Publications by authors named "Magda Cepeda"

29 Publications

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Access barriers, self-recognition, and recognition of depression and unhealthy alcohol use: A qualitative study.

Rev Colomb Psiquiatr (Engl Ed) 2021 Jul 8;50 Suppl 1:52-63. Epub 2021 Aug 8.

Departmento de Psiquiatría, Geisel School of Medicine, Dartmouth College, Hanover, United States.

Introduction: Access to healthcare services involves a complex dynamic, where mental health conditions are especially disadvantaged, due to multiple factors related to the context and the involved stakeholders. However, a characterisation of this phenomenon has not been carried out in Colombia, and this motivates the present study.

Objectives: The objective of this study was to explore the causes that affect access to health services for depression and unhealthy alcohol use in Colombia, according to various stakeholders involved in the care process.

Methods: In-depth interviews and focus groups were conducted with health professionals, administrative professionals, users, and representatives of community health organisations in five primary and secondary-level institutions in three regions of Colombia. Subsequently, to describe access to healthcare for depression and unhealthy alcohol use, excerpts from the interviews and focus groups were coded through content analysis, expert consensus, and grounded theory. Five categories of analysis were created: education and knowledge of the health condition, stigma, lack of training of health professionals, culture, and structure or organisational factors.

Results: We characterised the barriers to a lack of illness recognition that affected access to care for depression or unhealthy alcohol use according to users, healthcare professionals and administrative staff from five primary and secondary care centres in Colombia. The groups identified that lack of recognition of depression was related to low education and knowledge about this condition within the population, stigma, and lack of training of health professionals, as well as to culture. For unhealthy alcohol use, the participants identified that low education and knowledge about this condition, lack of training of healthcare professionals, and culture affected its recognition, and therefore, healthcare access. Neither structural nor organisational factors seemed to play a role in the recognition or self-recognition of these conditions.

Conclusions: This study provides essential information for the search for factors that undermine access to mental health in the Colombian context. Likewise, it promotes the generation of hypotheses that can lead to the development and implementation of tools to improve care in the field of mental illness.
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http://dx.doi.org/10.1016/j.rcpeng.2021.06.008DOI Listing
July 2021

Technology-based mental healthcare models: A systematic review of the literature.

Rev Colomb Psiquiatr (Engl Ed) 2021 Jul 2;50 Suppl 1:30-41. Epub 2021 Aug 2.

Departamento de Epidemiología Clínica y Bioestadística, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia; Hospital Universitario San Ignacio, Bogotá, Colombia; Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia.

Introduction: This systematic review summarises the existing evidence on the implementation of technology-based mental healthcare models in the primary care setting.

Methods: A systematic search was conducted (MEDLINE, Embase, CENTRAL) in August 2019 and studies were selected according to predefined eligibility criteria. The main outcomes were clinical effectiveness, adherence to primary treatment and cost of implementation.

Selection Criteria: Studies with an experimental or quasi-experimental design that evaluated the implementation of technology-based mental healthcare models were included.

Results: Five articles met the inclusion criteria. The models included technological devices such as tablets, cellphones and computers, with programs and mobile apps that supported decision-making in the care pathway. These decisions took place at different times, from the universal screening phase to the follow-up of patients with specific conditions. In general, the studies showed a decrease in the reported symptoms. However, there was great heterogeneity in both the health conditions and the outcomes, which hindered a quantitative synthesis. The assessment of risk of bias showed low quality of evidence.

Conclusion: There is not enough evidence to support the implementation of a technology-based mental healthcare model. High quality studies that focus on implementation and effectiveness outcomes are needed to evaluate the impact of technology-based mental healthcare models in the primary care setting.
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http://dx.doi.org/10.1016/j.rcpeng.2021.07.002DOI Listing
July 2021

Scaling Up Science-Based Care for Depression and Unhealthy Alcohol Use in Colombia: An Implementation Science Project.

Psychiatr Serv 2021 Aug 4:appips202000041. Epub 2021 Aug 4.

Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire (Marsch, Bartels, Bell, Martinez Camblor, Cubillos, John, Lemley, Torrey); Department of Psychiatry, Pontificia Universidad Javeriana, Bogotá, Colombia (Gómez-Restrepo, Castro, Cárdenas Charry, Cepeda, Jassir, Suárez-Obando, Uribe); Hospital Universitario San Ignacio, Bogotá, Colombia (Gómez-Restrepo, Suárez-Obando); Department of Psychiatry, Dartmouth-Hitchcock, Lebanon, New Hampshire (Cubillos, Torrey); National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (Williams).

Background: Mental disorders are a major cause of the global burden of disease and significantly contribute to disability and death. This challenge is particularly evident in low- and middle-income countries (LMICs), where >85% of the world's population live. Latin America is one region comprising LMICs where the burden of mental disorders is high and the availability of mental health services is low. This is particularly evident in Colombia, a country with a long-standing history of violence and associated mental health problems.

Methods: This article describes the design of a multisite implementation science project, "Scaling Up Science-Based Mental Health Interventions in Latin America" (also known as the DIADA project), that is being conducted in six primary care systems in Colombia. This project, funded via a cooperative agreement from the National Institute of Mental Health, seeks to implement and assess the impact of a new model for promoting widespread access to mental health care for depression and unhealthy alcohol use within primary care settings and building an infrastructure to support research capacity and sustainability of the new service delivery model in Colombia. This care model centrally harnesses mobile health technology to increase the reach of science-based mental health care for depression and unhealthy alcohol use.

Results: This initiative offers great promise to increase capacity for providing and sustaining evidence-based treatment for depression and unhealthy alcohol use in Colombia.

Next Steps: This project may inform models of care that can extend to other regions of Latin America or other LMICs.
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http://dx.doi.org/10.1176/appi.ps.202000041DOI Listing
August 2021

Global mental health and the DIADA project.

Rev Colomb Psiquiatr (Engl Ed) 2021 Jul 30;50 Suppl 1:13-21. Epub 2021 Jul 30.

Departamento de Psiquiatría y Salud Mental, Pontificia Universidad Javeriana, Bogotá, Colombia; Departamento de Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Bogotá, Colombia.

The DIADA project, understood as a mental healthcare implementation experience in the context of a middle-income country like Colombia, promotes a necessary discussion about its role in the global mental health framework. The following article outlines the main points by which this relationship occurs, understanding how the project contributes to global mental health and, at the same time, how global mental health nurtures the development of this project. It reflects on aspects like the systematic screening of patients with mental illness, the use of technology in health, the adoption of a collaborative model, the investigation on implementation, a collaborative learning and the Colombian healthcare system. These are all key aspects when interpreting the feedback cycle between the individual and the global. The analysis of these components shows how collaborative learning is a central axis in the growth of global mental health: from the incorporation of methodologies, implementation of models, assessment of outcomes and, finally, the dissemination of results to local, regional and international stakeholders.
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http://dx.doi.org/10.1016/j.rcpeng.2021.07.001DOI Listing
July 2021

Relationship between the sociodemographic characteristics of participants in the DIADA project and the rate of compliance with follow-up assessments in the initial stage of the intervention.

Rev Colomb Psiquiatr (Engl Ed) 2021 Jul 21;50 Suppl 1:102-109. Epub 2021 Jul 21.

Departamento de Epidemiología Clínica y Bioestadística, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia; Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia; Hospital Universitario San Ignacio, Bogotá, Colombia.

Objective: Analyse the relationship between the sociodemographic profile of the DIADA study participants and the rate of compliance with the follow-up assessments in the early stage of this project's intervention for depression and unhealthy alcohol use offered within primary care.

Methods: A non-experimental quantitative analysis was conducted. The sociodemographic data of DIADA [Detección y Atención Integral de Depresión y Abuso de Alcohol en Atención Primaria (Detection and Integrated Care for Depression and Alcohol Use in Primary Care)] study participants had been previously collected. At the time of the evaluation (September 12, 2019), only the participants who had been in the project for a minimum of 3 months were included. By using univariate (Chi-squared) analyses, we studied the association between participants' sociodemographic profile and their rate of compliance with the first follow-up assessment at 3 months after study initiation.

Results: At the date of the evaluation, 584 adult participants were identified, of which 389 had been involved in the project for more than 3 months. From the participants included, 320 performed the first follow-up, while 69 did not. The compliance rate to the first follow-up was 82.3% (95 % [CI] 78.1%-86%) and was not affected by: site location, age, sex, civil status, level of education, use of smartphone, PHQ9 score (measuring depression symptomatology) or AUDIT score (measuring harmful alcohol use). Participants who do not use a smartphone, from rural areas and with a lower socioeconomic status, tended to show higher compliance rates. Statistically significant associations were found; participants with lower job stability and a lack of access to the Internet showed higher compliance rates to the early initial follow-up assessment.

Conclusions: The compliance rate was high and generally constant in spite of the variability of the sociodemographic profiles of the participants, although several sub-groups of participants showed particularly high rates of compliance. These findings may suggest that integrating mental health into primary care allows the structural and financial barriers that hinder access to health in Colombia to be broken down by raising awareness about mental illnesses, their high prevalence and the importance of timely and accessible medical management.
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http://dx.doi.org/10.1016/j.rcpeng.2021.06.006DOI Listing
July 2021

Characterizing the perceived stigma towards mental health in the early implementation of an integrated services model in primary care in Colombia. A qualitative analysis.

Rev Colomb Psiquiatr (Engl Ed) 2021 Jul 10;50 Suppl 1:91-101. Epub 2021 Jul 10.

Pontificia Universidad Javeriana, Bogotá, Colombia.

Background: Stigma is a sociocultural barrier to accessing mental health services and prevents individuals with mental health disorders from receiving mental health care. The Ministry of Health and Social Protection of Colombia acknowledges that a great number of people with mental disorders do not seek medical aid due to stigma.

Objectives: Characterise the perceived stigma towards mental health among the stakeholders involved in the early implementation of the DIADA project [Detección y Atención Integral de Depresión y Abuso de Alcohol en Atención Primaria (Detection and Integrated Care for Depression and Alcohol Use in Primary Care)]. Explore whether the implementation of this model can decrease stigma. Describe the impact of the implementation on the lives of patients and medical practice.

Materials And Methods: Eighteen stakeholders (7 patients, 5 physicians and 6 administrative staff) were interviewed and a secondary data analysis of 24 interview transcripts was conducted using a rapid analysis technique.

Results: The main effects of stigma towards mental health disorders included refusing medical attention, ignoring illness, shame and labelling. Half of the stakeholders reported that the implementation of mental health care in primary care could decrease stigma. All of the stakeholders said that the implementation had a positive impact.

Conclusions: The perceived stigma was characterised as social and aesthetic in nature. Communication and awareness about mental health is improving, which could facilitate access to mental health treatment and strengthen the doctor-patient relationship. Culture is important for understanding stigma towards mental health in the population studied.
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http://dx.doi.org/10.1016/j.rcpeng.2021.06.009DOI Listing
July 2021

The DIADA project: A technology-based model of care for depression and risky alcohol use in primary care centres in Colombia.

Rev Colomb Psiquiatr (Engl Ed) 2021 Jul 7;50 Suppl 1:4-12. Epub 2021 Jul 7.

Department of Psychiatry, Dartmouth's Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, United States.

Introduction: People with mental health conditions frequently attend primary care centers, but these conditions are underdiagnosed and undertreated. The objective of this paper is to describe the model and the findings of the implementation of a technology-based model of care for depression and unhealthy alcohol use in primary care centers in Colombia.

Methods: Between February 2018 and March 2020, we implemented a technology-based model of care for depression and unhealthy alcohol use, following a modified stepped wedge methodology, in six urban and rural primary care centers in Colombia. The model included a series of steps aimed at screening patients attending medical appointments with general practitioners and supporting the diagnosis and treatment given by the general practitioner. We describe the model, its implementation and the characteristics of the screened and assessed patients.

Results: During the implementation period, we conducted 22,354 screenings among 16,188 patients. The observed rate of general practitioner (GP)-confirmed depression diagnosis was 10.1% and of GP-confirmed diagnosis of unhealthy alcohol use was 1.3%. Patients with a depression diagnosis were primarily middle-aged women, while patients with unhealthy alcohol use were mainly young adult men.

Discussion: The provision of training and technology-based strategies to screen patients and support the decision-making of GPs during the medical appointment enhanced the diagnosis and care provision of patients with depression and unhealthy alcohol use. However, time constraints, as well as structural and cultural barriers, were challenges for the implementation of the model, and the model should take into account local values, policies and resources to guarantee its long-term sustainability. As such, the long-term sustainability of the model will depend on the alignment of different stakeholders, including decision-makers, institutions, insurers, GPs, patients and communities, to reduce the amount of patients seeking medical care whose mental health conditions remain undetected, and therefore untreated, and to ensure an appropriate response to the demand for mental healthcare that was revealed by the implementation of our model.
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http://dx.doi.org/10.1016/j.rcpeng.2020.11.005DOI Listing
July 2021

The DIADA Project: A technology-based model of care for depression and risky alcohol use in Primary Care Centres in Colombia.

Rev Colomb Psiquiatr 2021 Jun 15;50 Suppl 1:4-13. Epub 2021 May 15.

Department of Psychiatry, Dartmouth's Geisel School of Medicine, Dartmouth College, Hanover (New Hampshire), Estados Unidos.

Introduction: People with mental health conditions frequently attend primary care centres, but these conditions are underdiagnosed and undertreated. The objective of this paper is to describe the model and the findings of the implementation of a technology-based model of care for depression and unhealthy alcohol use in primary care centres in Colombia.

Methods: Between February 2018 and March 2020, we implemented a technology-based model of care for depression and unhealthy alcohol use, following a modified stepped wedge methodology, in 6urban and rural primary care centres in Colombia. The model included a series of steps aimed at screening patients attending medical appointments with general practitioners and supporting the diagnosis and treatment given by the general practitioner. We describe the model, its implementation and the characteristics of the screened and assessed patients.

Results: During the implementation period, we conducted 22,354 screenings among 16,188 patients. The observed rate of general practitioner-confirmed depression diagnosis was 10.1% and of confirmed diagnosis of unhealthy alcohol use was 1.3%. Patients with a depression diagnosis were primarily middle-aged women, while patients with unhealthy alcohol use were mainly young adult men.

Discussion: The provision of training and technology-based strategies to screen patients and support the decision-making of general practitioners during the medical appointment enhanced the diagnosis and care provision of patients with depression and unhealthy alcohol use. However, time constraints, as well as structural and cultural barriers, were challenges for the implementation of the model, and the model should take into account local values, policies and resources to guarantee its long-term sustainability. As such, the long-term sustainability of the model will depend on the alignment of different stakeholders, including decision-makers, institutions, insurers, general practitioners, patients and communities, to reduce the amount of patients seeking medical care whose mental health conditions remain undetected, and therefore untreated, and to ensure an appropriate response to the demand for mental healthcare that was revealed by the implementation of our model.
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http://dx.doi.org/10.1016/j.rcp.2020.11.022DOI Listing
June 2021

Access barriers, self-recognition, and recognition of depression and unhealthy alcohol use: A qualitative study.

Rev Colomb Psiquiatr 2021 Jun 13;50 Suppl 1:55-66. Epub 2021 May 13.

Departmento de Psiquiatría, Geisel School of Medicine, Dartmouth College, Hanover, Estados Unidos.

Introduction: Access to healthcare services involves a complex dynamic, where mental health conditions are especially disadvantaged, due to multiple factors related to the context and the involved stakeholders. However, a characterisation of this phenomenon has not been carried out in Colombia, and this motivates the present study.

Objectives: The objective of this study was to explore the causes that affect access to health services for depression and unhealthy alcohol use in Colombia, according to various stakeholders involved in the care process.

Methods: In-depth interviews and focus groups were conducted with health professionals, administrative professionals, users, and representatives of community health organisations in five primary and secondary-level institutions in three regions of Colombia. Subsequently, to describe access to healthcare for depression and unhealthy alcohol use, excerpts from the interviews and focus groups were coded through content analysis, expert consensus, and grounded theory. Five categories of analysis were created: education and knowledge of the health condition, stigma, lack of training of health professionals, culture, and structure or organisational factors.

Results: We characterised the barriers to a lack of illness recognition that affected access to care for depression or unhealthy alcohol use according to users, healthcare professionals and administrative staff from five primary and secondary care centres in Colombia. The groups identified that lack of recognition of depression was related to low education and knowledge about this condition within the population, stigma, and lack of training of health professionals, as well as to culture. For unhealthy alcohol use, the participants identified that low education and knowledge about this condition, lack of training of healthcare professionals, and culture affected its recognition, and therefore, healthcare access. Neither structural nor organisational factors seemed to play a role in the recognition or self-recognition of these conditions.

Conclusions: This study provides essential information for the search for factors that undermine access to mental health in the Colombian context. Likewise, it promotes the generation of hypotheses that can lead to the development and implementation of tools to improve care in the field of mental illness.
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http://dx.doi.org/10.1016/j.rcp.2020.11.021DOI Listing
June 2021

Technology-based mental healthcare models: A systematic review of the literature.

Rev Colomb Psiquiatr 2021 Jun 16;50 Suppl 1:32-43. Epub 2021 Apr 16.

Departamento de Epidemiología Clínica y Bioestadística, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia; Hospital Universitario San Ignacio, Bogotá, Colombia; Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia.

Introduction: This systematic review summarises the existing evidence on the implementation of technology-based mental healthcare models in the primary care setting.

Methods: A systematic search was conducted (MEDLINE, Embase, CENTRAL) in August 2019 and studies were selected according to predefined eligibility criteria. The main outcomes were clinical effectiveness, adherence to primary treatment and cost of implementation.

Selection Criteria: Studies with an experimental or quasi-experimental design that evaluated the implementation of technology-based mental healthcare models were included.

Results: Five articles met the inclusion criteria. The models included technological devices such as tablets, cellphones and computers, with programs and mobile apps that supported decision-making in the care pathway. These decisions took place at different times, from the universal screening phase to the follow-up of patients with specific conditions. In general, the studies showed a decrease in the reported symptoms. However, there was great heterogeneity in both the health conditions and the outcomes, which hindered a quantitative synthesis. The assessment of risk of bias showed low quality of evidence.

Conclusion: There is not enough evidence to support the implementation of a technology-based mental healthcare model. High quality studies that focus on implementation and effectiveness outcomes are needed to evaluate the impact of technology-based mental healthcare models in the primary care setting.
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http://dx.doi.org/10.1016/j.rcp.2021.01.002DOI Listing
June 2021

Global Mental Health and the DIADA Project.

Rev Colomb Psiquiatr 2021 Jun 17;50 Suppl 1:14-22. Epub 2021 Mar 17.

Departamento de Psiquiatría y Salud Mental, Pontificia Universidad Javeriana, Bogotá, Colombia; Departamento de Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Bogotá, Colombia; Hospital Universitario San Ignacio, Bogotá DC, Colombia.

The DIADA project, understood as a mental healthcare implementation experience in the context of a middle-income country like Colombia, promotes a necessary discussion about its role in the global mental health framework. The following article outlines the main points by which this relationship occurs, understanding how the project contributes to global mental health and, at the same time, how global mental health nurtures the development of this project. It reflects on aspects like the systematic screening of patients with mental illness, the use of technology in health, the adoption of a collaborative model, the investigation on implementation, a collaborative learning and the Colombian healthcare system. These are all key aspects when interpreting the feedback cycle between the individual and the global. The analysis of these components shows how collaborative learning is a central axis in the growth of global mental health: from the incorporation of methodologies, implementation of models, assessment of outcomes and, finally, the dissemination of results to local, regional and international stakeholders.
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http://dx.doi.org/10.1016/j.rcp.2020.12.002DOI Listing
June 2021

Relationship between the sociodemographic characteristics of participants in the DIADA Project and the rate of compliance with follow-up assessments in the initial stage of the intervention.

Rev Colomb Psiquiatr 2021 Jun 15;50 Suppl 1:106-113. Epub 2021 Mar 15.

Departamento de Epidemiología Clínica y Bioestadística, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia; Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia; Hospital Universitario San Ignacio, Bogotá, Colombia.

Objective: Analyse the relationship between the sociodemographic profile of the DIADA study participants and the rate of compliance with the follow-up assessments in the early stage of this project's intervention for depression and unhealthy alcohol use offered within primary care.

Methods: A non-experimental quantitative analysis was conducted. The sociodemographic data of DIADA [Detección y Atención Integral de Depresión y Abuso de Alcohol en Atención Primaria (Detection and Integrated Care for Depression and Alcohol Use in Primary Care)] study participants had been previously collected. At the time of the evaluation (September 12, 2019), only the participants who had been in the project for a minimum of three months were included. By using univariate (Chi-squared) analyses, we studied the association between participants' sociodemographic profile and their rate of compliance with the first follow-up assessment at three months after study initiation.

Results: At the date of the evaluation, 584 adult participants were identified, of which 389 had been involved in the project for more than three months. From the participants included, 320 performed the first follow-up, while 69 did not. The compliance rate to the first follow-up was 82.3% (CI 95% 78.1%-86%) and was not affected by: site location, age, sex, civil status, level of education, use of smartphone, PHQ9 score (measuring depression symptomatology) or AUDIT score (measuring harmful alcohol use). Participants who do not use a smartphone, from rural areas and with a lower socioeconomic status, tended to show higher compliance rates. Statistically significant associations were found; participants with lower job stability and a lack of access to the Internet showed higher compliance rates to the early initial follow-up assessment.

Conclusions: The compliance rate was high and generally constant in spite of the variability of the sociodemographic profiles of the participants, although several sub-groups of participants showed particularly high rates of compliance. These findings may suggest that integrating mental health into primary care allows the structural and financial barriers that hinder access to health in Colombia to be broken down by raising awareness about mental illnesses, their high prevalence and the importance of timely and accessible medical management.
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http://dx.doi.org/10.1016/j.rcp.2020.11.019DOI Listing
June 2021

Characterizing the perceived stigma towards mental health in the early implementation of an integrated services model in Primary Care in Colombia. A qualitative analysis.

Rev Colomb Psiquiatr 2021 Jun 23;50 Suppl 1:95-105. Epub 2021 Feb 23.

Departamento de Epidemiología Clínica y Bioestadística, Pontificia Universidad Javeriana, Bogotá DC, Colombia; Departamento de Psiquiatría y Salud Mental, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá DC, Colombia; Hospital Universitario San Ignacio, Bogotá DC, Colombia.

Background: Stigma is a sociocultural barrier to accessing mental health services and prevents individuals with mental health disorders from receiving mental health care. The Ministry of Health and Social Protection of Colombia acknowledges that a great number of people with mental disorders do not seek medical aid due to stigma.

Objectives: Characterise the perceived stigma towards mental health among the stakeholders involved in the early implementation of the DIADA project [Detección y Atención Integral de Depresión y Abuso de Alcohol en Atención Primaria (Detection and Integrated Care for Depression and Alcohol Use in Primary Care)]. Explore whether the implementation of this model can decrease stigma. Describe the impact of the implementation on the lives of patients and medical practice.

Materials And Methods: Eighteen stakeholders (7 patients, 5 physicians and 6 administrative staff) were interviewed and a secondary data analysis of 24 interview transcripts was conducted using a rapid analysis technique.

Results: The main effects of stigma towards mental health disorders included refusing medical attention, ignoring illness, shame and labelling. Half of the stakeholders reported that the implementation of mental health care in primary care could decrease stigma. All of the stakeholders said that the implementation had a positive impact.

Conclusions: The perceived stigma was characterised as social and aesthetic in nature. Communication and awareness about mental health is improving, which could facilitate access to mental health treatment and strengthen the doctor-patient relationship. Culture is important for understanding stigma towards mental health in the population studied.
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http://dx.doi.org/10.1016/j.rcp.2020.11.017DOI Listing
June 2021

The effectiveness and cost-effectiveness of integrating mental health services in primary care in low- and middle-income countries: systematic review.

BJPsych Bull 2021 Feb;45(1):40-52

Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth, USA.

Aims And Method: This systematic review examines the effectiveness and cost-effectiveness of behavioural health integration into primary healthcare in the management of depression and unhealthy alcohol use in low- and middle-income countries. Following PRISMA guidelines, this review included research that studied patients aged ≥18 years with unhealthy alcohol use and/or depression of any clinical severity. An exploration of the models of integration was used to characterise a typology of behavioural health integration specific for low- and middle-income countries.

Results: Fifty-eight articles met inclusion criteria. Studies evidenced increased effectiveness of integrated care over treatment as usual for both conditions. The economic evaluations found increased direct health costs but cost-effective estimates. The included studies used six distinct behavioural health integration models.

Clinical Implications: Behavioural health integration may yield improved health outcomes, although it may require additional resources. The proposed typology can assist decision-makers to advance the implementation of integrated models.
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http://dx.doi.org/10.1192/bjb.2020.35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058938PMC
February 2021

Implementing Technology-Supported Care for Depression and Alcohol Use Disorder in Primary Care in Colombia: Preliminary Findings.

Psychiatr Serv 2020 07 10;71(7):678-683. Epub 2020 Mar 10.

Department of Psychiatry (Torrey, Bartels, Cubillos, Marsch) and Department of Biomedical Data Science (Camblor), Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Clinical Epidemiology and Biostatistics (Cepeda, Castro, Gómez-Restrepo), Institute of Human Genetics (Suárez Obando), and Department of Psychiatry and Mental Health (Uribe-Restrepo, Gómez-Restrepo), Pontificia Universidad Javeriana, Bogotá, Colombia; Office for Research on Disparities and Global Mental Health, National Institute of Mental Health, Bethesda, Maryland (Williams).

Objective: Depression and alcohol use disorder are among the most common causes of disability and death worldwide. Health care systems are seeking ways to leverage technology to screen, evaluate, and treat these conditions, because workforce interventions alone, particularly in low- and middle-income countries, are insufficient. This article reports data from the first year of implementation of a technology-supported, systematic approach to identify and care for persons with these disorders in primary care in Colombia.

Methods: A care process that includes waiting room kiosks to screen primary care patients, decision support tablets to guide doctors in diagnosis and treatment, and access to digital therapeutics as a treatment option was implemented in two primary care clinics, one urban and one in a small town. The project collected data on the number of people screened, diagnosed, and engaged in the research and their demographic characteristics.

Results: In the first year, 2,656 individuals were screened for depression and unhealthy alcohol use in the two clinics. Primary care doctors increased the percentage of patients diagnosed as having depression and alcohol use disorder from next to 0% to 17% and 2%, respectively.

Conclusions: Early experience with implementing technology-supported screening and decision support for depression and alcohol use disorder into the workflow of busy primary care clinics in Colombia indicates that this care model is feasible and leads to dramatically higher rates of diagnoses of these conditions. Diagnosis in these settings appeared to be easier for depression than for alcohol use disorder.
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http://dx.doi.org/10.1176/appi.ps.201900457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332379PMC
July 2020

Assessing the Integration of Behavioral Health Services in Primary Care in Colombia.

Adm Policy Ment Health 2020 05;47(3):435-442

Departamento de Epidemiología Clínica y Bioestadística, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia.

Integration of behavioral health care into primary care can improve health and economic outcomes. This study adapted the Behavioral Health Integration in Medical Care (BHIMC) index to the Colombian context and assessed the baseline level of behavioral health integration in a sample of primary care organizations. The BHIMC was able to detect the capacity to provide integrated behavioral care in Colombian settings. Results indicate a minimal to partial integration level across all sites, and that it is possible to measure the degree of integrated care capacity and identify improvement areas for better behavioral health care provision.
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http://dx.doi.org/10.1007/s10488-019-01002-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7159997PMC
May 2020

Seasonality of antimicrobial resistance rates in respiratory bacteria: A systematic review and meta-analysis.

PLoS One 2019 15;14(8):e0221133. Epub 2019 Aug 15.

Institute of Social and Preventive Medicine, Faculty of Medicine, University of Bern, Bern, Switzerland.

Background: Antimicrobial resistance (AMR) rates may display seasonal variation. However, it is not clear whether this seasonality is influenced by the seasonal variation of infectious diseases, geographical region or differences in antibiotic prescription patterns. Therefore, we assessed the seasonality of AMR rates in respiratory bacteria.

Methods: Seven electronic databases (Embase.com, Medline Ovid, Cochrane CENTRAL, Web of Science, Core Collection, Biosis Ovid, and Google Scholar), were searched for relevant studies from inception to Jun 25th, 2019. Studies describing resistance rates of Streptococcus pneumoniae and Haemophilus influenzae were included in this review. By using random-effects meta-analysis, pooled odd ratios of seasonal AMR rates were calculated using winter as the reference group. Pooled odd ratios were obtained by antibiotic class and geographical region.

Results: We included 13 studies, of which 7 were meta-analyzed. Few studies were done in H. influenzae, thus this was not quantitively analyzed. AMR rates of S. pneumoniae to penicillins were lower in other seasons than in winter with pooled OR = 0.71; 95% CI = 0.65-0.77; I2 = 0.0%, and to all antibiotics with pooled OR = 0.68; 95% CI = 0.60-0.76; I2 = 14.4%. Irrespective of geographical region, the seasonality of AMR rates in S. pneumoniae remained the same.

Conclusion: The seasonality of AMR rates could result from the seasonality of infectious diseases and its accompanied antibiotic use.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221133PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6695168PMC
March 2020

Effects of Air Pollution on Lung Innate Lymphoid Cells: Review of In Vitro and In Vivo Experimental Studies.

Int J Environ Res Public Health 2019 07 2;16(13). Epub 2019 Jul 2.

Department of Immunology, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands.

Outdoor air pollution is associated with respiratory infections and allergies, yet the role of innate lymphoid cells (ILCs) in pathogen containment and airway hyperresponsiveness relevant to effects of air pollutants on ILCs is poorly understood. We conducted a systematic review to evaluate the available evidence on the effect of outdoor air pollutants on the lung type 1 (ILC1) and type 2 ILCs (ILC2) subsets. We searched five electronic databases (up to Dec 2018) for studies on the effect of carbon monoxide (CO), sulfur dioxide (SO), nitrogen dioxide (NO), diesel exhaust particles (DEP), ozone (O), and particulate matter (PM) on respiratory ILCs. Of 2209 identified citations, 22 full-text papers were assessed for eligibility, and 12 articles describing experimental studies performed in murine strains (9) and on human blood cells (3) were finally selected. Overall, these studies showed that exposure to PM, DEP, and high doses of O resulted in a reduction of interferon gamma (IFN-γ) production and cytotoxicity of ILC1. These pollutants and carbon nanotubes stimulate lung ILC2s, produce high levels of interleukin (IL)-5 and IL-13, and induce airway hyperresponsiveness. These findings highlight potential mechanisms by which human ILCs react to air pollution that increase the susceptibility to infections and allergies.
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http://dx.doi.org/10.3390/ijerph16132347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650824PMC
July 2019

Seasonal variation of diet quality in a large middle-aged and elderly Dutch population-based cohort.

Eur J Nutr 2020 Mar 8;59(2):493-504. Epub 2019 Feb 8.

Department of Epidemiology, Erasmus MC, University Medical Centre, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.

Purpose: Several studies have reported seasonal variation in intake of food groups and certain nutrients. However, whether this could lead to a seasonal pattern of diet quality has not been addressed. We aimed to describe the seasonality of diet quality, and to examine the contribution of the food groups included in the dietary guidelines to this seasonality.

Methods: Among 9701 middle-aged and elderly participants of the Rotterdam Study, a prospective population-based cohort, diet was assessed using food-frequency questionnaires (FFQ). Diet quality was measured as adherence to the Dutch dietary guidelines, and expressed in a diet quality score ranging from 0 to 14 points. The seasonality of diet quality and of the food group intake was examined using cosinor linear mixed models. Models were adjusted for sex, age, cohort, energy intake, physical activity, body mass index, comorbidities, and education.

Results: Diet quality had a seasonal pattern with a winter-peak (seasonal variation = 0.10 points, December-peak) especially among participants who were men, obese and of high socio-economic level. This pattern was mostly explained by the seasonal variation in the intake of legumes (seasonal variation = 3.52 g/day, December-peak), nuts (seasonal variation = 0.78 g/day, January-peak), sugar-containing beverages (seasonal variation = 12.96 milliliters/day, June-peak), and dairy (seasonal variation = 17.52 g/day, June-peak).

Conclusions: Diet quality varies seasonally with heterogeneous seasonality of food groups counteractively contributing to the seasonal pattern in diet quality. This seasonality should be considered in future research on dietary behavior. Also, season-specific recommendations and policies are required to improve diet quality throughout the year.
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http://dx.doi.org/10.1007/s00394-019-01918-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058580PMC
March 2020

Air pollution control and the occurrence of acute respiratory illness in school children of Quito, Ecuador.

J Public Health Policy 2019 Mar;40(1):17-34

Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, 02155, USA.

Because of air quality management and control, traffic-related air pollution has declined in Quito, Ecuador. We evaluated the effect of a city-wide 5-year air pollution control program on the occurrence of acute respiratory illness (ARI). We compared two studies conducted at the same location in Quito: in 2000, 2 years before the policy to control vehicle emission was introduced, and in 2007. Each study involved ~ 730 children aged 6-12 years, observed for 15 weeks. We examined associations between carboxyhemoglobin (COHb) serum concentration-an exposure proxy for carbon monoxide (CO)-ambient CO, and ARI in both cohorts. In 2007, we found a 48% reduction in the ARI incidence (RR 0.52; 95% CI 0.45-0.62, p < 0.0001), and 92% decrease in the percentage of children with COHb > 2.5% as compared to the 2000 study. We found no association between COHb concentrations above the safe level of 2.5% and the ARI incidence (p = 0.736). The decline in air pollution due to vehicle emissions control was associated with a lower incidence of respiratory illness in school children.
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http://dx.doi.org/10.1057/s41271-018-0148-6DOI Listing
March 2019

Seasonality of physical activity, sedentary behavior, and sleep in a middle-aged and elderly population: The Rotterdam study.

Maturitas 2018 Apr 27;110:41-50. Epub 2018 Jan 27.

Department of Epidemiology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.

Introduction: Physical activity (PA) and sedentary behavior (SB) have seasonal patterns. It remains unclear how these patterns are associated with sleep, meteorological factors, and health.

Methods: Activity levels were continuously measured with an accelerometer for seven days between July 2011 and May 2016, among middle-aged (50-64 years), young-elderly (65-74 years) and old-elderly (≥75 years) participants of a population-based Dutch cohort study (n = 1116). Meteorological factors (ambient temperature, wind speed, sunlight hours, precipitation, and minimum visibility) were locally recorded. We first examined the seasonality of PA, SB, and nighttime sleep, stratified by age group. Second, we examined the influence of meteorological factors. Third, we modeled the potential seasonality of the all-cause mortality risk due to the seasonality of PA and SB, by using previously published relative risks.

Results: Levels of light and moderate-to-vigorous PA were higher in summer than in winter among middle-aged (seasonal variation = 18.1 and 14.8 min/day) and young-elderly adults (12.8 and 8.6 min/day). The pattern was explained by ambient temperature and sunlight hours. Nighttime sleep was 31.8 min/day longer in winter among middle-aged adults. SB did not show a seasonal pattern. No seasonality in activity levels was observed among old-elderly adults. The all-cause mortality risk may be higher in winter than in summer due to the accumulation of low levels of moderate to vigorous PA and high levels of SB.

Conclusion: PA has a larger degree of seasonality than SB and nighttime sleep among middle-aged and young-elderly adults. SB appears strongly ingrained in daily routine. Recommending the interruption of SB with light PA might be a good starting point for public health institutions.
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http://dx.doi.org/10.1016/j.maturitas.2018.01.016DOI Listing
April 2018

Seasonality of Insulin Resistance, Glucose, and Insulin Among Middle-Aged and Elderly Population: The Rotterdam Study.

J Clin Endocrinol Metab 2018 03;103(3):946-955

Department of Epidemiology, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands.

Context: There are discrepancies in the seasonality of insulin resistance (IR) across the literature, probably due to age-related differences in the seasonality of lifestyle factors and thermoregulation mechanisms.

Objective: To estimate the seasonality of IR according to the homeostatic model assessment-IR (HOMA-IR), glucose, and insulin levels and to examine the role of lifestyle markers [body mass index (BMI) and physical activity] and meteorological factors, according to age.

Design, Setting, And Participants: Seasonality was examined using cosinor analysis among middle-aged (45 to 65 years) and elderly (≥65 years) participants of a population-based Dutch cohort. We analyzed 13,622 observations from 8979 participants (57.6% women) without diagnosis of diabetes and fasting glucose <7 mmol/L. BMI was measured, physical activity was evaluated using a validated questionnaire, and meteorological factors (daily mean ambient temperature, mean relative humidity, total sunlight hours, and total precipitation) were obtained from local records. Seasonality estimates were adjusted for confounders.

Results: Among the middle-aged participants, seasonal variation estimates were: 0.11 units (95% confidence interval: 0.03, 0.20) for HOMA-IR, 0.28 µIU/mL (-0.05, 0.69) for insulin, and 0.05 mmol/L (0.01, 0.09) for glucose. These had a summer peak, and lifestyle markers explained the pattern. Among the elderly, seasonal variations were: 0.29 units (0.21, 0.37) for HOMA-IR, 0.96 µIU/mL (0.58, 1.28) for insulin, and 0.01 mmol/L (-0.01, 0.05) for glucose. These had a winter peak and ambient temperature explained the pattern.

Conclusion: Impaired thermoregulation mechanisms could explain the winter peak of IR among elderly people without diabetes. The seasonality of lifestyle factors may explain the seasonality of glucose.
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http://dx.doi.org/10.1210/jc.2017-01921DOI Listing
March 2018

Physical activity derived from questionnaires and wrist-worn accelerometers: comparability and the role of demographic, lifestyle, and health factors among a population-based sample of older adults.

Clin Epidemiol 2018 18;10:1-16. Epub 2017 Dec 18.

Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands.

Background: Agreement between questionnaires and accelerometers to measure physical activity (PA) differs between studies and might be related to demographic, lifestyle, and health characteristics, including disability and depressive symptoms.

Methods: We included 1,410 individuals aged 51-94 years from the population-based Rotterdam Study. Participants completed the LASA Physical Activity Questionnaire and wore a wrist-worn accelerometer on the nondominant wrist for 1 week thereafter. We compared the Spearman correlation and disagreement (level and direction) for total PA across levels of demographic, lifestyle, and health variables. The level of disagreement was defined as the absolute difference between questionnaire- and accelerometer-derived PA, whereas the direction of disagreement was defined as questionnaire PA minus accelerometer PA. We used linear regression analyses with the level and direction of disagreement as outcome, including all demographic, lifestyle, and health variables in the model.

Results: We observed a Spearman correlation of 0.30 between questionnaire- and accelerometer-derived PA in the total population. The level of disagreement (ie, absolute difference) was 941.9 (standard deviation [SD] 747.0) minutes/week, and the PA reported by questionnaire was on average 529.4 (SD 1,079.5) minutes/week lower than PA obtained by the accelerometer. The level of disagreement decreased with higher educational levels. Additionally, participants with obesity, higher disability scores, and more depressive symptoms underestimated their self-reported PA more than their healthier counterparts.

Conclusion: We observed large differences in PA time derived from the LASA Physical Activity Questionnaire and the wrist-worn accelerometer. Differences between the methods were related to body-mass index, level of disability, and presence of depressive symptoms. Future studies using questionnaires and/or accelerometers should account for these differences.
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http://dx.doi.org/10.2147/CLEP.S147613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5739112PMC
December 2017

Levels of ambient air pollution according to mode of transport: a systematic review.

Lancet Public Health 2017 01 26;2(1):e23-e34. Epub 2016 Nov 26.

Department of Epidemiology, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands.

Background: Controversy exists about the differences in air pollution exposure and inhalation dose between mode of transport. We aimed to review air pollution exposure and inhaled dose according to mode of transport and pollutant and their effect in terms of years of life expectancy (YLE).

Methods: In this systematic review, we searched ten online databases from inception to April 13, 2016, without language or temporal restrictions, for cohort, cross-sectional, and experimental studies that compared exposure to carbon monoxide, black carbon, nitrogen dioxide, and fine and coarse particles in active commuters (pedestrian or cyclist) and commuters using motorised transport (car, motorcycle, bus, or massive motorised transport [MMT-ie, train, subway, or metro]). We excluded studies that measured air pollution exposure exclusively with biomarkers or on the basis of simulated data, reviews, comments, consensuses, editorials, guidelines, in-vitro studies, meta-analyses, ecological studies, and protocols. We extracted average exposure and commuting time per mode of transport and pollutant to calculate inhaled doses. We calculated exposure and inhaled dose ratios using active commuters as the reference and summarised them with medians and IQRs. We also calculated differences in YLE due to fine particle inhaled dose and physical activity.

Findings: We identified 4037 studies, of which 39 were included in the systematic review. Overall, car commuters had higher exposure to all pollutants than did active commuters in 30 (71%) of 42 comparisons (median ratio 1·22 [IQR 0·90-1·76]), followed by those who commuted by bus in 57 (52%) of 109 (1·0 [0·79-1·41]), by motorcycle in 16 (50%) of 32 (0·99 [0·86-1·38]), by a car with controlled ventilation settings in 39 (45%) of 86 (0·95 [0·66-1·54]), and by MMT in 21 (38%) of 55 (0·67 [0·49-1·13]). Overall, active commuters had higher inhalation doses than did commuters using motorised transport (median ratio car with controlled ventilation settings 0·16 [0·10-0·28]; car 0·22 [0·15-0·30]; motorcycle 0·38 [0·26-0·78]; MMT 0·49 [0·34-0·81]; bus 0·72 [IQR 0·50-0·99]). Commuters using motorised transport lost up to 1 year in YLE more than did cyclists.

Interpretation: Proximity to traffic and high air interchange increased the exposure to air pollution of commuters using motorised transport. Larger inhalation rates and commuting time increased inhaled dose among active commuters. Benefits of active commuting from physical activity are larger than the risk from an increased inhaled dose of fine particles.

Funding: Departamento Administrativo de Ciencia, Tecnología e Innovación (COLCIENCIAS), National Health and Medical Research Council, Nestlé Nutrition (Nestec), Metagenics, and AXA.
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http://dx.doi.org/10.1016/S2468-2667(16)30021-4DOI Listing
January 2017

Objective Measures of Activity in the Elderly: Distribution and Associations With Demographic and Health Factors.

J Am Med Dir Assoc 2017 Oct;18(10):838-847

Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands.

Background: Little is known about the distribution of activity over the full 24-hour spectrum in late old age and its association with demographic and health factors. Therefore, we aimed to evaluate the distribution of physical activity (PA), sedentary behavior, and sleep, and associated factors in the elderly population.

Methods: Our study included 1210 participants (51.9% women) aged 70-94 years [mean age 77.5 years, standard deviation (SD) 5.0] from the population-based Rotterdam Study. Participants wore a triaxial accelerometer (GENEActiv) around the wrist for 7 days between July 2014 and June 2016. We examined if PA, sedentary behavior, and sleep differed by age, sex, body mass index (BMI), smoking status, alcohol consumption, education, season, functional capacity, marital status, presence of chronic disease, and use of sleep medication.

Results: Mean total PA, expressed in milli-gravity (mg) units, was slightly higher for women (20.3, SD 5.6) than for men (19.3, SD 5.2, P < .01). Mean (SD) daily duration spent in sedentary behavior and light and moderate-to-vigorous PA was 13.3 (1.5) h/d, 147.5 (31.5) min/d, and 75.0 (25.5) min/d, respectively, among women; and 13.8 (1.6) h/d, 140.5 (31.1) min/d, and 71.5 (24.5) min/d, respectively, among men. Women spent on average 6.7 (SD 1.1) h/d sleeping and men 6.6 (1.4) h/d. Across increasing categories of age and BMI and in participants with chronic disease and disability, time spent in light and moderate-to-vigorous PA was decreased. Higher age and BMI were associated with more sedentary time. In addition, obese men spent slightly more time sleeping than their normal weight counterparts and women spent slightly less time sleeping in the summer than in spring.

Conclusions: PA and sedentary behavior in the elderly differed by sex, age, BMI, prevalence of chronic disease, and disability, whereas there were no clear patterns for sleep. On average, our participants spent up to 79.5% of their time awake being sedentary and 7%-8% in moderate-to-vigorous PA. Replacing sedentary behavior with light PA would be a good starting point for those with the lowest level of PA. Older adults, those with high BMI and worse health could benefit from targeted interventions to increase PA.
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http://dx.doi.org/10.1016/j.jamda.2017.04.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6276982PMC
October 2017

The associations between sleep disorders and anthropometric measures in adults from three Colombian cities at different altitudes.

Maturitas 2016 Dec 20;94:1-10. Epub 2016 Aug 20.

Faculty of Dentistry, Pontificia Universidad Javeriana, Bogotá DC, Colombia.

Background: Sleep disorders are common but underdiagnosed conditions, which are associated with obesity. In Colombia, the distribution of sleep disorders remains unclear. We aimed to describe the distribution of sleep disorders, according to demographic, geographic and anthropometric characteristics, in adult Colombian populations.

Methods: A multicenter study was conducted with 5474 participants recruited from three Colombian cities at different altitudes. A two-stage cluster sampling method was applied. Participants' mean age was 40.2 years and 53.8% were female. Collected data included demographic information and anthropometric characteristics of adiposity such as body mass index, neck circumference and waist circumference, as well as participants' scores on five scales used to assess sleep disorders. Disorders included sleepiness, obstructive sleep apnea (OSA), insomnia, poor sleep quality and restless legs syndrome; the scales were the Epworth Sleepiness Scale, Berlin questionnaire, STOP-Bang questionnaire, Pittsburgh Sleep Quality Index and diagnostic criteria for the restless legs syndrome set out by the International Restless Legs Syndrome Study Group.

Results: Nearly two-thirds of the population reported at least one sleep disorder according to their results on the five scales (59.6% [95%CI 57.4; 61.81)]. This proportion was similar by sex. Prevalence of overweight was 34.8% and of obesity was 14.4%. Sleep disorders were more frequent among those aged 65 years or more (91.11 [95%CI 86.1; 94.43]), those who were obese (83.71% [95%CI 78.94; 87.56]) and those who resided in the cities at the lowest altitude (72.4% [95%CI 70.2; 74.5]). Waist circumference showed a stronger association with sleep disorders among women than among men.

Conclusions: Sleep disorders are common in Colombia, irrespective of sex and geographical location. They are associated with obesity. Abdominal obesity could explain the high frequency of sleep disorders among women. We believe that this part of the study will substantially contribute to the understanding of sleep disorders. Further research is needed to identify key factors behind the high prevalence rates of sleep disorders and obesity in Colombia.
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http://dx.doi.org/10.1016/j.maturitas.2016.08.013DOI Listing
December 2016

Social conditions and urban environment associated with participation in the Ciclovia program among adults from Cali, Colombia.

Cad Saude Publica 2015 Nov;31 Suppl 1:257-66

School of Medicine in St. Louis, Washington University, St. Louis, U.S.A.

The Ciclovia program (CP) has emerged as an effective initiative to promote active living in urban spaces in Latin America. This study assessed the association between social conditions, the urban environment and participation in the CP among adults living in the city of Cali, Colombia. A cross-sectional study was conducted in 2011 and 2012 among 719 adults aged 18 to 44. Urban environment measures were obtained using Geographic Information Systems. A multilevel logistic regression was used for the analysis. Slightly more than 7% of participants had participated in the CP in the previous four weekends. Being male and having a high school degree were positively associated with participation in the CP. Participation in the CP was positively associated with living in neighborhoods with Ciclovia lanes. In contrast, a negative association was found among those living in neighborhoods with a presence of traffic fatalities. This study provides new insights about a recreational program that has potential health benefits in a region marked by urban inequalities in terms of opportunities for physical activity.
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http://dx.doi.org/10.1590/0102-311X00086814DOI Listing
November 2015

[Birth cohort effect on prevalence of cardiovascular risk factors in coronary artery disease. Experience in a Latin-american country].

Arch Cardiol Mex 2015 Jan-Mar;85(1):9-15. Epub 2015 Feb 7.

Laboratorio de cateterismo cardiaco, Unidad cardiovascular, Fundación Valle del Lili, Cali, Colombia.

Background: The prevalence of major risk factors associated to coronary artery disease has changed over time. Today, the frequency of dyslipidemia, hypertension and diabetes mellitus has increased, while smoking has decreased. The birth cohort effect for coronary artery disease in subjects as an approximation of the true prevalence over time has not been studied in Latin-America.

Objective: To determine the trends in the prevalence of major risk factors for coronary artery disease by birth cohort effect in a high risk population.

Methods: We estimate the prevalence of diabetes mellitus, smoking, hypertension and dyslipidemia from a prospective institutional registry (DREST registry) of patients who underwent percutaneous coronary intervention for acute coronary event. Birth cohort effect was defined as a statistical, epidemiological and sociological methodology to identify the influence of the environment in the lifetime from birth by each decade. Univariate and multivariate analyses were performed adjusted by gender.

Results: Out of 3,056 subjects who were enrolled, 72% were male, with a median age of 61 years (interquartile range=53-69). Hypertension prevalence was 62.3%, for diabetes mellitus it was 48.8%, for smoking it was 18.8% and for dyslipidemia it was 48.8%. We observed an increase in prevalence for diabetes mellitus and dyslipidemia in each cohort according to birth decade, while there was a reduction in prevalence for hypertension in the same decades.

Conclusions: The prevalence of major cardiovascular risk factors has changed in time and the presence of time at birth effect is evident, possibly influenced by the environment's social conditions in each decade of life.
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http://dx.doi.org/10.1016/j.acmx.2014.10.002DOI Listing
December 2015

Efficacy and safety of oral low-dose glucocorticoids in patients with estrogen-dependent primary osteoarthritis.

Rheumatol Int 2014 May 19;34(5):733-5. Epub 2013 Jan 19.

Rheumatology Unit, Fundación Valle del Lili, ICESI University, Cra. 98 18-49, Cali, Colombia,

Estrogen-dependent osteoarthritis (EDPOA) is a disease of perimenopausal-age women. Their manifestations are polyarticular pain with common co-morbidities (carpal tunnel syndrome, insomnia, fatigue, depression, and fibromyalgia). Based on dual role of glucocorticoids, its trophic action on the chondrocyte and its anti-inflammatory effect, we conducted a prospective interventional cohort study where we evaluate the efficacy and safety of oral low-dose GC in one hundred women with EDPOA. The pain intensity, number of tender joints as well as impact in co-morbidities were analyzed. We conclude that the use of low-dose GC in patients with EDPOA can be an effective and a safe therapeutic option.
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http://dx.doi.org/10.1007/s00296-012-2603-1DOI Listing
May 2014
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