Training opportunities for noncommunicable diseases research in Latin America: A scoping review

ABSTRACT Objective. To identify gaps in postgraduate training and options for building capacity in noncommunicable disease (NCDs) research in Latin America. Methods. This was a scoping review of postgraduate opportunities in NCDs at top universities in Latin America and of training grants awarded by international funding bodies. Three global university rankings were considered—the QS Ranking, the Shanghai Ranking, and the Times Ranking. Latin American universities appearing in at least two of these were selected. University websites were searched for current graduate programs in biostatistics, epidemiology, global health, health economics, and public health. Information was extracted, summarized, and evaluated to identify any programs focused on NCDs. In addition, seven international funding bodies’ websites were searched for training grants. Results. In all, 33 universities offering 72 postgraduate programs met the inclusion criteria. One of these programs was exclusively devoted to NCD, and 12 offered NCDs as a dissertation research topic. Only two training grants were awarded to a Latin American institution for NCD capacity building. There are few NCD research training programs in Latin America and only one program exclusively focused on NCDs. Conclusion. There seem to be few NCD-specific research training programs in Latin America. Leveraging existing programs and expanding those with a focus on NCDs could help enhance NCD research capacity in the region. These initiatives should be supported by international funding agencies through more funding opportunities.

to develop the skills necessary for conducting high-quality research. A successful example is a clinical research and capacity building program for NCDs prevention and control held in India since 2001; it has now trained more than 2 000 health professionals who have been granted over 30 projects by various international institutions (2). Another successful program is the International Tobacco and Health Research and Capacity Building Program, which aims to promote research and train professionals to reduce tobacco burden. Started in 2002, it has now trained more than 3 000 professionals in low-and middle-income countries around the world and facilitated international collaborations to develop their research capacity (3).
Only a few education institutions in Latin America focus on research in NCDs (4,5) and their training capacity does not meet current needs. Furthermore, in countries where the available training opportunities may be sufficient, they fall short on the regional level where comprehensive research training is needed to implement evidence-based interventions.
This scoping review sought to identify training gaps and options for building NCD research capacity in Latin America by summarizing and synthesizing the currently-available training programs and grants in the region.

Study design
This was a scoping review of training opportunities in NCD research at top universities in Latin America and training grants awarded by international funding bodies. Training opportunities were defined as formal academic programs in NCD related areas, i.e., biostatistics, epidemiology, global health, health economics, and public health.
Scoping review methodology was chosen because it "comprehensively summarizes and synthesizes evidence with the aim of informing practice, programs, and policy, providing direction to future research priorities" (6). In this context, the study sought to identify and describe training opportunities that could inform new programs and educational policies, thereby potentially building capacity in the region. By doing so, two goals were attained: (i) an estimate of the number of academic institutions offering graduate research programs with a concentration in NCD and an understanding of their key characteristics; and (ii) an estimate of the number of research training grants awarded by international funding bodies through May 2018.

Data sources
Available postgraduate programs. Three university rankings, the QS ranking (7), the Shanghai ranking (8), and the Times ranking (9), were chosen for determining the top universities in Latin America in 2017. Those universities that were listed within the top 500 universities in the world in at least two of the three rankings, regardless of their ranking position, were selected for inclusion. Two independent researchers evaluated each institution's official website, identifying all postgraduate (master's and doctoral) programs on biostatistics, epidemiology, global health, health economics, and public health. An information extraction form was developed and used to summarize key features (see Variables section) of each program (e.g., length of program, core courses, costs/funding). When these details were unavailable or unclear, the researchers emailed the contact person to request the information. The search and email inquiries were conducted in February -May 2018.
Research training grants. Relevant grant opportunities offered by key global funding agencies were reviewed. These key agencies were: Grand Challenges Canada (10), International Development Research Centre from Canada (IDRC; 11), the United States National Institutes of Health (NIH; 12), Swiss National Science Foundation (13), Swiss Agency for Development and Cooperation (14), the EU Framework Programme for Research and Innovation (15), and the Wellcome Trust (16

Variables
The characteristics examined for each program were: (i) focus on NCD (yes/no if stated in the aim, introduction, or presentation of the program); (ii) length of the program (years proposed for program completion/degree); (iii) modality (face-to-face or online); (iv) frequency (days per week of required class/online attendance); (v) prerequisites and requirements for admission and completion; and (iv) total cost of the program (in US dollar except public universities in Brazil which are free of charge by law). Each program's objectives and curriculum were also retrieved.

Statistical analysis
All the aforementioned variables and data were collected using a Microsoft Excel™ (Microsoft Corp., Redmond, Washington, United States) spreadsheet. Statistical analysis was performed using Excel™ software. The unit of analysis was one program or training grant awarded. Absolute and relative frequencies were used to describe categorical variables, while central tendency and dispersion measures were used for quantitative variables

Ethics
This study did not require IRB approval as human subjects did not participate.

Available postgraduate programs
Regarding the QS ranking, of the top 500 universities for medicine, 35 were in Latin America. With respect to the Shanghai ranking, of the top 500 universities for public health, 20 were in Latin America. Finally, of the top 596 universities for medicine or dentistry in the Times ranking, 59 were in Latin America. A total of 33 universities were included in at least two of the three rankings (Table 1) and were located in seven countries: Brazil (n = 17), Chile (n = 5), Colombia (n = 5), Mexico (n = 3), Argentina (n = 1), Peru (n = 1), and Venezuela (n = 1). A total of 72 biostatistics, epidemiology, global health, health economics, and public health postgraduate programs were found to be offered by the universities for which information was accessible (Figure 1).

Characteristics of the postgraduate programs
One-half of the programs found were located in Brazil. Most of the programs found were MPH (36.1%) or PhD (36.1%); the remainder were MSc (27.8%). All of the programs were face-toface. Most of the master's programs had a duration of 2 years (40/43), ranging from 1 -3 years with some programs allowing up to 4 years to graduate. Most of the doctoral programs had a duration of 4 years (21/25), ranging from 3 -5 years, with some allowing up to 8 years to graduate (Tables 2 and 3).
Only 61 postgraduate programs reported their requisites for graduation. All required a dissertation, with one having an option to complete an unspecified equivalent, and two requiring a dissertation plus practice as a teaching assistant.
Schedules varied widely across programs. Almost one-third required 2 -5 days of classes per week (16/59). Others permitted students to design their own schedules (37/59). Only six programs required full time or 6 days per week.
Of the 72 programs, only one was devoted to health economics and one to NCD-these programs explicitly stated that NCD was their principle topic. The latter was a clinical research program focused on hypertension. In addition, 12 of 72 had NCDs as a suggested research topic. These 12 programs had an institute or a senior researcher in charge of guiding students interested in NCD research.

Research training grants
There were no past funding opportunities devoted to developing NCD training programs in Latin America among    A total of 12 active International Research Training Planning Grants (D71) were available using the RePORT from NIH, of which 5 focused on NCDs (23)(24)(25) and the remaining on infectious diseases. Of the 5 NCD-oriented programs, only 1 was based in Peru. There were also 159 International Research Training Grants (D43) found using RePORT. Of these, 34 were devoted to NCDs; the remainder focused on infectious diseases or injuries. Of the grants dedicated to either a specific NCD or NCDs in general, two were awarded in Latin America: the "Interdisciplinary Cerebrovascular Diseases Training Program in South America," from the University of Washington (Seattle, Washington, United States), Universidad Peruana Cayetano Heredia (Lima, Peru), and the Instituto Nacional de Ciencias Neurológicas del Perú (Lima, Peru) (5); and "Promoting Capacity Building in Chronic Diseases Research in South America" from Instituto de Efectividad Clínica y Sanitaria (Buenos Aires, Argentina) and Harvard University (Cambridge, Massachusetts, United States) (4).

Main results
We found a total of 72 postgraduate training programs on biostatistics, epidemiology, global health, health economics, or public health offered by 33 universities in Latin America. The sole program devoted to NCDs was a master's degree on clinical epidemiology offered in Venezuela. We also found 12 programs with NCDs as the research area-seven PhDs and five master's-most of which were offered by universities in Brazil. We found only two training grants dedicated to NCDs, of which only one was a training planning grant; both were funded by the Fogarty International Center at the NIH. The limited opportunities for postgraduate training in NCD research signal the need to reshape, enhance, and update existing programs and develop new ones to address the shortage.

Opportunities and challenges of available programs
We found only one available postgraduate program exclusively devoted to a noncommunicable disease, hypertension. It was based in Venezuela. However, there were several biostatistics, epidemiology, and public health programs that could be complemented with NCD research training, especially where there was an NCD senior researcher or research group in charge. Students would be able to develop methodological skills and possibly pursue a career in NCDs, though a research career would be better built on a formal training program, MSc or PhD, specifically focused on NCDs. Such formal NCD programs would improve the probability of adequate capacity-building and ensure a sufficient workforce of professionals dedicated to NCD research in Latin America.
Supporting early career investigators has been proposed as an action to move forward on the fight against NCDs. Creating an adequate training environment can be challenging because there is a dearth of researchers who can dedicate time to training, teaching, and mentoring activities (26,27). This is indeed an important barrier to improved capacity building, though grants for these pursuits could encourage researchers to allocate time to training, teaching, and mentoring.
Regarding funding opportunities, to the best of our knowledge, only the Fogarty International Center at NIH offered training grants. However, most of the awarded proposals were oriented toward infectious diseases. This does not necessarily mean that applications were only aimed at communicable diseases. However, communicable diseases seem to make a stronger case for research funding than do NCDs, although the latter are responsible for more deaths worldwide. Or it could be that certain conditions have prompted a sharp rise in training and research funding for communicable disease; for example, the impact of climate on vector distribution. Such aspects need to be identified for NCD in Latin America; for example, high attitude locations could offer an interesting scenario for the study of NCDs under the physiological challenges of hypoxia (28).
All in all, training grants offered by funding institutions, such as Fogarty International Center and the Wellcome Trust, provide support to researchers for advancing in their careers (29,30) and capabilities. And it is time for Latin America to expand and train the next cadre of NCDs-specific researchers. The robust methodology of this scoping review allowed us to draw convincing conclusions about the lack of training programs in Latin America, especially for NCDs research.
Consequently, we implore research groups and universities in Latin America to apply to funding calls on training activities, and focus these on NCDs. Not long ago, high-quality training on infectious diseases was urgently needed. Response efforts led to several renowned institutions dedicated to research on infectious diseases-the Instituto Nacional de Medicina Tropical (31) in Argentina and the Instituto de Medicina Tropical Alexander von Humboldt in Peru (32) are two such examples. Also, training programs were developed, such as the Gorgas Program in Peru and Panama (33, 34). Now, the same efforts are needed for NCDs.

Limitations
As a scoping review, the study was dependent on response information being available for each review question (35). Thus, choosing programs offered only at universities listed on two or more of the chosen rankings could have introduced selection bias. That said, we believe that a junior researcher interested in pursuing a master's or PhD program would likely look at top universities, i.e., those included in these rankings. Still, some universities lacked or had outdated information on their websites. When contacted, these institutions explained that their programs were not currently recruiting; therefore, it is possible that these were missed. However, even if all universities with missing information had an NCD-oriented training program, there would still be few, upholding the overall study findings and concerns.
Regarding training grants, most of the funding agencies did not have available records of past grants from funding calls. However, we minimized the chance of missing any record by performing a structured search on each agency's website. It is unlikely that any training grant was missed because these agencies mostly fund research activities, with or without some training component, rather than training projects exclusively.
Regarding the Swiss Confederation's bilateral programs with Brazil (15) and Argentina (16), specific details for each program were not accessible, so these results could not be generalized for this agency.

Conclusions
There are few NCD-specific research training programs in Latin America, and only one exclusively focused on NCDs. Masters and PhD program directors could prioritize NCDs as a research theme within existing biostatistics, epidemiology, global health, health economics, and public health programs. This would allow newer researchers to work on NCD-related projects and develop skills and expertise on a specific NCD-related topic.
International funding agencies should respond to the increasing burden of NCDs in Latin America and provide more funding opportunities to implement NCDs training programs.
In spite of the scarce training opportunities found, we believe that leveraging from and expanding upon existing programs with an NCD focus within a larger theme could be valuable to enhanced NCD research capacity in the region. These initiatives should be supported by international funding agencies through more grant opportunities.