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Background In Mexico, patients with hematologic malignancies (HMs) are characterized by being at high risk and advanced stages at diagnosis and by having a low cure rate; yet information on their experiences with health care and health-related quality of life (HRQL) is scarce. We aimed to evaluate experiences with health care and HRQL of patients with HMs and the association between these patient-reported measures. Methods We conducted a cross-sectional survey in two public oncology hospitals in Mexico City. The study included outpatient cancer patients aged ≥18 years with a diagnosis of leukemia, lymphoma, or multiple myeloma. We used a patient-centered quality of cancer care questionnaire to assess patient experiences with receiving 1) timely care; 2) clear information; 3) information for treatment decision-making; 4) care to address biopsychosocial needs; and 5) respectful and coordinated care. We applied the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) to measure HRQL. We performed a multiple linear regression to evaluate the association between patient-reported experiences (independent variables) and the QLQ-C30 summary score (dependent variable). Results Of the 515 participating HM patients, 46.6% had lymphoma, 34% leukemia, and 19.4% multiple myeloma; 70.9% were at advanced stages or at high risk. Additionally, 15.1% had anxiety and 12.8% had depression. Over one third (35.9%) reported receiving clear information, 28.5% timely care, 20.6% information for treatment decision-making, 23.7% care that addressed their biopsychosocial needs, and 31% respectful and coordinated care. The mean QLQ-C30 summary score was 71.9 points. Timely care, clear information, and care that addresses biopsychosocial needs were associated with higher HRQL. Conclusions Health care services for HM patients at public oncology hospitals in Mexico need improvement. Notably, providing timely care, clear information, and care that addresses patients’ biopsychosocial needs can increase the likelihood of better HRQL. Health care providers should measure and improve the experiences of HM patients with health care.

Universal health coverage is a national priority in Mexico, with active efforts to expand public healthcare system access, increase financial protection and improve quality of care. We estimated effective coverage of multiple conditions within the Mexican Institute of Social Security (IMSS), which covers 62 million individuals. We identified routinely collected performance indicators at IMSS from 2016 related to use and quality of care for conditions avertable with high-quality healthcare; where candidate indicators were available, we quantified need for service from a population-representative survey and calculated effective coverage as proportion of individuals in need who experience potential health gains. We assessed subnational inequality across 32 states, and we weighted conditions by relative contribution to national disease burden to estimate composite effective coverage. Conditions accounting for 51% of healthcare-avertable disability-adjusted life years lost in Mexico could be assessed: antenatal care, delivery care, newborn care, childhood diarrhoea, cardiovascular disease and diabetes. Estimated effective coverage ranged from a low of 27% for childhood diarrhoea to a high of 74% for newborn care. Substantial inequality in effective coverage existed between states, particularly for maternal and child conditions. Overall effective coverage of these six conditions in IMSS was 49% in 2016. Gaps in use and quality of care must be addressed to ensure good health for all in Mexico. Despite extensive monitoring of health status and services in Mexico, currently available data are inadequate to the task of fully and routinely assessing health system effective coverage. Leaders at IMSS and similar healthcare institutions must be more purposeful in planning the assessment of population need, utilization of care and quality impacts of care to enable linkage of these data and disaggregation by location or population sub-group. Only then can complex health systems be fairly and fully evaluated.

Objective To evaluate factors associated with COVID-19 preventive health behaviors among adults in Mexico City and the State of Mexico. Methods and findings We conducted a cross-sectional survey from June to October 2020 through a structured, internet-based questionnaire in a non-probabilistic sample of adults >18 years living in Mexico City and the State of Mexico. The independent variables included sociodemographic and clinical factors; health literacy; access to COVID-19 information; and perception of COVID-19 risk and of preventive measures’ effectiveness. The dependent variable was COVID-19 preventive health behaviors, defined as the number of preventive actions adopted by participants. The data were analyzed through multivariate negative binomial regression analysis. The survey was completed by 1,030 participants. Most participants were women (70.7%), had a high school or above level of education (98.8%), and had adequate health literacy and access to COVID-19 information. Only 18% perceived having a high susceptibility to COVID-19, though 83.8% recognized the disease’s severity and 87.1% the effectiveness of preventive measures. The median number of COVID-19 preventive actions was 13.5 (range 0–19). The factors associated with preventive health behavior were being female, of older age, a professional worker, a homemaker, or a retiree; engaging in regular physical exercise; having high health literacy and access to COVID-19 information sources; and perceiving COVID-19 as severe and preventive measures as effective. Conclusion People with high education and internet access in Mexico City and the State of Mexico reported significant engagement in COVID-19 preventive actions during the first wave of the COVID-19 pandemic.

Purpose To assess the supportive care needs (SC-needs), quality of patient-centered care (PCC), and factors associated with increased SC-needs of patients with lung cancer (LC) in Mexico. Methods We conducted a cross-sectional survey in the main oncology hospital of the Mexican Institute of Social Security in Mexico City. The study included LC ambulatory patients aged ≥18 years with at least one hospitalization before the survey, ≤five years since diagnosis, and without memory loss. Participants answered SC-needs and quality of PCC questionnaires. We performed a multiple negative binomial regression analysis to evaluate the factors associated with an increased number of SC-needs. Results One hundred twenty-eight LC patients participated. Most participants had adenocarcinoma (61.7%) and were at an advanced disease stage (92.1%). In the month preceding the survey, 3.9% had undergone surgery and 78.9% had been receiving chemotherapy and/or radiotherapy; 28.9% had symptoms of depression and 21.9% had anxiety. All patients reported one or more SC-needs—predominantly physical, daily living, information, and psychological needs. The significant gaps in PCC-quality were in the domains of care that addressed biopsychosocial needs and information for treatment decision-making. Factors that decreased the probability of SC-needs were respectful and coordinated care, high-school education, and older age. The factors increasing the likelihood of SCneeds were the type of LC (adenocarcinoma, mesenchymal tumors), chemotherapy and/or radiotherapy, and anxiety. Conclusion PCC improvement initiatives to address SC-needs of LC patients should be prioritized and focus on: (1) information on physical suffering relief and treatment; (2) psychological support; and (3) SC-needs monitoring.

ObjectivesTo develop and validate a Patient-Centred Quality of Cancer Care Questionnaire in Spanish (PCQCCQ-S) appropriate to the Mexican context.DesignPsychometric validation of a questionnaire.SettingTwo public oncology hospitals in Mexico City.Participants1809 patients with cancer aged ≥18 years.Source of informationCross-sectional survey.MethodsThe validation procedures comprised (1) content validity through a group of experts and patients; (2) item reduction and evaluation of the factor structure, through an exploratory factor analysis based on the polychoric correlation matrix; (3) internal consistency using Cronbach’s alpha; (4) convergent validity between the PCQCCQ-S and supportive care needs scale; (5) correlation analysis between the PCQCCQ-S and quality of life scale by calculating Spearman’s rank-correlation coefficient; and (6) differentiation by ‘known groups’ through the Wilcoxon rank-sum test.ResultsThe PCQCCQ-S has 30 items with the following five factors accounting for 96.5% of the total variance: (1) timely care; (2) clarity of the information; (3) information for treatment decision-making; (4) activities to address biopsychosocial needs; and (5) respectful and coordinated care. Cronbach’s alpha values ranged from 0.73 to 0.90 among the factors. PCQCCQ-S has moderate convergent validity with supportive care needs scale, revealing that higher quality is correlated with lower patient needs. PCQCCQ-S has acceptable ability to differentiate by ‘known groups’, showing that older patients and those with low levels of education perceived lower total quality of care as compared with their counterparts.ConclusionPCQCCQ-S has acceptable psychometric properties and can be used to measure quality of patient-centred cancer care in Mexico and serve as a reference to develop PCQCCQ-S in other Spanish-speaking countries.

ObjectiveThis study aimed to investigate factors associated with patient experience with primary care in a large public health system in Mexico and determine the amount of variability in experience attributable to facility-level and state-level factors.MethodsWe analysed cross-sectional 2016 national satisfaction survey data from the Mexican Social Security Institute (IMSS). Patient-level data were merged with facility-level data and information on poverty by state. We assessed general contextual effects and examined the relationship of patient, facility and state factors with four patient experience measures using random effects logistic regression.Results25 745 patients’ responses from 319 facilities were analysed. The majority experienced good communication (78%), the opportunity to share health concerns (91%) and resolution of doubts (85%). 29% of visits were rated as excellent. Differences between facilities and states accounted for up to 12% and 6% of the variation in patient experience, respectively. Inclusion of facility-level contextual effects improved model predictions by 8%–12%; models with facility random effects and individual covariates correctly predicted 64%–71% of individual outcomes. In adjusted models, larger patient population was correlated with worse reported communication, less opportunity to share concerns and less resolution of doubts. Men reported more positive communication; older individuals reported more positive communication and experiences overall, but less opportunity to share concerns; and more educated individuals were less likely to report positive communication but more likely to report resolution of doubts and overall positive experiences. Preventive care visits were rated higher than curative visits for resolution of doubts, but lower for opportunity to share concerns, and specific conditions were associated with better or worse reported experiences in some cases.ConclusionQuality improvement efforts at IMSS facilities might bolster individual experiences with primary care, given that up to 12% of the variation in experience was attributable to facility-level differences. The relationship between individual characteristics and experience ratings reinforces the importance of patients’ expectations of care and the potential for differential treatment by providers to impact experience.

Background and Aims There is a growing need for evidence based answers to multimorbidity, especially in primary care settings. The aim was estimate the prevalence and patterns of multimorbidity in a Mexican population of public health institution users ≥60 years old. Methods Observational and multicenter study was carried out in four family medicine units in Mexico City; included older men and women who attended at least one consultation with their family doctor during 2013. The most common diseases were grouped into 11 domains. The observed and expected rates, as well as the prevalence ratios, were calculated for the pairs of the more common domains. Logistic regression models were developed to estimate the magnitude of the association. Cluster and principal components analyses were performed to identify multimorbidity patterns. Results Half of all of the patients who were ≥60 years old and treated by a family doctor had multimorbidity. The most common disease domains were hypertensive and endocrine diseases. The highest prevalence of multimorbidity concerned the renal domain. The domain pairs with the strongest associations were endocrine + renal and hypertension + cardiac. The cluster and principal components analyses revealed five consistent patterns of multimorbidity. Conclusions The domains grouped into five patterns could establish the framework for developing treatment guides, deepen the knowledge of multimorbidity, develop strategies to prevent it, decrease its burden, and align health services to the care needs that doctors face in daily practice.

Background The study aimed to assess the performance of a multidisciplinary-team diabetes care program called DIABETIMSS on glycemic control of type 2 diabetes (T2D) patients, by using available observational patient data and machine-learning-based targeted learning methods. Methods We analyzed electronic health records and laboratory databases from the year 2012 to 2016 of T2D patients from six family medicine clinics (FMCs) delivering the DIABETIMSS program, and five FMCs providing routine care. All FMCs belong to the Mexican Institute of Social Security and are in Mexico City and the State of Mexico. The primary outcome was glycemic control. The study covariates included: patient sex, age, anthropometric data, history of glycemic control, diabetic complications and comorbidity. We measured the effects of DIABETIMSS program through 1) simple unadjusted mean differences; 2) adjusted via standard logistic regression and 3) adjusted via targeted machine learning. We treated the data as a serial cross-sectional study, conducted a standard principal components analysis to explore the distribution of covariates among clinics, and performed regression tree on data transformed to use the prediction model to identify patient sub-groups in whom the program was most successful. To explore the robustness of the machine learning approaches, we conducted a set of simulations and the sensitivity analysis with process-of-care indicators as possible confounders. Results The study included 78,894 T2D patients, from which 37,767patients received care through DIABETIMSS. The impact of DIABETIMSS ranged, among clinics, from 2 to 8% improvement in glycemic control, with an overall (pooled) estimate of 5% improvement. T2D patients with fewer complications have more significant benefit from DIABETIMSS than those with more complications. At the FMC’s delivering the conventional model the predicted impacts were like what was observed empirically in the DIABETIMSS clinics. The sensitivity analysis did not change the overall estimate average across clinics. Conclusions DIABETIMSS program had a small, but significant increase in glycemic control. The use of machine learning methods yields both population-level effects and pinpoints the sub-groups of patients the program benefits the most. These methods exploit the potential of routine observational patient data within complex healthcare systems to inform decision-makers.

espanolAntecedentes: en Mexico, se desconoce la calidad de la atencion medica para los pacientes con el virus de la inmunodeficiencia humana (VIH). Los objetivos del estudio fueron desarrollar indicadores de calidad de la atencion (QoC) para la atencion ambulatoria de pacientes con VIH, evaluar la calidad de los procesos de atencion (QPC) y los resultados, y analizar la asociacion entre la QPC y la supresion viral entre los pacientes con VIH. Metodos: El estudio utilizo un enfoque de metodos mixtos: (1) Desarrollo de indicadores de QoC a traves del metodo RAND / UCLA; (2) estudio transversal de evaluacion de QoC; y (3) regresiones multiples de Poisson para medir la asociacion entre el QPC y la supresion viral. El estudio incluyo a 439 pacientes con VIH, ≥ 19 anos de edad, con al menos una consulta ambulatoria durante 2017 en un hospital publico en el Estado de Mexico. Resultados: desarrollamos 21 indicadores de QoC para evaluar la atencion del VIH. Segun estos indicadores, las brechas de QoC que surgieron estaban relacionadas con la historia clinica (el 24% de los registros de pacientes incluian informacion de historia sexual), la evaluacion de cumplimiento de rutina (ningun registro demostro el registro regular de la adherencia al tratamiento antirretroviral) y la deteccion y derivacion (50% fueron examinado para detectar depresion y 42% para tuberculosis; 1.2% de los pacientes con indice de masa corporal anormal fueron remitidos a un dietista). En promedio, los pacientes con VIH recibieron el 63% de los QPC recomendados; El 77.7% logro la supresion viral. Recibir mas del 75% de los QPC recomendados se asocio con una mayor probabilidad de supresion viral (razon de prevalencia ajustada 1.13, intervalo de confianza del 95% 1.03-1.24). Conclusiones: La evaluacion de la QoC para pacientes con VIH es esencial para identificar y abordar las brechas en la calidad de la atencion medica para aumentar la probabilidad de supresion viral. EnglishBackground: In Mexico, the quality of health care for human immunodeficiency virus (HIV) patients is unknown. The study objectives were to develop quality of care (QoC) indicators for outpatient care of HIV patients, evaluate the quality of the processes of care (QPC) and outcomes, and analyze the association between the QPC and viral suppression among HIV patients. Methods: The study used a mixed-methods approach: (1) Development of QoC indicators through RAND/UCLA method; (2) cross-sectional study of QoC evaluation; and (3) multiple Poisson regressions to measure the association between the QPC and viral suppression. The study included 439 HIV patients, ≥ 19 years of age, with at least one outpatient consultation during 2017 at a public hospital in the State of Mexico. Results: We developed 21 QoC indicators to evaluate HIV care. Based on these in- dicators, the QoC gaps that emerged were related to clinical history (24% of patient records included sexual history information), routine adherence assessment (no records demonstrated regular recording of antiretroviral treatment adherence), and screen- ing and referral (50% were screened for depression, and 42% for tuberculosis; 1.2% of patients with abnormal body mass index were referred to a dietitian). On average, HIV patients received 63% of recommended QPC; 77.7% achieved viral suppression. Receiving over 75% of recommended QPC was associated with a higher probability of viral suppression (adjusted prevalence ratio 1.13, 95% confidence interval 1.03-1.24). Conclusions: Evaluation of the QoC for HIV patients is essential to identify and address gaps in health-care quality to increase the probability of viral suppression. (REV INVEST CLIN. 2019;71:330-8)

This study evaluates the health literacy of people with type 2 diabetes and its association with health outcomes. We conducted a cross-sectional survey in two family medicine clinics of the Mexican Institute of Social Security that included 778 diabetic patients19 years of age. The Spanish version of the European Health Literacy questionnaire served to measure health literacy. Multiple logistic regressions were performed to determine the association between the independent variable (health literacy) and dependent variables (good self-rated health, glycemic control, and diabetes-related hospitalizations) after controlling for conceptually relevant patient's characteristics. Only 17.6% of patients had adequate health literacy; while, the remaining percentage showed inadequate (23%), or problematic (59.4%) health literacy. After adjusting for the patients' characteristics, those with adequate health literacy had 4.66 (95%CI: 2.26-9.61) times the odds of good self-rated health compared to those with inadequate literacy. Patients with adequate health literacy had 0.65 (95%CI: 0.49-0.86) times the odds of hospitalization due to diabetes compared to those with inadequate literacy. Compared to inadequate health literacy, problematic literacy was associated with increased odds of glycemic control. In conclusion, healthcare providers should actively address the health literacy needs of patients to increase good self-rated health, glucose control and reduce hospitalizations.

To analyze the coverage of lung cancer in Mexico and offer recommendations in this regard.By means of the conformation of a multidisciplinary group, we analyze the burden of the disease relative to the lung cancer and the access to the medical treatment offered by the different public health subsystems in Mexico.Important inequalities in lung cancer care are documented among the different public health subsystems. Our data suggest differential access and coverage to both traditional treatments and existing therapeutic innovations and differences in the capacity of health service providers to guarantee the right to health protection without distinction.Recommendations are made on the need to improve actions for tobacco control, early diagnosis for lung cancer and inclusion of innovative therapies and homologation among different public health service providers through financing via tobacco taxes.Analizar la cobertura en salud de cáncer pulmonar en México y ofrecer recomendaciones al respecto.Mediante la conformación de un grupo multidisciplinario se analizó la carga de la enfermedad relativa al cáncer de pulmón y el acceso al tratamiento médico que ofrecen los diferentes subsistemas de salud en México.Se documentan desigualdades importantes en la atención del cáncer de pulmón entre los distintos subsistemas de salud que sugieren acceso y cobertura en salud variable, tanto a los tratamientos tradicionales como a las innovaciones terapéuticas existentes, y diferencias en la capacidad de los prestadores de servicios de salud para garantizar el derecho a la protección de la salud sin distinciones.Se hacen recomendaciones sobre la necesidad de mejorar las acciones para el control del tabaco, el diagnóstico temprano y la inclusión de terapias innovadoras y la homologación entre los diferentes prestadores públicos de servicios de salud a través del financiamiento con la recaudación de impuestos al tabaco.

Background To describe the demographic and clinical characteristics of Type 1 diabetes (T1D) patients affiliated with the Mexican Institute of Social Security (IMSS) and ascertain the socio-demographic and clinical risk factors associated with emergency room (ER) visits and diabetes-related hospitalizations. Methods We conducted secondary data analysis of a cross-sectional study. The study included T1D patients 18 years of age and older who in 2016 attended follow-up visits at the endocrinology department of two IMSS tertiary care hospitals in Mexico City. The study variables included demographics, acute and chronic complications, and healthcare services utilization. Multiple Poisson and negative binomial regressions served to determine the association between the study covariates and the dependent variables: ER visits and diabetes-related hospitalizations. Results The study included 192 patients, of which 29.2% were men; average age was 32.3 years, with only 13.6% controlled (glycosylated hemoglobin (HbA1C) 10 years and HbA1c > 9.0% were additional risk factors for hospitalization. Conclusion The poor clinical conditions of T1D patients contribute to explain the escalating demand for health services for diabetes patients at the IMSS. The identification of risk factors enables focalizing interventions to improve the health outcomes of T1D patients and reduce the proportion of ER visits and hospital admissions.

The purpose of this study is to validate the Mexican version of the Short-Form Supportive Care Needs survey (SCNS-SFM). A cross-sectional survey was conducted from June to December 2013 at the Oncology Hospital of the Mexican Institute of Social Security in Mexico City. The study included 825 subsequent cancer patients >20 years of age with all forms of solid cancer. Patients had prior surgical removal of histologically confirmed cancer and attended outpatient consultations. Validation of SCNS-SFM included the following: (1) content validity through a group of experts; (2) construct validity through an exploratory factor analysis based on the polychoric correlation matrix; (3) internal consistency using Cronbach’s alpha; (4) convergent validity between SCNS-SFM and quality of life, anxiety, and depression scales by calculating Pearson’s correlation coefficient; (5) discriminative validity through analysis of MANOVAs; and (6) test–retest reliability using intraclass correlation coefficient calculations. SCNS-SFM has 33 items with five factors accounting for 59 % of total variance. Cronbach’s alpha values ranged from 0.78 to 0.90 among factors. SCNS-SFM has good convergent validity compared with quality of life and depression and anxiety scales and good discriminative validity, revealing great information, psychological support, and physical daily living needs for women, patients

Background Patients with cancer have supportive care needs. Studies that analyze the relationship between supportive care needs and health-related quality of life (HRQoL) are scarce. Cultural differences in supportive care needs and perceived QoL are also worth analyzing. Objective The aim of this study was to assess the association between supportive care needs and HRQoL of Mexican adults given a diagnosis of solid cancers. Methods We performed a secondary data analysis of a cross-sectional survey of 825 adult patients with cancer treated at the Oncology Hospital of the Mexican Institute of Social Security. The QLQ-30 from the European Organization for Research and Treatment of Cancer served to measure HRQoL, and the Supportive Care Needs Questionnaire was used to ascertain the needs. The analysis included multiple linear regression models for each HRQoL domain controlled for demographic, clinical, and social support covariates. Results There was an association between psychological needs with low scores in the HRQoL domains of global health, emotional functioning, and increased fatigue. Physical and daily living needs were associated with most HRQoL domains except the emotional domain. Patient care needs were related to low scores in the emotional and social functioning domains. Health systems and information needs were associated with low scores on cognitive functioning. Conclusions Physical, psychological, patient care, and informational needs were associated with decreased HRQoL of Mexican patients with cancer. Implications for practice Healthcare providers, including nurses, are encouraged to perform routine, comprehensive evaluations of the supportive care needs and HRQoL of patients with solid cancers to respond in a timely manner to their needs.

Objective. To assess the association between quality of care and health-related quality of life among type 2 diabetes patients. Design. A cross-sectional study assessing the association between quality of care and quality of life using multiple linear regression analysis. Setting. Family medicine clinics (FMC) (n= 39) of the Mexican Institute of Social Security (IMSS) in Mexico City. Participants. Type 2 diabetes patients (n= 312), older than 19 years. Main Outcome Measure(s). Health-related quality of life was measured using the MOS Short-Form-12 (SF-12); quality of healthcare was measured as the percentage of recommended care received under each of four domains: early detection of diabetes complications, non-pharmacological treatment, pharmacological treatment and health outcomes. Results. The average quality of life score was 41.4 points on the physical component and 47.9 points on the mental component. Assessment of the quality of care revealed deficiencies. The average percentages of recommended care received were 21.9 for health outcomes and 56.6 for early detection of diabetes complications and pharmacological treatment; for every 10 percent additional points on the pharmacological treatment component, quality of life improved by 0.4 points on the physical component (coefficient 0.04, 95% confidence intervals 0.01–0.07). Conclusions. There was a positive association between the quality of pharmacological care and the physical component of quality of life. The quality of healthcare for type 2 diabetes patients in FMC of the IMSS in Mexico City is not optimal.

Objective. To adapt and validate in Spanish of Mexico scales to measure self-efficacy (SES) and empowerment for self-care (ES) among climacteric women. Materials and methods. The study was conducted from February to July 2011 in two family medicine clinics in Mexico City. The adaptation phase was done through testing for language comprehension. To validate the scales we used the principal Axis factoring analysis with oblique rotation technique and estimation of Cronbach’s alpha (CA). Results. Three hundred eighty women aged 45-59 years participated in the study. SES had 16 items with four factors: participation in the doctor-patient relationship; in the study control of mental health and sexual changes; risk of dying from cancer, and other health risks that explained 39.8% of the variability, CA= 0.84. ES had eight items with one factor explaining 47.1% variability; CA= 0.83. Conclusion. Both scales had acceptable psychometric properties and are suitable for interventions aimed at improving self-care of climacteric women.

Research on factors associated with poor adherence to self-care focuses primarily on psychiatric emotional disorders such as depression and anxiety, whereas non-psychiatric chronic-disease-related emotional distress has received little attention in hypertensive patients. The objective of this study was to evaluate the association of hypertension-related distress with the lack of self-care including low adherence to pharmacological treatment, lack of regular physical activity, low intake of fruits and vegetables and frequent intake of high-salt foods. A cross-sectional survey was conducted in 2014 in two family medical units affiliated with the Mexican Institute of Social Security. The study included 487 hypertensive patients >19 years of age. The conceptual framework for the study was based on the Health Promotion Model. The analysis included multiple Poisson regression models. We found that 21.1% of participants had hypertension-related distress. Low adherence to pharmacological treatment was identified in 45.8% of patients, whereas 46.8% lacked regular physical activity, 30.8% reported a low consumption of fruits and vegetables, and 54.6% frequently consumed foods high in salt content. Hypertension-related distress was associated with lack of regular physical activity and low intake of fruits and vegetables. These findings highlight the importance of addressing distress in order to improve self-care of hypertensive patients.

Background To analyze the factors associated with regular physical exercise and routine consumption of fruits and vegetables, and both healthy behaviors among Mexican older adults. Methods We conducted a secondary data analysis of the baseline data (2014) of the Study on Obesity, Sarcopenia and Fragility in older adults affiliated with the Mexican Institute of Social Security. The study included 948 adults who were ≥60 years of age. Multiple Poisson regression was performed. Results Routine consumption of fruits and vegetables was reported by 53.8 % of older adults, 42.7 % reported engaging in regular physical exercise and 23.1 % reported participating in both types of healthy behaviors. Women, adults with a stable income, those with a self-perception of good health and those with a history of physical exercise at the age of 50 years had an increased likelihood of engaging in healthy eating and regular physical activity. Conclusions Many older adults do not routinely consume fruits and vegetables or engage in regular physical exercise despite the fact that most have a fixed income and a social network. It is relevant to conduct research-based interventions that take into account the contextual factors to promote healthy behaviors.

To evaluate an integrative health-care model (IHCM) with an empowerment approach for self-care in terms of improving health-related quality of life (HR-QoL) and lifestyle.We conducted a field trial with one intervention (IHCM) and one comparison group receiving usual care (UC), with ex ante and ex post measurements. The IHCM was provided for 3 months to each woman in the first group, with follow-up of both groups at 3 and 6 months. The differences in differences estimator was used to assess the effect of intervention, adjusting for clinically important covariates in the framework of a generalized linear regression model.A total of 380 women (IHCM 190 and UC 190) participated in the study. The differences in differences estimator between IHCM and UC for aerobic physical activity was 81 and 87 min/week at 3 and 6 months, respectively; for consumption of dairy products, fruit and vegetables the estimator was 4.8, 6.6 and 9.4 servings per week respectively at 3 months, and 3.9, 6.3 and 9.7 servings at 6 months. The effect of IHCM on HR-QoL at 3 months was greater for the domains of vasomotor, somatic symptoms and sleep problems (11.7, 10.0 and 13.2 points, respectively); at 6 months the differences of major positive change were observed in the domains of memory/concentration, vasomotor symptoms and sleep problems (12.2, 10.4 and 10.8 points, respectively).The results support the importance of patient-centered health care during the climacteric stage, within integrative care programs with an empowerment approach.

Background The ongoing influenza A (H1N1) pandemic stroked Mexico and posed a huge challenge to the medical care and public health systems. This report analyzes the clinical course and process of care of patients who died due to atypical pneumonia and fulfilled the clinical criteria of suspected case of novel influenza A (H1N1) virus infection. Methods We conducted a retrospective analysis of a series of 38 patients who died between April 7 and April 28, 2009 at Instituto Mexicano del Seguro Social (IMSS) hospitals due to severe pneumonia and respiratory distress. These cases coincided with the beginning of the outbreak, so patients did not undergo laboratory testing to diagnose influenza. According to IMSS and CDC criteria, post-hoc analysis allowed considering the presumptive diagnosis of S-OIV infection. A multidisciplinary group analyzed the information from the clinical charts, laboratory tests, radiographic studies and death certificates, using descriptive statistics. Results Most cases were middle-aged (mean 33 years, range: 4–62 years) and previously healthy; 18.4% had an underlying chronic disease, 23.7% were obese and 7.9% were current smokers. None had received the seasonal influenza vaccine; they had cough (92%), fever (86.8%), and malaise (73.7%). The median time from disease onset to hospital admission was 6 days (range 0–8 days). All were admitted to the intensive care unit with pneumonia and/or respiratory distress. Average time from disease onset to death was 8 days (range 4–18 days). Conclusions An increased number of severe cases of atypical pneumonia in previously healthy adults highlight the importance of the availability of a timely surveillance system able to identify sudden increases in the number of cases or presentation of apparently known diseases.

This study evaluated primary care attributes of patient-centered care associated with the public perception of good quality in Brazil, Colombia, Mexico and El Salvador. We conducted a secondary data analysis of a Latin American survey on public perceptions and experiences with healthcare systems. The primary care attributes examined were access, coordination, provider-patient communication, provision of health-related information and emotional support. A double-weighted multiple Poisson regression with robust variance model was performed. The study included between 1500 and 1503 adults in each country. The results identified four significant gaps in the provision of primary care: not all respondents had a regular place of care or a regular primary care doctor (Brazil 35.7%, Colombia 28.4%, Mexico 22% and El Salvador 45.4%). The communication with the primary care clinic was difficult (Brazil 44.2%, Colombia 41.3%, Mexico 45.1% and El Salvador 56.7%). There was a lack of coordination of care (Brazil 78.4%, Colombia 52.3%, Mexico 48% and El Salvador 55.9%). Also, there was a lack of information about healthy diet (Brazil 21.7%, Colombia 32.9%, Mexico 16.9% and El Salvador 20.8%). The public's perception of good quality was variable (Brazil 67%, Colombia 71.1%, Mexico 79.6% and El Salvador 79.5%). The primary care attributes associated with the perception of good quality were a primary care provider 'who knows relevant information about a patient's medical history', 'solves most of the health problems', 'spends enough time with the patient', 'coordinates healthcare' and a 'primary care clinic that is easy to communicate with'. In conclusion, the public has a positive perception of the quality of primary care, although it has unfulfilled expectations; further efforts are necessary to improve the provision of patient-centered primary care services in these four Latin American countries.

Objective (i) To develop quality-of-care indicators suitable for evaluation of care for knee and hip osteoarthritis (KHOA) at the primary care level using data from the electronic health records (EHRs) and (ii) to evaluate the quality of care that patients with KHOA receive at family medicine clinics (FMCs). Design (i) Development of indicators following the RAND-UCLA method. (ii) A cross-sectional analysis of quality-of-care provided for patients with osteoarthritis. Setting Four FMCs in Mexico City. Participants Knee and hip osteoarthritis patients, older than 19 years. Source of the Information 2009 EHR data. Main Outcome Measure(s) Quality of care was evaluated using six indicators developed in the first stage of this study. Results The quality of care evaluation identified that 26.1% of patients were advised in regard to physical exercise, and weight loss was encouraged in 19.7%. Only 5% of patients received acetaminophen as an initial oral analgesic; 54% of patients at risk for gastrointestinal complications received gastroprotective medicines. On average, the percentage of recommended care received was lower for patients who attended only one visit with family physician (17.6%) and higher for those with >3 visits (41.9%). Conclusion The quality of osteoarthritis care at FMCs in Mexico is suboptimal relative to the standards of care and requires continuous evaluation and implementation of improvement strategies.

While studies have attributed the favourable birth outcomes of Mexico-born mothers in the USA to a 'healthy immigrant effect' that confers protection to immigrants, a comparison of immigrants with the source population in Mexico has been lacking. We compared preterm delivery (PTD) rates of Mexico-born immigrants who delivered in California with Mexico-born women who delivered in Mexico (WIMX) and with a subgroup who delivered in the five top immigrant sending states in Mexico.Using 2009 birth records, we selected all live-born singletons of primiparous WIMX (699 129) and immigrants in California (33 251). We examined the unadjusted and adjusted association between place of delivery and any PTD (37 weeks gestation), including PTD subcategories (early, moderate, late), using relative risks (RR) and 95% CIs. Multivariate models controlled for demographic and health system characteristics.PTD rates were higher among immigrants in California (6.7%) than WIMX (5.8%) and compared to women in the sending states (5.5%). The unadjusted risk of any PTD (RR=1.17 (1.12 to 1.22)), early/moderate PTD (34 weeks gestation; RR=1.27 (1.18 to 1.38)) and late PTD (34-36 weeks; RR=1.14 (1.08 to 1.19)) was higher for immigrants than for WIMX and remained higher when controlling for age, education and healthcare variables. Birth weight1500 g was also higher among immigrants (RR=1.27 (1.14 to 1.44)). Similar patterns were observed when comparing women in the sending states.We found no evidence of a 'healthy immigrant effect'. Further research must assess the comparability of gestational-age data in Mexican and Californian birth certificates.

Background Evaluation of the quality of antenatal care (ANC) using indicators should be part of the efforts to improve primary care services in developing countries. The growing use of the electronic health record (EHR) has the potential of making the evaluation more efficient. The objectives of this study were: (a) to develop quality indicators for ANC and (b) to evaluate the quality of ANC using EHR information in family medicine clinics (FMCs) of Mexico City. Methods We used a mixed methods approach including: (a) in-depth interviews with health professionals; (b) development of indicators following the RAND-UCLA method; (c) a retrospective cohort study of quality of care provided to 5342 women aged 12–49 years who had completed their pregnancy in 2009 and attended to at least one ANC visit with their family doctor. The study took place in four FMCs located in Mexico City. The source of information was the EHR. SAS statistical package served for programing and performing the descriptive statistical analysis. Results 14 ANC quality indicators were developed. The evaluation showed that 40.6% of women began ANC in the first trimester; 63.5% with low-risk pregnancy attended four or more ANC visits; 4.4% were referred for routine obstetric ultrasound, and 41.1% with vaginal infection were prescribed metronidazole. On average, the percentage of recommended care that women received was 32.7%. Conclusions It is feasible to develop quality indicators suitable for evaluating the quality of ANC using routine EHR data. The study identified the ANC areas that require improvement; which can guide future strategies aimed at improving ANC quality.

Objectives To compare the sociodemographic characteristics, reasons for attending, perception of quality and associated out-of-pocket (OOP) expenditures of doctors’ offices adjacent to private pharmacies (DAPPs) users with users of Social Security (SS), Ministry of Health (MoH), private doctor9s offices independent from pharmacies and non-users. Setting Secondary data analysis of the 2012 National Survey of Health and Nutrition of Mexico. Participants The study population comprised 25 852 individuals identified as having had a health problem 15 days before the survey, and a random sample of 12 799 ambulatory health service users. Outcome measures Sociodemographic characteristics, reasons for attending healthcare services, perception of quality and associated OOP expenditures. Results The distribution of users was as follows: DAPPs (9.2%), SS (16.1%), MoH (20.9%), private providers (15.4%) and non-users (38.5%); 65% of DAPP users were affiliated with a public institution (MoH 35%, SS 30%) and 35% reported not having health coverage. DAPP users considered the services inexpensive, convenient and with a short waiting time, yet they received ≥3 medications more often (67.2%, 95% CI 64.2% to 70.1%) than users of private doctors (55.7%, 95% CI 52.5% to 58.6%) and public institutions (SS 53.8%, 95% CI 51.6% to 55.9%; MoH 44.7%, 95% CI 42.5% to 47.0%). The probability of spending on consultations (88%, 95% CI 86% to 89%) and on medicines (97%, 95% CI 96% to 98%) was much higher for DAPP users when compared with SS (2%, 95% CI 2% to 3% and 12%, 95% CI 11% to 14%, respectively) and MoH users (11%, 95% CI 9% to 12% and 32%, 95% CI 30% to 34%, respectively). Conclusions DAPPs counteract current financial protection policies since a significant percentage of their users were affiliated with a public institution, reported higher OOP spending and higher number of medicines prescribed than users of other providers. The overprescription should prompt studies to learn about DAPPs’ quality of care, which may arise from the conflict of interest implicit in the linkage of prescribing and dispensing processes.

OBJECTIVES Patients with hypertension require life-long care and should be monitored to identify whether they are receiving the appropriate healthcare and reach their expected health outcomes. Our objectives were to develop quality of healthcare indicators (QCI) and evaluate the quality of care that hypertensive patients receive in family medicine clinics at the Mexican Institute of Social Security. METHOD We used a two-stage mixed methods approach: development of QCIs following the RAND-UCLA method; quality of care evaluation using electronic health record (EHR) data from 47 150 hypertensive patients who received care in 2009. We developed 15 QCIs, which were possible to construct using EHR data. The QCIs evaluated the process of care and health outcomes. RESULTS Most hypertensive patients were women (64%) more than 60 years old; 79% were overweight/obese and 31% had diabetes. On average, these patients attended regularly to the family doctor (≥7 visits a year); however, they received only 27% of recommended care. Among the hypertensive patients without comorbidity, 62% had achieved blood pressure (BP) control, whereas in the group of hypertensive patients with diabetes or chronic kidney disease, only 7% had achieved BP control. CONCLUSION EHR can become a source of information to evaluate routinely quality of care in developing countries that are beginning to modernize their health information systems.

Background Several low and middle-income countries are implementing electronic health records (EHR). In the near future, EHRs could become an efficient tool to evaluate healthcare performance if appropriate indicators are developed. The aims of this study are: a) to develop quality of care indicators (QCIs) for type 2 diabetes (T2DM) in the Mexican Institute of Social Security (IMSS) health system; b) to determine the feasibility of constructing QCIs using the IMSS EHR data; and c) to evaluate the quality of care (QC) provided to IMSS patients with T2DM. Methods We used a three-stage mixed methods approach: a) development of QCIs following the RAND-UCLA method; b) EHR data extraction and construction of indicators; c) QC evaluation using EHR data from 25,130 T2DM patients who received care in 2009. Results We developed 18 QCIs, of which 14 were possible to construct using available EHR data. QCIs comprised both process of care and health outcomes. Several flaws in the EHR design and quality of data were identified. The indicators of process and outcomes of care suggested areas for improvement. For example, only 13.0% of patients were referred to an ophthalmologist; 3.9% received nutritional counseling; 63.2% of overweight/obese patients were prescribed metformin, and only 23% had HbA1c Conclusions EHR data can be used to evaluate QC. The results identified both strengths and weaknesses in the electronic information system as well as in the process and outcomes of T2DM care at IMSS. This information can be used to guide targeted interventions to improve QC.

OBJECTIVE: To describe the incidence and management of severe maternal and newborn complications in selected health facilities in Mexico. MATERIALS AND METHODS: As part of the WHO Multicountry Survey on Maternal and Newborn health, information was collected from medical records of women with deliveries and/or severe maternal complications during pregnancy or puerperium in 14 hospitals in Mexico City and the state of Guanajuato, Mexico. RESULTS: Of 13 311 women, 157 (12 per 1 000 live births) had severe maternal complications including 4 maternal deaths. The most frequent complications were preeclampsia, postpartum hemorrhage, and chronic hypertension. Adverse perinatal outcomes were more frequent among women with severe maternal complications. A high use of uterotonics and parenteral antibiotics was found. A small proportion of women with eclampsia received magnesium sulfate. CONCLUSION: This study provides indicators on the incidence and management of maternal and neonatal complications in Mexico, which may be useful in studying and evaluating the performance of obstetric services.OBJETIVO: Describir la incidencia y manejo de complicaciones maternas y neonatales severas en hospitales seleccionados de México. MATERIAL Y MÉTODOS: En el marco de la Encuesta Multipaís de la OMS sobre Salud Materna y Neonatal, se recolectó información de los expedientes médicos de las mujeres que tuvieron su parto o experimentaron complicaciones maternas severas durante el embarazo o puerperio en 14 hospitales de la Ciudad de México y el estado de Guanajuato, México. RESULTADOS: De 13 311 mujeres, 157 (12/1 000 nacidos vivos) tuvieron complicaciones maternas severas, incluyendo 4 muertes maternas. Las complicaciones más frecuentes fueron preeclampsia, hemorragia postparto e hipertensión crónica. Los resultados perinatales adversos fueron más frecuentes en las mujeres con complicaciones severas. Hubo un uso amplio de uterotónicos y antibióticos parenterales. Una baja proporción de mujeres con eclampsia recibió sulfato de magnesio. CONCLUSIONES: Esta encuesta proporciona indicadores sobre la incidencia y manejo de las complicaciones maternas y neonatales en México, los cuales pueden ser de utilidad para estudiar y evaluar el desempeño de los servicios obstétricos.

While they progress through the climacteric stage, women often develop physical and psychological health needs, calling for innovative health-care services that can be translated into preventive programs and empowerment towards self-care.To identify the changes in women's discourse regarding their concerns and needs about the climacteric stage and self-care after they had participated in an integrative women-centered health-care model with empowerment for self-care.Women's narratives during counseling group sessions were analyzed using qualitative inductive thematic analysis.A total of 121 women between 45 and 59 years of age participated. At the beginning of the counseling group sessions, we identified the following themes: (1) Lack of information about changes during the climacteric stage and self-care; (2) Tradition: the climacteric stage as a taboo subject; (3) Life's changes and transitions: the complexity of the climacteric experience; (4) Stigma of menopause; (5) Relationship between the traditional gender role and the lack of self-care. At the end of the counseling group sessions, the themes were: (1) The climacteric as a natural stage; (2) Expectations for old age; (3) Empowerment and the change of awareness for self-care; (3) De-medicalization of the climacteric; (4) The richness of group work; (5) Empowerment as motivation to convey acquired knowledge.Women in the climacteric stage require more information about their physical, psychological and social needs, as well as the potential impact on their health during old age. Empowerment during the climacteric can contribute to improving the perception about this stage as well as the importance of self-care.

This study analyzes the potential economic benefits of identifying and treating patients with so-called prediabetes and prehypertension through the Mexican prevention program known by its Spanish acronym PREVENIMSS. The results show that for each US dollar invested in prevention, $84-$323 would be saved over a twenty-year period. For this and other reasons, providing preventive care for prediabetes and prehypertension patients is better than the current routine care model, in which care is provided in most cases when the disease has progressed substantially. Yet data show that screening and preventive care services are still not being used widely enough in Mexico, are provided too late, or are not sufficiently targeted to the most at-risk individuals. Investing in preventive care for patients with prediabetes and prehypertension is cost saving.

To develop and test two educational programmes (interactive and passive) aimed at improving family doctors' (FD) prescribing practices and patient's knowledge and use of non-opioid analgesics (NOA).The educational programmes were conducted in two family medicine clinics by using a three-stage approach: baseline evaluation, design, and implementation of educational activities, and post-programme evaluation. An interactive educational programme (IEP) was compared with a passive educational programme (PEP); both were participated by FDs and patients. The IEP for FDs comprised of workshops, discussion groups, in-service training and guidelines, while for patients the IEP consisted of an interactive session with a video, leaflets and a discussion. The PEP consisted in delivering the guidelines to the FDs and the leaflets to patients. The effect of the programmes on the FDs was measured through the appropriateness of prescriptions and analysed using the differences-in-differences estimator (D-in-D), and on patients through changes in self-medication and in their knowledge about the proper use and adverse events by analysing the inter- and intra-group differences before and after the programmes.The IEP obtained better results to improve appropriate FDs prescription of NOA than PEP (D-in-D = 15%). Regarding the patients, the PEP group reached higher reduction of self-medication than the IEP group (13.4% vs. 9.1%); the knowledge of proper NOA use increased by 8.5% in both groups, whereas knowledge of NOA-related adverse events was better in the IEP (39.6%) than in the PEP group (9.2%).The IEP was better to improve the doctors' abilities to prescribe NOAs, and both programmes improved patients' knowledge.

Objectives 1) To design and validate indicators to measure the quality of the process of care that climacteric stage women receive in family medicine clinics (FMC). 2) To assess the quality of care that climacteric stage women receive in FMC. 3) To determine the association between quality of care and health-related quality of life (HR-QoL) among climacteric stage women. Methods The study had two phases: I. Design and validation of indicators to measure the quality of care process by using the RAND/UCLA Appropriateness Method. II. Evaluation of the quality of care and its association with HR-QoL through a cross-sectional study conducted in two FMC located in Mexico City that included 410 climacteric stage women. The quality of care was measured by estimating the percentage of recommended care received (PRCR) by climacteric stage women in three process components: health promotion, screening, and treatment. The HR-QoL was measured using the Cervantes scale (0-155). The association between quality of care and HR-QoL was estimated through multiple linear regression analysis. Results The lowest mean of PRCR was for the health promotion component (24.1%) and the highest for the treatment component (86.6%). The mean of HR-QoL was 50.1 points. The regression analysis showed that in the treatment component, for every 10 additional points of the PRCR, the global HR-QoL improved 2.8 points on the Cervantes scale (coefficient -0.28, P < 0.0001). Conclusion The indicators to measure quality of care for climacteric stage women are applicable and feasible in family medicine settings. There is a positive association between the quality of the treatment component and HR-QoL; this would encourage interventions to improve quality of care for climacteric stage women.

The Mexican Institute of Social Security (IMSS) is the largest public health care system in Mexico. IMSS family physicians' management of clinical problems is frequently not consistent with published evidence. This study aimed to evaluate the effects of a multifaceted educational intervention to improve management of acute respiratory infections (ARI) by IMSS family physicians.A non-randomized pre-post intervention with comparison group design was conducted in eight IMSS family medicine clinics in which 106 family physicians practiced. An evidence-based clinical guideline for ARI management was developed, and clinical tutors were trained. The three-stage intervention comprised interactive workshops, individual tutorials, and round-table peer-review sessions. The main outcome was appropriate ARI case management. The intervention effect was calculated by using the differences-in-differences model, adjusting for cluster of physicians.In the intervention group, the difference in mean proportion of improvement compared with baseline evaluation was 22.6% (95% confidence interval [CI]=10.3 to 34.9) for appropriate prescription of antibiotics, 29.8% (95% CI=17.2 to 42.4) for indication of worsening signs, and 19.6% (95% CI=11.2 to 28.0) for overall appropriate case management. The comparison group showed no significant changes.The educational intervention improved ARI management. Further studies are needed to analyze organizational implications, cost, sustainability, and effects on health outcomes.

To evaluate the effectiveness of involving primary care nurses in comprehensive care of patients with hypertension and diabetes mellitus type II (DM2).A quasi-experimental, before-and-after study was conducted, without a control group, in eight family-practice clinics. Trained nurses offered comprehensive care in conjunction with a team made up of a family doctor, a nutritionist, a social worker, and a dentist. The intervention lasted seven months and its outcome variables were changes in body mass index, fasting blood glucose, blood pressure, self-perceived health status, treatment compliance, and emergency services requests. Any change was determined by comparing the baseline to the final measurement through interviews and recording the variables of interest in a spreadsheet.In all, 1 131 patients completed the follow-up, of which 44.9% were diagnosed with hypertension, 27% with DM2, and 28.1% with both conditions. The proportion of patients seen by the coordinated health teams increased; there was a rise in cases of normal weight and overweight; a decrease in the proportion of obese (P0.05); and an increase in hypertensives with high blood pressure (130/ 80mmHg) (P0.05). There was no change in the proportion of diabetics with high blood glucose (140 mg/dl); 18.2% reported improved self-perceived health status (P0.05); there was improved treatment compliance (P0.05); and a decrease in requests for emergency services at the clinics (-4.5%) and at the hospitals (-6.8%) (P0.05).Comprehensive care for chronically ill patients through the involvement of nurses contributes to improved health outcomes in primary care.

To assess the quality of medication prescribing in ambulatory elderly patients attending to family medicine clinics due to non-malignant pain syndrome.By doing a secondary data analysis we evaluated the quality of medication prescribing in 495 subjects aged 60 or more years, which were seen due to non-malignant pain syndrome in family medicine clinics belonging to Instituto Mexicano del Seguro Social. The analyzed information included general patient characteristics, medical histories, and medication (complete data). The quality of medication prescribing was assessed by using the Beers criteria and the MAI. All data were analyzed by using descriptive statistics.The total number of medicines prescribed was 3017, with an average number of prescribed drugs of 6 (+/- 2.5). About 35% of patients had prescriptions with at least one inappropriate medication according to the Beers criteria. The mean MAI score was 3.5 (+/- 4.3) for drug and 20.9 (+/- 10.7) per patient. According to MAI criteria, the most frequent errors were: failure to provide practical directions, prescription of drug combinations with potential drug-drug interactions, and inappropriate indications.Inappropriate prescription is a common problem in elderly patients with nonmalignant pain syndrome attending to primary care facilities.

To evaluate the efficacy of a clinical practice guideline for treating type-2 diabetes patients in family medicine clinics.Nonrandomized control trial that took place in two family medicine clinics. Patients with more than 10 years of being diabetic were included. The study comprised one intervention group and one control group. The intervention group was treated by family doctors previously trained to use the guideline, while the control group was treated by family doctors unaware of the clinical practice guideline. The clinical practice guideline identifies disease risk factors, classifies the disease, and indicates criteria for diagnosis, pharmacological treatment, monitoring and timely identification of acute complications. It also addresses patients' education regarding dietary and exercise recommendations. The study had three stages: baseline, intervention and post-intervention.the primary outcome was control of glycemia, determined by HbA1c levels. The criterion for control was an HbA1c value of 7% or below. Secondary outcomes were changes in lifestyle, body mass index, cholesterol and triglyceride levels.Of the 419 patients with type-2 diabetes included in the study, 340 (81%, 175 intervention group and 165 control group) completed the six-month follow-up. In the final evaluation, the mean HbA1c in the intervention group had decreased from 9 to 8.3%, while it increased from 8.9 to 9.5% in the control group (p0.001). The proportion of obese patients decreased in the intervention group but remained the same in the control group.The clinical practice guideline was effective in improving the HbA1c level and decreasing the proportion of obese patients.

To evaluate self-rated health (SRH) in climacteric women and to identify the factors associated with negative SRH.Information from 9 248 women aged 40 to 59 years was analyzed. SRH was the dependent variable. Independent variables were demographic characteristics, history of reproductive and chronic diseases, physical activity, and participation in screening and health education programs. Data were analyzed using descriptive statistics, bivariate analysis, and logistic regression modeling.Forty-two percent of women reported positive SRH and 58% reported negative SRH. Factors associated with negative SRH were: low literacy level (OR 1.78, CI95% 1.62-1.95), unemployment (OR 1.20, CI95% 1.09-1.33), menopause (OR 1.22, CI95% 1.11-1.33), type 2 diabetes (OR 1.88, CI95% 1.65-2.13) hypertension (OR 2.01, CI95% 1.82-2.22), irregular physical exercise (OR 1.30, CI95% 1.12-1.50), sedentarism (OR 1.395, CI95% 1.23-1.57), lack of information about climacteric (OR 1.17, CI95% 1.07-1.28) and lack of screening for chronic diseases (OR 0.82, CI95% 0.75-0.89).Factors associated with negative SRH such as lack of information and physical activity should be strengthened.

Objectives While the benefits of Seguro Popular health insurance in Mexico relative to no insurance have been widely documented, little has been reported on its effects relative to the pre-existing Social Security health insurance. We analyse the effects of Social Security and Seguro Popular health insurances in Mexico on access to healthcare of older adults, and on financial risk protection to their households, compared with older adults without health insurance. Setting Secondary data analysis was performed using the 2012 Mexican Survey of Health and Nutrition (ENSANUT). Participants The study population comprised 18 847 older adults and 13 180 households that have an elderly member. Outcome measures The dependent variables were access to healthcare given the reported need, the financial burden imposed by health expenditures measured through catastrophic health-related expenditures, and using savings for health-related expenditures. Separate propensity score matching analyses were conducted for each comparison. The analysis for access was performed at the individual level, and the analysis for financial burden at the household level. In each case, matching on a wide set of relevant characteristics was achieved. Results Seguro Popular showed a protective effect against lack of access to healthcare for older adults compared with those with no insurance. The average treatment effect on the treated (ATET) was ascertained through using the nearest-neighbour matching (−8.1%, t-stat −2.305) analysis. However, Seguro Popular did not show a protective effect against catastrophic expenditures in a household where an older adult lived. Social Security showed increased access to healthcare (ATET −11.3%, t-stat −3.138), and protective effect against catastrophic expenditures for households with an elderly member (ATET −1.9%, t-stat −2.178). Conclusions Seguro Popular increased access to healthcare for Mexican older adults. Social Security showed a significant protective effect against lack of access and catastrophic expenditures compared with those without health insurance.

ObjetivoAnalizar las necesidades de salud en la población adscrita al Instituto Mexicano del Seguro Social (IMSS).DiseñoEstudio observacional, descriptivo y transversal.EmplazamientoLa Unidad de Medicina Familiar número 8 del IMSS en la ciudad de Tlaxcala, México.ParticipantesMuestra de 1.200 familias por muestreo polietápico. El estudio se realizó entre octubre de 1999 y marzo de 2000.Mediciones principalesSe ha aplicado el cuestionario «Diagnóstico de salud de la familia», previamente elaborado y validado.ResultadosEl 19,2% de las familias tenía un nivel socioeconómico muy bajo y un 14,9% de los sujetos no tuvo derecho a la Seguridad Social. El 12,6% de las familias tenía al menos un miembro analfabeto. De acuerdo con el resultado del test de Apgar familiar, el 93% de las familias era functional y los dos tercios de las familias se clasificaron como nucleares. La cobertura de los programas de detección de cáncer cervicouterino y de mama en las mujeres fue del 51,1 y el 36,9%, respectivamente. Sólo en el 25% de la población adulta se realizaron pruebas de detección de diabetes mellitus e hipertensión arterial. El 10,9% de la población refirió tener alguna enfermedad crónica. El 56,4% de las familias consideró que la calidad de la atención fue buena y sólo el 18,13% estuvo satisfecho con la atención recibida.ConclusionesEl diagnóstico de salud familiar es importante en el proceso de evaluación de las necesidades de salud en la población para la jerarquización de problemas, así como para el desarrollo de los programas de salud que permitirán una mayor equidad en la atención.ObjectiveTo assess the health needs of the eligible public population of the Mexican Institute of Social Security (IMSS).DesignObservational, descriptive, transversal study.SettingFamily Medicine Unit number 8 of the IMSS, in the city of Tlaxcala, Mexico.ParticipantsA sample of 1200 families using multi-stage sampling, between October 1999 and March 2000.Main measurementsThe designed and validated questionnaire on “Family health diagnosis” was used.ResultsA 19.2% of the families had a very low socio-economic level, and 14.9% of subjects were not entitled to Social Security. Functional illiteracy in at least one member was found in 12.6% of the families. According to the family Apgar, 93% of families were functional and two-thirds of the families were classified as nuclear. About 51.1% and 36.9% of women used programs for detection of cervical/uterine and breast cancer, respectively. Only 25% of the adult population underwent the detection tests for diabetes mellitus and hypertension and 10.9% had a chronic disease. 56.4% of families considered the quality of health care good, and only 18.13% were satisfied with the care received.ConclusionsIdentification of health needs through diagnosis of family health is useful as a basis for establishing a hierarchy of problems as well as for developing health programs that may facilitate greater equity in attention.

Objective. The purpose of this paper is to describe some of the results of the Morelos HPV Study. The main objective of the Morelos HPV Study is to evaluate the use of human papillomavirus (HPV) DNA testing, as compared to the Papanicolaou (Pap) test, for cervical cancer (CC) screening. Material and Methods. The Morelos HPV Study is currently being conducted in Mexico, to examine the possibility of using HPV testing for CC screening. The HPV testing of self-collected vaginal and clinician-collected cervical specimens was evaluated as part of this study. The acceptability of the HPV testing of self-collected specimens was compared to that of the Pap test. A cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) was also performed. Results. The Morelos HPV Study results indicate that HPV testing has a greater sensitivity to detect cervical intraepithelial neoplasia (CIN) 2/3 and CC than the Pap test. Our results also indicate an over-all lower acceptability of the Pap test as compared to the self-collected procedure. The results of the CEA and CBA indicate that screening women between the ages of 20-80 for CC using some type of HPV testing is always more cost-effective than screening for CC using the Pap test. Conclusions. Our results suggest that self- and clinician-collected HPV testing could be used in CC prevention programs, as an effective complement or substitute for the Pap test. This paper is available too at: http://www.insp.mx/salud/index.html

The uterine cervix is the most common cancer site for females. Approximately 52,000 new cases occur annually in Latin America, thus the need to improve efficiency and effectiveness of Cervical Cancer Screening Programs (CCSP) is mandatory to decrease the unnecessary suffering women must bear. This paper is addressing essential issues to revamp the CCSP as proposed by the Mexican official norm. A general framework for institutionaling CCSP is outlined. Furthermore, strategies to strengthen CCSP performance through managerial strategies and quality assurance activities are described. The focus is on the following activities: 1) improving coverage; 2) implementing smear-taking quality control; 3) improving quality in interpretation of Pap test; 4) guaranteeing treatment for women for whom abnormalities are detected; 5) improving follow-up; 6) development of quality control measures and 7) development of monitoring and epidemiological surveillance information systems. Changes within the screening on cervical cancer may be advocated as new technologies present themselves and shortcomings in the existing program appear. It is crucial that these changes should be measured through careful evaluation in order to tally up potential benefits.

A prospective cohort study was conducted to analyze factors associated with antibiotic noncompliance and waste among patients suffering acute respiratory infection (ARI) and acute diarrhea (AD). The study took place in four primary health care clinics in Mexico City, two belonging to the Ministry of Health (MoH) and two to the Mexican Social Security Institute (IMSS). Two hundred twenty-two patients with ARI and 155 with AD were included. Data about study variables and the assessment of compliance were obtained through patient interviews and direct observation. Factors associated with noncompliance were assessed through a multiple logistic regression procedure. Noncompliance was 60% for ARI and 55.5% for AD in both health care systems. Prescription of an antibiotic was justified only in 13.5% of cases. Associated factors were: increased duration of illness (OR 2.95; 95% CI, 1.17-7.41); complexity of the treatment: 3 or more doses per day (OR 2.47; 95% CI, 1.56-3.92), and treatment for more than 7 days (OR 1.94; 95% CI, 1.16-3.26); younger age of patient (OR 1.89; 95% CI, 1.18-3.02); and an inadequate physician-patient relationship (OR 1.87; 95% CI, 1.16-3.02). Antibiotic waste was higher in IMSS (ARI 39.3%, AD 32.6%), than in the MoH (ARI 21.2%, AD 16.4%). Educational strategies to modify physician prescribing practices and strengthen physician-patient relationships might improve compliance and decrease drug waste.

To improve prescribing practices for rhinopharyngitis, an interactive educational intervention and a managerial intervention were carried out in 18 primary care facilities in metropolitan Mexico City. Four family medicine clinics of the Mexican Social Security Institute (IMSS) and 14 health centres of the Ministry of Health (SSA) were included. A quasi-experimental design was employed. One hundred and nineteen physicians (IMSS 68, SSA 51) participated. Sixty-five physicians (IMSS 32, SSA 33) were in the study group, while 54 were in the control group (IMSS 36, SSA 18). The study had four stages: (I) baseline, to evaluate the physicians' prescribing behaviour for rhinopharyngitis; (II) intervention, using an interactive educational workshop and a managerial peer review committee; (III) post-intervention evaluation of short-term impact; and (IV) follow-up evaluation of long-term effect 18 months after the workshop. The control group did not receive any intervention but was evaluated at the same time as the study group. At baseline, most patients in both institutions received antibiotic prescriptions (IMSS 85.2%, SSA 68.8%). After the workshop, the percentage of patients receiving antibiotic prescriptions in the IMSS went from 85.2% to 48.1%, while in the SSA it went from 68.8% to 49.1%. Appropriateness of treatment was analyzed using the physician as the unit of analysis. At baseline, 30% of IMSS physicians in the study group treated their patients appropriately. After the intervention, this percentage increased to 57.7%, and at the 18-month follow-up it was 54.2%. The SSA study group increased the appropriate use of antibiotics from 35.7% to 46.2%, with this percentage falling to 40.9% after the 18-month follow-up period. In the control group there were no significant changes in prescribing patterns with respect to either the prescribing of antibiotics or the appropriateness of treatment. The intervention strategies were successful in both institutions. Forty per cent of physicians improved their prescribing practices after the workshop, with this change remaining in 27.5% of them throughout the follow-up period. On the other hand, 42.5% of the physicians did not change their prescribing practices after the intervention. The rest (17.5%) showed appropriate prescribing practices during all the stages of the study. We conclude that it is possible to improve the physicians' prescribing practices through interactive educational strategies and managerial interventions. This type of intervention can be an affordable way to provide continuing medical education to primary care physicians who do not have access to continuing educational activities, and to improve the quality of care they provide.

Background Climacteric stage women experience significant biological, psychological and social changes. With demographic changes being observed in the growing number of climacteric stage women in Mexico, it is important to improve their knowledge about the climacteric stage and its potential associated problems, encourage their participation in screening programs, and promote the acquisition of healthy lifestyles. At Mexican health care institutions the predominant health care model for climacteric stage women has a biomedical perspective. Medical doctors provide mostly curative services and have limited support from other health professionals. This study aims to design an integrative health care model (IHCM: bio-psycho-social, multidisciplinary and women-centered) applicable in primary care services aimed at climacteric stage women. Methods/Design We present the design, inclusion criteria and detailed description of an IHCM. The IHCM consists of collaborative and coordinated provision of services by a health team, which is involves a family doctor, nurse, psychologist, and the woman herself. The health team promotes the empowerment of women through individual and group counseling on the climacteric stage and health related self-care. The intervention lasts three months followed by a three-month follow-up period to evaluate the effectiveness of the model. The effectiveness of the model will be evaluated through the following aspects: health-related quality of life (HR-QoL), empowerment, self-efficacy and knowledge regarding the climacteric stage and health-related self-care activities, use of screening services, and improvement in lifestyles (regular leisure time physical activity and healthy diet). Discussion Participation in preventive activities should be encouraged among women in Mexico. Designing and evaluating the effectiveness of an integrative health care model for women at the climacteric stage, based on the empowerment approach and focus on health-related self-care to improve their HR-QoL is pertinent for current health conditions of this age group. Trial registration The study is registered at the ClinicalTrials.gov (NCT01272115).

Background In 2001, the Instituto Mexicano del Seguro Social (IMSS) carried out a major reorganization to provide comprehensive preventive care to reinforce primary care services through the PREVENIMSS program. This program divides the population into programmatic age groups that receive specific preventive services: children (0-9 years), adolescents (10-19 years), men (20-59 years), women (20-59 years) and older adults (> = 60 years). The objective of this paper is to describe the improvement of the PREVENIMSS program in terms of the increase of coverage of preventive actions and the identification of unmet needs of unsolved and emergent health problems. Methods From 2003 to 2006, four nation-wide cross-sectional probabilistic population based surveys were conducted using a four stage sampling design. Thirty thousand households were visited in each survey. The number of IMSS members interviewed ranged from 79,797 respondents in 2003 to 117,036 respondents in 2006. Results The four surveys showed a substantial increase in coverage indicators for each age group: children, completed schemes of vaccination (> 90%), iron supplementation (17.8% to 65.5%), newborn screening for metabolic disorders (60.3% to 81.6%). Adolescents, measles - rubella vaccine (52.4% to 71.4%), hepatitis vaccine (9.3% to 46.2%), use of condoms (17.9% to 59.9%). Women, measles-rubella vaccine (28.5% to 59-2%), cervical cancer screening (66.7% to 75%), breast cancer screening (> 2.1%). Men, type 2 diabetes screening (38.6% to 57.8%) hypertension screening (48-4% to 64.0%). Older adults, pneumococcal vaccine (13.2% to 24.9%), influenza vaccine (12.6% to 52.9) Regarding the unmet needs, the prevalence of anemia in children was 30% and a growing prevalence of overweight and obesity, type 2 diabetes, and hypertension was found in men, women and older adults. Conclusion PREVENIMSS showed an important increase in the coverage of preventive services and stressed the magnitude of the old and new challenges that this healthcare system faces. The unsolved problems such as anemia, and the emerging ones such as overweight, obesity, among others, point out the need to strength preventive care through designing and implementing innovative programs aimed to attain effective coverage for those conditions in which prevention obtains substandard results.