая доля затрат в обеих странах пришлась на оплату кадровых ресурсов (90,1%, 34 398,20/38 174,57 доллара США в Гватемале и 94,8%, 37 262,74/39 287,15 доллара США в Индии), за которыми следовали инфраструктурная поддержка и информационные технологии. Поскольку большая часть шагов для адаптации руководства к использованию ОМСР была выполнена в ходе описываемого исследования, авторы полагают, что впредь затраты на адаптацию будут ниже. Методы, использованные в данном исследовании, служат примером того, каким образом оценивать затраты на адаптацию мер в будущем.

BACKGROUND: In Guatemala, childhood vaccination rates, particularly in Indigenous communities, are low due to inaccessible information and mistrust. Using a human-centered design (HCD) process with community partners, we developed CLAVE (Culturally and Linguistically Appropriate Vaccine Education), a video series on routine and human papillomavirus (HPV) immunization in Kaqchikel, K’iche’, and Spanish. Content was distributed via social media and through community health workers (CHWs). This study describes the instructional design process and assesses implementation feasibility through community-level measures of reach and engagement and acceptability among CHWs across 12 communities in the Central Highlands of Guatemala. METHOD: To develop content, we applied an HCD framework and collected iterative feedback from communities through 16 CHW interviews and nine focus group discussions with 42 community members. We implemented CLAVE in 12 communities, with four communities randomly assigned in parallel to each arm: (1) a six-week, geographically targeted social media campaign promoting CLAVE videos; (2) the same social media campaign plus CLAVE videos and complementary digital infographic job aids provided to CHWs; and (3) a control arm with no exposure to CLAVE videos or the CHW intervention. Platform analytics were used to assess the reach and engagement potential on social media, and CHW survey data were used to assess acceptability of content among CHWs. RESULTS: The CLAVE campaign reached 486,594 unique social media platform users, with over 4.1 million impressions and a high overall engagement rate reflecting multiple user interactions with content. Spanish and Kaqchikel versions reached the largest audiences, while K’iche’ content generated proportionally higher engagement and viewing rates, suggesting stronger interaction among smaller language audiences. Vaccine acceptance was high across all CHWs. Amid a high baseline, the intervention was not associated with significant differences in CHWs’ perceptions of the efficacy or importance of routine childhood vaccination or HPV vaccination, nor with knowledge measures. However, CHWs receiving CLAVE content directly were more likely to strongly agree that the HPV vaccine is safe (p < 0.05). CHWs reported high perceived usefulness and frequent utilization of CLAVE content. CONCLUSIONS: This pilot suggests that geographically targeted paid social media distribution of community-engaged, multilingual vaccine education content can achieve broad exposure, and that pairing videos with job aids can support CHW vaccine education efforts. REGISTRY: ClinicalTrials.gov, TRN: NCT06186206, Registration date: 05 January 2024.

Nixtamalization is an alkaline cooking process known to lower aflatoxin B1 (AFB1) in maize, yet reported efficacy varies (28-100% reduction). Thus, existing data are not sufficient to inform nixtamalization practices in specific local contexts. To investigate this, we conducted a controlled lab study using AFB1-contaminated Guatemalan maize to evaluate the effect of current rural Guatemalan cooking practices on the AFB1 concentration. We evaluated nine conditions varying calcium hydroxide concentration, steeping duration, maize washing, and tortilla-cooking parameters. Across all conditions, the AFB1 concentration decreased by 81%, with extended steeping achieving an 86% decrease. As expected, nixtamalization substantially increased calcium content (808.22%) with modest increases in iron, copper, and magnesium, while untargeted metabolomics identified processing-associated chemical changes and preliminary annotations to inform future targeted analysis. We demonstrate that incorporating local cooking practices into systematic laboratory evaluation provides useful food safety and nutrition data, offering a scalable model for household-level interventions in toxin-exposed populations worldwide.

BackgroundStunting is a pervasive issue in low- and middle-income countries, particularly affecting rural and Indigenous populations. Little reported data is available on the growth of clinical populations of children with stunting, including those with more severe stunting.ObjectiveThis study examines growth trajectories of children under 5 years of age from a long-standing clinical care program to address childhood stunting that provides monthly at-home growth monitoring, family food rations, nutrition counseling, micronutrient supplementation, and childhood illness management.HypothesisWe hypothesized that children with stunting are a clinically heterogeneous group, where some experience ongoing growth failure and others catch-up growth.MethodsWe utilized data from 2827 children and 38 864 height measurements. We applied superimposition by translation and rotation modeling to characterize growth patterns.ResultsMedian age at first measurement was 9 months (IQR: 3, 16) and median length of growth monitoring was 17 months (IQR: 8, 30). Median height-for-age Z-score at first measurement was -2.51 (IQR: -3.23, -1.68). There was variability in growth dynamics, with some children showing potential catch-up growth, particularly those with the lowest initial height-for-age metrics. In regression analysis, factors significantly associated with growth improvement over time included greater initial severity of stunting, male sex, and geographical region.ConclusionsThese findings underscore the heterogeneity of growth responses among stunted children and the need for individualized intervention strategies. They emphasize the necessity for ongoing investigations of both tailored clinical interventions and novel factors associated with growth variability and catch-up growth. Understanding growth patterns of stunted children under 5 years of age in Guatemala: a chart review.

Chronic heat stress and recurrent dehydration from strenuous labour in hot environments are recognised drivers of acute kidney injury among agricultural workers in Mesoamerica and may contribute to Chronic Kidney Disease of Unknown Aetiology (CKDu). This study explored how members of a long-term community-based cohort in northwest Nicaragua perceive, experience and adapt to extreme heat, within the broader context of environmental and labour changes. This qualitative study used focus group discussions with participants from a community-based cohort followed for over a decade and community members. Transcripts were analysed thematically using an interpretative approach, with trustworthiness ensured through peer debriefing, audit trails, triangulation and achievement of thematic saturation. Rural agricultural communities in northwest Nicaragua participating in a long-term community-based cohort. Participants were purposively sampled from a prospective community-based cohort and community members were invited to participate. Men and women across different age groups were invited. In total, 91 adults aged ≥18 years participated in 11 face-to-face focus groups, each comprising 8-11 men or women. Themes describing experiences of heat stress, occupational risk and adaptive responses among agricultural workers. Participants described worsening heat linked to deforestation, unsafe and inadequate water access and unrealistic production targets that prioritised output over health. In response, workers reported adaptive practices including self-paced labour, hydration routines and peer monitoring. Community solidarity and mutual aid emerged as key sources of resilience despite structural constraints. Heat stress amplifies occupational hazards and exacerbates health inequities among marginalised agricultural workers. Integrating climate adaptation and equity into labour protections-ensuring access to clean water, adequate shade and fair workloads-can strengthen resilience in agricultural communities facing rising heat-related health risks.

OBJECTIVE: Our objective was to determine the prevalence of hypertension, overall and by sociodemographic factors, in a large clinical population of 13,873 primarily rural and Indigenous Guatemalan women. The purpose of the research is to present epidemiological findings that can be useful for public health planning and resource allocation. RESULTS: Overall prevalence of hypertension was 16.3% (95% CI 15.7–17.0%) and age-adjusted prevalence was 16.0% (95% CI 15.3–16.8%) using American Heart Association thresholds of 130 mmHg for systolic blood pressure and 80 mmHg for diastolic blood pressure for classification. Seventy-nine percent of those classified as hypertensive were previously undiagnosed. Hypertension prevalence increased with age and body mass index. Indigenous women and women who spoke Mayan languages both had approximately 20% lower prevalence of hypertension than non-Indigenous and Spanish-speaking women, respectively. In general, hypertension prevalence increased as likelihood of poverty decreased. Among those classified as hypertensive who had a second blood pressure reading available, 53% had elevated blood pressure on the second reading. When thresholds of 140 mmHg and 90 mmHg were used for systolic and diastolic blood pressure, respectively, overall hypertension prevalence was 5.4% (95% CI 5.0-5.8%) and age-adjusted prevalence was 6.0% (95% CI 5.4–6.6%).

Child growth failure (CGF), which includes underweight, wasting, and stunting, is among the factors most strongly associated with mortality and morbidity in children younger than 5 years worldwide. Poor height and bodyweight gain arise from a variety of biological and sociodemographic factors and are associated with increased vulnerability to infectious diseases. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 to estimate CGF prevalence, the risk of infectious diseases associated with CGF, and the disease mortality, morbidity, and overall burden associated with CGF. In this analysis we estimated the all-cause and cause-specific (diarrhoea, lower respiratory tract infections, malaria, and measles) disability-adjusted life-years (DALYs) lost and mortality associated with stunting, wasting, underweight, and CGF in aggregate. We combined the burden associated with mild, moderate, and severe forms of CGF: stunting was defined as height-for-age Z scores (HAZ) less than -1, underweight was defined as weight-for-age Z scores (WAZ) less than -1, and wasting was defined as weight-for-height Z scores (WHZ) less than -1, according to WHO Child Growth Standards. Population-level continuous distributions of HAZ, WAZ, and WHZ were estimated for 2000 to 2023 using data from surveys, literature, and individual-level study data. The risk of incidence of, and mortality due to, diarrhoea, lower respiratory infections, malaria, and measles was separately estimated in a meta-regression framework from longitudinal cohort data for Z scores less than -1. Finally, fatal outcomes associated with these diseases were estimated with vital registration, verbal autopsy, and case-fatality data, while non-fatal outcomes were estimated with surveys as well as health-care utilisation and case reporting data. The exposure prevalence and relative risk estimates were from continuous distributions, allowing for direct assessment of the attributable fractions for mild, moderate, and severe stunting, underweight, wasting, and the combined impact of child growth failure within populations. All estimates were age-specific, sex-specific, geography-specific, and year-specific. We estimated that, in children younger than 5 years in 2023, CGF was associated with 79·4 million (95% uncertainty interval [UI] 47·0-106) DALYs lost and 880 000 (517 000-1 170 000) deaths. This represented 17·9% (10·6-23·8) of 444 million (434-457) total under-5 DALYs and 18·8% (11·1-25·0) of all 4·67 million (4·59-4·75) under-5 deaths. Compared to stunting (33·0 million [24·1-42·2] DALYs, 373 000 [272 000-477 000] deaths) and wasting (39·2 million [23·8-53·0] DALYs, 428 000 [256 000-583 000] deaths), childhood underweight was associated with the largest share of CGF-related disease burden: 52·2 million (21·9-75·1) DALYs and 573 000 (236 000-824 000) deaths in children younger than 5 years in 2023. CGF remains a leading factor associated with death and disability in children younger than 5 years, despite global attention and focused interventions to reduce the prevalence of associated CGF indicators. Our findings underscore the need for policies, strategies, and interventions that focus on all indicators of CGF to reduce its associated health burden. Gates Foundation.

There is worldwide interest in determining whether frequent egg provision during complementary feeding enhances child development and growth in low-resource settings. We evaluated effects of adding one whole egg per day to local standard nutrition care on infant outcomes. The Saqmolo' Project individually randomized, partially blinded, comparative effectiveness clinical trial was conducted in rural Guatemala from 2021 to 2023. Maya infants aged 6-9 months were randomized to standard nutrition care alone (growth monitoring, complementary and responsive feeding education, deworming medication, multiple micronutrient powders, and referrals for medical care) versus standard care plus one whole egg per day for 6 months. Mixed linear or logistic regression models were used to estimate between-group differences in primary (global development score) and secondary (growth, anemia status, and diet quality) outcomes. This trial included 1200 Maya infants (51.3% male). After adjustment for baseline values and participant characteristics, there was no significant between-group difference in global development score (β -0.08 points [95% CI -0.22 to 0.06]). There were also no significant between-group differences for most secondary outcomes. Intervention participants did have significantly higher odds of stunting (odds ratio [OR] 1.42 [95% CI 1.10-1.82]; p = 0.007) and of meeting minimum dietary diversity (OR 1.41 [95% CI 1.20-1.65]; p < 0.001) and minimum adequate diet (OR 1.44 [95% CI 1.26-1.64]; p < 0.001) benchmarks than standard care participants. Provision of one whole egg per day in addition to standard care improved diet quality but did not benefit development, growth, or anemia status among Maya infants. Academy of Nutrition and Dietetics Foundation via an Egg Nutrition Center investigator-initiated research grant.

To assess human papillomavirus (HPV) vaccine awareness and uptake among caregivers in rural Indigenous communities in Guatemala and to identify sociodemographic predictors of vaccine unawareness and non-uptake. This cross-sectional survey was conducted across 12 rural Indigenous communities in Guatemala's Central Highlands. Using a community-engaged research approach, trained multilingual health workers administered surveys in Spanish, Kaqchikel or K'iche'. Eligible participants were adults who served as primary caregivers to children. The survey assessed HPV vaccine awareness, vaccine attitudes and uptake among those with daughters aged 8 or older. Logistic regression was used to examine predictors of vaccine unawareness and bivariate analysis explored differences in vaccine uptake. Among 602 participants (92.5% identified as Indigenous), 95% expressed willingness to vaccinate a child against cervical cancer, yet only 56% had heard of the HPV vaccine. Of the 175 participants with eligible daughters, only 33.7% reported vaccination. Indigenous identity, older age and illiteracy were significantly associated with HPV vaccine unawareness. Speaking an Indigenous language at home was associated with greater awareness. Departmental differences were significant: participants from Sololá were more likely to be unaware of the vaccine, while those from Sacatepéquez had higher awareness and uptake. Community partners noted that access to information, geographic connectivity and social desirability may influence both awareness and response accuracy. Despite strong willingness to vaccinate, significant knowledge gaps persist among Indigenous caregivers. Tailored, community-informed education strategies-delivered through trusted channels and adapted linguistically and culturally-are urgently needed to increase awareness and uptake of the HPV vaccine in underserved Guatemalan communities.

[Abstract not available]

Chronic kidney disease (CKD) is common and ranks among the leading causes of mortality and morbidity. This analysis aimed to present global CKD estimates using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 to inform evidence-based policies for CKD identification and treatment. This analysis focused on adults aged 20 years and older over the period 1990 to 2023, from 204 countries and territories. Data sources used were published literature, vital registration systems, kidney failure treatment registries, and household surveys. Estimates of CKD burden, including deaths, incidence, prevalence, and disability-adjusted life-years (DALYs), were produced using a Cause of Death Ensemble model and a Bayesian meta-regression analytical tool. A comparative risk assessment approach estimated the proportion of cardiovascular deaths attributable to impaired kidney function and estimated risk factors for CKD. Globally, in 2023, 788 million (95% uncertainty interval 743-843) people aged 20 years and older were estimated to have CKD, up from 378 million (354-407) in 1990. The global age-standardised prevalence of CKD in adults was 14·2% (13·4-15·2), a relative rise of 3·5% (2·7-4·1) from 1990. The region with the highest age-standardised prevalence was north Africa and the Middle East (18·0%; 16·9-19·4). Most people had stage 1-3 CKD, with a combined prevalence of 13·9% (13·1-15·0). In 2023, CKD was the ninth leading cause of death globally, accounting for 1·48 million (1·30-1·65) deaths, and the 12th leading cause of DALYs, with an age-standardised DALY rate of 769·2 (691·8-857·4) per 100 000. Impaired kidney function as a risk factor accounted for 11·5% (8·4-14·5) of cardiovascular deaths. High fasting plasma glucose, body-mass index, and systolic blood pressure were all leading risk factors for CKD DALYs. CKD is a major global health issue, with rising prevalence and increasing importance as a cause of death and as a risk factor for cardiovascular death. A better understating of aetiology, appropriate screening, and implementation programmes are needed to translate advances in CKD treatment into improved patient outcomes. Gates Foundation, Wellcome, US National Kidney Foundation, and US National Institute of Diabetes and Digestive and Kidney Diseases.

This study presents a technical framework for real-time fetal Doppler data quality assessment using deep learning and edge-AI, designed to improve data collection and support future clinical studies in low-resource settings. Integrated into a low-cost, edge-computing system co-designed with Indigenous midwives in rural Guatemala, our solution utilizes an Android phone for data acquisition and decision support. Retrospective analysis demonstrates the potential to detect fetal growth restriction, hypertension, and other pregnancy-related conditions using Doppler-based fetal cardiac signals. To ensure accurate assessments and provide immediate feedback, a real-time signal quality metric is essential. We analyzed two fetal Doppler datasets: 191 recordings, captured in rural Guatemala, for training and validation, and five captured in a German hospital (in Leipzig) for testing. The data were segmented into 3.75 s intervals, and categorized into five quality levels: good, poor, radiofrequency interference, talking, and silent. A deep neural network was trained on these segments, achieving a micro F 1 score of 97.4% and a macro F 1 score of 94.2%, with 99.2% accuracy for 'Good' quality in the Guatemala dataset, based on five-fold cross-validation. For the Leipzig dataset, the F 1 score was 93.3% on 'Good' quality segments, demonstrating the model's ability to generalize across different datasets. By implementing the algorithm within an Android decision-support application in an mHealth framework, we have enabled real-time feedback during signal acquisition, improving data quality at the source. This scalable, edge mHealth solution offers significant potential to enhance maternal and fetal health monitoring in the Global South, contributing to global health efforts through the integration of mobile technology, AI, and healthcare.

For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. Gates Foundation and Bloomberg Philanthropies.

Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.

Neonatal mortality remains a significant equity issue in rural Indigenous communities of Guatemala, where structural barriers and systemic discrimination impede access to quality newborn care. This field report describes a novel community-based initiative implemented by Maya Health Alliance, an Indigenous-lead NGO, to address high neonatal mortality in Maya Kaqchikel communities through a quality improvement (QI) framework. The intervention centers on home-based neonatal care delivered by trained Neonatal Technicians (NTs), supported by a co-designed smartphone application enabling early identification of neonatal danger signs, clinical decision-making, and data collection. The initiative also leverages a culturally responsive referral and patient navigation system to overcome humanistic barriers to care. Designed using QI methodology, the project applies iterative cycles to track key performance indicators such as perinatal and neonatal mortality rates, referral success rates, and the proportion of newborns receiving timely home evaluations. Since launching in 2024, the program has reached 85% of reported newborns, increased referral rates, and engaged local midwives and health staff through ongoing training and co-design efforts. However, challenges have emerged, including high prevalence of low birth weight, limitations in local hospital capacity, and discriminatory care at facilities that discourage families from accepting referrals. The intervention centers Indigenous practices by positioning TMMs at the frontline and adapting protocols to the communities' lived realities. This initiative demonstrates the potential for culturally embedded, digitally supported, and equity-focused QI interventions to improve neonatal outcomes in resource-limited Indigenous settings. Future efforts will focus on expanding staff capacity, deepening community trust, and strengthening health system partnerships. Main findings: A community-based neonatal health program that integrates traditional Maya practices, home visits, and digital decision support in rural Guatemala has improved detection of at-risk newborns and referral rates.Added knowledge: This study highlights the feasibility of combining culturally tailored care, mHealth tools, and accompaniment in Indigenous settings, while documenting significant barriers rooted in structural inequities and cultural distrust.Global health impact for policy and action: Scaling such integrated models may strengthen neonatal care in marginalized communities, but it requires systemic reforms, investment in local health systems, and respect for cultural autonomy.

Cancer is a leading cause of death globally. Accurate cancer burden information is crucial for policy planning, but many countries do not have up-to-date cancer surveillance data. To inform global cancer-control efforts, we used the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 framework to generate and analyse estimates of cancer burden for 47 cancer types or groupings by age, sex, and 204 countries and territories from 1990 to 2023, cancer burden attributable to selected risk factors from 1990 to 2023, and forecasted cancer burden up to 2050. Cancer estimation in GBD 2023 used data from population-based cancer registration systems, vital registration systems, and verbal autopsies. Cancer mortality was estimated using ensemble models, with incidence informed by mortality estimates and mortality-to-incidence ratios (MIRs). Prevalence estimates were generated from modelled survival estimates, then multiplied by disability weights to estimate years lived with disability (YLDs). Years of life lost (YLLs) were estimated by multiplying age-specific cancer deaths by the GBD standard life expectancy at the age of death. Disability-adjusted life-years (DALYs) were calculated as the sum of YLLs and YLDs. We used the GBD 2023 comparative risk assessment framework to estimate cancer burden attributable to 44 behavioural, environmental and occupational, and metabolic risk factors. To forecast cancer burden from 2024 to 2050, we used the GBD 2023 forecasting framework, which included forecasts of relevant risk factor exposures and used Socio-demographic Index as a covariate for forecasting the proportion of each cancer not affected by these risk factors. Progress towards the UN Sustainable Development Goal (SDG) target 3.4 aim to reduce non-communicable disease mortality by a third between 2015 and 2030 was estimated for cancer. In 2023, excluding non-melanoma skin cancers, there were 18·5 million (95% uncertainty interval 16·4 to 20·7) incident cases of cancer and 10·4 million (9·65 to 10·9) deaths, contributing to 271 million (255 to 285) DALYs globally. Of these, 57·9% (56·1 to 59·8) of incident cases and 65·8% (64·3 to 67·6) of cancer deaths occurred in low-income to upper-middle-income countries based on World Bank income group classifications. Cancer was the second leading cause of deaths globally in 2023 after cardiovascular diseases. There were 4·33 million (3·85 to 4·78) risk-attributable cancer deaths globally in 2023, comprising 41·7% (37·8 to 45·4) of all cancer deaths. Risk-attributable cancer deaths increased by 72·3% (57·1 to 86·8) from 1990 to 2023, whereas overall global cancer deaths increased by 74·3% (62·2 to 86·2) over the same period. The reference forecasts (the most likely future) estimate that in 2050 there will be 30·5 million (22·9 to 38·9) cases and 18·6 million (15·6 to 21·5) deaths from cancer globally, 60·7% (41·9 to 80·6) and 74·5% (50·1 to 104·2) increases from 2024, respectively. These forecasted increases in deaths are greater in low-income and middle-income countries (90·6% [61·0 to 127·0]) compared with high-income countries (42·8% [28·3 to 58·6]). Most of these increases are likely due to demographic changes, as age-standardised death rates are forecast to change by -5·6% (-12·8 to 4·6) between 2024 and 2050 globally. Between 2015 and 2030, the probability of dying due to cancer between the ages of 30 years and 70 years was forecasted to have a relative decrease of 6·5% (3·2 to 10·3). Cancer is a major contributor to global disease burden, with increasing numbers of cases and deaths forecasted up to 2050 and a disproportionate growth in burden in countries with scarce resources. The decline in age-standardised mortality rates from cancer is encouraging but insufficient to meet the SDG target set for 2030. Effectively and sustainably addressing cancer burden globally will require comprehensive national and international efforts that consider health systems and context in the development and implementation of cancer-control strategies across the continuum of prevention, diagnosis, and treatment. Gates Foundation, St Jude Children's Research Hospital, and St Baldrick's Foundation.

Chronic kidney disease (CKD) of unknown etiology (CKDu) is a form of tubulointerstitial kidney disease predominantly affecting impoverished agricultural communities in the global tropics, with major hotspots identified in Mesoamerica and South Asia. From February 14 to 16, 2024, the Consortium for the Epidemic of Nephropathy in Central America and Mexico (CENCAM) hosted the Fourth International Workshop on CKDu in Antigua, Guatemala. The workshop hosted > 100 experts of CKDu from Central America and around the world. For the first time, a panel discussion was dedicated to the ethical challenges of conducting CKDu research and interventions in low-resource communities affected by the disease. Epidemiologists, nephrologists, and scientists with expertise in community-based research and bioethics on the panel identified several key ethical considerations, primarily centered on researcher interactions with affected communities or other CKDu stakeholders. These included aligning research priorities, study designs, consent procedures, and the return of results with the needs and concerns of CKDu-affected communities; fostering equitable North-South collaboration in CKDu research; and ensuring that research findings are translated into meaningful actions to help mitigate the disease's impact, even as scientific understanding remains incomplete. The panel emphasized that affected communities, local health care systems, regional governments, and international researchers are all critical stakeholders in CKDu research. Ongoing discussion is essential to ensure that ethical considerations remain centered in response to emerging challenges and insights related to CKDu.

Indigenous languages are integral to the individual and collective identity of humankind. Health benefits of speaking Indigenous languages have been demonstrated but may also be masked by various forms of linguistic and ethnic discrimination. Guatemala has experienced a significant degree of Mayan language loss and endangerment in recent decades. Recognition of the positive associations between Mayan languages and health may positively influence their trajectory. We undertook a cross-sectional analysis of a pre-existing dataset from a clinical population of women from Central and Western Guatemala. We compared prevalence of diabetes, hypertension, obesity and underweight among Mayan- and Spanish-speaking Indigenous women, and among non-Indigenous women. We used multiple logistic regression to estimate adjusted odds ratios for each condition by language preference, controlling for confounding factors. A total of 10,876 women were included in the analysis. Indigenous speakers of Mayan languages had the lowest prevalence of diabetes, hypertension and obesity, and non-Indigenous women had the highest prevalence of underweight. After controlling for sociodemographic factors, Mayan language preference was associated with decreased odds of diabetes [aOR 0.80, 95%CI (0.67, 0.94)], hypertension [aOR 0.80, 95%CI (0.71, 0.91)] and obesity [aOR 0.82, 95%CI (0.74, 0.90)]. The reduced odds of diabetes, hypertension and obesity among women who prefer to speak Mayan languages might be explained by cultural and lifestyle factors that are inextricably tied to Mayan language use. These findings are consistent with several previous studies, although associations between Indigenous languages and obesity have been varied. Our findings strengthen the impetus to maintain the vitality of Mayan languages in Guatemala.

There has been an alarming increase in the incidence of a chronic kidney disease (CKD) of unknown etiology primarily affecting young individuals engaged in agricultural activities in Mesoamerica and South Asia. Despite extensive research over the past 2 decades, causes remain unclear. The disease is characterized by progressive loss of kidney function with the absence of heavy proteinuria and hematuria. The International Prospective Study of CKD of Unknown Etiology in Agricultural Communities (CURE study) aims to do the following: (i) identify factors associated with kidney function decline among individuals with or at risk for CKD of uncertain etiology (CKDu); (ii) better characterize the clinical phenotypes of individuals with CKDu and differentiate them from other forms of CKD; (iii) employ advanced laboratory and data analysis methods to conduct discovery science related to risk factors, biomarkers, and causal mechanisms; and (iv) establish a biorepository for future research. The CURE study is a prospective cohort study of up to 3600 participants from 7 sites in Central America and India aged 18 to 45 years with estimated glomerular filtration rate (eGFR) ≥ 20 ml/min per 1.73 m2, no evidence of diabetes, and no other known causes of CKD. Biological samples and questionnaire data are collected from participants during 4 visits at 8-month intervals. Blood, urine, and hair will be analyzed for kidney function biomarkers, trace elements, pesticides and other contaminants, untargeted metabolomics, and genetic assays. Environmental samples, collected from a subset of study participants, will be analyzed for trace elements, agrochemicals, and burning exposures. This study will provide novel information about CKDu etiology and clinical phenotypes across distinct geographies.

Chronic kidney disease of unknown etiology (CKDu) is a major health concern among outdoor manual workers in rural Central America and South Asia. The CURE study is a prospective longitudinal cohort designed to investigate CKDu's environmental risk factors through standardized exposure assessments, questionnaires, and biological and environmental sample collection. This manuscript details the development of a standardized exposure assessment protocol within the CKDu CURE Consortium. The study recruits adults (18-45 years) from CKDu hotspots across five countries, ensuring proportional representation across three eGFR categories (20-59, 60-89, ≥90 mL/min/1.73m2) and excluding participants with diabetes or other known CKD causes. The CURE study is committed to promptly returning clinically and environmentally relevant test results to participants after analysis. Exposure assessment includes demographics, healthcare access, nephrotoxic medications, infectious pathogens, and agricultural work conditions (e.g., heat stress, hydration, diet, agrochemicals, toxicants). Biological and environmental samples (water, dust, soil, wristbands) are collected considering seasonal variations. Omics analyses, including metabolomics, will investigate environmental and biological interactions. Statistical analyses will assess relationships between exposures and CKDu onset or progression, incorporating environmental mixture analyses. CURE will provide critical insights into CKDu risk factors, supporting future research and prevention strategies. A comprehensive exposure assessment will enhance understanding of environmental contributors, guiding interventions at individual, workplace, and community levels to mitigate CKDu's impact.

Organ donation and transplantation are essential for improving the quality of life of people with organ failure due to chronic diseases (e.g., chronic kidney disease) or irreparable organ damage from accidents. In Nicaragua, chronic kidney disease of unknown etiology (CKDu) has emerged as a significant public health challenge, disproportionally affecting young agricultural workers and leading to premature deaths. Despite enactment of Law 847 in 2013, which regulates organ donations and transplantation, Nicaragua faces critical challenges, including lack of awareness, inadequate infrastructure, and limited public dissemination on the value of organ donation leading to an increasing number of patients on waiting lists. To address these gaps, we conducted an online cross-sectional survey to assess the knowledge, attitudes, and practices (KAP) regarding organ donation and transplantation in Nicaragua, a lower-middle-income country. We conducted an online cross-sectional survey among 4,407 Nicaraguan residents aged 18 and above from all 15 departments and two regions between November 2022 and February 2023. Most participants were women (60.3%), people aged 18-35 years (79.9%), and residents in urban areas (62.8%). The findings revealed that only 28.6% had good knowledge regarding organ and tissue donation and transplantation, 91.9% expressed positive attitudes toward organ and tissue donation, being willing to donate regardless of religious believes (88.5%) or personal health conditions (90.0%). About 72.6% engaged in donation-related behaviors. Men, those with higher education, and unemployed participants showed greater adherence to these practices. In summary, while Nicaraguans show positive attitudes towards organ and tissue donation and transplantation, significant knowledge and supply-demand gaps persist. Targeted educational campaigns and infrastructure development are urgently needed to address these gaps, enhance public awareness, and promote organ donation, particularly in the context of CKDu´s burden on public health.

Aflatoxin B1 (AFB1) contamination of food crops pose severe public health risks, particularly in decentralized agricultural systems common in low-resource settings. Effective monitoring tools are critical for mitigating exposure, but their adoption is limited by barriers such as cost, infrastructure, and technical expertise. The objectives of this study were: (1) to evaluate common AFB1 detection methods, including enzyme-linked immunosorbent assays (ELISA) and lateral-flow assays (LFA), validated via high-performance liquid chromatography (HPLC), focusing on their suitability for possible applications in decentralized, low-resource settings; and (2) to conduct a barriers-to-use assessment for commonly available AFB1 detection methods and their applicability in low-resource settings. Among four ELISA kits, the AgraQuant Aflatoxin B1 2/50 ELISA Kit demonstrated the highest accuracy and precision, reliably quantifying AFB1 in maize and tortillas across 5-150 ppb with minimal cross-reactivity. For LFA, a smartphone-based algorithm achieved a high presence/absence accuracy rate of 84% but struggled with concentration prediction. The barriers-to-use analysis highlighted the practicality of low-cost tools like moisture readers for field screening but underscored their qualitative limitations. Advanced methods like HPLC and LC-MS offer greater precision but remain impractical due to their high costs and infrastructure requirements, suggesting a potential role for adapted ELISA or LFA methods as confirmatory approaches. These findings support the development of multi-tiered frameworks integrating affordable field tools with regional or centralized confirmatory testing. Addressing systemic barriers through capacity building, partnerships, and improved logistics will enhance AFB1 monitoring in decentralized systems, protecting public health in vulnerable communities.

The World Health Organization HEARTS Technical Package is a widely implemented global initiative to improve the primary care management of cardiovascular disease risk factors. The study's objective is to report outcomes from a pilot implementation trial of integrated hypertension and diabetes management based on the HEARTS model in Guatemala. We conducted a single-arm pilot implementation trial over six months from October 2023 to May 2024 in 11 Guatemalan Ministry of Health primary care facilities in two districts. The pilot evaluated a package of five HEARTS-aligned implementation strategies to improve the pharmacological treatment of hypertension and diabetes. The primary outcomes were feasibility and acceptability, measured through 20 structured interviews with Ministry of Health employees and by examining enrolment and retention data. Secondary outcomes included a suite of implementation and clinical outcomes, including treatment rates. When baseline data were available, we analyzed secondary outcomes as the net change from baseline or using an interrupted time series approach. The study enrolled 964 patients, of whom 58.8% had hypertension only, 30.4% had diabetes only, and 10.8% had both conditions. Surveys on feasibility and acceptability among Ministry of Health staff had a median score of 5.0 (IQR: 5.0 to 5.0) and 5.0 (IQR range: 4.8 to 5.0), respectively, exceeding the prespecified benchmark of ≥3.5. Both districts achieved the prespecified benchmark of enrolling ≥25 hypertension patients and ≥25 diabetes patients. Only 36% of patients attended a follow-up visit within three months, lower than the prespecified benchmark of ≥75%. Monthly treatment rates during the pilot increased by 22.3 (95% CI: 16.2 to 28.4; P < 0.001) and 3.5 (95% CI: -1.6 to 8.7; P = 0.17) patients per month for hypertension and diabetes, respectively. Implementation of an integrated hypertension and diabetes model based on HEARTS was generally feasible and acceptable in the Ministry of Health in Guatemala. Findings can refine national scale-up in Guatemala and inform HEARTS implementation projects in other settings.

Cardiotocography and obstetric ultrasound imaging are the standard for fetal monitoring during pregnancy and labor. These technologies are often expensive and, with very few exceptions, can only be used by highly trained personnel. Medical care during gestation differs in low- to middle-income countries (LMIC) from high-income countries. Our research has previously demonstrated that a low-cost 1D Doppler ultrasound (DUS) can be used during pregnancy to assess maternal and fetal health. However, differentiation between DUS signals from the fetal heart (FH) and umbilical cord (UC) can be challenging for untrained users. We trained a random forest classifier to detect whether 1D DUS recordings originated from FH activity or UC blood flow. This classifier was trained using the relative energy in each 10 Hz interval of the power spectrum derived from a balanced set of recordings. We used leave-one-out cross-validation to test our results. We achieved an area under the curve of 0.82 and an accuracy of 75% for identifying FH activity, and 84% for UC blood flow. It is possible to differentiate the source of the 1D Doppler ultrasound signal. Depending on the source, different clinical parameters can be analyzed, enabling more targeted assessments of maternal and fetal health.

The disadvantaged populations eGFR (estimated glomerular filtration rate) epidemiology (DEGREE) study was designed to gain insight into the burden of chronic kidney disease (CKD) of undetermined cause (CKDu) using standard protocols to estimate the general-population prevalence of low eGFR internationally. Therefore, we estimated the age-standardized prevalence of eGFR under 60 ml/min per 1.73m2 in adults aged 18-60, excluding participants with commonly known causes of CKD; an ACR (albumin/creatinine ratio) over 300 mg/g or equivalent, or self-reported or measured (HT) hypertension or (DM) diabetes mellitus, stratified by sex and location. We included population-representative surveys conducted around the world that were either designed to estimate CKDu burden or were re-analyses of large surveys. There were 60,964 participants from 43 areas across 14 countries, with data collected 2007- 2023. The highest prevalence was seen in rural men in Uddanam, India (14%) and Northwest Nicaragua (14%). Prevalence above 5% was generally only observed in rural men, with exceptions for rural women in Ecuador (6%) and parts of Uddanam (6%‒8%), and for urban men in Leon, Nicaragua (7%). Outside of Central America and South Asia, prevalence was below 2%. Our observations represent the first attempts to estimate the prevalence of eGFR under 60 without commonly known causes of CKD around the world, as an estimate of CKDu burden, and provide a starting point for global monitoring. It is not yet clear what drives the differences, but available evidence supports a high general-population burden of CKDu in multiple areas within Central America and South Asia, although the possibility that unidentified clusters of disease may exist elsewhere cannot be excluded.

The disadvantaged populations eGFR (estimated glomerular filtration rate) epidemiology (DEGREE) study was designed to gain insight into the burden of chronic kidney disease (CKD) of undetermined cause (CKDu) using standard protocols to estimate the general-population prevalence of low eGFR internationally. We estimated the age-standardised prevalence of eGFR<60ml/min/1.73m2 in adults aged 18-60, excluding participants with commonly known causes of CKD, i.e., ACR>300mg/g or equivalent, or self-reported or measured hypertension or diabetes (eGFR<60[absent HT,DM,high ACR]), and stratified by sex and location. We included population-representative surveys conducted around the world that were either designed to estimate CKDu burden or were re-analyses of large surveys. There were 60 964 participants from 43 areas across 14 countries, with data collected during 2007-2023. The highest prevalence was seen in rural men in Uddanam, India (14%) and Northwest Nicaragua (14%). Prevalence above 5% was generally only observed in rural men, with exceptions for rural women in Ecuador (6%) and parts of Uddanam (6-8%), and for urban men in Leon, Nicaragua (7%). Outside of Central America and South Asia, prevalence was below 2%. These observations represent the first attempts to estimate the prevalence of eGFR<60[absent HT,DM,high ACR] around the world, as an estimate of CKDu burden, and provide a starting point for global monitoring. It is not yet clear what drives the differences, but available evidence to date supports a high general-population burden of CKDu in multiple areas within Central America and South Asia, although the possibility that unidentified clusters of disease may exist elsewhere cannot be excluded.

Fungal toxins in local food supplies are a critical environmental health risk to communities globally. To better characterize hypothesized toxin control points among households, we conducted household surveys across four departments (first administrative division) in Guatemala. Data gathered included maize harvesting, processing, storage, and traditional nixtamalization practices. In total, n = 33 households participated in the survey and were from 4 unique departments, 17 unique municipalities, and represented 4 different languages. The results suggested that the majority of households consumed a combination of personally cultivated and purchased maize. There was significant variation in how this maize was stored, in regards to pre-processing (kernel vs whole cob), as well as storage system type. For nixtamalization, the largest differences in practices (e.g., cooking time) were based on household size while the majority of households reported practices that aligned with previously reported best practices. Lastly, all reported maize-based food products produced by households utilized the nixtamalization process except one. Current maize handling and nixtamalization practices reported by a majority of households aligned with best practices, however, with locally tailored and culturally sensitive guidance disseminated by key stakeholders, the prevalence of best practice use among households can be improved. Further community-based research on traditional farming and nixtamalization practices can improve these recommendations.

This paper introduces a novel approach to address the challenges associated with transferring blood pressure (BP) data obtained from oscillometric devices used in self-measured BP monitoring systems to integrate this data into medical health records or a proxy database accessible by clinicians, particularly in low literacy populations. To this end, we developed an automated image transcription technique to effectively transcribe readings from BP devices, ultimately enhancing the accessibility and usability of BP data for monitoring and managing BP during pregnancy and the postpartum period, particularly in low-resource settings and low-literate populations. In the designed study, the photos of the BP devices were captured as part of perinatal mobile health (mHealth) monitoring programs, conducted in four studies across two countries. The Guatemala Set 1 and Guatemala Set 2 datasets include the data captured by a cohort of 49 lay midwives from 1697 and 584 pregnant women carrying singletons in the second and third trimesters in rural Guatemala during routine screening. Additionally, we designed an mHealth system in Georgia for postpartum women to monitor and report their BP at home with 23 and 49 African American participants contributing to the Georgia I3 and Georgia IMPROVE projects, respectively. We developed a deep learning-based model which operates in two steps: LCD localization using the You Only Look Once (YOLO) object detection model and digit recognition using a convolutional neural network-based model capable of recognizing multiple digits. We applied color correction and thresholding techniques to minimize the impact of reflection and artifacts. Three experiments were conducted based on the devices used for training the digit recognition model. Overall, our results demonstrate that the device-specific model with transfer learning and the device independent model outperformed the device-specific model without transfer learning. The mean absolute error (MAE) of image transcription on held-out test datasets using the device-independent digit recognition were 1.2 and 0.8 mmHg for systolic and diastolic BP in the Georgia IMPROVE and 0.9 and 0.5 mmHg in Guatemala Set 2 datasets. The MAE, far below the FDA recommendation of 5 mmHg, makes the proposed automatic image transcription model suitable for general use when used with appropriate low-error BP devices.

The World Health Organization HEARTS Technical Package is a widely implemented global initiative to improve the primary care management of cardiovascular disease risk factors. The study's objective is to report outcomes from a pilot implementation trial of integrated hypertension and diabetes management based on the HEARTS model in Guatemala. We conducted a single-arm pilot implementation trial over 6 months from October 2023 to May 2024 in 11 Guatemalan Ministry of Health primary care facilities in two districts. The pilot evaluated a package of five HEARTS-aligned implementation strategies to improve the pharmacological treatment of hypertension and diabetes. The primary outcomes were feasibility and acceptability, measured through 20 structured interviews with Ministry of Health employees and by examining enrollment and retention. Secondary outcomes included a suite of implementation and clinical outcomes, including treatment rate. The study enrolled 964 patients, of whom 58.8% had hypertension only, 30.4% had diabetes only, and 10.8% had both conditions. Surveys on feasibility and acceptability among Ministry of Health staff had a median score of 5.0 (IQR: 5.0 to 5.0) and 5.0 (IQR range: 4.8 to 5.0), respectively, exceeding the prespecified benchmark of ≥3.5. Both districts achieved the prespecified benchmark of enrolling ≥25 hypertension patients and ≥25 diabetes patients. Only 36% of patients attended a follow-up visit within three months, lower than the prespecified benchmark of ≥75%. M treatment rates during the pilot increased by 22.3 (95% CI: 16.2 to 28.4; P<0.001) and 3.5 (95% CI: -1.6 to 8.7; P=0.17) patients per month for hypertension and diabetes, respectively. Implementation of an integrated hypertension and diabetes model based on HEARTS was generally feasible and acceptable in the Ministry of Health in Guatemala. Findings can refine national scale-up in Guatemala and inform HEARTS implementation projects in other settings.

As statistical reviewers and editors for BMJ Paediatrics Open (BMJPO), we frequently see methodological and statistical errors in articles submitted to our journal. To make a list of these common errors and propose suitable corrections, and inspired by similar efforts at other leading journals, we surveyed the statistical reviewers and editors at BMJPO to collect their 'pet peeves' and examples of best practices.(1, 2) We have divided these into seven sections: graphics; statistical significance and related issues; presentation, vocabulary, textual and tabular presentation; causality; model building, regression and choice of methods; meta-analysis; and miscellaneous. Here, we present the common errors, with brief explanations. We hope that the guidance provided here will help guide authors as they prepare their submissions to the journal, leading to higher quality and more robust research reporting.

Undetected high-risk conditions in pregnancy are a leading cause of perinatal mortality in low-income and middle-income countries. A key contributor to adverse perinatal outcomes in these settings is limited access to high-quality screening and timely referral to care. Recently, a low-cost one-dimensional Doppler ultrasound (1-D DUS) device was developed that front-line workers in rural Guatemala used to collect quality maternal and fetal data. Further, we demonstrated with retrospective preliminary data that 1-D DUS signal could be processed using artificial intelligence and deep-learning algorithms to accurately estimate fetal gestational age, intrauterine growth and maternal blood pressure. This protocol describes a prospective observational pregnancy cohort study designed to prospectively evaluate these preliminary findings. This is a prospective observational cohort study conducted in rural Guatemala. In this study, we will follow pregnant women (N =700) recruited prior to 18 6/7 weeks gestation until their delivery and early postpartum period. During pregnancy, trained nurses will collect data on prenatal risk factors and obstetrical care. Every 4 weeks, the research team will collect maternal weight, blood pressure and 1-D DUS recordings of fetal heart tones. Additionally, we will conduct three serial obstetric ultrasounds to evaluate for fetal growth restriction (FGR), and one postpartum visit to record maternal blood pressure and neonatal weight and length. We will compare the test characteristics (receiver operator curves) of 1-D DUS algorithms developed by deep-learning methods to two-dimensional fetal ultrasound survey and published clinical pre-eclampsia risk prediction algorithms for predicting FGR and pre-eclampsia, respectively. Results of this study will be disseminated at scientific conferences and through peer-reviewed articles. Deidentified data sets will be made available through public repositories. The study has been approved by the institutional ethics committees of Maya Health Alliance and Emory University.

Sensitive measures to predict neuromotor outcomes from data collected early in infancy are lacking. Measures derived from the recordings of infant movement using wearable sensors may be a useful new technique. We collected full-day leg movement of 41 infants in rural Guatemala across 3 visits between birth and 6 months of age using wearable sensors. Average leg movement rate and fuzzy entropy, a measure to describe the complexity of signals, of the leg movements' peak acceleration time series and the time series itself were derived. We tested the three measures for the predictability of infants' developmental outcome, Bayley Scales of Infant and Toddler Development III motor, language, or cognitive composite score assessed at 12 months of age. We performed quantile regressions with clustered standard errors, accounting for the multiple visits for each infant. Fuzzy entropy was associated with the motor composite score at the 0.5 quantiles; this association was not found for the other two measures. Also, no leg movement characteristic was associated with language or cognitive composite scores. We propose that the entropy of leg movement associated peak accelerations calculated from the wearable sensor data collected for a full-day can be considered as one predictor for infants' motor developmental outcome assessed with Bayley Scales of Infant and Toddler Development III at 12 months of age.

The objective of this study is to investigate the prevalence of diabetes in a clinical population of primarily Indigenous women in Guatemala. In a retrospective chart review of a clinical program serving 13,643 primarily Indigenous women in Guatemala, crude diabetes prevalence was 8.3% (95% Confidence Interval [CI]: 7.8 to 8.7) and age-adjusted diabetes prevalence was 7.9% (95% CI: 7.3 to 8.5). Among those with diabetes, 37.9% (95% CI: 35.1 to 40.8) of women were undiagnosed. Diabetes prevalence rose significantly with increasing age and was significantly higher among women with obesity (risk ratio: 1.4 [95% CI: 1.1 to 1.8]) and among women least likely to be in poverty (risk ratio: 2.0 [95% CI: 1.5 to 2.6]). Diabetes prevalence was significantly lower among Indigenous women (risk ratio: 0.7 [95% CI: 0.6 to 0.9]) and among women who spoke Mayan languages rather than Spanish (risk ratio: 0.7 [95% CI: 0.6 to 0.9]). There was no significant difference in diabetes prevalence between women who lived in rural settings and women who lived in urban settings.

Food crops around the world are commonly contaminated with Aspergillus flavus, which can produce the carcinogenic mycotoxin aflatoxin B1 (AFB1). The objective of this study is to test an X-ray irradiation sterilization method for studying AFB1 in contaminated maize samples in the laboratory. Maize that had been naturally contaminated with 300 ppb AFB1 by the growth of aflatoxigenic A. flavus was ground and then irradiated at 0.0, 1.0, 1.5, 2.0, 2.5, and 3.0 kGy. A. flavus was quantified by dilution plating on potato dextrose agar (PDA) and modified Rose Bengal media (MDRB) for viability and qPCR for gene presence. AFB1 was quantified by HPLC and ELISA. A. flavus viability, but not gene copies, significantly decreased with increasing doses of radiation (PDA: p < 0.001; MDRB: p < 0.001; qPCR: p = 0.026). AFB1 concentration did not significantly change with increasing doses of radiation (HPLC: p = 0.153; ELISA: p = 0.567). Our results imply that X-ray irradiation is an effective means of reducing viable A. flavus without affecting AFB1 concentrations. Reducing the hazard of fungal spores and halting AFB1 production at the targeted dose are important steps to safely and reproducibly move forward research on the global mycotoxin challenge.

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021-2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies. Main findings: The International Guide for Monitoring Child Development, an early childhood development support and monitoring tool, was successfully adapted for use by frontline workers in rural India and Guatemala.Added knowledge: Our Methods Forum paper uses a detailed framework to document the collaborative, co-creating process used and the adaptive decisions taken.Global health impact for policy and action: Evidence on how best to adapt and optimize early childhood interventions for frontline workers will be useful or scaling up support for children globally.

[Abstract not available]

Neonatal mortality is a global public health challenge. Guatemala has the fifth highest neonatal mortality rate in Latin America, and Indigenous communities are particularly impacted. This study aims to understand factors driving neonatal mortality rates among Maya Kaqchikel communities. We used sequential explanatory mixed methods. The quantitative phase was a secondary analysis of 2014-2016 data from the Global Maternal and Newborn Health Registry from Chimaltenango, Guatemala. Multivariate logistic regression models identified factors associated with perinatal and late neonatal mortality. A number of 33 in-depth interviews were conducted with mothers, traditional Maya midwives and local healthcare professionals to explain quantitative findings. Of 33 759 observations, 351 were lost to follow-up. There were 32 559 live births, 670 stillbirths (20/1000 births), 1265 (38/1000 births) perinatal deaths and 409 (12/1000 live births) late neonatal deaths. Factors identified to have statistically significant associations with a higher risk of perinatal or late neonatal mortality include lack of maternal education, maternal height <140 cm, maternal age under 20 or above 35, attending less than four antenatal visits, delivering without a skilled attendant, delivering at a health facility, preterm birth, congenital anomalies and presence of other obstetrical complications. Qualitative participants linked severe mental and emotional distress and inadequate maternal nutrition to heightened neonatal vulnerability. They also highlighted that mistrust in the healthcare system-fueled by language barriers and healthcare workers' use of coercive authority-delayed hospital presentations. They provided examples of cooperative relationships between traditional midwives and healthcare staff that resulted in positive outcomes. Structural social forces influence neonatal vulnerability in rural Guatemala. When coupled with healthcare system shortcomings, these forces increase mistrust and mortality. Collaborative relationships among healthcare staff, traditional midwives and families may disrupt this cycle.

Tools to accurately assess infants' neurodevelopmental status very early in their lives are limited. Wearable sensors may provide a novel approach for very early assessment of infant neurodevelopmental status. This may be especially relevant in rural and low-resource global settings. We conducted a longitudinal observational study and used wearable sensors to repeatedly measure the kinematic leg movement characteristics of 41 infants in rural Guatemala three times across full days between birth and 6 months of age. In addition, we collected sociodemographic data, growth data, and caregiver estimates of swaddling behaviors. We used visual analysis and multivariable linear mixed models to evaluate the associations between two leg movement kinematic variables (awake movement rate, peak acceleration per movement) and infant age, swaddling behaviors, growth, and other covariates. Multivariable mixed models of sensor data showed age-dependent increases in leg movement rates (2.16 [95% CI 0.80,3.52] movements/awake hour/day of life) and movement acceleration (5.04e-3 m/s2 [95% CI 3.79e-3, 6.27e-3]/day of life). Swaddling time as well as growth status, poverty status and multiple other clinical and sociodemographic variables had no impact on either movement variable. Collecting wearable sensor data on young infants in a rural low-resource setting is feasible and can be used to monitor age-dependent changes in movement kinematics. Future work will evaluate associations between these kinematic variables from sensors and formal developmental measures, such as the Bayley Scales of Infant and Toddler Development.

Mesoamerican nephropathy is a leading contributor to premature mortality in Central America. Efforts to identify the cause are hampered by difficulties in distinguishing associations with potential initiating factors from common exposures thought to exacerbate the progression of all forms of established chronic kidney disease (CKD). We explored evidence of disease onset or departure from the healthy estimated glomerular filtration rate distribution [departure from ∼eGFR(healthy)] in an at-risk population. Two community-based cohorts (adults aged 18-30 years, n = 351 and 420) from 11 rural communities in Northwest Nicaragua were followed up over 7 and 3 years respectively. We examined associations with both (i) incident CKD and (ii) the time point of departure from ∼eGFR(healthy), using a hidden Markov model. CKD occurred in men only (male incidence rate: 0.7%/year). Fifty-three (out of 1878 visits, 2.7%) and 8 (out of 1067 visits, 0.8%) episodes of probable departure from ∼eGFR(healthy) occurred in men and women, respectively. Cumulative time in sugarcane work and symptoms of excess occupational sun exposure were associated with incident CKD. The same exposures were associated with probability of departure from ∼eGFR(healthy) in time-updated analyses along with measured and self-reported weight loss, nausea, vomiting and cramps, as well as non-steroidal anti-inflammatory drug use. CKD burden in this population is high and risk factors for established disease are occupational. Additionally, a syndrome suggesting an alternative exposure is associated with evidence of disease onset supporting a possible separate unknown initiating factor for which further investigation is needed. Interventions to reduce the impact of occupational risks should be pursued meanwhile.

Improving hypertension control in low- and middle-income countries has uncertain implications across socioeconomic groups. In this study, we simulated improvements in the hypertension care cascade and evaluated the distributional benefits across wealth quintiles in 44 low- and middle-income countries using individual-level data from nationally representative, cross-sectional surveys. We raised diagnosis (diagnosis scenario) and treatment (treatment scenario) levels for all wealth quintiles to match the best-performing country quintile and estimated the change in 10-year cardiovascular disease (CVD) risk of individuals initiated on treatment. We observed greater health benefits among bottom wealth quintiles in middle-income countries and in countries with larger baseline disparities in hypertension management. Lower-middle-income countries would see the greatest absolute benefits among the bottom quintiles under the treatment scenario (29.1 CVD cases averted per 1,000 people living with hypertension in the bottom quintile (Q1) versus 17.2 in the top quintile (Q5)), and the proportion of total CVD cases averted would be largest among the lowest quintiles in upper-middle-income countries under both diagnosis (32.0% of averted cases in Q1 versus 11.9% in Q5) and treatment (29.7% of averted cases in Q1 versus 14.0% in Q5) scenarios. Targeted improvements in hypertension diagnosis and treatment could substantially reduce socioeconomic-based inequalities in CVD burden in low- and middle-income countries.

SARS-CoV-2 has impacted globally the care of chronic diseases. However, direct evidence from certain vulnerable communities, such as Indigenous communities in Latin America, is missing. We use observational data from a health district that primarily serves people of Maya K'iche' ethnicity to examine the care of type 2 diabetes in Guatemala during the pandemic. We used a parallel convergent mixed methods design. Quantitative data (n=142 individuals with diabetes) included glycated haemoglobin (HbA1c), blood pressure, body mass index and questionnaires on diabetes knowledge, self-care and diabetes distress. Quantitative data was collected at two points, at baseline and after COVID restrictions were lifted. For quantitative outcomes, we constructed multilevel mixed effects models with multiple imputation for missing data. Qualitative data included interviews with providers, supervisors and individuals living with diabetes (n=20). We conducted thematic framework analysis using an inductive approach. Quantitative data was collected between June 2019 and February 2021, with a median of 487 days between data collection points. HbA1c worsened +0.54% (95% CI, 0.14 to 0.94) and knowledge about diabetes decreased -3.54 points (95% CI, -4.56 to -2.51). Qualitatively, the most important impact of the pandemic was interruption of the regular timing of home visits and peer group meetings which were the standard of care. The deterioration of diabetes care was primarily attributed to the loss of regular contact with healthcare workers. The results emphasize the vulnerability of rural and Indigenous populations in Latin America to the suspension of chronic disease care.

The HEARTS technical package was developed by the World Health Organization to address the implementation gap in cardiovascular disease prevention in low- and middle-income countries. Guatemala is a middle-income country that is currently implementing HEARTS. National authorities in Guatemala are interested in exploring how hypertension and diabetes management can be integrated in HEARTS implementation. The objective of this study is to conduct a feasibility and acceptability pilot trial of integrated hypertension and diabetes management based on HEARTS in the publicly funded primary care system in Guatemala. A single-arm pilot trial for 6 months will be carried out in 11 Ministry of Health primary care facilities starting in September 2023. A planned sample of 100 adult patients diagnosed with diabetes (n = 45), hypertension (n = 45), or both (n = 10) will be enrolled. The intervention will consist of HEARTS-aligned components: Training health workers on healthy-lifestyle counseling and evidence-based treatment protocols, strengthening access to medications and diagnostics, training on risk-based cardiovascular disease management, team-based care and task sharing, and systems monitoring and feedback, including implementation of a facility-based electronic monitoring tool at the individual level. Co-primary outcomes of feasibility and acceptability will be assessed using an explanatory sequential mixed-methods design. Secondary outcomes include clinical effectiveness (treatment with medication, glycemic control, and blood pressure control), key implementation outcomes (adoption, fidelity, usability, and sustainability), and patient-reported outcome measures (diabetes distress, disability, and treatment burden). Using an implementation mapping approach, a Technical Advisory Committee will develop implementation strategies for subsequent scale-up planning. This trial will produce evidence on implementing HEARTS-aligned hypertension and diabetes care in the MOH primary care system in Guatemala. Results also will inform future HEARTS projects in Guatemala and other low- and middle-income countries. ClinicalTrials.gov ID NCT06080451. The trial was prospectively registered on October 12, 2023.

There are limited data on diabetes among Indigenous populations in Guatemala. In a retrospective chart review of a clinical program serving more than 13 000 primarily Indigenous women in Guatemala, age-adjusted diabetes prevalence was 7.9% (95% CI: 7.3 to 8.5), and 37.9% (95% CI: 35.1 to 40.8%) of women were undiagnosed.

To facilitate the shift from risk-factor management to primordial prevention of cardiovascular disease, the American Heart Association developed guidelines to score and track cardiovascular health (CVH). How the prevalence and trajectories of a high level of CVH across the life course compare among high- and lower-income countries is unknown. Nationally representative survey data with CVH variables (physical activity, cigarette smoking, body mass index, blood pressure, blood glucose, and total cholesterol levels) were identified in Ethiopia, Bangladesh, Brazil, England, and the US for adults (aged 18-69 years and not pregnant). Data were harmonized, and CVH metrics were scored using the American Heart Association guidelines, as high (2), moderate (1), or low (0), with the prevalence of high scores (better CVH) across the life course compared across countries. Among 28,092 adults (Ethiopia n = 7686, 55.2% male; Bangladesh n = 6731, 48.4% male; Brazil n = 7241, 47.9% male; England n = 2691, 49.5% male, and the US n = 3743, 50.3% male), the prevalence of high CVH scores decreased as country income level increased. Declining CVH with age was universal across countries, but differences were already observable in those aged 18 years. Excess body weight appeared to be the main driver of poor CVH in higher-income countries, and the prevalence of current smoking was highest in Bangladesh. Our findings suggest that CVH decline with age may be universal. Interventions to promote and preserve CVH throughout the life course are needed in all populations, tailored to country-specific time courses of the decline. In countries where the level of CVH remains relatively high, protection of whole societies from risk-factor epidemics may still be feasible. Afin de faciliter la transition de la prise en charge des facteurs de risque vers la prévention primordiale des maladies cardiovasculaires, l’American Heart Association a élaboré des lignes directrices en vue de mesurer la santé cardiovasculaire (SCV) et d’en faire le suivi. On ignore dans quelle mesure la prévalence et la trajectoire d’un niveau élevé de SCV au cours d’une vie se comparent entre les pays à revenu élevé et les pays à plus faible revenu. Des résultats de sondages représentatifs des pays concernant les variables de la SCV (activité physique, tabagisme, indice de masse corporelle, pression artérielle, glycémie et taux de cholestérol total) ont été obtenus de l’Éthiopie, du Bangladesh, du Brésil, de l’Angleterre et des États-Unis, pour des adultes âgés de 18 à 69 ans, excluant les femmes enceintes. Les données ont été harmonisées, et la SCV a été mesurée conformément aux lignes directrices de l’American Heart Association, et notée en fonction des scores suivants : élevée (2), modérée (1) ou faible (0). La prévalence de scores élevés, soit une meilleure SCV tout au long de la vie, a été comparée entre les pays. Parmi 28 092 adultes (Éthiopie, n = 7 686, 55,2 % de sexe masculin; Bangladesh, n = 6 731, 48,4 % de sexe masculin; Brésil, n = 7 241, 47,9 % de sexe masculin; Angleterre, n = 2 691, 49,5 % de sexe masculin, et États-Unis, n = 3 743, 50,3 % de sexe masculin), la prévalence de scores correspondant à une SCV élevée diminuait à mesure que le niveau de revenu du pays augmentait. La diminution de la SCV avec l’âge était universelle dans tous les pays, mais des différences étaient déjà observables chez les personnes âgées de 18 ans. Un surplus de poids corporel semblait être le principal facteur d’une faible SCV dans les pays à revenu plus élevé; la prévalence d’un tabagisme actuel était la plus élevée au Bangladesh. Nos observations laissent croire que le déclin de la SCV avec l’âge pourrait être universel. Il est nécessaire de mener des interventions adaptées à la progression du déclin dans chacun des pays en vue de favoriser et de préserver la SCV tout au long de la vie, et ce, dans toutes les populations. Dans les pays où le niveau de SCV demeure relativement élevé, il pourrait être encore possible de protéger des sociétés entières contre des épidémies liées aux facteurs de risque.

[Abstract not available]

Multiple studies have highlighted the inequities minority and Indigenous children face when accessing health care. Health and wellbeing are positively impacted when Indigenous children are educated and receive care in their maternal language. However, less is known about the association between minority or Indigenous language use and child development risks and outcomes. In this study, we provide global estimates of development risks and assess the associations between minority or Indigenous language status and early child development using the ten-item Early Child Development Index (ECDI), a tool widely used for global population assessments in children aged 3-4 years. We did a secondary analysis of cross-sectional data from 65 UNICEF Multiple Indicator Cluster Surveys (MICS) containing the ECDI from 2009-19 (waves 4-6). We included individual-level data for children aged 2-4 years (23-60 months) from datasets with ECDI modules, for surveys that captured the language of the respondent, interview, or head of household. The Expanded Graded Intergenerational Disruption Scale was used to classify household languages as dominant versus minority or Indigenous at the country level. Our primary outcome was on-track overall development, defined per UNICEF's guidelines as development being on track for at least three of the four ECDI domains (literacy-numeracy, learning, physical, and socioemotional). We performed logistic regression of pooled, weighted ECDI scores, aggregated by language status and adjusting for the covariables of child sex, child nutritional status (stunting), household wealth, maternal education, developmental support by an adult caregiver, and country-level early child education proportion. Regression analyses were done for all children aged 3-4 years with ECDI results, and separately for children with functional disabilities and ECDI results. 65 MICS datasets were included. 186 393 children aged 3-4 years had ECDI and language data, corresponding to an estimated represented population of 34 714 992 individuals. Estimated prevalence of on-track overall development as measured by ECDI scores was 65·7% (95% CI 64·2-67·2) for children from a minority or Indigenous language-speaking household, and 76·6% (75·7-77·4) for those from a dominant language-speaking household. After adjustment, dominant language status was associated with increased odds of on-track overall development (adjusted OR 1·54, 95% CI 1·40-1·71), which appeared to be largely driven by significantly increased odds of on-track development in the literacy-numeracy and socioemotional domains. For the represented population aged 2-4 years (n=11 465 601), the estimated prevalence of family-reported functional disability was 3·6% (95% CI 3·0-4·4). For the represented population aged 3-4 years with a functional disability (n=292 691), language status was not associated with on-track overall development (adjusted OR 1·02, 95% CI 0·43-2·45). In a global dataset, children speaking a minority or Indigenous language were less likely to have on-track ECDI scores than those speaking a dominant language. Given the strong positive benefits of speaking an Indigenous language on the health and development of Indigenous children, this disparity is likely to reflect the sociolinguistic marginalisation faced by speakers of minority or Indigenous languages as well as differences in the performance of ECDI in these languages. Global efforts should consider performance of measures and monitor developmental data disaggregated by language status to stimulate efforts to address this disparity. None. For the Spanish, Kaqchikel and K'iche' translations of the abstract see Supplementary Materials section.

CKD of unknown etiology (CKDu) disproportionately affects young people in Central America who lack traditional CKD risk factors (diabetes and hypertension) and has instead been variably linked to heat stress, occupational and environmental exposures, nephrotoxic medications, and/or genetic susceptibility. This study aimed to estimate the prevalence of CKD and identify risk factors for traditional CKD and CKDu in Nicaragua. Surveys and assessment for CKD markers in urine and serum were performed in 15-59 year olds in households of the León municipality of Nicaragua. The survey included questions on demographics, health behaviors, occupation, and medical history. Participants with CKD were subdivided into traditional CKD and suspected CKDu based on history of diabetes, hypertension, or other specified conditions. A multinomial logistic regression model was used to identify factors associated with traditional CKD and suspected CKDu, compared to the non-CKD reference group. In 1795 study participants, CKD prevalence was 8.6%. Prevalence in males was twofold higher than females (12% vs 6%). Of those with CKD, 35% had suspected CKDu. Both traditional CKD and CKDu were associated with male sex and increasing age. Traditional CKD was associated with a family history of CKD, history of urinary tract infections, and lower socioeconomic status, while CKDu was associated with drinking well water and a lower body mass index. Both traditional CKD and CKDu are significant burdens in this region. Our study supports previous hypotheses of CKDu etiology and emphasizes the importance of CKD screening.

The potential of chicken eggs as a nutritionally complete protein and source of key micronutrients during the first 1000 days post-conception has been progressively recognized across the globe, particularly in resource-poor settings. Fluctuation of egg nutrient content by season is relatively unknown, which may influence international food composition databases and outcomes in intervention studies using egg supplementation. To better interpret the findings of The Saqmolo' Project, we conducted comprehensive nutrient analyses on eggs produced during the wet and dry seasons in the highlands of central Guatemala. We randomly collected 36 shell eggs from a local farm during both seasons, hard-boiled, and prepared them for transport to the United States, where they were pooled and assessed for their nutrient composition. Methods of the Association of Official Analytical Chemists, the American Oil Chemists Society, and the American Association of Cereal Chemists were utilized to determine total energy, moisture, ash, total protein, total fat, fatty acids, total carbohydrates, 12 vitamins, 11 minerals, and carotenoids, by season, in some instances with modifications. Differences in nutrient composition between de-shelled hard-boiled eggs collected between seasons were assessed using an analysis of variance (ANOVA) and Tukey's family error rate comparison test. Most nutrients in eggs produced in the highlands of central Guatemala differed negligibly (but statistically significantly) based on seasonality. Only vitamins A and E, folate, choline, and calcium fluctuated at clinically significant levels relative to the AI/RDA for infants 7-12 months. Total energy, protein, trans fatty acids, moisture, and vitamin D3 levels did not differ between seasons (p > .05). Further multi-year sampling is needed to examine how seasonal variation affects the nutrient composition of eggs. These data may be used to supplement existing national and regional food composition databases.

Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD. To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries. Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years. Countries' per capita income levels and world region; individuals' socioeconomic demographics. Self-reported use of aspirin for secondary prevention of CVD. The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.1% [95% CI, 7.6%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries. Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

With the greatest burden of cardiovascular disease morbidity and mortality increasingly observed in lower-income countries least prepared for this epidemic, focus is widening from risk factor management alone to primordial prevention to maintain high levels of cardiovascular health (CVH) across the life course. To facilitate this, the American Heart Association (AHA) developed CVH scoring guidelines to evaluate and track CVH. We aimed to compare the prevalence and trajectories of high CVH across the life course using nationally representative adult CVH data from five diverse high- to low-income countries. Surveys with CVH variables (physical activity, cigarette smoking, body mass, blood pressure, blood glucose, and total cholesterol levels) were identified in Ethiopia, Bangladesh, Brazil, England, and the United States (US). Participants were included if they were 18-69y, not pregnant, and had data for these CVH metrics. Comparable data were harmonized and each of the CVH metrics was scored using AHA guidelines as high (2), moderate (1), or low (0) to create total CVH scores with higher scores representing better CVH. High CVH prevalence by age was compared creating country CVH trajectories. The analysis included 28,092 adults (Ethiopia n=7686, 55.2% male; Bangladesh n=6731, 48.4% male; Brazil n=7241, 47.9 % male; England n=2691, 49.5% male, and the US n=3743, 50.3% male). As country income level increased, prevalence of high CVH decreased (>90% in Ethiopia, >68% in Bangladesh and under 65% in the remaining countries). This pattern remained using either five or all six CVH metrics and following exclusion of underweight participants. While a decline in CVH with age was observed for all countries, higher income countries showed lower prevalence of high CVH already by age 18y. Excess body weight appeared the main driver of poor CVH in higher income countries, while current smoking was highest in Bangladesh. Harmonization of nationally representative survey data on CVH trajectories with age in 5 highly diverse countries supports our hypothesis that CVH decline with age may be universal. Interventions to promote and preserve high CVH throughout the life course are needed in all populations, tailored to country-specific time courses of the decline. In countries where CVH remains relatively high, protection of whole societies from risk factor epidemics may still be feasible.

Mental health (MH) disorders are major causes of disability in Guatemala. Unfortunately, limited academic training and funding resources make MH care inaccessible to most people in rural Guatemala. These disparities leave many indigenous populations without care. Project ECHO™ is an educational model used globally to deliver virtual training for providers in rural/ underserved communities. The aim of this project was to implement and evaluate a Project ECHO™ program bridging MH training gaps for providers who serve rural communities in Guatemala. The Project ECHO™ curriculum was implemented through a partnership between educational and nonprofit institutions in Guatemala City and the United States. Participants were primary care physicians and nurses working in rural Guatemala as well as medical/nursing/psychology students. Evaluation of its implementation was guided by a RE-AIM framework. Reach, effectiveness, adoption, fidelity, sustainability, acceptability, feasibility, and appropriateness were evaluated using a mixed-methods approach, using a pre-post survey and semi-structured focus groups. Forty unique participants attended the five sessions. Attitudes about mental health did not change quantitatively but self-efficacy improved in four of five modules. High quality fidelity scores were noted in two of five sessions. Sustainability scores across multiple domains were highly rated. Scores on instruments measuring acceptability, feasibility, and appropriateness were high. Focus groups showed two main themes: the curriculum filled a gap in education and further adaptation of the model might help improve the experience. Implementation of the Project ECHO™ educational model appeared to have good reach/adoption, showed improvements in self-efficacy, illuminated facilitators and barriers to sustainability, and was felt to be acceptable, feasible, and appropriate. Qualitative analysis supported these conclusions. Future directions would include ongoing evaluation and monitoring of further Project ECHO™ curricular experiences through this partnership and adaptation of this project to other learners and settings in Latin America.

[Abstract not available]

Aflatoxin B1 (AFB1) is a carcinogen produced by Aspergillus flavus and Aspergillus parasiticus which grow on maize. Given the high prevalence of child stunting (ie, impaired growth) and other nutritional disorders in low-income and middle-income countries, where maize is consumed, the role of aflatoxin exposure may be significant. Observational reports have demonstrated associations between aflatoxin exposure and impaired child growth; however, most have been cross-sectional and have not assessed seasonal variations in aflatoxin, food preparation and dynamic changes in growth. Biological mechanistic data on how aflatoxin may exert an impact on child growth is missing. This study incorporates a prospective cohort of children from rural Guatemala to assess (1) temporal associations between aflatoxin exposure and child growth and (2) possible mediation of the gut microbiome among aflatoxin exposure, inflammation and child growth. We will prospectively evaluate aflatoxin exposure and height-for-age difference trajectories for 18 months in a cohort of 185 children aged 6-9 months at enrolment. We will assess aflatoxin exposure levels and biomarkers of gut and systemic inflammation. We will examine the faecal microbiome of each child and identify key species and metabolic pathways for differing AFB1 exposure levels and child growth trajectories. In parallel, we will use bioreactors, inoculated with faeces, to investigate the response of the gut microbiome to varying levels of AFB1 exposure. We will monitor key microbial metabolites and AFB1 biotransformation products to study nutrient metabolism and the impact of the gut microbiome on aflatoxin detoxification/metabolism. Finally, we will use path analysis to summarise the effect of aflatoxin exposure and the gut microbiome on child growth. Ethics approval was obtained from Arizona State University Institutional Review Board (IRB; STUDY00016799) and Wuqu' Kawoq/Maya Health Alliance IRB (WK-2022-003). Findings will be disseminated in scientific presentations and peer-reviewed publications.

We seek to understand the coexisting effects of population aging and a rising burden of diabetes on healthy longevity in South Africa. We used longitudinal data from the 2015 and 2018 waves of the "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI) study to explore life expectancy (LE) and disability-free life expectancy (DFLE) of adults aged 45 and older with and without diabetes in rural South Africa. We estimated LE and DFLE by diabetes status using Markov-based microsimulation. We find a clear gradient in remaining LE and DFLE based on diabetes status. At age 45, a man without diabetes could expect to live 7.4 [95% CI 3.4 - 11.7] more years than a man with diabetes, and a woman without diabetes could expect to live 3.9 [95% CI: 0.8 - 6.9] more years than a woman with diabetes. Individuals with diabetes lived proportionately more years subject to disability than individuals without diabetes. We find large and important decrements in disability-free aging for people with diabetes in South Africa. This finding should motivate efforts to strengthen prevention and treatment efforts for diabetes and its complications for older adults in this setting.

As of July 2022, a little over one-third of Guatemalans were fully vaccinated. While COVID-19 vaccination rates are not officially reported nationally by racial/ethnic groups, non-governmental organisations and reporters have observed that COVID-19 vaccination rates are especially low among high-risk Indigenous populations. We conducted one of the first studies on COVID-19 vaccine acceptance in Indigenous populations in the Central Highlands of Guatemala, which aimed to better understand the barriers to COVID-19 vaccine uptake and how to improve vaccine promotional campaigns. In November 2021, we conducted eight focus group discussions (FGDs) with 42 Indigenous men and women and 16 in-depth interviews (IDIs) with community health workers, nurses and physicians in Chimaltenango and Sololá. Using a participatory design approach, our qualitative analysis used constant comparative methods to understand the inductive and deductive themes from the FGD and IDI transcripts. We found three major overarching barriers to vaccination within the sampled population: (1) a lack of available easily understandable, linguistically appropriate and culturally sensitive COVID-19 vaccine information; (2) vaccine access and supply issues that prevented people from being vaccinated efficiently and quickly; and (3) widespread misinformation and disinformation that prey on people's fears of the unknown and mistrust of the medical establishment and government. When developing COVID-19 vaccine messages, content should be culturally relevant, appropriate for low-literacy populations and in the languages that people prefer to speak. Promotional materials should be in multiple modalities (print, radio and social media) and also have specific Maya cultural references (dress, food and concepts of disease) to ensure messaging connects with intended targets. This study supports the need for more robust research into best practices for communicating about COVID-19 vaccines to marginalised communities globally and suggests that policy makers should invest in targeted local solutions to increase vaccine uptake.

The burden of diabetes mellitus is increasing in low-income and middle-income countries (LMICs). Few studies have explored pathways to care among individuals with diabetes in LMICs. This study evaluates care trajectories among adults with diabetes in rural Guatemala. A qualitative investigation was conducted as part of a population-based study assessing incidence and risk factors for chronic kidney disease in two rural sites in Guatemala. A random sample of 807 individuals had haemoglobin A1c (HbA1c) screening for diabetes in both sites. Based on results from the first 6 months of the population study, semistructured interviews were performed with 29 adults found to have an HbA1c≥6.5% and who reported a previous diagnosis of diabetes. Interviews explored pathways to and experiences of diabetes care. Detailed interview notes were coded using NVivo and used to construct diagrams depicting each participant's pathway to care and use of distinct healthcare sectors. Participants experienced fragmented care across multiple health sectors (97%), including government, private and non-governmental sectors. The majority of participants sought care with multiple providers for diabetes (90%), at times simultaneously and at times sequentially, and did not have longitudinal continuity of care with a single provider. Many participants experienced financial burden from out-of-pocket costs associated with diabetes care (66%) despite availability of free government sector care. Participants perceived government diabetes care as low-quality due to resource limitations and poor communication with providers, leading some to seek care in other health sectors. This study highlights the fragmented, discontinuous nature of diabetes care in Guatemala across public, private and non-governmental health sectors. Strategies to improve diabetes care access in Guatemala and other LMICs should be multisectorial and occur through strengthened government primary care and innovative private and non-governmental organisation care models.

To evaluate the impact of culturally and linguistically tailored informational videos delivered via social media campaigns on COVID-19 vaccine uptake in Indigenous Maya communities in Guatemala. Our team designed a series of videos utilising community input and evaluated the impact using a pre-post intervention design. In-person preintervention surveys were collected from a sample of respondents in four rural municipalities in Guatemala in March 2022. Facebook, Instagram and browser ads were flooded with COVID-19 vaccine informational videos in Spanish, Kaqchikel and Kiche for 3 weeks. Postintervention surveys were conducted by telephone among the same participants in April 2022. Logistic regression models were used to estimate the OR of COVID-19 vaccine uptake following exposure to the intervention videos. Preintervention and postintervention surveys were collected from 1572 participants. The median age was 28 years; 63% (N=998) identified as women, and 36% spoke an Indigenous Mayan language. Twenty-one per cent of participants (N=327) reported watching the intervention content on social media. At baseline, 89% (N=1402) of participants reported having at least one COVID-19 vaccine, compared with 97% (N=1507) in the follow-up. Those who reported watching the videos had 1.78 times the odds (95% CI 1.14 to 2.77) of getting vaccinated after watching the videos compared with those who did not see the videos when adjusted by age, community, sex and language. Our findings suggest that culturally and linguistically tailored videos addressing COVID-19 vaccine misinformation deployed over social media can increase vaccinations in a rural, indigenous population in Guatemala, implying that social media content can influence vaccination uptake. Providing accurate, culturally sensitive information in local languages from trusted sources may help increase vaccine uptake in historically marginalised populations.

Nearly 50% of Guatemalans are Indigenous Maya, yet few studies have examined the prevalence of modifiable cardiovascular disease (CVD) risk factors in Indigenous Maya populations. Therefore, we sought to estimate the prevalence of modifiable CVD risk factors in two Indigenous Maya areas in Guatemala. We conducted, between June 2018 and October 2019, a population-representative survey of adults aged 18 years and older in two rural Indigenous Maya municipalities in Guatemala. Our primary outcomes were five modifiable CVD risk factors: diabetes, hypertension, obesity, smoking, and alcohol use. We estimated the crude and age-standardized prevalence of each outcome. We also constructed multivariable logistic regression models to assess prevalence over covariates including age, sex, education level, ethnicity, and poverty. Sampling weights adjusted for nonresponse, and appropriate survey commands were used in all analyses. The crude prevalence of diabetes was 12.5% (95% confidence Interval [CI] 9.6% to 16.1%), hypertension 20.3% (95% CI 17.1% to 23.9%), obesity 23.7% (95% CI 19.4% to 28.6%), smoking 10.7% (95% CI 7.8% to 14.5%), and high alcohol use 0.9% (95% CI 0.5% to 1.6%). Age-standardized prevalence of each outcome was similar to the crude prevalence. The prevalence of multiple CVD risk factors increased between the age groups 18-29 years and 50-59 years before decreasing among older age groups. Men had twenty-fold higher smoking prevalence than women (20.5% vs. 1.2%, respectively) and women had nearly double the age-adjusted prevalence of obesity as men (30.1% vs. 17.0%, respectively). There is a substantial prevalence of modifiable CVD risk factors in rural, Indigenous populations in Guatemala, in particular hypertension, diabetes, obesity (among women), and smoking (among men). These findings can help catalyze policy and clinical investments to improve the prevention, management, and control of CVD risk factors in these historically marginalized communities.

[Abstract not available]

Diabetes prevalence is increasing rapidly in rural areas of low- and middle-income countries (LMICs), but there are limited data on the performance of health systems in delivering equitable and effective care to rural populations. We therefore assessed rural-urban differences in diabetes care and control in LMICs. We pooled individual-level data from nationally representative health surveys in 42 countries. We used Poisson regression models to estimate age-adjusted differences in the proportion of individuals with diabetes in rural versus urban areas achieving performance measures for the diagnosis, treatment, and control of diabetes and associated cardiovascular risk factors. We examined differences across the pooled sample, by sex, and by country. The pooled sample from 42 countries included 840,110 individuals (35,404 with diabetes). Compared with urban populations with diabetes, rural populations had ∼15-30% lower relative risk of achieving performance measures for diabetes diagnosis and treatment. Rural populations with diagnosed diabetes had a 14% (95% CI 5-22%) lower relative risk of glycemic control, 6% (95% CI -5 to 16%) lower relative risk of blood pressure control, and 23% (95% CI 2-39%) lower relative risk of cholesterol control. Rural women with diabetes had lower achievement of performance measures relating to control than urban women, whereas among men, differences were small. Rural populations with diabetes experience substantial inequities in the achievement of diabetes performance measures in LMICs. Programs and policies aiming to strengthen global diabetes care must consider the unique challenges experienced by rural populations.

The underdevelopment of the higher education system in Guatemala and the fragility of its science and technology (S&T) contexts have compelled a significant number of talented Guatemalan scientists to be trained, educated, and employed abroad. The relocation of such skilled human power to different countries and regions has resulted in a growing Guatemalan Scientific Diaspora (GSD). Until recently, the emigration of scientists from the Global South to scientifically advanced countries in the North was studied as it negatively impacted the countries of origin. However, technological upgrades and globalization have progressively shifted the paradigm in which such scientific diasporas interact and connect, thus enabling them to influence their home countries positively. Due to the lack of knowledge-based evidence and functioning connecting platforms, the value and potential of the GSD in their involvement in proposing solutions to complex socio-economic, environmental, and other challenges faced by Guatemalan society remain unknown. Moreover, the lack of interaction of relevant stakeholders (S&T policy agents, international partners, higher education institutions and research centers, industry, and relevant not governmental organizations) represents a pervasive obstacle to the untapped impact of the GSD in the country. This study outlines the Guatemalan scientific diasporas' networking as a mechanism for building research excellence and intellectual capital. This force could respond to the need to strengthen the national science capacities and meet the demands for knowledge production and access to broader sectors of society. This research applied qualitative methodology that, through the conduction of focus group discussions and semi-structured interviews with members of the Guatemalan scientific community and relevant key stakeholders, delved into the existence and articulation of the GSD and potential stages for their engagement with their country of origin. Findings highlight the importance of digital and technological pathways that might leverage the GSD's knowledge and experience, channeling skills, and international connections for better interaction with the Guatemalan society. Furthermore, the discussion addresses how technology might turn brain drain into brain circulation, enabling the articulation of the GSD as a viable opportunity to generate collaboration between scientists abroad and local actors, ultimately impacting the building and development of Guatemalan science and national research capacities.

Optimal timing to initiate mechanical circulatory support (MCS) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) remains unclear with studies showing conflicting results on whether to start before or after primary percutaneous coronary intervention (PPCI). This study aims to examine the association between mortality and MCS initiated before vs after PPCI in patients with STEMI complicated by CS. We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to October 2021. Studies were included if they evaluated the association of mortality in patients who initiated MCS (specifically intra-aortic balloon pump (IABP), Impella, and venoarterial extracorporeal membrane oxygenation (VA-ECMO)) before PPCI versus after PPCI, specifically in patients with STEMI complicated by CS. Data were integrated using the random-effects models. Ten studies involving 1,352 patients (956, 203, and 193 patients underwent IABP, Impella, and VA-ECMO respectively) with STEMI complicated by CS were included. There was no difference in mortality using IABP before or after PPCI ([OR] 1.77, 95% CI 0.77-1.61, I2 = 27%, p = 0.57). Nevertheless, Impella and VA-ECMO started before PPCI were significantly associated with a reduced risk of mortality compared to that started after PPCI ([OR] 0.49, 95% CI 0.26-0.92, I2 = 0%, p = 0.03 and [OR] 0.29, 95% CI 0.14-0.62, I2 = 0%, p = 0.001, respectively). In patients with STEMI complicated by CS undergoing PPCI, the use of IMPELLA or VA-ECMO prior to PPCI significantly decreased mortality, in contrast to IABP, in which no difference in mortality was found between using it before or after PPCI. More rigorous studies are needed to clarify this association.

Compulsory rural service is one method of addressing limitations in health care access in marginalized areas of low- and middle-income countries, including Guatemala. This study aimed to explore Guatemalan medical students' experiences of compulsory rural service and the impact of rural service on their professional development. Qualitative semi-structured interviews were conducted with 40 medical school graduates who completed compulsory rural service between 2012 and 2017. Interview transcripts were coded for dominant themes using an inductive approach. The majority of interviewees felt that rural service contributed to their professional development by increasing their clinical autonomy, awareness of social determinants of health, and humanistic practice. Interviewees identified limited supervision as a key challenge during the rotation. The majority found rural service rewarding. Guatemalan medical students felt that rural service contributed to their professional and personal development. Rural rotations build primary care skills and may increase awareness of health inequity among clinical trainees. Given ongoing healthcare worker shortages in Guatemala, innovative approaches to improving professional supervision and rural health mentoring are needed.

[Abstract not available]

The Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) provided systematic estimates of incidence, morbidity, and mortality to inform local and international efforts toward reducing cancer burden. To estimate cancer burden and trends globally for 204 countries and territories and by Sociodemographic Index (SDI) quintiles from 2010 to 2019. The GBD 2019 estimation methods were used to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 2019 and over the past decade. Estimates are also provided by quintiles of the SDI, a composite measure of educational attainment, income per capita, and total fertility rate for those younger than 25 years. Estimates include 95% uncertainty intervals (UIs). In 2019, there were an estimated 23.6 million (95% UI, 22.2-24.9 million) new cancer cases (17.2 million when excluding nonmelanoma skin cancer) and 10.0 million (95% UI, 9.36-10.6 million) cancer deaths globally, with an estimated 250 million (235-264 million) DALYs due to cancer. Since 2010, these represented a 26.3% (95% UI, 20.3%-32.3%) increase in new cases, a 20.9% (95% UI, 14.2%-27.6%) increase in deaths, and a 16.0% (95% UI, 9.3%-22.8%) increase in DALYs. Among 22 groups of diseases and injuries in the GBD 2019 study, cancer was second only to cardiovascular diseases for the number of deaths, years of life lost, and DALYs globally in 2019. Cancer burden differed across SDI quintiles. The proportion of years lived with disability that contributed to DALYs increased with SDI, ranging from 1.4% (1.1%-1.8%) in the low SDI quintile to 5.7% (4.2%-7.1%) in the high SDI quintile. While the high SDI quintile had the highest number of new cases in 2019, the middle SDI quintile had the highest number of cancer deaths and DALYs. From 2010 to 2019, the largest percentage increase in the numbers of cases and deaths occurred in the low and low-middle SDI quintiles. The results of this systematic analysis suggest that the global burden of cancer is substantial and growing, with burden differing by SDI. These results provide comprehensive and comparable estimates that can potentially inform efforts toward equitable cancer control around the world.

Home gardening is a strategy to improve nutrition and food security. More information is needed about optimizing gardens in different contexts. The aim was to identify implementation barriers and facilitators for a home gardening intervention in rural Guatemala and inform future larger-scale interventions in the region. A mixed-methods implementation study using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework was conducted from January 2019 to July 2020. Families (n = 70) in rural Guatemala participated in the intervention. Staff (n = 4), families (n = 6), and community stakeholders (n = 3) participated in interviews or focus groups. Participating households received seeds and seedlings for 16 crops, garden construction materials, agronomist-delivered education and assistance, and a standard-of-care nutrition program. Implementation data were collected from program records and observations, participant surveys, and interviews and focus groups. Crop count and nutritional functional diversity of home gardens were assessed. Descriptive statistics were calculated for quantitative outcomes. Qualitative data were double-coded and organized into overarching themes. Reach: Ninety percent of eligible households participated. Child nutritional eligibility criteria was a barrier to reach. Participants and stakeholders felt the intervention improved access to diverse foods. Cultivated crops increased an average of five species (95% confidence interval [CI], 4-6) at 6 months, although not all were consumed. Adoption: The main community adoption barrier was water sourcing for garden irrigation. Raised beds were the most common gardening method, with good adoption of agricultural best practices. Gray water filters and flexible implementation were important for participation. Maintenance: Crops failure rates were low. Seed availability was a sustainability challenge. Direct costs were 763 USD per household. Interest and engagement with a home garden intervention in Guatemala were high. Gaps between garden production and consumption, access to water, and seed sourcing should be addressed in future work.

The aim of this study is to examine the association between vascular access sites and the incidence of AKI in patients with STEMI undergoing primary PCI. Emerging evidence has suggested that transradial access (TRA) may be associated with lower rates of acute kidney injury (AKI) as compared with transfemoral access (TFA). However, most of these studies have included a nonselected study population undergoing diagnostic cardiac catheterization or percutaneous coronary intervention (PCI). Data on the association between TRA and AKI in this setting of STEMI are limited and with conflicting results. We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to July 13th of 2021. Studies included were randomized controlled trials (RCTs) and propensity-score-matched (PSM) studies evaluating the association of TRA versus TFA access with AKI in patients undergoing primary PCI for STEMI. Data were integrated using the random effects model and generic inverse-variance method of DerSimonian and Laird. A total of 10,093 studies were found. After applying our inclusion criteria, 5 studies from 2014 to 2021 with a total of 8,536 STEMI patients were included. TRA was not significantly associated with a reduced risk for AKI compared with TFA (odds ratio 0.85, 95% CI 0.71-1.01, p 0.07, I 2 = 40%). Transradial access was not significantly associated with lower risk of AKI in patients undergoing primary PCI for STEMI compared with TFA. Larger studies are needed to clarify this outcome.

In the prevention of cardiovascular disease, a WHO target is that at least 50% of eligible people use statins. Robust evidence is needed to monitor progress towards this target in low-income and middle-income countries (LMICs), where most cardiovascular disease deaths occur. The objectives of this study were to benchmark statin use in LMICs and to investigate country-level and individual-level characteristics associated with statin use. We did a cross-sectional analysis of pooled, individual-level data from nationally representative health surveys done in 41 LMICs between 2013 and 2019. Our sample consisted of non-pregnant adults aged 40-69 years. We prioritised WHO Stepwise Approach to Surveillance (STEPS) surveys because these are WHO's recommended method for population monitoring of non-communicable disease targets. For countries in which no STEPS survey was available, a systematic search was done to identify other surveys. We included surveys that were done in an LMIC as classified by the World Bank in the survey year; were done in 2013 or later; were nationally representative; had individual-level data available; and asked questions on statin use and previous history of cardiovascular disease. Primary outcomes were the proportion of eligible individuals self-reporting use of statins for the primary and secondary prevention of cardiovascular disease. Eligibility for statin therapy for primary prevention was defined among individuals with a history of diagnosed diabetes or a 10-year cardiovascular disease risk of at least 20%. Eligibility for statin therapy for secondary prevention was defined among individuals with a history of self-reported cardiovascular disease. At the country level, we estimated statin use by per-capita health spending, per-capita income, burden of cardiovascular diseases, and commitment to non-communicable disease policy. At the individual level, we used modified Poisson regression models to assess statin use alongside individual-level characteristics of age, sex, education, and rural versus urban residence. Countries were weighted in proportion to their population size in pooled analyses. The final pooled sample included 116 449 non-pregnant individuals. 9229 individuals reported a previous history of cardiovascular disease (7·9% [95% CI 7·4-8·3] of the population-weighted sample). Among those without a previous history of cardiovascular disease, 8453 were eligible for a statin for primary prevention of cardiovascular disease (9·7% [95% CI 9·3-10·1] of the population-weighted sample). For primary prevention of cardiovascular disease, statin use was 8·0% (95% CI 6·9-9·3) and for secondary prevention statin use was 21·9% (20·0-24·0). The WHO target that at least 50% of eligible individuals receive statin therapy to prevent cardiovascular disease was achieved by no region or income group. Statin use was less common in countries with lower health spending. At the individual level, there was generally higher statin use among women (primary prevention only, risk ratio [RR] 1·83 [95% CI 1·22-2·76), and individuals who were older (primary prevention, 60-69 years, RR 1·86 [1·04-3·33]; secondary prevention, 50-59 years RR 1·71 [1·35-2·18]; and 60-69 years RR 2·09 [1·65-2·65]), more educated (primary prevention, RR 1·61 [1·09-2·37]; secondary prevention, RR 1·28 [0·97-1·69]), and lived in urban areas (secondary prevention only, RR 0·82 [0·66-1·00]). In a diverse sample of LMICs, statins are used by about one in ten eligible people for the primary prevention of cardiovascular diseases and one in five eligible people for secondary prevention. There is an urgent need to scale up statin use in LMICs to achieve WHO targets. Policies and programmes that facilitate implementation of statins into primary health systems in these settings should be investigated for the future. National Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy and Innovation, and National Institute of Diabetes and Digestive and Kidney Diseases. For the Spanish translation of the abstract see Supplementary Materials section.

More than 80% of cervical cancer cases and deaths occur in low- and middle-income countries. Here, we analyze a large geographically extensive cross-sectional data set from the Western rural highlands of Guatemala. Our objective is to better characterize weak points in care along the cervical cancer care continuum and investigate sociodemographic and clinical correlates of loss to follow-up. We conducted a retrospective review of electronic health records data from July 21, 2015, through December 10, 2020 for a cytology-based screening and cervical cancer treatment program. We used a care cascade analysis to characterize the progression of individuals through screening, confirmatory testing, and treatment. We examined demographic and clinical factors correlated with screening and loss to follow-up using multivariate logistic regression. A total of 8,872 individuals were included in the analysis. Five thousand nine hundred thirteen cervical cancer screenings were conducted. 4.1% of all screening tests were abnormal, including 0.61% cervical intraepithelial neoplasia or overt cervical cancer. Care cascade analysis showed that 67% of eligible women accepted screening. Of those requiring confirmatory testing or treatment, 73% completed recommended follow-up. In adjusted multivariable analysis, prior history of sexual transmitted infection, prior experience with cervical cancer screening, older age, and current contraceptive use were associated with accepting screening. Age and contraceptive use were also associated with retention in care after a positive first screen. In a large rural Guatemalan retrospective cohort, a care continuum analysis showed that both declining the opportunity to receive cervical cancer screening as well as declining confirmatory testing after a first positive screen were both important weak points along the care continuum. These data support the need for comprehensive and culturally appropriate initiatives to improve screening uptake and retention in care.

To address the global diabetes epidemic, lifestyle counseling on diet, physical activity, and weight loss is essential. This study assessed the implementation of a diabetes self-management education and support (DSMES) intervention using a mixed-methods evaluation framework. We implemented a culturally adapted, home-based DSMES intervention in rural Indigenous Maya towns in Guatemala from 2018 through 2020. We used a pretest-posttest design and a mixed-methods evaluation approach guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative data included baseline characteristics, implementation metrics, effectiveness outcomes, and costs. Qualitative data consisted of semistructured interviews with 3 groups of stakeholders. Of 738 participants screened, 627 participants were enrolled, and 478 participants completed the study. Adjusted mean change in glycated hemoglobin A1c was -0.4% (95% CI, -0.6% to -0.3%; P < .001), change in systolic blood pressure was -5.0 mm Hg (95% CI, -6.4 to -3.7 mm Hg; P < .001), change in diastolic blood pressure was -2.6 mm Hg (95% CI, -3.4 to -1.9 mm Hg; P < .001), and change in body mass index was 0.5 (95% CI, 0.3 to 0.6; P < .001). We observed improvements in diabetes knowledge, distress, and most self-care activities. Key implementation factors included 1) recruitment barriers for men, 2) importance of patient-centered care, 3) role of research staff in catalyzing health worker involvement, 4) tradeoffs between home and telephone visits, and 5) sustainability challenges. A community health worker-led DSMES intervention was successfully implemented in the public health system in rural Guatemala and resulted in significant improvements in most clinical and psychometric outcomes. Scaling up sustainable DSMES in health systems in rural settings requires careful consideration of local barriers and facilitators.

Child stunting is a critical global health issue. Guatemala has one of the world's highest levels of stunting despite the sustained commitment to international nutrition policy best practices endorsed by the Scaling Up Nutrition (SUN) movement. Our objective was to use Guatemala as a case study to project the impact of a recently published national nutrition policy, the Great Crusade, that is consistent with SUN principles. We used the Lives Saved Tool (LiST) to project the impact of scaling-up of nutrition interventions proposed in the Great Crusade and recommended by SUN. Our outcomes were changes in stunting prevalence, number of stunting cases averted, and number of cases averted by intervention in children under 5 years of age from 2020 to 2030. We considered 4 scenarios: (1) intervention coverage continues based on historical trends, (2) coverage targets in the Great Crusade are achieved, (3) coverage targets in the Great Crusade are achieved with reduced fertility risk, and (4) coverage reaches an aspirational level. All scenarios led to modest reductions in stunting prevalence. In 2024, stunting prevalence was estimated to change by -0.1% (95% confidence interval [CI]= 0.0%,-0.2%) if historical trends continue, -1.1% (95% CI=-0.8%,-1.5%) in the Great Crusade scenario, and -2.2% (95% CI=-1.6%,-3.0%) in the aspirational scenario. In 2030, we projected a stunting prevalence of -0.4% (95% CI=-0.2%,-0.8%) and -3.7% (95% CI=-2.8%,-5.1%) in the historical trends and aspirational scenario, respectively. Complementary feeding, sanitation, and breastfeeding were the highest-impact interventions across models. Targeted reductions in child stunting prevalence in Guatemala are unlikely to be achieved solely based on increases in intervention coverage. Our results show the limitations of current paradigms recommended by the international nutrition community. Policies and strategies are needed to address the broader structural drivers of stunting.

Given the increasing prevalence of diabetes in low-income and middle-income countries (LMICs), we aimed to estimate the health and cost implications of achieving different targets for diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among LMICs. We constructed a microsimulation model to estimate disability-adjusted life-years (DALYs) lost and health-care costs of diagnosis, treatment, and control of blood pressure, dyslipidaemia, and glycaemia among people with diabetes in LMICs. We used individual participant data-specifically from the subset of people who were defined as having any type of diabetes by WHO standards-from nationally representative, cross-sectional surveys (2006-18) spanning 15 world regions to estimate the baseline 10-year risk of atherosclerotic cardiovascular disease (defined as fatal and non-fatal myocardial infarction and stroke), heart failure (ejection fraction of <40%, with New York Heart Association class III or IV functional limitations), end-stage renal disease (defined as an estimated glomerular filtration rate <15 mL/min per 1·73 m2 or needing dialysis or transplant), retinopathy with severe vision loss (<20/200 visual acuity as measured by the Snellen chart), and neuropathy with pressure sensation loss (assessed by the Semmes-Weinstein 5·07/10 g monofilament exam). We then used data from meta-analyses of randomised controlled trials to estimate the reduction in risk and the WHO OneHealth tool to estimate costs in reaching either 60% or 80% of diagnosis, treatment initiation, and control targets for blood pressure, dyslipidaemia, and glycaemia recommended by WHO guidelines. Costs were updated to 2020 International Dollars, and both costs and DALYs were computed over a 10-year policy planning time horizon at a 3% annual discount rate. We obtained data from 23 678 people with diabetes from 67 countries. The median estimated 10-year risk was 10·0% (IQR 4·0-18·0) for cardiovascular events, 7·8% (5·1-11·8) for neuropathy with pressure sensation loss, 7·2% (5·6-9·4) for end-stage renal disease, 6·0% (4·2-8·6) for retinopathy with severe vision loss, and 2·6% (1·2-5·3) for congestive heart failure. A target of 80% diagnosis, 80% treatment, and 80% control would be expected to reduce DALYs lost from diabetes complications from a median population-weighted loss to 1097 DALYs per 1000 population over 10 years (IQR 1051-1155), relative to a baseline of 1161 DALYs, primarily from reduced cardiovascular events (down from a median of 143 to 117 DALYs per 1000 population) due to blood pressure and statin treatment, with comparatively little effect from glycaemic control. The target of 80% diagnosis, 80% treatment, and 80% control would be expected to produce an overall incremental cost-effectiveness ratio of US$1362 per DALY averted (IQR 1304-1409), with the majority of decreased costs from reduced cardiovascular event management, counterbalanced by increased costs for blood pressure and statin treatment, producing an overall incremental cost-effectiveness ratio of $1362 per DALY averted (IQR 1304-1409). Reducing complications from diabetes in LMICs is likely to require a focus on scaling up blood pressure and statin medication treatment initiation and blood pressure medication titration rather than focusing on increasing screening to increase diabetes diagnosis, or a glycaemic treatment and control among people with diabetes. None.

More than 40% of children under 5 years of age in low-income and middle-income countries are at risk of not reaching their developmental potential. The international Guide for Monitoring Child Development (GMCD) early intervention package is a comprehensive programme to address developmental difficulties using an individualised intervention plan for young children and their families. We will conduct a hybrid type 1 effectiveness-implementation evaluation of the GMCD intervention in rural India and Guatemala. Using a cluster-randomised design, 624 children aged 0-24 months in 52 clusters (26 in India, 26 in Guatemala) will be assigned to usual care or the GMCD intervention plus usual care delivered by frontline workers for 12 months. After 12 months, the usual care arm will cross over to the intervention, which will continue for 12 additional months (24 total). The intervention will be delivered using a digital mobile device interface. Effectiveness will be assessed for developmental functioning (Bayley Scales of Infant Development, 3rd edition) and nurturing care (Home Observation for Measurement of the Environment Scale) outcomes. Implementation will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. Explanatory qualitative analysis guided by the Consolidated Framework for Implementation Research will explore determinants between clusters with high versus low implementation effectiveness. The study has been approved by the Institutional Review Boards of Brigham and Women's Hospital, Mahatma Gandhi Institute of Medical Sciences and Maya Health Alliance; and by the Indian Council of Medical Research/Health Ministry Screening Committee. Key study findings will be published in international open-access journals. NCT04665297, CTRI/2020/12/029748. 1.0 (12 November 2020).

The Washington Group (WG) tools capture self-reported functional limitations, ranging from 6 domains in the Short Set (SS) to 11 in the Extended Set (ESF). Prevalence estimates can vary considerably on account of differences between modules and the different applications of them. We compare prevalence estimates by WG module, threshold, application and domain to explore these nuances and consider whether alternative combinations of questions may be valuable in reduced sets. We conducted secondary analyses of seven population-based surveys (analyses restricted to adults 18+) in Low- and Middle-Income Countries that used the WG tools. The prevalence estimates using the SS standard threshold (a lot of difficulty or higher in one or more domain) varied between 3.2% (95% Confidence Interval 2.9-3.6) in Vanuatu to 14.1% (12.2-16.2) in Turkey. The prevalence was higher using the ESF than the SS, and much higher (5 to 10-fold) using a wider threshold of "some" or greater difficulty. Two of the SS domains (communication, self-care) identified few additional individuals with functional limitations. An alternative SS replacing these domains with the psychosocial domains of anxiety and depression would identify more participants with functional limitations for the same number of items. The WG tools are valuable for collecting harmonised population data on disability. It is important that the impact on prevalence of use of different modules, thresholds and applications is recognised. An alternative SS may capture a greater proportion of people with functional domains without increasing the number of items.

Rural Indigenous Maya communities in Guatemala have some of the worst obstetrical health outcomes in Latin America, due to widespread discrimination in healthcare and an underfunded public sector. Multiple systems-level efforts to improve facility birth outcomes have been implemented, primarily focusing on early community-based detection of obstetrical complications and on reducing discrimination and improving the quality of facility-level care. However, another important feature of public facility-level care are the out-of-pocket payments that patients are often required to make for care. To estimate the burden of out-of-pocket costs for public obstetrical care in Indigenous Maya communities in Guatemala. We conducted a retrospective review of electronic medical record data on obstetrical referrals collected as part of an obstetrical care navigation intervention, which included documentation of out-of-pocket costs by care navigators accompanying patients within public facilities. We compared the median costs for both emergency and routine obstetrical facility care. Cost data on 709 obstetric referrals from 479 patients were analyzed (65% emergency and 35% routine referrals). The median OOP costs were Q100 (IQR 75-150) [$13 USD] and Q50 (IQR 16-120) [$6.50 USD] for emergency and routine referrals. Costs for transport were most common (95% and 55%, respectively). Costs for medication, supply, laboratory, and imaging costs occurred less frequently. Food and lodging costs were minimal. Out-of-pocket payments for theoretically free public care are a common and important barrier to care for this rural Guatemalan setting. These data add to the literature in Latin American on the barriers to obstetrical care faced by Indigenous and rural women.

Jordan hosts the largest Palestine refugee population in the world. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is the primary healthcare provider for Palestine refugees. To better inform UNRWA's health programme, we conducted this study to assess the prevalence and determinants of malnutrition among Palestine refugee children in Jordan and to analyse caregiver perceptions of food insecurity and structural barriers to accessing food. A cross-sectional study was conducted with a randomly selected sample of 405 households, for children under 5 years old in two refugee camps in Jordan, Jerash and Souf. Sociodemographic, food insecurity, diet quality and child anthropometric data were collected. Also, twenty in-depth interviews were conducted with children's caregivers, along with two focus group discussions with UNRWA staff. Out of the 367 participants, the prevalence of stunting was 23.8% in Jerash and 20.4% in Souf (p=0.46), and overweight was 18.2% versus 7.1%, respectively (p=0.008). However, high food insecurity in Jerash was 45.7% and 26.5% in Souf (p=0.001), with no significant difference after multivariable adjustment. Qualitative perspectives saw food insecurity and low-quality children's diets as largely mediated by job and income insecurity, especially marked in Jerash due to the lack of Jordanian citizenship. We found a moderate-to-high prevalence of stunting and overweight levels among Palestine refugee children, which are three times higher than the 2012 Demographic and Health Survey data for Jordanian non-refugee children. High rates of household food insecurity were closely tied to households' lack of essential civil and economic rights. We call for international collective efforts to expand economic livelihoods for Palestine refugees and to support UNRWA's ongoing operations.

The majority of indigenous Guatemalan women give birth at home with traditional birth attendants (TBAs), and maternal mortality rates are high (Ministerio de Salud, 2017). Our objective was to better understand decision-making around whether to remain in the home or to seek facility-level care for obstetric complications. This study was a qualitative analysis using semi-structured interviews in a Maya population in the Western Highlands of Guatemala who received prenatal care between April 2017 and December 2018. We used qualitative interviews with women who were identified as medically high-risk and needing facility-level care, offered assistance with acquiring such care, and yet declined this option. Women interviewed were connected to a primary care organization called Maya Health Alliance, through care with TBAs involved in a program utilizing a smartphone-based decision support application to identify maternal and neonatal complications of pregnancy. Interviews were analyzed using Dedoose (www.dedoose.com). Deductive and inductive analysis was performed. Barriers to care included a disagreement between the respondent and TBA about indications for facility care, fear of hospital care, concerns about the quality of hospital care, logistical obstacles, and lack of control; and they were more often described by respondents who had previous healthcare experiences. Therapeutic misalignment occurred more with conditions perceived to be less severe. Participants described a balancing of fears and apprehensions against concerns of low quality and disrespectful maternity care, and in the setting of emergent conditions, disregarded barriers that were often described as inhibiting non-urgent obstetric care. The decision to engage in medical care in this population of Maya women involves a weighing of the perception of seriousness of the medical complication against fears of facility level care and concerns of a poor quality of care.

Global disparities in maternal mortality could be reduced by universal facility delivery. Yet, deficiencies in the quality of care prevent some mothers from seeking facility-based obstetric care. Obstetric care navigators (OCNs) are a new form of lay health workers that combine elements of continuous labor support and care navigation to promote obstetric referrals. Here we report qualitative results from the pilot OCN project implemented in Indigenous villages in the Guatemalan central highlands. We conducted semi-structured interviews with 17 mothers who received OCN accompaniment and 13 staff-namely physicians, nurses, and social workers-of the main public hospital in the pilot's catchment area (Chimaltenango). Interviews queried OCN's impact on patient and hospital staff experience and understanding of intended OCN roles. Audiorecorded interviews were transcribed, coded, and underwent content analysis. Maternal fear of surgical intervention, disrespectful and abusive treatment, and linguistic barriers were principal deterrents of care seeking. Physicians and nurses reported cultural barriers, opposition from family, and inadequate hospital resources as challenges to providing care to Indigenous mothers. Patient and hospital staff identified four valuable services offered by OCNs: emotional support, patient advocacy, facilitation of patient-provider communication, and care coordination. While patients and most physicians felt that OCNs had an overwhelmingly positive impact, nurses felt their effort would be better directed toward traditional nursing tasks. Many barriers to maternity care exist for Indigenous mothers in Guatemala. OCNs can improve mothers' experiences in public hospitals and reduce limitations faced by providers. However, broader buy-in from hospital staff-especially nurses-appears critical to program success. Future research should focus on measuring the impact of obstetric care navigation on key clinical outcomes (cesarean delivery) and mothers' future care seeking behavior.

Adequate nutrition during the complementary feeding period is critical for optimal child growth and development and for promoting long-term educational attainment and economic potential. To prioritize limited public health resources, there is a need for studies that rigorously assess the influence of multicomponent integrated nutrition interventions in children younger than age 2 years in different contexts. This study aimed to describe the rationale and protocol for the Saqmolo' Project using the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. The Saqmolo' (ie, "egg" in the Mayan language, Kaqchiquel) Project is an individually randomized, partially blinded, controlled comparative effectiveness trial to evaluate the influence of adding delivery of a single whole egg per day to local standard nutrition care (ie, growth monitoring, medical care, deworming medication, multiple micronutrient powders for point-of-use food fortification [chispitas], and individualized complementary and responsive feeding education for caregivers) for 6 months, compared with the local standard nutrition care package alone, on child development, growth, and diet quality measures in rural indigenous Mayan infants aged 6 to 9 months at baseline (N = 1,200). The study is being executed in partnership with the Wuqu' Kawoq/Maya Health Alliance, a primary health care organization located in central Guatemala. Primary outcomes for this study are changes in global development scores, assessed using the Guide for Monitoring Global Development and the Caregiver Reported Child Development Instruments. Secondary outcomes include changes in infant hemoglobin, anthropometric measures (including z scores for weight for age, length for age, weight for length, and head circumference for age), and diet quality as measured using the World Health Organization's infant and young child feeding indicators. The results of the Saqmolo' Project may help to inform public health decision making regarding resource allocation for effective nutrition interventions during the complementary feeding period.

Routine blood pressure (BP) measurement in pregnancy is commonly performed using automated oscillometric devices. Since no wireless oscillometric BP device has been validated in preeclamptic populations, a simple approach for capturing readings from such devices is needed, especially in low-resource settings where transmission of BP data from the field to central locations is an important mechanism for triage. To this end, a total of 8192 BP readings were captured from the Liquid Crystal Display (LCD) screen of a standard Omron M7 self-inflating BP cuff using a cellphone camera. A cohort of 49 lay midwives captured these data from 1697 pregnant women carrying singletons between 6 weeks and 40 weeks gestational age in rural Guatemala during routine screening. Images exhibited a wide variability in their appearance due to variations in orientation and parallax; environmental factors such as lighting, shadows; and image acquisition factors such as motion blur and problems with focus. Images were independently labeled for readability and quality by three annotators (BP range: 34-203 mm Hg) and disagreements were resolved. Methods to preprocess and automatically segment the LCD images into diastolic BP, systolic BP and heart rate using a contour-based technique were developed. A deep convolutional neural network was then trained to convert the LCD images into numerical values using a multi-digit recognition approach. On readable low- and high-quality images, this proposed approach achieved a 91% classification accuracy and mean absolute error of 3.19 mm Hg for systolic BP and 91% accuracy and mean absolute error of 0.94 mm Hg for diastolic BP. These error values are within the FDA guidelines for BP monitoring when poor quality images are excluded. The performance of the proposed approach was shown to be greatly superior to state-of-the-art open-source tools (Tesseract and the Google Vision API). The algorithm was developed such that it could be deployed on a phone and work without connectivity to a network.

Approximately 80% of the 463 million adults worldwide with diabetes live in low- and middle-income countries (LMICs). A major obstacle to designing evidence-based policies to improve diabetes outcomes in LMICs is the limited nationally representative data on the current patterns of treatment coverage. The objectives of this study are (1) to estimate the proportion of adults with diabetes in LMICs who receive coverage of recommended pharmacological and non-pharmacological diabetes treatment and (2) to describe country-level and individual-level characteristics that are associated with treatment. We conducted a cross-sectional analysis of pooled, individual data from 55 nationally representative surveys in LMICs. Our primary outcome of self-reported diabetes treatment coverage was based upon population-level monitoring indicators recommended in the 2020 World Health Organization Package of Essential Noncommunicable Disease Interventions. We assessed coverage of three pharmacological and three non-pharmacological treatments among people with diabetes. At the country level, we estimated the proportion of individuals reporting coverage by per-capita gross national income and geographic region. At the individual level, we used logistic regression models to assess coverage along several key individual characteristics including sex, age, BMI, wealth quintile, and educational attainment. In the primary analysis, we scaled sample weights such that countries were weighted equally. The final pooled sample from the 55 LMICs included 680,102 total individuals and 37,094 individuals with diabetes. Using equal weights for each country, diabetes prevalence was 9.0% (95% confidence interval [CI], 8.7-9.4), with 43.9% (95% CI, 41.9-45.9) reporting a prior diabetes diagnosis. Overall, 4.6% (95% CI, 3.9-5.4) of individuals with diabetes self-reported meeting need for all treatments recommended for them. Coverage of glucose-lowering medication was 50.5% (95% CI, 48.6-52.5); antihypertensive medication, 41.3% (95% CI, 39.3-43.3); cholesterol-lowering medication, 6.3% (95% CI, 5.5-7.2); diet counseling, 32.2% (95% CI, 30.7-33.7); exercise counseling, 28.2% (95% CI, 26.6-29.8); and weight-loss counseling, 31.5% (95% CI, 29.3-33.7). Countries at higher income levels tended to have greater coverage. Female sex and higher age, BMI, educational attainment, and household wealth were also associated with greater coverage. Fewer than one in ten people with diabetes in LMICs receive coverage of guideline-based comprehensive diabetes treatment. Scaling-up the capacity of health systems to deliver treatment not only to lower glucose but also to address cardiovascular disease risk factors such as hypertension and high cholesterol are urgent global diabetes priorities.

Despite the life-saving work they perform, community health workers (CHWs) have long been subject to global debate about their remuneration. There is now, however, an emerging consensus that CHWs should be paid. As the discussion evolves from whether to financially remunerate CHWs to how to do so, there is an urgent need to better understand the types of CHW payment models and their implications. This study examines the legal framework on CHW compensation in five countries: Brazil, Ghana, Nigeria, Rwanda, and South Africa. In order to map the characteristics of each approach, a review of the regulatory framework governing CHW compensation in each country was undertaken. Law firms in each of the five countries were engaged to support the identification and interpretation of relevant legal documents. To guide the search and aid in the creation of uniform country profiles, a standardized set of questions was developed, covering: (i) legal requirements for CHW compensation, (ii) CHW compensation mechanisms, and (iii) CHW legal protections and benefits. The five countries profiled represent possible archetypes for CHW compensation: Brazil (public), Ghana (volunteer-based), Nigeria (private), Rwanda (cooperatives with performance based incentives) and South Africa (hybrid public/private). Advantages and disadvantages of each model with respect to (i) CHWs, in terms of financial protection, and (ii) the health system, in terms of ease of implementation, are outlined. While a strong legal framework does not necessarily translate into high-quality implementation of compensation practices, it is the first necessary step. Certain approaches to CHW compensation - particularly public-sector or models with public sector wage floors - best institutionalize recommended CHW protections. Political will and long-term financing often remain challenges; removing ecosystem barriers - such as multilateral and bilateral restrictions on the payment of salaries - can help governments institutionalize CHW payment.

We propose that the collection of infant experiential and environmental data using smartphone surveys has the potential to fill a gap in foundational and clinical knowledge. To achieve this, these data need to be collected in a systematic way that is translatable globally. We can then begin to understand differences in child development and physical therapy from a variety of cultures and traditions. An infant's development is shaped by experiences in everyday life, and everyday experiences vary around the world. Hence, it is important to quantify these experiences to better understand variability in developmental trajectories. Recent increase in smartphone access has made the capability of collecting infant experiential data more feasible around the world. We provide examples and suggestions for ways in which experiential and environmental data can be collected for future practice.

Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrition workers through electronic worklists, performance dashboards, and one-on-one feedback sessions. We visualized performance indicators and child nutrition outcomes during the improvement intervention using run charts and control charts. In this small community-based sample (125 households at program initiation), over the two-year improvement period, there were marked improvements in the delivery of program components, such as growth monitoring services and micronutrient supplements. The prevalence of child stunting fell from 42.4 to 30.6%, meeting criteria for special cause variation. The mean length/height-for-age Z-score rose from -1.77 to -1.47, also meeting criteria for special cause variation. In conclusion, the addition of structured performance visualization and audit and feedback components to an existing community-based nutrition program improved child health indicators significantly through improving the fidelity of an existing evidence-based nutrition package.

A cluster of factors affects nutritional status among adolescent girls in low- and middle-income countries (LMICs). We investigated the association between school attendance and diet quality among 498 rural adolescent girls (352 attending and 146 not attending school) in Tecpán, Guatemala. In a cross-sectional study, we collected sociodemographic and anthropometric data and characterized the dietary intake using a Food Frequency Questionnaire. We then calculated diet quality using the Healthy Eating Score (HES). Multiple linear regression models were conducted to evaluate the effects of school attendance on diet quality. We found that the overall diet quality among the study participants was poor, according to the HES. However, those who attended school had significantly higher intakes of vitamin A-rich fruits and vegetables (P = 0.04), other fruits (P = 0.01), and milk and milk products (P = 0.004), but a higher intake of fast foods, chips, and saturated fatty acids (P < 0.001). Furthermore, the effects of school attendance on diet quality were significant after adjusting for sociodemographic and lifestyle factors (β coefficient = -1.70, 95% CI: -3.30 to -0.11) but was attenuated when further adjusted for weight status (β coefficient = -1.58, 95% CI: -3.17 to 0.02). Our findings suggest that diet quality among girls in rural Guatemala is poor, particularly among those who do not attend school. To advance our understanding of adolescent diet in LMICs, future studies should include adolescents who are out of school.

Chronic kidney disease (CKD) is an emerging public health priority in Central America. However, data on the prevalence of CKD in Guatemala, Central America's most populous country, are limited, especially for rural communities. We conducted a population-representative survey of 2 rural agricultural municipalities in Guatemala. We collected anthropometric data, blood pressure, serum and urine creatinine, glycosylated hemoglobin, and urine albumin. Sociodemographic, health, and exposure data were self-reported. We enrolled 807 individuals (63% of all eligible, 35% male, mean age 39.5 years). An estimated 4.0% (95% confidence interval [CI] 2.4-6.6) had CKD, defined as an estimated glomerular filtration rate (eGFR) less than 60 ml/min per 1.73 m2. Most individuals with an eGFR below 60 ml/min per 1.73 m2 had diabetes or hypertension. In multivariable analysis, the important factors associated with risk for an eGFR less than 60 ml/min per 1.73 m2 included a history of diabetes or hypertension (adjusted odds ratio [aOR] 11.21; 95% CI 3.28-38.24), underweight (body mass index [BMI] <18.5) (aOR 21.09; 95% CI 2.05-217.0), and an interaction between sugar cane agriculture and poverty (aOR 1.10; 95% CI 1.01-1.19). In this population-based survey, most observed CKD was associated with diabetes and hypertension. These results emphasize the urgent public health need to address the emerging epidemic of diabetes, hypertension, and CKD in rural Guatemala. In addition, the association between CKD and sugar cane in individuals living in poverty provides some circumstantial evidence for existence of CKD of unknown etiology in the study communities, which requires further investigation.

There is limited evidence regarding the utility of fetal monitoring during pregnancy, particularly during labor and delivery. Developed countries rely on consensus 'best practices' of obstetrics and gynecology professional societies to guide their protocols and policies. Protocols are often driven by the desire to be as safe as possible and avoid litigation, regardless of the cost of downstream treatment. In high-resource settings, there may be a justification for this approach. In low-resource settings, in particular, interventions can be costly and lead to adverse outcomes in subsequent pregnancies. Therefore, it is essential to consider the evidence and cost of different fetal monitoring approaches, particularly in the context of treatment and care in low-to-middle income countries. This article reviews the standard methods used for fetal monitoring, with particular emphasis on fetal cardiac assessment, which is a reliable indicator of fetal well-being. An overview of fetal monitoring practices in low-to-middle income counties, including perinatal care access challenges, is also presented. Finally, an overview of how mobile technology may help reduce barriers to perinatal care access in low-resource settings is provided.

Population-representative household survey methods require up-to-date sampling frames and sample designs that minimize time and cost of fieldwork especially in low- and middle-income countries. Traditional methods such as multi-stage cluster sampling, random-walk, or spatial sampling can be cumbersome, costly or inaccurate, leading to well-known biases. However, a new tool, Epicentre's Geo-Sampler program, allows simple random sampling of structures, which can eliminate some of these biases. We describe the study design process, experiences and lessons learned using Geo-Sampler for selection of a population representative sample for a kidney disease survey in two sites in Guatemala. We successfully used Epicentre's Geo-sampler tool to sample 650 structures in two semi-urban Guatemalan communities. Overall, 82% of sampled structures were residential and could be approached for recruitment. Sample selection could be conducted by one person after 30 min of training. The process from sample selection to creating field maps took approximately 40 h. In combination with our design protocols, the Epicentre Geo-Sampler tool provided a feasible, rapid and lower-cost alternative to select a representative population sample for a prevalence survey in our semi-urban Guatemalan setting. The tool may work less well in settings with heavy arboreal cover or densely populated urban settings with multiple living units per structure. Similarly, while the method is an efficient step forward for including non-traditional living arrangements (people residing permanently or temporarily in businesses, religious institutions or other structures), it does not account for some of the most marginalized and vulnerable people in a population-the unhoused, street dwellers or people living in vehicles.

Effective health system interventions may help address the disproportionate burden of diabetes in low- and middle-income countries (LMICs). We assessed the impact of health system interventions to improve outcomes for adults with type 2 diabetes in LMICs. We searched Ovid MEDLINE, Cochrane Library, EMBASE, African Index Medicus, LILACS, and Global Index Medicus from inception of each database through February 24, 2020. We included randomized controlled trials (RCTs) of health system interventions targeting adults with type 2 diabetes in LMICs. Eligible studies reported at least 1 of the following outcomes: glycemic change, mortality, quality of life, or cost-effectiveness. We conducted a meta-analysis for the glycemic outcome of hemoglobin A1c (HbA1c). GRADE and Cochrane Effective Practice and Organisation of Care methods were used to assess risk of bias for the glycemic outcome and to prepare a summary of findings table. Of the 12,921 references identified in searches, we included 39 studies in the narrative review of which 19 were cluster RCTs and 20 were individual RCTs. The greatest number of studies were conducted in the East Asia and Pacific region (n = 20) followed by South Asia (n = 7). There were 21,080 total participants enrolled across included studies and 10,060 total participants in the meta-analysis of HbA1c when accounting for the design effect of cluster RCTs. Non-glycemic outcomes of mortality, health-related quality of life, and cost-effectiveness had sparse data availability that precluded quantitative pooling. In the meta-analysis of HbA1c from 35 of the included studies, the mean difference was -0.46% (95% CI -0.60% to -0.31%, I2 87.8%, p < 0.001) overall, -0.37% (95% CI -0.64% to -0.10%, I2 60.0%, n = 7, p = 0.020) in multicomponent clinic-based interventions, -0.87% (-1.20% to -0.53%, I2 91.0%, n = 13, p < 0.001) in pharmacist task-sharing studies, and -0.27% (-0.50% to -0.04%, I2 64.1%, n = 7, p = 0.010) in trials of diabetes education or support alone. Other types of interventions had few included studies. Eight studies were at low risk of bias for the summary assessment of glycemic control, 15 studies were at unclear risk, and 16 studies were at high risk. The certainty of evidence for glycemic control by subgroup was moderate for multicomponent clinic-based interventions but was low or very low for other intervention types. Limitations include the lack of consensus definitions for health system interventions, differences in the quality of underlying studies, and sparse data availability for non-glycemic outcomes. In this meta-analysis, we found that health system interventions for type 2 diabetes may be effective in improving glycemic control in LMICs, but few studies are available from rural areas or low- or lower-middle-income countries. Multicomponent clinic-based interventions had the strongest evidence for glycemic benefit among intervention types. Further research is needed to assess non-glycemic outcomes and to study implementation in rural and low-income settings.

This qualitative study explores perceptions of chronic kidney disease (CKD) among adults with abnormal estimated glomerular filtration rate (eGFR) in Guatemala, where the burden of CKD is rising. Qualitative semi-structured interviews were conducted with 39 individuals screened for CKD and found to have abnormal eGFR (defined as <90 mL/min/1.73 m2, per Kidney Disease Improving Global Outcomes [KDIGO] guidelines). Interviews occurred in participants' homes in Spanish or Kaqchikel Mayan. Interview notes were coded for dominant themes through an inductive approach. Interviewees had limited awareness of diabetes and hypertension as CKD risk factors, but appreciated the progressive nature of the disease. While most reported willingness to pursue renal replacement therapies, if necessary, they anticipated economic and geographic barriers. Public health interventions should focus on the association between diabetes, hypertension, and CKD. Improvement of primary care and screening infrastructure is imperative in CKD prevention in low- and middle-income countries (LMICs).

[Abstract not available]

In-utero progress of fetal development is normally assessed through manual measurements taken from ultrasound images, requiring relatively expensive equipment and well-trained personnel. Such monitoring is therefore unavailable in low- and middle-income countries (LMICs), where most of the perinatal mortality and morbidity exists. The work presented here attempts to identify a proxy for IUGR, which is a significant contributor to perinatal death in LMICs, by determining gestational age (GA) from data derived from simple-to-use, low-cost one-dimensional Doppler ultrasound (1D-DUS) and blood pressure devices. A total of 114 paired 1D-DUS recordings and maternal blood pressure recordings were selected, based on previously described signal quality measures. The average length of 1D-DUS recording was 10.43 ± 1.41 min. The min/median/max systolic and diastolic maternal blood pressures were 79/102/121 and 50.5/63.5/78.5 mmHg, respectively. GA was estimated using features derived from the 1D-DUS and maternal blood pressure using a support vector regression (SVR) approach and GA based on the last menstrual period as a reference target. A total of 50 trials of 5-fold cross-validation were performed for feature selection. The final SVR model was retrained on the training data and then tested on a held-out set comprising 28 normal weight and 25 low birth weight (LBW) newborns. The mean absolute GA error with respect to the last menstrual period was found to be 0.72 and 1.01 months for the normal and LBW newborns, respectively. The mean error in the GA estimate was shown to be negatively correlated with the birth weight. Thus, if the estimated GA is lower than the (remembered) GA calculated from last menstruation, then this could be interpreted as a potential sign of IUGR associated with LBW, and referral and intervention may be necessary. The assessment system may, therefore, have an immediate impact if coupled with suitable intervention, such as nutritional supplementation. However, a prospective clinical trial is required to show the efficacy of such a metric in the detection of IUGR and the impact of the intervention.

On October 14-15, 2019, the 1st Symposium to Promote Chronic Kidney Disease (CKD) Research in Guatemala was held in Guatemala City, Guatemala. The Symposium hosted more than 50 attendees, including health care professionals, policy makers, researchers, and leaders of nongovernmental organizations. The meeting's objectives were to (1) share clinical and health delivery experiences, (2) disseminate local research, and (3) establish consensus priorities for future research. In this report, we review the state of CKD nephrology in Guatemala, summarize experiences shared during the meeting from representatives of the clinical settings in Guatemala where CKD care is provided, and describe consensus priorities for future research.

COVID-19 disproportionately affects the poor and vulnerable. Community health workers are poised to play a pivotal role in fighting the pandemic, especially in countries with less resilient health systems. Drawing from practitioner expertise across four WHO regions, this article outlines the targeted actions needed at different stages of the pandemic to achieve the following goals: (1) PROTECT healthcare workers, (2) INTERRUPT the virus, (3) MAINTAIN existing healthcare services while surging their capacity, and (4) SHIELD the most vulnerable from socioeconomic shocks. While decisive action must be taken now to blunt the impact of the pandemic in countries likely to be hit the hardest, many of the investments in the supply chain, compensation, dedicated supervision, continuous training and performance management necessary for rapid community response in a pandemic are the same as those required to achieve universal healthcare and prevent the next epidemic.

Cervical cancer screening is not well implemented in many low- and middle-income countries (LMICs). Mobile health (mHealth) refers to utilization of mobile technologies in health promotion and disease management. We aimed to qualitatively synthesize published articles reporting the impact of mHealth on cervical cancer screening-related health behaviors. Three reviewers independently reviewed articles with the following criteria: the exposure or intervention of interest was mHealth, including messages or educational information sent via mobile telephone or e-mail; the comparison was people not using mHealth technology to receive screening-related information, and studies comparing multiple different mHealth interventional strategies were also eligible; the primary outcome was cervical cancer screening uptake, and secondary outcomes included awareness, intention, and knowledge of screening; appropriate research designs included randomized controlled trials and quasi-experimental or observational research; and the study was conducted in an LMIC. Of the 8 selected studies, 5 treated mobile telephone or message reminders as the exposure or intervention, and 3 compared the effects of different messages on screening uptake. The outcomes were diverse, including screening uptake (n = 4); health beliefs regarding the Papanicolaou (Pap) test (n = 1); knowledge of, attitude toward, and adherence to colpocytologic examination (n = 1); interest in receiving messages about Pap test results or appointment (n = 1); and return for Pap test reports (n = 1). Overall, our systematic review suggests that mobile technologies, particularly telephone reminders or messages, lead to increased Pap test uptake; additional work is needed to unequivocally verify whether mhealth interventions can improve knowledge regarding cervical cancer. Our study will inform mHealth-based interventions for cervical cancer screening promotion in LMICs.

Low birth weight is one of the leading contributors to global perinatal deaths. Detecting this problem close to birth enables the initiation of early intervention, thus reducing the long-term impact on the fetus. However, in low-and middle-income countries, sometimes newborns are weighted days or months after birth, thus challenging the identification of low birth weight. This study aims to estimate birth weight from observed postnatal weights recorded in a Guatemalan highland community. With 918 newborns recorded in postpartum visits at a Guatemalan highland community, we fitted traditional infant weight models (Count's and Reeds models). The model that fitted the observed data best was selected based on typical newborn weight patterns reported in the medical literature and previous longitudinal studies. Then, estimated birth weights were determined using the weight gain percentage derived from the fitted weight curve. The best model for both genders was the Reeds2 model, with a mean square error of 0.30 kg2 and 0.23 kg2 for male and female newborns, respectively. The fitted weight curves exhibited similar behavior to those reported in the literature, with a maximum weight loss around three to five days after birth, and birth weight recovery, on average, by day ten. Moreover, the estimated birth weight was consistent with the 2015 Guatemalan National Survey, no having a statistically significant difference between the estimated birth weight and the reported survey birth weights (two-sided Wilcoxon rank-sum test; [Formula: see text]). By estimating birth weight at an opportune time, several days after birth, it may be possible to identify low birth weight more accurately, thus providing timely treatment when is required.

Race, ethnicity, and indigenous status should be considered as potential drivers of provider bias in family planning services globally. Efforts to confront provider bias in family planning counseling should include concrete strategies that promote provider recognition of biases and longitudinal curriculums that allow for sustained feedback and self-reflection.

Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals' perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala. Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions. Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services. Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.

Ever since the 1960s, Guatemala has been a principle site for global academic research on child growth and nutrition. Nevertheless, Guatemala still has one of the highest rates of child stunting in the world. Since 2012, Guatemala has had a comprehensive national policy on stunting, calling for a renewed investment in innovative, multilevel nutrition interventions and implementation science. Our objective was to perform a systematic search and scoping review of the literature on stunting in Guatemala to identify gaps in research and opportunities for responding to this unique policy opportunity. We conducted a systematic search and scoping review on stunting in Guatemala, searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were of any design or format, published in English and Spanish from 2000 to 2018. Articles were thematically grouped by those published before (2000-2011) and after (2012-2018) the new national policy initiatives. We identified a total of 1934 articles through database searches. After full-text review, 104 were included in the synthesis. The volume of published articles on stunting increased from a mean of 3.2 to 9.4 articles/year before and after 2012. There was a shift toward articles generating new data on priority populations, including rural indigenous Maya populations (34% vs 61%, χ2 test, p=0.01). However, the proportion of studies conducting implementation evaluations or testing new interventions was low and did not change significantly (34% vs 18%, χ2 test, p=0.07). Among 17 identified intervention studies, only 4 tested multilevel interventions, and there were no published interventions incorporating nutrition-sensitive interventions. A systematic search and scoping review of the literature on child stunting in Guatemala identified critical opportunities for new research in multilevel interventions, nutrition-sensitive interventions and implementation science.

Many maternal and perinatal deaths in low-resource settings are preventable. Inadequate access to timely, quality care in maternity facilities drives poor outcomes, especially where women deliver at home with traditional birth attendants (TBA). Yet few solutions exist to support TBA-initiated referrals or address reasons patients frequently refuse facility care, such as disrespectful and abusive treatment. We hypothesised that deploying accompaniers-obstetric care navigators (OCN)-trained to provide integrated patient support would facilitate referrals from TBAs to public hospitals. This project built on an existing collaboration with 41 TBAs who serve indigenous Maya villages in Guatemala's Western Highlands, which provided baseline data for comparison. When TBAs detected pregnancy complications, families were offered OCN referral support. Implementation was guided by bimonthly meetings of the interdisciplinary quality improvement team where the OCN role was iteratively tailored. The primary process outcomes were referral volume, proportion of births receiving facility referral, and referral success rate, which were analysed using statistical process control methods. Over the 12-month pilot, TBAs attended 847 births. The median referral volume rose from 14 to 27.5, meeting criteria for special cause variation, without a decline in success rate. The proportion of births receiving facility-level care increased from 24±6% to 62±20% after OCN implementation. Hypertensive disorders of pregnancy and prolonged labour were the most common referral indications. The OCN role evolved to include a number of tasks, such as expediting emergency transportation and providing doula-like labour support. OCN accompaniment increased the proportion of births under TBA care that received facility-level obstetric care. Results from this of obstetric care navigation suggest it is a feasible, patient-centred intervention to improve maternity care.

There has been limited research on the relationship between contraception and child growth in low-income and middle-income countries (LMICs). This study examines the association between contraception and child linear growth in Guatemala, an LMIC with a very high prevalence of child stunting. We hypothesise that contraceptive use is associated with better child linear growth and less stunting in Guatemala. Using representative national data on 12 440 children 0-59 months of age from the 2014-2015 Demographic and Health Survey in Guatemala, we constructed multivariable linear and Poisson regression models to assess whether child linear growth and stunting were associated with contraception variables. All models were adjusted for a comprehensive set of prespecified confounding variables. Contraceptive use was generally associated with modest, statistically significant greater height-for-age z-score. Current use of a modern method for at least 15 months was associated with a prevalence ratio of stunting of 0.87 (95% CI 0.81 to 0.94; p<0.001), and prior use of a modern method was associated with a prevalence ratio of stunting of 0.93 (95% CI 0.87 to 0.98; p<0.05). The severe stunting models found generally similar associations with modern contraceptive use as the stunting models. There was no significant association between use of a modern method for less than 15 months and the prevalence ratio of stunting or severe stunting. Contraceptive use was associated with better child linear growth and less child stunting in Guatemala. In addition to the human rights imperative to expand contraceptive access and choice, family planning merits further study as a strategy to improve child growth in Guatemala and other countries with high prevalence of stunting.

In low- and middle-income countries, gender norms and access to energy-dense, nutrient-poor foods are well-studied determinants of food and physical activity choices for adolescent girls. However, most work has been done in urban and school settings. In many settings, a large proportion of the adolescent population is rural or not enrolled in school. We conducted in-depth interviews with 20 adolescent girls (ages 15-19) in Tecpán, Guatemala, a rural, largely indigenous Maya community. Interviews were coded and themes analyzed for insights into eating habits, food choices, and physical activity. Twelve participants were enrolled in school and eight were employed and not in school. Girls enrolled in school had more disrupted eating schedules and consumed more energy-dense, nutrient-poor foods. Girls not enrolled in school had fewer opportunities for physical activity and were more sedentary. To our knowledge, this study is the first in a low- and middle-income country to consider diet and physical activity of adolescent girls enrolled and not enrolled in school. Key implications include (1) the need to reduce exposure to nutrient-poor foods and promote healthy eating schedules in schools, and (2) the need to create community-based opportunities for the activity for girls no longer enrolled in school.

[Abstract not available]

This article will define "wearables" as objects that interface and move with users, spanning clothing through smart devices. A novel design approach merging information from across disciplines and considering users' broad needs will be presented as the optimal approach for designing wearables that maximize usage. Three categories of wearables applicable to rehabilitation and habilitation will be explored: (1) inclusive clothing (eg, altered fit, fasteners); (2) supportive wearables (eg, orthotics, exoskeletons); and (3) smart wearables (eg, with sensors for tracking activity or controlling external devices). For each category, we will provide examples of existing and emerging wearables and potential applications for assessment and intervention with a focus on pediatric populations. We will discuss how these wearables might change task requirements and assist users for immediate effects and how they might be used with intervention activities to change users' abilities across time. It is important for rehabilitation clinicians and researchers to be engaged with the design and use of wearables so they can advocate and create better wearables for their clients and determine how to most effectively use wearables to enhance their assessment, intervention, and research practices.

Open research on fetal heart rate (FHR) estimation is relatively rare, and evidence for the utility of metrics derived from Doppler ultrasound devices has historically remained hidden in the proprietary documentation of commercial entities, thereby inhibiting its assessment and improvement. Nevertheless, recent studies have attempted to improve FHR estimation; however, these methods were developed and tested using datasets composed of few subjects and are therefore unlikely to be generalizable on a population level. The work presented here introduces a reproducible and generalizable autocorrelation (AC)-based method for FHR estimation from one-dimensional Doppler ultrasound (1D-DUS) signals. Simultaneous fetal electrocardiogram (fECG) and 1D-DUS signals generated by a hand-held Doppler transducer in a fixed position were captured by trained healthcare workers in a European hospital. The fECG QRS complexes were identified using a previously published fECG extraction algorithm and were then over-read to ensure accuracy. An AC-based method to estimate FHR was then developed on this data, using a total of 721 1D-DUS segments, each 3.75 s long, and parameters were tuned with Bayesian optimization. The trained FHR estimator was tested on two additional (independent) hand-annotated Doppler-only datasets recorded with the same device but on different populations: one composed of 3938 segments (from 99 fetuses) acquired in rural Guatemala, and another composed of 894 segments (from 17 fetuses) recorded in a hospital in the UK. The proposed AC-based method was able to estimate FHR within 10% of the reference FHR values 96% of the time, with an accuracy of 97% for manually identified good quality segments in both of the independent test sets. This is the first work to publish open source code for FHR estimation from 1D-DUS data. The method was shown to satisfy estimations within 10% of the reference FHR values and it therefore defines a minimum accuracy for the field to match or surpass. Our work establishes a basis from which future methods can be developed to more accurately estimate FHR variability for assessing fetal wellbeing from 1D-DUS signals.

[Abstract not available]

Conducting research with children in low/middle-income countries (LMIC) requires consideration of socioeconomic inequalities and cultural and linguistic differences. Our objective was to survey the literature on informed consent in paediatric LMIC research, assessing for practical guidance for culturally and linguistically appropriate procedures. We conducted a scoping review on informed consent in paediatric LMIC research searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were published in English, from any date range, of any study design or format. The search identified 2027 references, of which 50 were included in the analysis following full-text review. Reviewed guidelines emphasised individual, informed and voluntary consent from parents and caregivers. Reviewed articles provided detailed practical guidance on adapting these guiding principles to LMIC settings, including considerations for community engagement, verbal or other alternative consent procedures for low-literacy settings or less commonly spoken languages and guarding against therapeutic misconception by caregivers. There was uncertainty, however, on how to best protect individual autonomy, especially when influenced by gender dynamics, leadership hierarchies or the social status of researchers themselves. There was, furthermore, limited research discussing the special case of research involving adolescents or of procedures for documenting assent by participating children. A scoping review of paediatric research in LMICs revealed substantial guidance on several features of culturally appropriate informed consent. However, additional research and guidance is needed, especially in the areas of gender imbalances, research with adolescents and children's own assent to participate in research.

Stunting is a common cause of early child developmental delay; Guatemala has the fourth highest rate of stunting globally. The goal of this study was to examine the impact of an intensive community health worker-led complementary feeding intervention on early child development in Guatemala. We hypothesised that the intervention would improve child development over usual care. A substudy from a larger individually randomised (1:1 allocation ratio), parallel-group superiority trial, with blinding of study staff collecting outcomes data. Rural, indigenous Maya communities in Guatemala. 210 stunted children (height-for-age z-score ≤-2.5) aged 6-24 months, previously randomised to usual care (106) or an intensive complementary feeding intervention (104). 84 in the intervention and 91 in the usual care arm agreed to participate. Community health workers conducted monthly home visits for 6 months, providing usual care or individualised complementary feeding education. The primary outcomes were change in z-scores for the subscales of the Bayley Scales of Infant Development (BSID), Third Edition. 100 individuals were included in the final analysis, 47 in the intervention and 53 in the usual care arm. No statistically significant differences in age-adjusted scores between the arms were observed for any subscale. However, improvements within-subjects in both arms were observed (median duration between measurements 189 days (IQR 182-189)). Mean change for subscales was 0.45 (95% CI 0.23 to 0.67) z-scores in the intervention, and 0.43 (95% CI 0.25 to 0.61) in the usual care arm. An intensive complementary feeding intervention did not significantly improve developmental outcomes more than usual care in stunted, indigenous Guatemalan children. However, both interventions had significant positive impacts on developmental outcomes. NCT02509936. Results.

[Abstract not available]

Purpose Cervical cancer is an important cause of mortality in low- and middle-income countries. Although screening technologies continue to improve, systems of care remain fragmented. It is important to better understand factors that affect use of screening services and loss to follow-up along the care continuum. Methods We conducted a mixed-methods study of a cytology-based screening program in rural Guatemala. A retrospective electronic chart review was performed on data from all patients from 2013 to 2014. We analyzed progression through care and calculated loss-to-follow-up rates. We also analyzed the prior experiences of patients with cervical cancer screening on the basis of self-reported historical data available in the chart review. Structured interviews with a subset of individuals to explore social supports and barriers to screening and engagement in care were conducted at the time of screening. Results The analysis included 515 women (median age, 36 years). Cytologic screening showed concern for neoplastic changes in 0.83%; half resulted in biopsy-proven cervical intraepithelial neoplasia. An additional 9.9% showed severe inflammation. The rate of loss to follow-up was 11.3%. All losses to follow-up occurred for severe inflammation, not for cervical intraepithelial neoplasia. Historical data showed that 73% of the cohort had previously been screened and had high levels of loss to follow-up (57.4%). Qualitative interviews revealed factors that promoted loss to follow-up; these included cost, lack of social supports, transportation, distrust in public facilities, long turn-around times, and failure to return test results or offer follow-up treatments. Conclusions Taken together, these quantitative and qualitative results highlight the need for cervical cancer screening programs in Guatemala to improve uptake of screening services by eligible women and to improve follow-up after a first abnormal screen.

Guatemala's indigenous Maya population has one of the highest perinatal and maternal mortality rates in Latin America. In this population most births are delivered at home by traditional birth attendants (TBAs), who have limited support and linkages to public hospitals. The goal of this study was to characterize the detection of maternal and perinatal complications and rates of facility-level referral by TBAs, and to evaluate the impact of a mHealth decision support system on these rates. A pragmatic one-year feasibility trial of an mHealth decisions support system was conducted in rural Maya communities in collaboration with TBAs. TBAs were individually randomized in an unblinded fashion to either early-access or later-access to the mHealth system. TBAs in the early-access arm used the mHealth system throughout the study. TBAs in the later-access arm provided usual care until crossing over uni-directionally to the mHealth system at the study midpoint. The primary study outcome was the monthly rate of referral to facility-level care, adjusted for birth volume. Forty-four TBAs were randomized, 23 to the early-access arm and 21 to the later-access arm. Outcomes were analyzed for 799 pregnancies (early-access 425, later-access 374). Monthly referral rates to facility-level care were significantly higher among the early-access arm (median 33 referrals per 100 births, IQR 22-58) compared to the later-access arm (median 20 per 100, IQR 0-30) (p = 0.03). At the study midpoint, the later-access arm began using the mHealth platform and its referral rates increased (median 34 referrals per 100 births, IQR 5-50) with no significant difference from the early-access arm (p = 0.58). Rates of complications were similar in both arms, except for hypertensive disorders of pregnancy, which were significantly higher among TBAs in the early-access arm (RR 3.3, 95% CI 1.10-9.86). Referral rates were higher when TBAs had access to the mHealth platform. The introduction of mHealth supportive technologies for TBAs is feasible and can improve detection of complications and timely referral to facility-care within challenging healthcare delivery contexts. Clinicaltrials.gov NCT02348840 .

[Abstract not available]

In many low-resource settings around the world utilization of long-acting reversible contraception (LARC) is low, in part due to access barriers. We sought to explore LARC utilization patterns as well as factors associated with LARC initiation by women seeking contraception in rural Guatemala from a program working to reduce contraception access barriers. We analyzed data from a program that provides family planning in six remote, primarily indigenous, villages in Guatemala with limited access to alternative health services. Methods are free and delivered directly within villages by culturally competent providers. We conducted a retrospective chart review of all 288 women who initiated a contraceptive method over a 16-month period and conducted a logistic regression to obtain adjusted odds ratios (OR) for predictors of LARC uptake. Overall 79.2% of women elected a LARC method. More than half of women (49.8%) switched to LARC from short-acting hormonal methods. In the univariate analysis prior use of short-acting method (p = 0.014), number of prior methods (p = 0.049), and current contraceptive use (p<0.01) were significantly associated with choosing a LARC. In the logistic regression model current use of contraception remained significant (OR 3.29, 95% CI 1.67-8.04). Report of abnormal bleeding or other side effects from prior short-acting method use did not predict LARC uptake (p = 0.82 and p = 0.079). Most women in this marginalized population opted for a LARC method. Low utilization of LARCs may be related to service delivery factors. Further research is needed to validate these conclusions prospectively and in less selected populations.

Guatemala's indigenous Maya population has one of the highest rates of childhood stunting in the world. The goal of this study was to examine the impact of an intensive, individualised approach to complementary feeding education for caregivers on feeding practices and growth over usual care. An individually randomised (1:1 allocation ratio), parallel-group superiority trial, with blinding of study staff collecting outcome data. Rural Maya communities in Guatemala. 324 children aged 6-24 months with a height-for-age Z score of less than or equal to -2.5 SD were randomised, 161 to the intervention and 163 to usual care. Community health workers conducted home visits for 6 months, providing usual care or usual care plus individualised caregiver education. The main outcome was change in length/height-for-age Z score. Secondary outcomes were changes in complementary feeding indicators. Data were analysed for 296 subjects (intervention 145, usual care 151). There was a non-significant trend to improved growth in the intervention arm (length/height-for-age Z score change difference 0.07(95% CI -0.04 to 0.18)). The intervention led to a 22% improvement in minimum dietary diversity (RR 1.22, 95% CI 1.11 to 1.35) and a 23% improvement in minimal acceptable diet (RR 1.23, 95% CI 1.08 to 1.40) over usual care. Complementary feeding outcomes improved in the intervention arm, and a non-significant trend towards improved linear growth was observed. Community health workers in a low-resource rural environment can implement individualised caregiver complementary feeding education with significant improvements in child dietary quality over standard approaches. NCT02509936. Stage: Results.

The utilization of existing social networks is increasingly being recognized as a powerful strategy for delivering healthcare services to underserved populations in low- and middle-income countries. In Guatemala, multiple barriers prevent access to healthcare services for rural and indigenous populations, and strategies for delivering healthcare in more efficient ways are needed. The case study we describe here is a unique collaboration between a microfinance institution (Friendship Bridge) and a primary care organization (Wuqu' Kawoq | Maya Health Alliance) to scale up healthcare through an existing lending-borrowing social network. The program provides primary care services to female clients of Friendship Bridge in rural areas of Guatemala, with nurses working as frontline primary care providers, providing door-to-door healthcare services. Over the first 22 months of the project, we have reached over 3500 of Friendship Bridge's clients, with overall high acceptance of services. All clinical documentation and program monitoring and evaluation are done through audit trails within an electronical medical record system, which improves efficiency and lowers the associated time and resources costs. We utilize quality improvement methodologies to aid in decision making and programmatic adjustments scale up. These strategies have allowed us to expand services rapidly under challenging geographic and logistical constraints, while concurrently iteratively improving staff training and supervision, clinical care, and client engagement processes.

[Abstract not available]

Screening is a key strategy to address the rising burden of chronic kidney disease (CKD) in low-income and middle-income countries. However, there are few reports regarding the implementation of screening programmes in resource-limited settings. The objectives of this study are to (1) to share programmatic experiences implementing CKD screening in a rural, resource-limited setting and (2) to assess the burden of renal disease in a community-based diabetes programme in rural Guatemala. Cross-sectional assessment of glomerular filtration rate (GFR) and urine albumin. Central Highlands of Guatemala. We enrolled 144 adults with type 2 diabetes in a community-based CKD screening activity carried out by the sponsoring institution. Prevalence of renal disease and risk of CKD progression using Kidney Disease: Improving Global Outcomes definitions and classifications. We found that 57% of the sample met GFR and/or albuminuria criteria suggestive of CKD. Over half of the sample had moderate or greater increased risk for CKD progression, including nearly 20% who were classified as high or very high risk. Hypertension was common in the sample (42%), and glycaemic control was suboptimal (mean haemoglobin A1c 9.4%±2.5% at programme enrolment and 8.6%±2.3% at time of CKD screening). The high burden of renal disease in our patient sample suggests an imperative to better understand the burden and risk factors of CKD in Guatemala. The implementation details we share reveal the tension between evidence-based CKD screening versus screening that can feasibly be delivered in resource-limited global settings.

Disrespectful and abusive maternity care is a common and pervasive problem that disproportionately impacts marginalized women. By making mothers less likely to agree to facility-based delivery, it contributes to the unacceptably high rates of maternal mortality in low- and middle-income countries. Few programmatic approaches have been proposed to address disrespectful and abusive maternity care. Care navigation was pioneered by the field of oncology to improve health outcomes of vulnerable populations and promote patient autonomy by providing linkages across a fragmented care continuum. Here we describe the novel application of the care navigation model to emergency obstetric referrals to hospitals for complicated home births in rural Guatemala. Care navigators offer women accompaniment and labor support intended to improve the care experience-for both patients and providers-and to decrease opposition to hospital-level obstetric care. Specific roles include deflecting mistreatment from hospital staff, improving provider communication through language and cultural interpretation, advocating for patients' right to informed consent, and protecting patients' dignity during the birthing process. Care navigators are specifically chosen and trained to gain the trust and respect of patients, traditional midwives, and biomedical providers. We describe an ongoing obstetric care navigator pilot program employing rapid-cycle quality improvement methods to quickly identify implementation successes and failures. This approach empowers frontline health workers to problem solve in real time and ensures the program is highly adaptable to local needs. Care navigation is a promising strategy to overcome the "humanistic barrier" to hospital delivery by mitigating disrespectful and abusive care. It offers a demand-side approach to undignified obstetric care that empowers the communities most impacted by the problem to lead the response. Results from an ongoing pilot program of obstetric care navigation will provide valuable feedback from patients on the impact of this approach and implementation lessons to facilitate replication in other settings.

[Abstract not available]

Diabetes self-management education (DSME) is a fundamental element of type 2 diabetes care. Although 75% of adults with diabetes worldwide live in low-income and middle-income countries (LMICs), limited DSME research has been conducted in LMICs. The objective of this study was to evaluate a home-based DSME intervention in rural Guatemala. We conducted a prospective study of a DSME intervention using a quasi-experimental, single-group pretest-posttest design. We enrolled 90 participants in the intervention, which consisted of 6 home visits (May 2014-July 2016) conducted by a diabetes educator using a curriculum culturally and linguistically tailored to rural Mayan populations. Primary outcomes were changes in mean hemoglobin A1c (HbA1c) and mean systolic and diastolic blood pressure at baseline and at 12 months. Secondary outcomes were diabetes knowledge and self-care activities at baseline and intervention completion. HbA1c decreased significantly from baseline to 12 months (absolute mean change, -1.5%; 95% confidence interval [CI], -1.9% to -1.0%; P < .001). Systolic blood pressure also improved significantly at 12 months (-6.2 mm Hg; 95% CI, -10.1 to -2.2 mm Hg; P = .002); changes in diastolic blood pressure were not significant (-1.6 mm Hg; 95% CI, -3.9 to -0.7 mm Hg; P = .17). We also found significant improvements in diabetes knowledge and self-care activities from baseline to intervention completion. DSME interventions can be successfully delivered in a setting with an underresourced health system, high poverty rate, and unique cultural characteristics like Mayan Guatemala. Our findings point to the need for more DSME research in resource-limited settings globally.

Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients. Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care. This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework. A bundle of improvement activities were implemented at the home, clinic and institutional level. Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control. Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.

[Abstract not available]

Access to low-cost essential generic medicines is a critical health policy goal in low-and-middle income countries (LMICs). Guatemala is an LMIC where there is both limited availability and affordability of these medications. However, attitudes of physicians and pharmacy staff regarding low-cost generics, especially generics for non-communicable diseases (NCDs), have not been fully explored in Guatemala. Semi-structured interviews with 30 pharmacy staff and 12 physicians in several highland towns in Guatemala were conducted. Interview questions related to perceptions of low-cost generic medicines, prescription and dispensing practices of generics in the treatment of two NCDs, diabetes and hypertension, and opinions about the roles of pharmacy staff and physicians in selecting medicines for patients. Pharmacy staff were recruited from a random sample of pharmacies and physicians were recruited from a convenience sample. Interview data were analyzed using a thematic approach for qualitative data as well as basic quantitative statistics. Pharmacy staff and physicians expressed doubt as to the safety and efficacy of low-cost generic medicines in Guatemala. The low cost of generic medicines was often perceived as proof of their inferior quality. In the case of diabetes and hypertension, the decision to utilize a generic medicine was based on multiple factors including the patient's financial situation, consumer preference, and, to a large extent, physician recommendations. Interventions to improve generic medication utilization in Guatemala must address the negative perceptions of physicians and pharmacy staff toward low-cost generics. Strengthening state capacity and transparency in the regulation and monitoring of the drug supply is a key goal of access-to-medicines advocacy in Guatemala.

Technology provides the potential to empower frontline healthcare workers with low levels of training and literacy, particularly in low- and middle-income countries. An obvious platform for achieving this aim is the smartphone, a low cost, almost ubiquitous device with good supply chain infrastructure and a general cultural acceptance for its use. In particular, the smartphone offers the opportunity to provide augmented or procedural information through active audiovisual aids to illiterate or untrained users, as described in this article. In this article, the process of refinement and iterative design of a smartphone application prototype to support perinatal surveillance in rural Guatemala for indigenous Maya lay midwives with low levels of literacy and technology exposure is described. Following on from a pilot to investigate the feasibility of this system, a two-year project to develop a robust in-field system was initiated, culminating in a randomized controlled trial of the system, which is ongoing. The development required an agile approach, with the development team working both remotely and in country to identify and solve key technical and cultural issues in close collaboration with the midwife end-users. This article describes this process and intermediate results. The application prototype was refined in two phases, with expanding numbers of end-users. Some of the key weaknesses identified in the system during the development cycles were user error when inserting and assembling cables and interacting with the 1-D ultrasound-recording interface, as well as unexpectedly poor bandwidth for data uploads in the central healthcare facility. Safety nets for these issues were developed and the resultant system was well accepted and highly utilized by the end-users. To evaluate the effectiveness of the system after full field deployment, data quality, and corruption over time, as well as general usage of the system and the volume of application support for end-users required by the in-country team was analyzed. Through iterative review of data quality and consistent use of user feedback, the volume and percentage of high quality recordings was increased monthly. Final analysis of the impact of the system on obstetrical referral volume and maternal and neonatal clinical outcomes is pending conclusion of the ongoing clinical trial.

Limited funding for medical technology, low levels of education and poor infrastructure for delivering and maintaining technology severely limit medical decision support in low- and middle-income countries. Perinatal and maternal mortality is of particular concern with millions dying every year from potentially treatable conditions. Guatemala has one of the worst maternal mortality ratios, the highest incidence of intra-uterine growth restriction (IUGR), and one of the lowest gross national incomes per capita within Latin America. To address the lack of decision support in rural Guatemala, a smartphone-based system is proposed including peripheral sensors, such as a handheld Doppler for the identification of foetal compromise. Designed for use by illiterate birth attendants, the system uses pictograms, audio guidance, local and cloud processing, SMS alerts and voice calling. The initial prototype was evaluated on 22 women in highland Guatemala. Results were fed back into the refinement of the system, currently undergoing RCT evaluation.

The burden of chronic, non-communicable diseases such as diabetes is growing rapidly in low- and middle-income countries. Implementing management programs for diabetes and other chronic diseases for underserved populations is thus a critical global health priority. However, there is a notable dearth of shared programmatic and outcomes data from diabetes treatment programs in these settings. We describe our experiences as a non-governmental organization designing and implementing a type 2 diabetes program serving Maya indigenous people in rural Guatemala. We detail the practical challenges and solutions we have developed to build and sustain diabetes programming in this setting. We conduct a retrospective chart review from our electronic medical record to evaluate our program's performance. We generate a cohort profile, assess cross-sectional indicators using a framework adapted from the literature, and report on clinical longitudinal outcomes. A total of 142 patients were identified for the chart review. The cohort showed a decrease in hemoglobin A1C from a mean of 9.2% to 8.1% over an average of 2.1 years of follow-up (p <0.001). The proportions of patients meeting glycemic targets were 53% for hemoglobin A1C < 8% and 32% for the stricter target of hemoglobin A1C < 7%. We first offer programmatic experiences to address a gap in resources relating to the practical issues of designing and implementing global diabetes management interventions. We then present clinical data suggesting that favorable diabetes outcomes can be attained in poor areas of rural Guatemala.

Western allopathic physicians working internationally might encounter allopathic colleagues who endorse local healing practices that are not scientifically supported and, hence, might pose harm to patients. Respect for the autonomy of local physicians and patients thus can conflict with the ethical principles of beneficence and nonmaleficence. In such a situation, it is advisable for Western allopathic physicians to communicate their concerns to local colleagues as equal partners. Making an effort to understand local meanings associated with a traditional therapy demonstrates one's respect for local cultural ideas and practices, even if one disagrees with that therapy, and is crucial to tailoring messages about clinical practice change. A realistic approach to cross-cultural clinical practice change seeks to reduce, rather than eliminate, harm.

A recent article in GHSP calls for classifying fertility awareness methods as “modern contraceptives” despite their inferiority. We believe in a rights-based approach, which considers the real-world conditions that many women face, including constrained sexual agency and low baseline reproductive health literacy. We must demonstrate true commitment to increasing access to the most effective and reliable contraceptive methods. A recent article in GHSP calls for classifying fertility awareness methods as “modern contraceptives” despite their inferiority. We believe in a rights-based approach, which considers the real-world conditions that many women face, including constrained sexual agency and low baseline reproductive health literacy. We must demonstrate true commitment to increasing access to the most effective and reliable contraceptive methods.

Global health practitioners may feel frustration that current models of global health research, delivery, and implementation are overly focused on specific interventions, slow to provide health services in the field, and relatively ill-equipped to adapt to local contexts. Adapting design principles from the agile software development movement, we propose an analogous approach to designing global health programs that emphasizes tight integration between research and implementation, early involvement of ground-level health workers and program beneficiaries, and rapid cycles of iterative program improvement. Using examples from our own fieldwork, we illustrate the potential of 'agile global health' and reflect on the limitations, trade-offs, and implications of this approach.

Guatemala's rural indigenous population suffers from one of the highest rates of chronic child malnutrition (stunting) in the world. Successfully addressing stunting requires defining the barriers to and opportunities for new behaviour-change initiatives. We undertook a mixed-methods assessment of feeding practices and food purchasing behaviours around infants and young children aged 6-36 months in two rural indigenous Guatemalan communities. We found that most caregivers were aware only of acute forms of child malnutrition and that they greatly underestimated the local prevalence of malnutrition. Despite moderate adherence to exclusive breastfeeding and timing of complementary food introduction, diets had poor diversity and inadequate meal frequency. Furthermore, perceptions of food insecurity were high even in the presence of land ownership and agricultural production. Although fortified foods were highly valued, they were considered expensive. At the same time, proportionally equivalent amounts of money were spent on junk foods or other processed foods by most participants. Biological mothers often lacked autonomy for food purchasing and nutritional decisions because of the power exerted by husbands and paternal grandmothers. Our findings suggest several creative and community-based programming initiatives including education about the acute vs. chronic malnutrition distinction, engaging landowners in discussions about domestic food consumption, engaging with caregivers to redirect funds towards fortified foods rather than junk food purchases and directing behaviour-change initiatives towards all household stakeholders.

to examine the present-day knowledge formation and practice of indigenous Kaqchikel-speaking midwives, with special attention to their interactions with the Guatemalan medical community, training models, and allopathic knowledge in general. a qualitative study consisting of participant-observation in lay midwife training programs; in-depth interviews with 44 practicing indigenous midwives; and three focus groups with midwives of a local non-governmental organization. Kaqchikel Maya-speaking communities in the Guatemalan highlands. the cumulative undermining effects of marginalization, cultural and linguistic barriers, and poorly designed training programs contribute to the failure of lay midwife-focused initiatives in Guatemala to improve maternal-child health outcomes. Furthermore, in contrast to prevailing assumptions, Kaqchikel Maya midwives integrate allopathic obstetrical knowledge into their practice at a high level. as indigenous midwives in Guatemala will continue to provide a large fraction of the obstetrical services among rural populations for many years to come, maternal-child policy initiatives must take into account that: (1)Guatemalan midwife training programs can be significantly improved when instruction occurs in local languages, such as Kaqchikel, and (2)indigenous midwives' increasing allopathic repertoire may serve as a productive ground for synergistic collaborations between lay midwives and the allopathic medical community.

In Guatemala, diabetes is an emerging public health concern. Guatemala has one of the largest indigenous populations in Latin America, and this population frequently does not access the formal health care system. Therefore, knowledge about the emergence of diabetes in this population is limited. Interview participants (n=23) were recruited from a convenience sample of indigenous adults with type 2 diabetes at one rural diabetes clinic in Guatemala. A structured interview was used to assess knowledge about diabetes and its complications; access to diabetes-related health care and treatment; dietary and lifestyle changes; and family and social supports for individuals living with diabetes. Interviews were supplemented with two group interviews with community leaders and health care providers. Thematic analysis was used to produce insights into diabetes knowledge, attitudes, and practices. In addition, a chart review of the clinic's electronic medical record identified all adult patients (n=80) presenting in one calendar year for a first-time diabetic consultation. Sociodemographic and clinical variables were extracted and summarized from these records. Salient demographic factors in both the structured interview and chart review samples included low educational levels and high indigenous language preference. In the interview sample, major gaps in biomedical knowledge about diabetes included understanding the causes, chronicity, and long-term end-organ complications of diabetes. Medication costs, medical pluralism, and limited social supports for dietary and lifestyles changes were major practical barriers to disease management. Quantitative data from medical records review revealed high rates of poor glycemic control, overweight and obesity, and medication prescription. This study provides a preliminary sketch of type 2 diabetes in an indigenous Guatemalan population. Combined qualitative and quantitative data point towards particular needs for implementation and future research, including the need to address gaps in diabetes knowledge, to improve social support systems, and to address the cost barriers associated with disease treatment.