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reduction in salt intake has been identified as one of the most cost-effective measures for improving health outcomes 1-3. Different studies have reported the benefit of salt-reduction interventions in decreasing blood pressure and cardiovascular events 4-6. Results from a meta-analysis show that modest reductions in salt intake are followed by a decrease in blood pressure levels among both hypertensive and normotensive subjects 7. Nevertheless, the evidence of the effectiveness of population-level, behavior change interventions on reducing salt intake is inconsistent, suggesting that education and awareness-raising interventions alone are not sufficient for reducing population salt intake 8. Salt substitutes, that is, salt enriched with potassium or other similar components such as magnesium or aluminum, have been reported to be effective in reducing both systolic blood pressure (SBP) and diastolic blood pressure (DBP) 9-11. Under controlled conditions, salt-substitution strategies can reduce the SBP up to 5 mm Hg and the DBP up to 1.5 mm Hg, and this effect was larger among individuals with hypertension than among normotensive subjects 12. There is limited evidence, however, from studying the population-level effect of these salt-substitution interventions. A cluster randomized trial conducted in China, evaluating the effect of a community-based sodium reduction program using a salt substitute on salt consumption and blood pressure, found reductions in urinary sodium excretion but not in blood pressure 13. Currently, an increasing number of countries have adopted national salt-reduction strategies 14. Salt-substitution initiatives could aid such strategies in settings where added salt during cooking is the main source of salt intake, particularly in low-and middle-income countries where hypertension rates are increasing at a fast rate 15. The aim of the present study was to assess the efficacy of a pragmatic intervention using a salt-substitution strategy to reduce blood pressure, as well as its impact on the incidence of hypertension, at the population level, using a stepped-wedge cluster trial in Peru. Results Population characteristics. Figure 1 shows the details of participants' enrollment, including dates, number of subjects assessed, those lost to follow-up and those analyzed for each step of the trial. A total of 2,376 (91.2%) out of 2,605 eligible subjects in the 6 villages were enrolled in the study from 2 April to 17 July, 2014: 49.6% females, mean age 43.3 ± 17.2 years. Of note, only 18.9% of the individuals had ≥12 years of education, 68.1% were in the overweight or obesity range with a body mass index (BMI) ≥25 kg m −2 and 18.3% had a diagnosis of hypertension. Table 1 shows the characteristics of the study population at baseline and a comparison between the control and the intervention periods. There were differences among villages in the distribution of age, education, wealth index, BMI, SBP, DBP and hypertension (see Supplementary Table 1). Effect of the salt substitute on blood pressure levels....

IMPORTANCEDepression is a leading contributor to disease burden globally. Digital mental health interventions can address the treatment gap in low-and middle-income countries, but the effectiveness in these countries is unknown.OBJECTIVE To investigate the effectiveness of a digital intervention in reducing depressive symptoms among people with diabetes and/or hypertension. DESIGN, SETTING, AND PARTICIPANTSParticipants with clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score Ն10) who were being treated for hypertension and/or diabetes were enrolled in a cluster randomized clinical trial (RCT) at 20 sites in

Introduction Understanding local complexities and challenges of stroke-related caregiving are essential to develop appropriate interventions. Our study aimed to characterize the impact of post-stroke care among caregivers in a setting of transitioning economy. Materials and Methods Qualitative study based on in-depth interviews with primary caregivers of stroke survivors in Lima, Peru. Transcribed data was organized into the emotional impact of caregiving, main stress factors and coping mechanisms to deal with the caregiving role, as well as the unmet needs of caregivers. Results We interviewed twelve caregivers, mean age 52.5 years, 8/12 were females, who were either the spouse or child of the stroke survivor. Stroke patients had a median age of 70 years, range 53–85 years. All participants reported having experienced emotional stress and depressive symptoms as a result of caregiving. Although most had family support, reduced social activities and added unanticipated financial burdens increased caregiver’s stress. None of the caregivers had received training in post-stroke care tasks after the patient’s discharge and only a few had received some psychological support, yet almost all expressed the need to see a professional to improve their mental health. Keeping a positive attitude towards their relative’s physical post-stroke condition was a key coping mechanism. Conclusions In the absence of structured institutional responses, family members endure with the provision of care for stroke survivors, a task escorted by major emotional, financial, and social strains. This burden could be prevented or curtailed if caregivers were to be targeted by interventions providing psychological and financial support, together with basic training on post-stroke care.

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