Elisa Brosina de Leon

Background: Childhood obesity remains a public health concern in the United States, disproportionately affecting Hispanic/Latino and rural populations. Despite this disparity, there is a lack of culturally relevant programs specifically designed to reach this population. To address this gap, our team culturally adapted a technology-based childhood obesity intervention, Hispanic Family Connections (HFC), targeting Hispanic/Latino families living in rural areas. The intervention comprises 2 main components: interactive voice response (IVR) calls and a workbook with at-home activities to promote family engagement. Objective: The objectives were to (1) evaluate the usability of the IVR calls and workbook included in the HFC intervention and (2) document and plan adaptations to these components using the FRAME (Framework for Reporting Adaptations and Modifications-Enhanced). Methods: We conducted 5 mixed methods, task-based usability tests (UTs) using the think-aloud procedure. All 5 participants were women, self-identified as Hispanic/Latino, and were Spanish literate. Each participant completed 3 think-aloud tasks designed to evaluate the usability of the IVR calls and workbook chapters. Usability was assessed using the After-Scenario Questionnaire (ASQ) at the end of each task and the System Usability Scale (SUS) at the end of the UT session. All sessions were recorded, and data were organized into two primary categories: (1) quantitative results (ASQ and SUS) and (2) qualitative data (participants’ comments and researchers’ observations). Findings were compiled and analyzed following the 8 main domains of FRAME. Results: For the workbook, ASQ scores showed a high level of ease in task completion (mean 1.1, SD 0.32), satisfaction with completion time (mean 1.0, SD 0.00), and satisfaction with support information (mean 1.5, SD 0.97). For the IVR calls, participants reported a higher level of ease in task completion (mean 1.0, SD 0.00), satisfaction with completion time (mean 1.0, SD 0.00), and satisfaction with support information (mean 1.2, SD 0.45). SUS results were positive for 80% (4/5) of participants, with an average usability score above the benchmark (mean 75.5, SD 15.04). Using FRAME, we identified and documented 30 suggestions for adaptations and improvements to the workbook and IVR calls. The majority of suggestions were content-related (n=26, 86.67%), with most focusing on tailoring/tweaking, or refining existing materials. Conclusions: The UT results, combined with systematic documentation using FRAME, allowed us to identify and prioritize the adaptations needed to improve the intervention materials. These refinements will prepare the HFC intervention for implementation in a subsequent feasibility study.

Introduction: aging is a multidimensional process characterized by physiological and psychosocial changes influenced by genetic, environmental, and lifestyle factors. Regular physical activity has been associated with better health, functionality, and well-being among older adults, particularly during periods of social disruption such as the COVID-19 pandemic. Objective: to evaluate quality of life and its domains (control, autonomy, self-realization, and pleasure) among community-dwelling older adults engaged in regular physical activity using the CASP-19 scale in the Brazilian Amazon. Methods: this longitudinal observational study was conducted in Coari, Amazonas, Brazil. Data were collected before the COVID-19 pandemic (2019–2020) and after the vaccination period (2021–2022). The convenience sample included adults aged ≥60 years who engaged in regular physical activity totaling at least 150 minutes per week. Sociodemographic characteristics and CASP-19 scores were collected. Data normality was assessed using the Shapiro-Wilk test, and comparisons between the two assessment periods were performed using the Wilcoxon signed-rank test. Results: at baseline, 66 older adults were evaluated; however, three participants died due to COVID-19, resulting in a final analytical sample of 63 participants with complete follow-up data. Most participants were women (76.2%; n = 48) aged 60–69 years (47.6%; n = 30). Regarding socioeconomic characteristics, 36.5% (n = 23) were illiterate, and 77.8% (n = 49) reported a monthly income between one and two minimum wages. Perceived quality of life remained favourable across the four CASP-19 domains, with most participants reporting meaning in life (78.8%; n = 52), satisfaction with daily activities (75.8%; n = 50), and pleasure in social interactions (83.3%; n = 55). Financial limitations were reported by 45.5% (n = 30) as barriers to achieving personal goals. A slight reduction in the median CASP-19 score was observed between the pre-pandemic assessment (41; IQR 39–46) and the post-vaccination assessment (40; IQR 38–44); however, this difference was not statistically significant (p = 0.0936). Likewise, no significant differences were observed across the four CASP-19 domains between assessment periods. Conclusion: perceived quality of life remained stable among community-dwelling older adults who were physically active before and after the COVID-19 pandemic. Stability was observed in both the overall CASP-19 score and its four domains, providing longitudinal evidence from a remote municipality in the Brazilian Amazon and contributing to a better understanding of quality of life among physically active older adults living in an underrepresented setting.

Aims: To investigate the barriers and facilitators to adopting healthy lifestyle habits among patients with type 2 diabetes mellitus (T2DM) in the Brazilian Amazon, using the Environmental Factors domain of the International Classification of Functioning, Disability and Health (ICF) as a conceptual framework. Methods: A qualitative study was conducted with 47 patients with T2DM and 17 community health workers (CHWs) from primary health care services in the Brazilian Amazon. Data were collected through two World Café group discussion sessions (one involving patients and one involving CHWs) and 15 semi‐structured interviews conducted in patients’ homes. Data were analysed using thematic analysis supported by Atlas.ti 24 software. Results: Three major categories emerged: attitudinal, social and physical factors. Attitudinal barriers included resistance to behaviour change, denial of disease severity and physical limitations, whereas fear of complications and valuing life motivated healthier behaviours. Social barriers comprised lack of family support, insecurity and transportation difficulties, while family involvement, professional guidance and trust in CHWs facilitated treatment adherence and lifestyle modification. Physical barriers included inadequate infrastructure, adverse weather conditions and the absence of safe public spaces for physical activity. Conversely, proximity to local markets and fairs facilitated access to healthy foods and supported dietary improvements. Conclusions: Barriers and facilitators to healthy lifestyle adoption among people with T2DM in the Brazilian Amazon are strongly influenced by attitudinal, social and environmental factors. Effective diabetes management in this context requires culturally sensitive interventions, improved urban infrastructure, strengthened community support networks and continued engagement of multidisciplinary healthcare teams, particularly CHWs. These findings provide important insights for developing context‐specific strategies to promote sustainable lifestyle changes, enhance patient autonomy and improve quality of life in remote Amazonian communities.

Introduction: health literacy is crucial for managing type 2 diabetes mellitus (T2DM). In the Brazilian Amazon, geographical barriers limit access to care, exacerbating low adherence and poor glycemic control, impacting the disease progression. Objective: to analyze patterns of health literacy and their associations with sociodemographic, clinical, and behavioral factors among individuals with T2DM in the Brazilian Amazon, using a network analysis approach. Methods: a cross-sectional study was conducted with 137 adults with T2DM receiving care in six Primary Health Care units in a Brazilian Amazon city. Health literacy was assessed using the Brazilian version of the Test of Functional Health Literacy in Adults, and diabetes knowledge was measured using the DiAbeTes Education Questionnaire (DATE-Q). Sociodemographic, clinical, and behavioral data were collected through structured interviews. Descriptive and inferential analyses were performed, and network analysis was applied to explore the interrelationships among variables. Results: most participants had inadequate health literacy (57.7%), and only 1.5% had adequate literacy. Lower literacy levels were significantly associated with older age, fewer years of schooling, lower income, unemployment, and longer diabetes duration (p<0.05). Individuals with lower literacy also reported poorer dietary practices and lower adherence to recommended self-care behaviors. In the network model, health literacy emerged as a central node, with the highest strength and betweenness indices, closely connected to education, retirement status, and age, indicating its key role in the structure of associations. Conclusion: the prevalence of low health literacy among participants was 57.7%. Lower health literacy was significantly associated with older age, fewer years of schooling, lower income, and longer diabetes duration. These factors may be related to barriers to understanding and accessing health services in the region, such as low income and limited access.

Introduction: aging associated with Type 2 Diabetes Mellitus (T2DM) increases the risk of cognitive impairment in older adults. During the COVID-19 pandemic, social isolation, disruption of Primary Health Care follow-up, and greater clinical vulnerability may have worsened cognitive health, especially in rural areas of the Amazonas state. Objective: to describe cognitive characteristics and their association with sociodemographic and clinical factors among older adults with Type 2 Diabetes Mellitus receiving Primary Health Care in the interior of Amazonas. Methods: this cross-sectional observational study included 58 older adults monitored by Primary Health Care Units in Coari, Amazonas, during the COVID-19 pandemic. Home-based data collection was conducted following biosafety protocols. Sociodemographic and health data were obtained using a semi-structured questionnaire. Cognitive assessment included the Mini-Mental State Examination (MMSE) and Verbal Fluency Test (VFT), administered by previously trained researchers. The results were expressed as regression coefficients (β), 95% confidence intervals (95% CI), and p-values. Analyses were performed using the Statistical Package for the Social Sciences (SPSS), version 20.0, adopting a significance level of 5% (p < 0.05). Results: most participants were women (68.9%), aged 60–69 years (76.3%), and had low educational levels (78%). Regarding health conditions, 71.1% used diabetes medication, 60.5% used insulin, and 42.1% had inadequate glycemic control. Cognitive deficit was identified in 42.1% of participants by MMSE and in 22% by VFT, with performance associated with educational level. After adjustment for sex, age, education, race/color, and income, no significant association was observed between MMSE and VFT scores (coefficient=0.14; p=0.254). Conclusion: older adults with T2DM showed high frequencies of low education, inadequate glycemic control, and cognitive deficits, reinforcing the need for early cognitive screening and culturally adapted health education strategies.

Introduction: Continuing education policies in health are essential but face limitations, including limited resources, work overload, and methodologies disconnected from professionals’ realities. Objective: To investigate the challenges and strengths of a training program for community health workers in the Brazilian Amazon on managing type 2 diabetes mellitus. Methods: Qualitative phenomenological study based on Martin Heidegger’s framework. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist and Standards for Reporting Qualitative Research (SRQR). The focus group sessions were fully transcribed and processed using Atlas.ti24 software, and analyzed through Thematic Network Analysis. Results: The main challenges reported included difficulties with technology, lack of technical and institutional support, extensive workload, and balancing personal and professional routines. On the other hand, Community Health Workers highlighted the following strengths: technical improvement, strengthening of professional networks, increased self-confidence, and recognition of the training as a personal growth opportunity and a form of professional appreciation. Conclusion: When professional qualifications focus on both skill development and the empowerment of professionals, as well as on strengthening collaborative bonds, they have a significant positive impact not only on Community Health Workers work but also on their well-being and career prospects.

Type 2 diabetes Mellitus (T2DM) is a prevalent chronic condition with global impact. Medication adherence is essential for disease control, but it remains a challenge in socially vulnerable contexts such as the Brazilian Amazon. Objective: To identify barriers and facilitators of medication adherence in the management of T2DM in the Amazon population. Materials and Methods: A qualitative, descriptive study was conducted in Iranduba (Amazonas) involving individuals with T2DM and community health workers (CHWs). The World Café method and semi-structured interviews were used. Data were analyzed with the support of ATLAS.ti software, using Thematic Network Analysis. Results: A total of 64 participants were included (47 individuals with T2DM and 17 CHWs). Reported barriers included difficulty remembering medication schedules, adverse effects, limited financial resources, lack of medication availability in primary care, and insufficient professional support. Facilitators included self-management strategies, commitment to treatment, purchasing power, family support, and CHWs' actions. Discussion: Medication adherence in Diabetes is shaped by barriers such as forgetfulness, adverse effects, and limited access to medications, while family support, professional guidance, and personal strategies facilitate treatment. These factors interact and affect self-care. Conclusion:Medication adherence among individuals with T2DM in the Amazon is shaped by intrapersonal, interpersonal, and environmental factors. Culturally adapted strategies, greater professional support, and public policies ensuring medication availability are essential to improving care and preventing complications.

This study aimed to investigate the use of medicinal plants for the treatment of diabetes mellitus among residents of the Brazilian Amazon. An observational study was conducted using data from the Amazon Population Primary Care Health Study (SAPPA), comprising 691 participants. Data were exported to Microsoft Excel and analyzed using descriptive statistics and the chi-square test, with a significance level set at p ≤ 0.05. Overall, 58.76% of the sample reported using medicinal plants for diabetes management. Among the participants with diabetes who reported using medicinal plants, the majority were older women, illiterate, married or in a stable union, and residents of Manacapuru. A total of 108 plant species were cited, most of them exotic. The most frequently reported species were Cymbopogon citratus (13.79%) and Bauhinia forficata L. (9.85%). Leaves were the most commonly used plant part (57.85%), followed by bark (19%), and infusion was the predominant method of preparation (75%). The findings indicate that the use of medicinal plants is widespread among individuals with diabetes in the Brazilian Amazon and involves considerable botanical diversity. These results highlight the importance of further pharmacological and clinical research to confirm the antidiabetic properties of these species and to establish evidence-based guidelines for their safe and effective use.

Background: Conducting health systems assessments helps highlight weaknesses and strengths to be explored to improve care delivery. The Assessment of Chronic Illness Care (ACIC) considers the perspective of professionals who work in the care-providing institution. Its structure comprises seven dimensions that provide specific data about the care offered. Objectives: (1) evaluate the institutional capacity for Type 2 Diabetes Mellitus (T2DM) management in the interior of the State of Amazonas from the perspective of health professionals; (2) verify the association between socio-educational, work and geographic location variables with the dimensions of the ACIC. Methods: A cross-sectional study carried out between October 2020 and December 2022 in 36 Primary Health Units (PHUs) of the seven cities of the Amazonas, totaling 230 participants. Excel 2019 and R (4.2.1) were used for data analysis. The association between independent variables and ACIC dimensions was analyzed using multiple logistic regression analysis. Result: The PHUs in the rural Amazonas have the basic capacity to care for patients with T2DM. Analysis of each dimension of the ACIC demonstrated that geographic location was the most relevant factor, showing an association with all instrument dimensions. Conclusions: Socioeducational variables showed an association with the dimensions of Decision Support, Design of the Service Delivery System, Clinical Information System, and Integration of components of the Care Model for Chronic Conditions. Work-related variables, on the other hand, were associated with the dimensions of Organization of Health Care, Community Resources, Support for Self-Management and Integration of the components of the Chronic Conditions Care Model.

Community Health Workers (CHWs) play a pivotal role in the management of Type 2 Diabetes Mellitus (T2DM) within Primary Health Care settings. Adequate training is essential to strengthen their capacity to deliver care, particularly by fostering dialogue between the health team and the community. This study aimed to describe the co‐design process underlying the development of an educational technology (ET) intended to train CHWs in T2DM management in the Brazilian Amazon. This mixed‐methods study involved the development of video lectures and printed support materials through the following stages: identification of CHWs' primary training needs; definition of the ET structure; development of thematic content, scripts, and instructional materials; creation of interactive resources; expert review; preliminary presentation to CHWs; and final evaluation and validation by experts. Usability was assessed by CHWs using the System Usability Scale (SUS), with scores ≥72.74 considered indicative of acceptable usability. The 17 participating CHWs rated the ET positively, with a mean SUS score of 84 ± 11.1, reflecting high usability. The educational technology demonstrated strong usability and, given its collaborative and problem‐oriented development process, represents a promising tool to enhance CHWs’ performance in T2DM management.