Marta Fajó-Pascual

Background: Progress on maternal health in low- and middle-income countries (LMICs) has stagnated, underscoring calls for holistic approaches to improve women’s nutrition. Diets link human health and environmental sustainability, necessitating equitable food system transformations to address climate change and malnutrition in all its forms. Food environments are a key entry point within food systems for improving nutrition; however, existing frameworks are not gender-sensitive and few consider vulnerable groups in low-resource settings. Methods: We conducted a systematic scoping review of peer-reviewed literature published in English, Spanish, Portuguese, and French from Web of Science, EBSCO, and PubMed to identify determinants of food acquisition practices and dietary intakes of women of reproductive age in LMICs. We synthesised 518 studies from 125 countries. By systematically identifying 143 eco-social, structural and individual-level determinants, we identified key determinants to develop an empirically grounded food environment conceptual framework for women. Findings: We identified women’s agency, characterised by decision-making and financial autonomy, bargaining power, control over time, and freedom of movement, as a prominent mediator of women’s food acquisition and dietary intakes, including across regions and the rural-urban continuum. Findings indicate that women’s agency, alongside supportive legislative, structural, and social enabling environments will be critical leverage points for improving women’s access to and consumption of nutritious foods, especially where resources are constrained. Conclusion: For countries to sustainably address malnutrition, this empirically grounded framework identifies pathways for addressing the macro, social and individual determinants of food acquisition and dietary intakes that are often overlooked yet critical for resilient food environments and sustainable development. Key messages: This is the first study to provide an empirically grounded food environment conceptual framework specific to women in LMICs. By systematically mapping key determinants of women’s food acquisition and dietary intakes, we identified novel food environment dimensions to develop an empirically grounded framework for women with applicability across regions and the rural-urban continuum in low- and middle-income countries. This novel conceptual framework, emphasising the importance of women’s agency in relation to external and personal food environments, may be used to guide research needs, analyses, and entry points for interventions to sustainably improve women’s nutrition in LMICs, especially in resource-constrained settings. Research in context: Evidence before this study: Women in low- and middle-income countries (LMICs) are disproportionally affected by malnutrition in all its forms. Food environments are a key food system entry point to improve nutrition. However, current food environment frameworks are not gender-sensitive, limiting the effectiveness of nutrition interventions. We systematically searched Web of Science Core Collection, EBSCO, and PubMed for peer-reviewed studies published between 1 ^st January 2010 and 30 ^th April 2023 in English, Spanish, Portuguese, and French reporting on determinants of women’s food acquisition practices and dietary intakes in LMICs. We used a broad search criterion based on emerging food environment concepts and the expanded food security definition. Data were extracted for women aged 15-49 years and by physiological status (pregnant, lactating, and non-pregnant/non-lactating). Added value of this study: This is the first study to provide an empirically grounded food environment conceptual framework specific to women in LMICs. By mapping patterns of 143 determinants inductively derived from the literature against existing conceptual frameworks, we identified novel determinants of women’s food acquisition and dietary intakes. Our results are representative across multiple geographical regions and the rural-urban continuum in LMICs. We add a novel socio-ecological layer: women’s agency as a key mediator for the ability of an individual to exert control over resources contributing to one’s own dietary outcomes. Implications of all the available evidence: Women’s food environments are complex, necessitating holistic systems approaches to sustainably improve women’s nutrition in LMICs. It is critical that policies and programmes address underlying legislative, structural and socio-cultural determinants mediating women’s agency, alongside other key external and personal food environment determinants influencing procurement and consumption of nutritious diets. This novel empirically grounded conceptual framework can guide future research priorities, analytical approaches, and key intervention points to optimise women’s nutrition.

Background: Health Promoting Schools (HPS) have emerged as a powerful framework to promote healthy behaviors in many countries. However, HPS still present several challenges, highlighting the excessive workload involved in the accreditation, design, implementation, and evaluation processes. In this sense, a resource to facilitate the implementation processes may have a positive impact on the support of HPS. Objective: The aim of this study was to describe the co-design processes undertaken and resulting learnings to develop the Red Escuelas Promotoras de Salud (network of health promoting schools; REDEPS)-Gestion platform to facilitate the accreditation, design, implementation procedures, and evaluation processes of the Aragon's Health-Promoting School Network. Methods: The Double Diamond Design Approach was used to co-design this web-platform. The different stakeholders that participated in this co-design, progressed through a 4-stage reflective phase, to discover, define, develop, and deliver the REDEPS-Gestion platform. Results: Participants agreed that the functions of the REDEPS-Gestion platform should permit the management of both the educational centers and the administration such as accreditation processes, definition and review intervention projects, and preparation and review of the different progress reports to evaluate the HPS. Despite co-design being a well-established approach to creative practice, especially within the public sector, some challenges emerged during the co-design process, such as engaging and facilitating stakeholders’ participation or the complexity of combining the interests of all stakeholders. This approach allowed us to identify the main barriers for future users and implement platform improvements. Conclusions: We hope that the REDEPS-Gestion platform will therefore be able to contribute to facilitating the implementation of HPS. The Double Diamond Design Approach used to co-design this web platform was an efficient and feasible methodological design approach. The REDEPS-Gestion platform will facilitate HPS implementation in Aragon as well as all the processes involving HPS. Future work will determine its effectiveness in improving HPS implementation. International Registered Report Identifier (IRRID): DERR1-10.2196/52110

BACKGROUND Health Promoting Schools (HPS) have emerged as a powerful framework to promote healthy behaviors in many countries. However, HPS still present several challenges, highlighting the excessive workload involved in the accreditation, design, implementation, and evaluation processes. In this sense, a resource to facilitate the implementation processes may have a positive impact on the support of HPS. OBJECTIVE The aim of this study was to describe the co-design processes undertaken and resulting learnings to develop the Red Escuelas Promotoras de Salud (network of health promoting schools; REDEPS)-Gestion platform to facilitate the accreditation, design, implementation procedures, and evaluation processes of the Aragon's Health-Promoting School Network. METHODS The Double Diamond Design Approach was used to co-design this web-platform. The different stakeholders that participated in this co-design, progressed through a 4-stage reflective phase, to discover, define, develop, and deliver the REDEPS-Gestion platform. RESULTS Participants agreed that the functions of the REDEPS-Gestion platform should permit the management of both the educational centers and the administration such as accreditation processes, definition and review intervention projects, and preparation and review of the different progress reports to evaluate the HPS. Despite co-design being a well-established approach to creative practice, especially within the public sector, some challenges emerged during the co-design process, such as engaging and facilitating stakeholders’ participation or the complexity of combining the interests of all stakeholders. This approach allowed us to identify the main barriers for future users and implement platform improvements. CONCLUSIONS We hope that the REDEPS-Gestion platform will therefore be able to contribute to facilitating the implementation of HPS. The Double Diamond Design Approach used to co-design this web platform was an efficient and feasible methodological design approach. The REDEPS-Gestion platform will facilitate HPS implementation in Aragon as well as all the processes involving HPS. Future work will determine its effectiveness in improving HPS implementation. CLINICALTRIAL INTERNATIONAL REGISTERED REPORT DERR1-10.2196/52110

A randomized crossover study was carried out in three University accommodation halls. Participants consumed either beef (Pirenaica breed) (PB) or conventional chicken (CC) three times per week for an 8-week periods with their usual diet, each one separated by a 5-week wash out period. Dietary variables were recollected by the Food Frequency Questionnaire (FFQ), and the Diet Quality Index (DQI) was calculated. Forty-seven healthy adults were included (19.9 ± 1.75 years). The inclusion of both types of diets did not modify the components of the DQI, such as the diversity, equilibrium, adequacy and excess. However, when only the first period was analyzed, a significant decrease in the consumption of fruits and vegetables was observed in those participants who received the PB diet (intervention group). The CC diet (control group) significantly reduced the consumption of fish and eggs, total DQI, and DQI quality component. The expected effect was observed in the significant increment of consumption of red meat after the intervention period.

Background: Initial medication non-adherence is highly prevalent in primary care but no previous studies have evaluated its impact on the use of healthcare services and/or days on sick leave.Aim: To estimate the impact of initial medication non-adherence on the use of healthcare services, days of sick leave, and costs overall and in specific medication groups.Design and setting: A 3-year longitudinal register-based study of all primary care patients (a cohort of 1.7 million) who were prescribed a new medication in Catalonia (Spain) in 2012.Method: Thirteen of the most prescribed and/or costly medication subgroups were considered. All medication and medication subgroups (chronic, analgesics, and penicillin) were analysed. The number of healthcare services used and days on sick leave were considered. Multilevel multivariate linear regression was used. Three levels were included: patient, GP, and primary care centre.Results: Initially adherent patients made more use of medicines and some healthcare services than non-adherent and partially adherent patients. They had lower productivity losses, producing a net economic return, especially when drugs for acute diseases (such as penicillins) were considered. Initial medication non-adherence resulted in a higher economic burden to the system in the short term.Conclusion: Initial medication non-adherence seems to have a short-term impact on productivity losses and costs. The clinical consequences and long-term economic consequences of initial medication non-adherence need to be assessed. Interventions to promote initial medication adherence in primary care may reduce costs and improve health outcomes.

Aims: Adherence to medicines is vital in treating diseases. Initial medication non‐adherence (IMNA) – defined as not obtaining a medication the first time it is prescribed – has been poorly explored. Previous studies show IMNA rates between 6 and 28% in primary care (PC). The aims of this study were to determine prevalence and predictive factors of IMNA in the most prescribed and expensive pharmacotherapeutic groups in the Catalan health system.Methods: This is a retrospective, register‐based cohort study which linked the Catalan PC System (Spain) prescription and invoicing databases. Medication was considered non‐initiated when it was not collected from the pharmacy by the end of the month following the one in which it was prescribed. IMNA prevalence was calculated using July 2013–June 2014 prescription data. Predictive factors related to patients, general practitioners and PC centres were identified through multilevel logistic regression analyses. Missing data were attributed using simple imputation.Results: Some 1.6 million patients with 2.9 million prescriptions were included in the study sample. Total IMNA prevalence was 17.6% of prescriptions. The highest IMNA rate was observed in anilides (22.6%) and the lowest in angiotensin‐converting‐enzyme (ACE) inhibitors (7.4%). Predictors of IMNA are younger age, American nationality, having a pain‐related or mental disorder and being treated by a substitute/resident general practitioner in a resident‐training centre.Conclusions: The rate of IMNA is high when all medications are taken into account. Attempts to strengthen trust in resident general practitioners and improve motivation to initiate a needed medication in the general young and older immigrant population should be addressed in Catalan PC.

Pese al interés creciente que presenta la movilidad académica internacional de los estudiantes universitarios europeos para su inserción profesional posterior, el porcentaje de estudiantes españoles que participan en el programa Erasmus es todavía pequeño. El objetivo de este trabajo fue determinar los principales obstáculos para la movilidad Erasmus percibidos por estudiantes de grado que no han participado en este programa, valorando la existencia de diferencias en función del grado (Sanitario vs. Ciencias Sociales). Se utilizó una encuesta auto-administrada elaborada para un estudio europeo previo en el que participó España. Los resultados muestran el impacto, a nivel general, de la falta de información sobre temas relevantes como: la calidad de la educación en el extranjero, o cómo van a ser evaluados, así como, las barreras económicas por becas insuficientes y retrasos en el pago de las mismas. Los obstáculos que mejor diferencian a los estudiantes de ambos grados están relacionados con la ordenación académica del grado, en concreto, bajo nivel de formación en inglés y presencia de asignaturas anuales, además de características personales del estudiante. Para incrementar la participación, se debería incidir en informar más y comunicar mejor además de incluir modificaciones en el programa académico de los grados que faciliten la movilidad internacional. [Despite the growing interest that presents academic international mobility for European University students for their later in life job prospects, the rate of Spanish students participating in the Erasmus programme is still small. The objective of this research was to determine the main barriers perceived by bachelor students who had not participated in the Erasmus programme assessing the differences between two bachelor degrees (Health vs. Social Sciences). A self-administered survey including reasons not to participate was used that had been set up for a previous European study including Spain. Results reveal the overall impact of lack of information on relevant issues such as the quality of university education system abroad and how they will be evaluated as well as financial barriers such as insufficient Erasmus grants or delays in the first grant payment. The barriers that better differentiate both bachelor degrees students are related to the bachelors’ curriculum i.e. insufficient training in English and presence of annual (vs. semester) courses as well as personal features. To increase participation, the focus should be on improving information and communication both on academic and financial issues, and changes in the bachelors’ curricula.] Fajó-Pascual, M.; Sanclemente, T.; Molina, A.; Asún, S.; Romero, R.; Poblador, J.A.; Ferrer-Mairal, A.M.; Gómez, E.M.; Vercet, A.

La misión de MásterFUEGO es formar técnicos con alta especialización en incendios forestales, a través de la ampliación del conocimiento científico, con el objetivo de obtener profesionales competentes en gestión de emergencias forestales. MasterFUEGO lo lidera la Universidad de Lleida (UdL) y completan Universidad de Córdoba (UCO) y Universidad de León (ULE). Con 90 créditos ECTS, es título compartido entre las tres y Oficial por el Ministerio Español de Educación. Es máster semi-presencial constituido por 7 periodos de 5 jornadas presenciales. Los factores condicionantes de la calidad del aprendizaje se han evaluado mediante una encuesta que rellenan los egresados y aquellos estudiantes que ya tienen suficiente conocimiento sobre el Máster (>40 créditos superados). De 129 alumnos potenciales de las cuatro primeras cohortes, obtuvimos un 81,4% de tasa de respuesta. El 84,7% de los encuestados se encuentran en situación laboral activa y el 68,5% declaran que su empleo versa sobre incendios forestales. La misión queda cumplida al constatarse que los que reportan haber adquirido mayor nivel en competencias y habilidades provienen de titulaciones forestales y llevan más de 6 años de experiencia. Asimismo, “Técnicos o Mandos Superiores” y “Mandos Intermedios” suponen un 50,5% y un 26,7% respectivamente. [MasterFUEGO’s mission is to train fire professionals to the best specialization level, through sound scientific knowledge, to obtain proficient professionals in wildland fire emergency management. This program is led by University of Lleida (UdL) and both University of Cordoba (UCO) and University of León (ULE) complete the team. With 90 ECTS credits, it is joint title of the three and official by the Spanish Ministry of Education. It is a largely on-line program with 7 Face-to-Face training periods of 5 days. Factors conditioning the quality of learning have been evaluated by a survey completed by graduates and those students who already have sufficient knowledge about the program (> 40 credits completed). Of 129 potential students from the first four cohorts, we obtained an 81.4% response rate. 84.7% of the respondents are in an active labor situation and 68.5% declare that their work deals with wildland fires. The mission is fulfilled because those who report having acquired a higher level in competences and skills come from forestry degrees and have more than 6 years of experience. Likewise, "Technicians or Superior Controls" and "Intermediate Controls" account for 50.5% and 26.7% of respondents respectively.] Blanco Fernández, Javier; Fajó-Pascual, Marta; Miguel Molina-Terrén, Domingo

Background: Lowering blood pressure (BP) by antihypertensive (AHT) drugs reduces the risks of cardiovascular events, stroke, and total mortality. However, poor adherence to AHT medications reduces their effectiveness and increases the risk of adverse events. Objective: To evaluate the effectiveness of a multifactorial adherence-based intervention in a primary care setting in lowering BP. Methods/design: Multicenter parallel randomized controlled trial. Thirty two nurses in 28 primary care centers of three Spanish regions. Patients aged 18–80 years, taking AHT drugs with uncontrolled BP (n=221) were randomized to a control group (usual care) or a multifactorial adherence-based intervention including nurse-led motivational interviews, pill reminders, family support, BP self-recording, and simplification of the dosing regimen by a pharmacist. Main outcome measures: The primary outcome was 12-month blinded measure of systolic BP (mean of three measurements). The secondary outcomes were 12-month diastolic BP and proportion of patients with adequately controlled BP. Results: One hundred and fourteen patients were allocated to the intervention group and 109 to the control group. At 12 months, 212 (89%) participants completed the study. The systolic BP in the intervention group was 151.3 versus 153.7 in the control group (P=0.294). The diastolic BP did not differ between groups (83.4 versus 83.6). Of the patients in the control group, 9.2% achieved BP control versus a 15.8% in the intervention group. The relative risk for achieving BP control was 1.72 (95% confidence interval: 0.83–3.56). Conclusion: A multifactorial intervention based on improving adherence in patients with uncontrolled hypertension failed to find evidence of effectiveness in lowering systolic BP. Trial registration: ISRCTN21229328.