# ABSTRACT

This study analyzes the conditions and possibilities of sustainability of the Salud al Paso program of the Metropolitan Health Secretariat of the Municipality of Quito, Ecuador, as an example for similar initiatives, in the context of the changes made by the new administration in May 2019. The analysis of the implementation of this initiative, focused on the prevention of noncommunicable diseases (NCDs), was based on the program’s user database, the information gathered on the perspectives of operational staff, knowledge of the program, and the opinion of local leaders and opinion leaders of the Quito Metropolitan District, as well as official information. Based on this data, the study identified factors that could have facilitated or hindered its sustainability and documented the rationale to suspend the on-demand activities included in the program and limit activities to the care of populations under municipal responsibility (day-care centers, schools and colleges, markets, elder care programs, and employees) and patients with identified cardiometabolic risk. The insufficient institutionalization of the program, conceived as a project with an insufficient vision of its sustainability in time, was mentioned as a possible obstacle by leaders and operational staff. The growing prevalence of NCDs requires initiatives for their prevention, which must be institutionalized to ensure their continuity and overcome eventual changes of government. In addition, future interventions similar to Salud al Paso should establish better sectoral coordination articulation, especially with the Ministry of Public Health and other service networks.

Keywords
Public policy; preventive health services; noncommunicable diseases; health management; Ecuador

# RESUMEN

Palabras clave
Política pública; servicios preventivos de salud; enfermedades no transmisibles; gestión en salud; Ecuador

In Ecuador, approximately 65% of the population over the age of 19 is overweight or obese—risk factors for noncommunicable diseases (NCDs)––, with a direct and indirect expense equivalent to 4.3% of the annual gross domestic product (GDP) (11. Fernández A, Martínez R. The cost of the double burden of malnutrition: social and economic impact. Summary of the pilot study in Chile, Ecuador and Mexico. UN Economic Commission for Latin America and the Caribbean (ECLAC). 2017. Available at: https://www.wfp.org/publications/2017-cost-double-burden-malnutrition-social-and-economic-impact
https://www.wfp.org/publications/2017-co...
). In parallel with the private health system, the public system operates in a fragmented and centralized manner in two sectors: the different social security programs and the Ministry of Public Health. The predominant national cure-focused model limits preventive approaches to address the increase in NCDs; health policies are stagnant or formulated at the discretion of the current government, with no medium- or long-term vision for ensuring their sustainability (22. Walugembe DR, Sibbald S, Le Ber MJ, Kothari A. Sustainability of public health interventions: where are the gaps? Health Research Policy and Systems. 2019;17(1):8.). Instead, they are designed to increase the visibility of politicians and their parties and to generate short-term revenue (33. Hurtado O. Ecuador entre dos siglos. Bogotá: Debate; 2017., 44. Campos-Herrera G, de Reguero SU. Populism in Latin America: past, present, and future. Lat Am Polit Soc. 2019;61(1):148-59.).

The Metropolitan District of Quito (DMQ), with nearly 2.5 million inhabitants, is experiencing a significant increase in NCDs (55. Secretaría Metropolitana de Salud. Diagnóstico de Salud - Distrito Metropolitano de Quito. Quito: Alcaldía del Distrito Metropolitano de Quito; 2017.), especially diabetes and hypertension, which are tied to malnutrition, a sedentary lifestyle, overweight, and obesity (66. Secretaría Metropolitana de Salud. Plan Decenal de Salud 2015-2025. Quito: Alcaldía del Distrito Metropolitano de Quito; 2015.). In addition to three health municipal units with limited on-demand healthcare services, the municipality of the DMQ had promotional preventive programs for the “captive” population under municipal responsibility, which accounts for less than 5% of Quito’s population. Metropolitan Ordinance No. 494 of 2014 called for the implementation of promotional, prevention, and surveillance activities throughout the DMQ, so the 10-Year Quito Health Plan for 2015-2025 set the goal of promoting the adoption of healthy lifestyles to help prevent or control NCDs (77. Berán D, Pedersen HB, Robertson J. Noncommunicable diseases, access to essential medicines and universal health coverage. Glob Health Action. 2019;12(1):1670014.). In this context, the Salud al Paso program (SAP) was created in May 2015 (88. Roldós MI, Hopenhayn C, Sacoto F, Bustamante K. Developing local health policy: Profiling needs and opportunities in the Municipality of Quito, Ecuador. J Public Health Pol. 2017;38(2):221-33.).

This study analyzes the conditions and possibilities for the sustainability of the SAP program in the Metropolitan Health Secretariat of Quito, Ecuador, in light of the changes made by the new government in May 2019. In particular, we examine the factors that may have influenced the decision made by the new authorities to suspend the program, as well as needs for improvement in the event of similar future initiatives.

# MATERIALS AND METHODS

## Study design and sample

The study is part of the initiative Improving Program Implementation through Embedded Research (iPIER) developed by the Alliance for Health Policies and Systems Research in collaboration with the Pan American Health Organization (PAHO). This initiative places program implementers in research centers in order to understand barriers to implementation, which will facilitate the identification of solutions and contribute to the effectiveness of health programs and policies (99. Langlois EV, Mancuso A, Elias V, Reveiz L. Embedding implementation research to enhance health policy and systems: a multi-country analysis from ten settings in Latin America and the Caribbean. Health Res Policy Sy. 2019;17(1):85.).

A descriptive study was conducted that focused on the design and execution of the SAP program by the DMQ Health Secretariat (22. Walugembe DR, Sibbald S, Le Ber MJ, Kothari A. Sustainability of public health interventions: where are the gaps? Health Research Policy and Systems. 2019;17(1):8.), the characteristics of users and the perceptions of operational staff, local leaders, and opinion leaders regarding the program. Using the guide of Peters et al. (1010. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Guide. Geneva: Alliance for Health Policy and Systems Research, World Health Organization; 2014.) for analyzing health policy implementation, the applicable outcome variables and potential needs for improvement were studied.

The perception of health workers regarding the SAP program was obtained based on the opinions of 69 of the 76 professional nutritionists who worked directly in screening, user education on NCD prevention, adoption of healthy lifestyles, and improvement of nutritional risk in 25 health care units.

In addition, 90 local leaders selected on the basis of their representation of beneficiary sectors (rural parish boards, municipal educational institutions, municipal markets, neighborhood community leaders) and opinion leaders (academia, social and health management, journalism, politics, local authorities and social actors) also participated.

## Data collection

### Database.

The anonymized database of SAP users was accessed under a confidentiality agreement with the Health Secretariat. This database covering the period from April 2015 to May 2019 included 525 252 people (1 058 880 visits), of which 444 990 (934 525 visits) were over the age of 18 years.

### Documentation.

The analyzed information includes documents issued by the Health Secretariat of the DMQ Municipality: legal frameworks, standards, the 10-Year Health Plan for the DMQ Municipality, and the SAP procedures manual (1111. Jarrín E, Carrillo D, Suárez E, Villalba J. Manual de procedimientos para detección y manejo de factores de riesgo de ECNT y malnutrición. Quito: Secretaría de Salud - Municipio del Distrito Metropolitano de Quito; 2016.), as well as technical, operational, and financial management reports, official communications of the new administration regarding the program, and the Health Secretariat’s “Proposal to Restructure the SAP” of June 2019.

### Operational staff interviews.

A self-administered structured interview was electronically sent to operational staff of the SAP program as a virtual form. After receiving instructions and signing an informed consent, their responses were returned in an anonymous and confidential manner. This survey included open-ended and closed questions on working conditions, perceptions, and perspectives of the program, as well as their own performance.

The survey of local and opinion leaders was administered by a member of the research team, who guided the participants. Some participants responded on their own using a virtual form, while others were surveyed by phone. Instructions and the informed consent form were provided prior to the questions. It was decided to conduct a survey instead of an interview in order to reach the most participants possible, since an initial contact showed that participants were more willing to take a survey that included open-ended and closed questions aimed at assessing their knowledge of the SAP program and NCDs, and their position and opinion regarding the program’s sustainability.

### Feedback workshop.

After the surveys, a feedback workshop was attended by 69 professionals: 62 direct care nutritionists, five supervisors, and two logistics people.

The participants shared their perspectives on organizational issues, user opinions, and the program’s future. The conversations were recorded with their consent and written contributions were compiled, transcribed, and stored in a protected file that could only be accessed by the investigators.

### Processing and analysis.

The telephone surveys of opinion makers were transcribed word-for-word and compiled along with responses sent virtually. The quantitative responses from the two surveys were disaggregated and tabulated by question, and the qualitative responses were compiled by question and initially coded in a matrix in open and inductive manner.

The quantitative data in the database were used for a descriptive statistical analysis of users, care, and intervention plans. The text of the qualitative questions was coded and compiled by similarity based on thematic categories, and their frequency was tabulated so as to identify the most common opinions shared by participants.

The quantitative and qualitative data were reviewed based on the recommendations of Peters et al. (1010. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Guide. Geneva: Alliance for Health Policy and Systems Research, World Health Organization; 2014.). This being an innovative intervention, the analysis focused on topics such as acceptability, adoption, sense of ownership, and feasibility, although coverage and costs were also included. The quantitative data in the database and the information provided by the new Health Secretariat authorities were analytically correlated, and also linked with the qualitative data from the respective surveys, documenting the reasoning and grounds for the institutional decision made on the future of the SAP program.

### Feedback with the new authorities.

On 12 May 2019 the preliminary results of the study were analyzed with the new technical directors of the Health Secretariat; at an expanded meeting held on 10 September 2019, various criteria and documents were received which the authorities used to justify the decision to suspend the SAP program.

## Ethical aspects

The participants were informed of their rights as participants in writing or verbally, before giving their consent. The transcripts of the workshops do not contain their names and the surveys of leaders were identified with a numerical code. The study was approved by the Ethics Review Committee of the Pan American Health Organization (PAHOERC-2019-01-0003) and by the Bioethics Committee for Human Subjects Research of the International University of Ecuador (CEU-082-19).

# RESULTS

Table 1 shows a summary of the results of each variable and its implementation outcomes, based on the model of Peters et al. (1010. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Guide. Geneva: Alliance for Health Policy and Systems Research, World Health Organization; 2014.).

## Coverage

The country’s official statistics records were obtained from the National Statistics and Census Institute (INEC). They do not include nutritional prevention activities, such as those offered by SAP, since only prevention consultations with physicians, obstetricians, psychologists, and nursing staff and the coverage of preventive dental services were recorded (1212. Instituto Nacional de Estadística y Censo. Registro estadístico de actividades y recursos de salud. Documento metodológico. 2018. Available at: https://www.ecuadorencifras.gob.ec/documentos/webinec/Estadisticas_Sociales/Recursos_Actividades_de_Salud/RAS_2018/Metodologia%20_RAS_%202018.pdf
).

Table 2 shows the coverage results obtained by the SAP program during the time it was in effect (April 2015 - May 2019). Three indicators were prepared: one general indicator of the total population in the DMQ, and two specific indicators: total population over 18 years of age, and users over 18 years of age living in the DMQ.

The SAP program (2015 - 2019) covered 21.6% of people over 18 years of age in the DMQ and intended to reach a target of 40% coverage by 2025. Of the total number of people at risk of NCDs who started an intervention plan, the SAP included the population between 18 and 64 years of age. A global analysis of cohorts monitored semiannually between April 2015 and September 2018 identified 233 753 overweight or obese users over 18 years of age that initiated the intervention plan, 52 565 (22.5%) of whom were subsequently seen more than one time.

TABLE 1.
Variables and implementation outcomes, based on Peters et al. (1010. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Guide. Geneva: Alliance for Health Policy and Systems Research, World Health Organization; 2014.), Salud al Paso program, Quito, 2015 - 2019

## Costs

The total budget accrued between April 2015 and December 2018 according to budget reports of the Finance Department of the DMQ Municipality was US$9 880 168. During this period, the unit cost per person seen (n = 525 252) was US$ 18.81, and US\$ 9.33 per visit (n = 1 058 880).

## Acceptability

The operational staff were consulted regarding their view of the acceptability of the program. They said the program was innovative and current, was located in places convenient for the population, and was promoted in public activities such as fairs and other events, so that, in their opinion, it was easy to access and did not impose a financial burden (free of cost). They also mentioned personalized care and the provision of educational materials that encouraged the population to adopt healthy practices.

Among restrictions, they pointed out that not all users were seen long enough to perform a complete assessment, which could adversely affect people at nutritional risk who require more support. A lack of waiting areas and lack of privacy was also reported.

Furthermore, the majority (85%) of the 32 consulted leaders who received care in the program rated their experience as excellent or very good, while the remaining 15% rated it as good.

The adoption variable was defined as the “intention, initial decision, or action taken to try to employ an intervention” (1010. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Guide. Geneva: Alliance for Health Policy and Systems Research, World Health Organization; 2014.). The study analyzed the gradation of the program; a reduction was observed in the number of people seen per year with respect to the initial period from April to December 2015. As of May 2019, the SAP program served 444 990 people over 18 years of age (Table 3), out of an estimated population of 1 728 717 in 2019 (1313. Instituto de la Ciudad. Proyecciones poblacionales del Distrito Metropolitano de Quito. Quito: Municipio del Distrito Metropolitano de Quito; 2013.).

Although there was a decline in the number of people served, the number of visits per user increased (Table 2). Services were expanded, from initially only including nutritional screening and general advice on healthy habits, to a risk criteria approach in June 2016 that included personalized counseling and monitoring of people considered low risk, who began a six-month intervention plan with at least four visits. Higher risk people were referred for cardiometabolic care provided by Municipal Health Units or other health services (1111. Jarrín E, Carrillo D, Suárez E, Villalba J. Manual de procedimientos para detección y manejo de factores de riesgo de ECNT y malnutrición. Quito: Secretaría de Salud - Municipio del Distrito Metropolitano de Quito; 2016.).

TABLE 2.
Care provided, number of visits, and coverage of the Salud al Paso program, Quito, April 2015 - May 2019

The adoption variable could also be regarded as a sense of “ownership” of the program by SAP operational staff. This aspect was addressed by asking whether they “regularly contributed ideas and opinions for improving the program.” Of all SAP operational staff, 88% (n = 61) reported that they did, while 29 professionals felt that their contributions were taken into account, and 14 thought that they were not. The remaining 18 individuals appeared to be neutral.

Along these lines, in surveys and the feedback workshop, the suggestions on improvement covered two areas: internal, with improvements in operational planning; and external, with possible measures to increase coverage and obtain higher rates of user return. The participants suggest increasing the number of points of care, especially rotational units that are open on weekends, and improving communications and information records. In terms of SAP human resources, they feel it is necessary to improve the rotation of shifts and schedules, encourage staff to update their knowledge, improve the work environment, and prevent and resolve occupational risks.

To improve user care, coverage, and return, they recommend increasing publicity, disseminating and communicating information about the program, holding more SAP-related health promotion events, creating waiting areas, establishing partnerships with local governments, community leaders, and social actors, companies, and institutions, and promoting greater coordination with territorial administrations (the municipality of Quito and the health system).

## Appropriateness

Regarding the relevance of SAP as an appropriate preventive strategy, 93% of the operational staff (n = 64) agreed that it was, rating the outcomes as excellent or very good; only 7% (n = 5) said they were good. Nevertheless, they recommended timelier monitoring of progress or setbacks in users’ nutritional risk, as well as effective medical referral systems, as required, with improvements in access and monitoring in rural areas.

TABLE 3.
Adults served and number of visits under the Salud al Paso program, Quito, April 2015-May 2019

## Feasibility

The feasibility variable is defined by Peters et al. (1010. Peters DH, Tran NT, Adam T. Implementation Research in Health: A Practical Guide. Geneva: Alliance for Health Policy and Systems Research, World Health Organization; 2014.) as the “extent to which an intervention can be carried out in a particular environment or organization.” The SAP program is endorsed in Ordinance No. 0494 of 2014, which was still in effect as of the date of this study. Institutional feasibility in the municipality of the DMQ is confirmed by the existence of organizational and financial resources included in the annual budgets of the Health Secretariat, the entity that by law should “lead comprehensive health management in the municipality…”. Institutional feasibility is, in turn, supported by constitutional mandates with a similar focus (1414. Constitución del Ecuador. Tít. VII, Art. 360. 2008. Available at: https://www.asambleanacional.gob.ec/sites/default/files/documents/old/constitucion_de_bolsillo.pdf
https://www.asambleanacional.gob.ec/site...
).

Growing public concern about the increase in NCDs and their risk factors, global evidence of the urgent need to prevent the serious social and economic impact of these diseases (1515. Legetic BE, Medici AE, Hernández-Ávila ME, Alleyne GAOE, Hennis AE. Economic Dimensions of Non-Communicable Diseases in Latin America and the Caribbean. Washington D.C.: PAHO; 2017.), and successful cases of similar interventions in other countries (1616. Elorriaga N, Garay OU, Belizán M, González VB, Rossi ML, Chaparro M, et al. Evaluación del impacto sanitario del Programa Estaciones Saludables en la Ciudad Autónoma de Buenos Aires, Argentina. Rev Panam Salud Publica. 2018;42:e150.,1717. Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, et al. Task shifting for non-communicable disease management in low and middle income countries–a systematic review. PloS One. 2014;9(8): e103754.) all lend feasibility to programs such as SAP. In the study, 99% of the leaders interviewed were aware that “obesity and excess weight contribute to diabetes, hypertension, cancer, and other noncommunicable diseases,” and 71% reported that there were people with hypertension, diabetes, or cancer in their own family circles.

In any case, well-supported initiatives such as the SAP could be even more feasible in the context of solid health institutions that position government health policies. In the absence of such a context, the authorities of the moment may or may not, at their discretion, decide to support these initiatives. Indeed, the greatest identified risk or obstacle to the sustainability of the SAP was “support from the authorities” (n = 24), followed by “funding” (n = 23).

## Sustainability

Sustainability is defined as the “degree to which an intervention is maintained or is institutionalized in a given environment.” The SAP program, as such, did not achieve sustainability in the municipality of Quito, since the new authorities decided to suspend its execution and instead refocus the original NCD prevention strategy (i.e., the program to “promote the adoption of healthy lifestyles in the Metropolitan District of Quito” and the program for timely detection and management of noncommunicable chronic disease risks in the population over 2 years of age in the DMQ [n= 2 672 429]) (Table 4). The new administration decided to “intervene in the population of the municipality through screening to identify metabolic risk factors in order to promote healthy lifestyles, prevent noncommunicable chronic diseases, and treat people at risk.” (1818. Municipio del Distrito Metropolitano de Quito. Propuesta de Reestructuración del Proyecto Salud Al Paso. Quito: Secretaría de Salud - Dirección Metropolitana de Promoción, Prevención y Vigilancia de la Salud; 2019.) This meant that only 60 221 people would be covered, in addition to patients identified as having cardiometabolic risk (Table 4).

TABLE 4.
Changes in the Salud al Paso program, Metropolitan District of Quito (DMQ), May 2019

# DISCUSSION

This study analyzes the conditions and possibilities for the sustainability of the Salud al Paso program of the Metropolitan Health Secretariat of the Municipality of Quito, following the change in leadership in May 2019. In the context of the country’s weak health institutions (1919. Torres I, López-Cevallos DF. Institutional challenges to achieving health equity in Ecuador. The Lancet Global Health. 2018;6(8): e832-e3.), the decision made by the new municipal administration to suspend the program took into consideration the limited capacity for public uptake, as illustrated by the low level of willingness (27%) (n = 24) of the leaders interviewed to publicly express their support. Another influencing factor may have been limited knowledge about the program among the heads of rural local governments (8 of 17 in this study) who, despite their political influence, had little contact with the SAP (only 3 of 17 reported having requested care under the program). Furthermore, it is possible that the second most common way that leaders learned about the program––through promotion, publicity, and news from the municipal authorities (29%)- may have led them to identify the SAP with the previous municipal government’s policies.

The insufficient institutionalization of the program––which was conceived as a project with an insufficient vision of its sustainability over time––contributed to the fact that after the municipal authorities in Quito were removed on 15 May 2019, the new mayor announced his decision to suspend the SAP program under its original scope. Among the changes introduced (Table 4), the most important were to: stop considering the target population in the DMQ when the rates of overweight and obesity (risk factors for NCDs) exceed 60% of people between the ages of 20 and 59 (66. Secretaría Metropolitana de Salud. Plan Decenal de Salud 2015-2025. Quito: Alcaldía del Distrito Metropolitano de Quito; 2015.); and change the promotional and preventive emphasis of the SAP to a curative approach instead, which has limited effectiveness against NCDs (77. Berán D, Pedersen HB, Robertson J. Noncommunicable diseases, access to essential medicines and universal health coverage. Glob Health Action. 2019;12(1):1670014.).

The lack of official records on preventive nutritional activities (a pending task in Ecuador) may be explained by the lack of initiatives such as Salud al Paso which, had it continued, could have created a need to add such records. But it could also be interpreted as a shortcoming because coordination with the national regulatory agency (the Ministry of Public Health) was not implemented when the program was launched. In fact, it was only toward the end of 2018 that a general agreement was signed between the municipality and the respective territorial agency of the MPH (2020. Ministerio de Salud Pública del Ecuador-Municipio del Distrito Metropolitano de Quito. Convenio de cooperación para la prestación de servicios de salud entre el Ministerio de Salud Pública a través de la Coordinación Zonal 9-Salud y el Municipio del Distrito Metropolitano de Quito. Memorando Nro. MSP-CZ9-2018-14245. 2018.).

On the other hand, the observed decrease in activity could be due to the fact that the demand at fixed points of care was “exhausted”; so there should have been a plan to replenish users, without ignoring the importance of monitoring people at nutritional risk. In this and other areas, it would have been extremely valuable to hear user opinions. Because these were not obtained due to logistical or financial problems, the analysis was restricted to secondary information. An additional limitation is the lack of a study on the program’s budgetary impact.

In the context of the global impact of the COVID-19 pandemic, as of the date of the most recent revision of this study (27 July 2020), and in the midst of major information gaps and significant difficulties in the timely detection of suspected cases, isolation, and control (2121. Torres I, López-Cevallos DF, Sacoto F. Elites can take care of themselves - Comment on “COVID-19: the rude awakening for the political elite in low-income and middle-income countries”. BMJ Global Health. 2020;5(7):e003063.), the DMQ had the highest number of confirmed cases in Ecuador: 12 561 (surpassing Guayaquil, with 11 823 cases) (2222. Secretaría de Gestión de Riesgos. Situación nacional por COVID19. No. 151. 2020; June 10. Available at: https://www.gestionderiesgos.gob.ec/wp-content/uploads/2020/07/INFOGRAFIA-NACIONALCOVI-19-COE-NACIONAL-08h00-27072020.pdf
https://www.gestionderiesgos.gob.ec/wp-c...
). Had the SAP program continued, its installed capacity of 25 fixed and mobile units in the DMQ, properly adapted, would have been crucial for testing, case and contact tracing, provision of information, and social protection measures.

## Conclusions

The growing prevalence of NCDs, with the resulting morbidity and mortality rates in the DMQ, requires initiatives and innovations aimed at NCD prevention. These should be institutionalized to ensure their continuity. This is especially challenging during changes of government; indeed, the SAP program implemented between April 2015 and June 2019 was limited in scope by the new municipal government.

In this context, it is important to reflect on how similar initiatives could be sustained in the future. To this end, similar regional initiatives may consider the following lessons learned:

• Include a research component from the start, documenting evidence on the intervention’s outcomes and challenges in order to make changes and improvements and generate knowledge.

• Implement strategies for monitoring by program users to improve adherence to interventions and adoption of the program.

• Besides the legitimacy that governments are able to give their initiatives, when communicating about services, especially social services and their outcomes, it is important to stress technical evidence that helps ensure sustainability.

• The continuity of a program involves ensuring the loyalty of its human talent through professional development strategies, including job stability mechanisms linked to performance evaluations.

• Improve ways to involve and serve rural communities so that they will use screening and nutritional counseling services.

• Ensure coordination with other health institutions, especially the national Ministry of Public Health and service networks.

The data on costs and coverage, as well as the responses of community providers and leaders, demonstrate that continuation of the Salud al Paso program, with appropriate adjustments, could have been beneficial to the population.

# Financing.

The study was financed by the Pan American Health Organization, which did not participate in the study design, data collection and analysis, the decision to publish this study, or preparation of the manuscript.

# Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or PAHO.

• Authors’ contributions.
IT and FS designed the original study, collected, analyzed, and interpreted data, and wrote and published the manuscript. DLC contributed to the analysis and interpretation of data, and the drafting and editing of the manuscript. All authors reviewed and approved the final version.
• Conflict of interests.
FS served as technical advisor to the Health Secretariat of the Municipality of Quito, with no direct links to the management of the Salud al Paso program. IT and DLC declare no conflict of interests.

The study received technical support from the National Public Health Institute of Mexico.

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# Publication Dates

• Publication in this collection
28 Apr 2021
• Date of issue
2021