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BackgroundComprehensive antenatal care (ANC) must prioritize competent, evidence-based medical attention to ensure a positive experience and value for its users. Unfortunately, there is scarce evidence of implementing this holistic approach to ANC in low- and middle-income countries, leading to gaps in quality and accountability. This study assessed care competence, women's experiences during the first ANC visit, and the factors associated with these care attributes.Methods and findingsThe study analyzed cross-sectional baseline data from the maternal eCohort study conducted in Mexico from August to December 2023. The study adapted the Quality Evidence for Health System Transformation (QuEST) network questionnaires to the Mexican context and validated them through expert group and cognitive interviews with women. Pregnant women aged 18 to 49 who had their first ANC visit with a family physician were enrolled in 48 primary clinics of the Instituto Mexicano del Seguro Social across 8 states. Care competence and women's experiences with care were the primary outcomes. The statistical analysis comprised descriptive statistics, multivariable linear and Poisson regressions. A total of 1,390 pregnant women were included in the study. During their first ANC visit, women received only 67.7% of necessary clinical actions on average, and 52% rated their ANC experience as fair or poor. Women with previous pregnancies (adjusted regression coefficient [aCoef.] -3.55; (95% confidence intervals [95% CIs]): -4.88, -2.22, p < 0.001), at risk of depression (aCoef. -3.02; 95% CIs: -5.61, -0.43, p = 0.023), those with warning signs (aCoef. -2.84; 95% CIs: -4.65, -1.03, p = 0.003), common pregnancy discomforts (aCoef. -1.91; 95% CIs: -3.81, -0.02, p = 0.048), or those who had a visit duration of less than 20 minutes (ConclusionsWe found important gaps in adherence to ANC standards and that care competence during the first ANC visit is an important predictor of positive user experience. To inform quality improvement efforts, IMSS should institutionalize the routine monitoring of ANC competencies and ANC user experience. This will help identify poorly performing facilities and providers and address gaps in the provision of evidence-based and women-centered care.

ObjectiveThe Mexican government has pursued multiple initiatives to improve healthcare coverage and financial protection. Yet, out-of-pocket health spending and use of private sector providers in Mexico remains high. In this paper, we sought to describe the characteristics of public and private healthcare users, describe recent visit quality across provider types, and to assess whether perceiving the public healthcare sector as poor quality is associated with private health sector use.Methods and findingsWe analyzed the cross-sectional People's Voice Survey conducted from December 2022 to January 2023. We used Chi-square tests to compare contextual, individual, and need-for-care factors and ratings of most recent visits between users of public (social security and other public providers) and private sector providers (stand-alone private providers and providers adjacent to pharmacies). We used a multivariable Poisson regression model to assess associations between low ratings of public healthcare sources and the use of private care. Among the 811 respondents with a healthcare visit in the past year, 31.2% used private sources. Private healthcare users were more educated and had higher incomes than public healthcare users. Quality of most recent visit was rated more highly in private providers (70.2% rating the visit as excellent or very good for stand-alone private providers and 54.3% for pharmacy-adjacent doctors) compared to social security (41.6%) and other public providers (46.6%). Those who perceived public health institutions as low quality had a higher probability of seeking private healthcare.ConclusionUsers rated public care visits poorly relative to private care; at the population level, perceptions of poor quality care may drive private care use and hence out-of-pocket costs. Improving public healthcare quality is necessary to ensure universal health coverage.

Abstract Background In Peru, a majority of individuals bypass primary care facilities even for routine services. Efforts to strengthen primary care must be informed by understanding of current practice. We conducted a time motion assessment in primary care facilities in Lima with the goals of assessing the feasibility of this method in an urban health care setting in Latin America and of providing policy makers with empirical evidence on the use of health care provider time in primary care. Methods This cross-sectional continuous observation time motion study took place from July – September 2019. We used two-stage sampling to draw a sample of shifts for doctors, nurses, and midwives in primary health facilities and applied the Work Observation Method by Activity Timing tool to capture type and duration of provider activities over a 6-h shift. We summarized time spent on patient care, paper and electronic record-keeping, and non-work (personal and inactive) activities across provider cadres. Observations are weighted by inverse probability of selection. Results Two hundred seventy-five providers were sampled from 60 facilities; 20% could not be observed due to provider absence (2% schedule error, 8% schedule change, 10% failure to appear). One hundred seventy-four of the 220 identified providers consented (79.1%) and were observed for a total of 898 h of provider time comprising 30,312 unique tasks. Outpatient shifts included substantial time on patient interaction (110, 82, and 130 min for doctors, nurses, and midwives respectively) and on paper records (132, 97, and 141 min) on average. Across all shifts, 1 in 6 h was spent inactive or on personal activities. Two thirds of midwives used computers compared to half of nurses and one third of doctors. Conclusions The time motion study is a feasible method to capture primary care operations in Latin American countries and inform health system strengthening. In the case of Lima, absenteeism undermines health worker availability in primary care facilities, and inactive time further erodes health workforce availability. Productive time is divided between patient-facing activities and a substantial burden of paper-based record keeping for clinical and administrative purposes. Electronic health records remain incompletely integrated within routine care, particularly beyond midwifery.

Objective. To analyze acute myocardial infarction (AMI) admissions and in-hospital mortality rates and evaluate the competence of the Ministry of Health (MOH) hospitals to provide AMI treatment. Materials and methods. We used a mixed-methods approach: 1) Joinpoint analysis of hos­pitalizations and in-hospital mortality trends between 2005 and 2017; 2) a nation-wide cross-sectional MOH hospital survey. Results. AMI hospitalizations are increasing among men and patients aged >60 years; women have higher mortal­ity rates. The survey included 527 hospitals (2nd level =471; 3rd level =56). We identified insufficient competence to diagnose AMI (2nd level 37%, 3rd level 51%), perform pharmacological perfusion (2nd level 8.7%, 3rd level 26.8%), and mechanical reperfusion (2nd level 2.8%, 3rd level 17.9%). Conclusions. There are wide disparities in demand, supply, and health outcomes of AMI in Mexico. It is advisable to build up the competence with gender and age perspectives in order to di­agnose and manage AMI and reduce AMI mortality effectively.

Abstract 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.

Abstract Background To evaluate the association between user experience and satisfaction with specialty consultations and surgical care at the Mexican Institute of Social Security (IMSS) secondary and tertiary level hospitals. Methods We conducted secondary data analysis of the cross-sectional 2017 IMSS National Satisfaction Survey. The dependent variables were user satisfaction with outpatient consultation and with surgery. The study’s independent variables were user experience with these services. The Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Era framework was used to guide the analysis. For each dependent variable a double-weighted Poisson regression model with robust variance was performed and considered clustering of the observations within 111 secondary level and 25 tertiary level hospitals. Results The study included 6713 outpatient consultation users and 528 surgery users. 83% of users attending outpatient consultations and 86.6% of users who underwent inpatient surgery at IMSS hospitals were satisfied with the service received. The common patient negative experiences with specialty consultations and surgical care were long waiting time (40%) and lack of hospital cleanliness (20%). An additional concern was the lack of clinical examination during the consultation (25%). Shorter waiting times, health provider courtesy, good communication, clinical examination, and hospital cleanliness were associated with patient satisfaction with specialty consultations. Having the surgery without prior postponement(s) and without complications increased the probability of patient satisfaction. Conclusion Patient satisfaction with hospital outpatient consultations and surgical care may be raised by focusing on improvement strategies to enhance positive patient experiences with care.

Abstract 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.

Abstract Background To estimate the incremental cost-effectiveness ratio (ICER) of the use of continuous subcutaneous insulin infusion (CSII) therapy versus multiple daily injections (MDI) therapy in adult patients with type 1 diabetes (T1D) at the Mexican Institute of Social Security (IMSS). Methods An analysis was developed using the internationally validated Core Diabetes Model (CDM) with which the incidence and progression of acute and chronic complications and the mortality of T1D was simulated throughout life. The baseline characteristics of the simulated cohorts were obtained from Mexican T1D adult patients aged ≥ 18 years that received care at two national IMSS medical centres in 2016. In the base case, the costs of the complications and treatment of the disease with both therapies were estimated in Mexican currency from the perspective of the institution, using Diagnosis Related Groups for outpatient and inpatient care. Utilities were taken from the international bibliography. In a secondary analysis, indirect costs were included using a human capital approach. The model used a lifetime time horizon, and a discount rate of 5% was applied for health outcomes and costs. A one-way sensitivity analysis was conducted on key variables and patient sub-groups; uncertainty was evaluated using a Cost-Effectiveness Acceptability Curve. Results The average age of the cohort was 32 years, with diabetes duration of 19 years, an average HbA1c of 9.2%; 29% were men. A gain of 0.614 Quality Adjusted Life Years (QALYs) was estimated with the use of CSII therapy. The estimated ICER was MXN$478,020 per QALY in the base case, and MXN$369,593 when indirect costs were considered. The sensitivity analysis showed that, in adult patients with HbA1c > 9.0%, the ICER was MXN$262,237. Conclusions This is the first economic evaluation study that compares CSII therapy versus MDI therapy for T1D adult patients in Mexico. The insulin pump therapy can be considered cost-effective in the context of the IMSS when considering a threshold of three GDPs per capita with 43.9% probability. Results improve substantially when patients have an HbA1c above 9%.

Objective. To analyze the coverage of lung cancer in Mexico and offer recommendations in this regard. Materials and methods. 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. Results. 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. Conclusions. 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.

ObjectiveTo evaluate factors associated with COVID-19 preventive health behaviors among adults in Mexico City and the State of Mexico.Methods and findingsWe 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.ConclusionPeople 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.

Abstract 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.

Abstract 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.

Abstract Background Risky sexual behaviors of adolescents in Mexico are a public health problem; 33.4 % of adolescent girls and 14.7 % of boys report not having used any protection at their first intercourse. The fertility rate is 77 births/1000 girls aged 15–19 years. The infrequent contact of adolescents with health services and the limited extent of school sex and reproductive health education require the support of innovative strategies. The objective of this paper is to present the design of an internet-based educational strategy to prevent risky sexual behaviors in Mexican adolescents. Methods A field trial with intervention and comparison group and with ex-ante and ex-post measurements will be conducted in two public secondary schools. Adolescents between 14 and 15 years of age will participate. The intervention will be conducted in one school and the second school will serve as a comparison group where the investigators will observe the usual sex education provided by the school. The intervention will be delivered using an internet web page that includes four educational sessions provided during a 4 week period. Follow-up will last 3 months. Information on the study variables will be obtained through an Internet-based self-applied questionnaire and collected on three occasions: 1) when the adolescents enter the study (baseline), 2) once the intervention is completed (at 1 month) and 3) after 3 months of follow-up (at the fourth month). There will be three outcome variables: 1) knowledge in regard to sexually transmitted infections, 2) attitudes regarding condom use, and 3) self-efficacy toward consistent condom use. The generalized linear model will be used to assess changes in each outcome variable controlling for baseline measures and for study covariates. Discussion The design and evaluation of an Internet-based educational strategy to prevent risky sexual behaviors in Mexican adolescents is important in order to provide a new, large-scale, easily implemented preventive tool. Trial registration The study was registered at the ClinicalTrials.gov ID: NCT02686736 .

Introducción: La evaluación de la calidad de la atención del recién nacido con complicaciones es un elemento indispensable para las estrategias de mejora orientadas a reducir las tasas de mortalidad neonatal. El objetivo de este trabajo fue evaluar la calidad de atención técnica e interpersonal en el manejo de la taquipnea transitoria del recién nacido (TTRN) de pacientes afiliados al Seguro Médico Siglo XXI. Métodos: Se realizó un estudio transversal en 61 hospitales de la Secretaría de Salud, que durante el primer semestre de 2011 reportaron al menos dos casos de TTRN. Se analizaron diferentes variables con respecto a la madre, el embarazo, el nacimiento y las complicaciones neonatales, así como intervenciones realizadas al recién nacido y condiciones de salud al egreso. Para medir la calidad de atención, se definieron y validaron indicadores de calidad en los ámbitos de la prevención, diagnóstico y tratamiento. Resultados: Se analizaron 256 expedientes de casos con diagnóstico de TTRN. El 8.9% de las madres tenía alguno de los factores de riesgo (asma, diabetes) y el 53.5% presentó complicaciones en el embarazo. El 60% de los casos de TTRN nacieron por cesárea; un tercio tuvieron bajo peso al nacimiento y el 14% fueron trasladados a otro hospital. En cuanto a los indicadores de calidad, en el rubro de prevención se identificó que en más del 90% se registraron los factores de riesgo (tabaquismo, asma, parto por cesárea); los de diagnóstico reflejaron que en el 86-98% se buscaron manifestaciones de insuficiencia respiratoria. Los de tratamiento lograron cifras satisfactorias para las medidas de monitorización y soporte. Conclusiones: Los resultados permiten considerar que la mayoría de los casos con TTRN recibieron un tratamiento apropiado. Es recomendable desarrollar estrategias efectivas, como reducir la creciente tasa de partos por cesárea, para prevenir la TTRN.

En noviembre de 2014, la Secretaría de Salud de México fue sede de una mesa redonda con miembros de la Comisión de The Lancet para la Inversión en Salud (CIS) para analizar el informe de esta misma comisión titulado Salud global 2035 y sus posibles implicaciones para el mejoramiento de la salud pública...

Objective. To estimate the requirements of human resources (HR) of two models of care for diabetes patients: conventional and specific, also called DiabetIMSS, which are provided in primary care clinics of the Mexican Institute of Social Security (IMSS). Materials and methods. An evaluative research was conducted. An expert group identified the HR activities and time required to provide healthcare consistent with the best clinical practices for diabetic patients. HR were estimated by using the evidence-based adjusted service target approach for health workforce planning; then, comparisons between existing and estimated HRs were made. Results. To provide healthcare in accordance with the patients’ metabolic control, the conventional model required increasing the number of family doctors (1.2 times) nutritionists (4.2 times) and social workers (4.1 times). The DiabetIMSS model requires greater increase than the conventional model. Conclusions. Increasing HR is required to provide evidence-based healthcare to diabetes patients.

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.

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.

OBJECTIVE:To evaluate the satisfaction and the factors related to dissatisfaction in patients suffering from type 2 diabetes and/or hypertension with care offered in family medicine clinics. MATERIAL AND METHOD: A secondary data analysis was conducted. Main outcome measures were two indices of satisfaction: family doctor-patient relationship (FDPR) and clinic organizational arrangements (OA). RESULTS: Approximately half of patients (n=1 323) were satisfied with care. In the FDPR index the items "kindness of the family doctor" (FD) scored high, while the lowest score was for the items: "the FD allows the patient to give an opinion about his/her treatment," "the patient understands the information" and "the FD spends enough time on the consultation." As for satisfaction with OA, the items "cleanliness of the clinic" and "ease of administrative procedures" obtained the lowest scores. In the logistic regression analysis the covariate "negative self-rated health" and "type of institution" were associated with dissatisfaction. CONCLUSIONS:There are aspects of the FDPR and OA that reveal dissatisfaction of patients with chronic conditions.OBJETIVO:Analizar la satisfacción y los factores relacionados con insatisfacción en pacientes con diabetes mellitus (DM) o hipertensión arterial (HTA) atendidos en clínicas de medicina familiar (MF). MATERIAL Y MÉTODOS:Se realizó análisis secundario de datos. Las variables de resultado fueron dos índices de satisfacción: relación médico familiar-paciente (RMFP) y aspectos organizacionales (AO). RESULTADOS:Aproximadamente la mitad de los pacientes (n=1 323) estuvieron satisfechos. Para la RMFP, "la amabilidad del MF" obtuvo la mayor calificación, y la más baja fue para "el MF permite la opinión del paciente sobre los tratamientos", "comprensión de la información" y "tiempo que el MF dedica al paciente". Para satisfacción con AO, "la limpieza de la clínica" y "fácil solución de los trámites administrativos" calificaron más bajo. En la regresión múltiple, la "autopercepción negativa de la salud" y "tipo de la institución" fueron relacionados con insatisfacción. CONCLUSIÓN: Existen aspectos de RMFP y AO que provocan mayor insatisfacción en los pacientes crónicos y requieren mayor atención.

OBJETIVO: Evaluar la autopercepción del estado de salud positivo (APES +) o negativo (APES -) de mujeres climatéricas e identificar los factores relacionados con la APES-. MATERIAL Y MÉTODOS: Se analizó la información de 9 248 mujeres de 40 a 59 años. Las variables dependientes fueron la APES y las independientes las características generales, antecedentes ginecoobstétricos, enfermedades crónicas, actividad física, participación en programas de detección y educación. Se realizó un análisis descriptivo, bivariado y multivariado. RESULTADOS: Una proporción de 42% de las mujeres refirió APES+ y 58% APES-. Los factores vinculados con APES- fueron primaria completa o menos (RM=1.78; IC95% 1.62-1.95), no tener trabajo remunerado (RM=1.20; IC95% 1.09-1.33), menopausia (RM=1.22; IC95% 1.11-1.33), diabetes (RM=1.88; IC95% 1.65-2.13), hipertensión (RM=2.01; IC95% 1.82-2.22), actividad física irregular (RM=1.30; IC95% 1.12-1.50), sedentarismo (RM=1.395; IC95% 1.23-1.57), falta de integridad de detección (RM=0.82; IC95% 0.75-0.89) y de información sobre el climaterio por parte de los servicios de salud (RM=1.17; IC95% 1.07-1.28). CONCLUSIÓN: Los factores relacionados con APES- son múltiples y algunos, como la información acerca del climaterio y la actividad física, deben fortalecerse.OBJECTIVE: To evaluate self-rated health (SRH) in climacteric women and to identify the factors associated with negative SRH. MATERIAL AND METHODS: 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. RESULTS: 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). CONCLUSIONS: Factors associated with negative SRH such as lack of information and physical activity should be strengthened.

Background: Rates of caesarean section surgery are rising worldwide, but the determinants of this increase, especially in low-income and middle-income countries, are controversial. In this study, we aimed to analyse the contribution of specific obstetric populations to changes in caesarean section rates, by using the Robson classification in two WHO multicountry surveys of deliveries in health-care facilities. The Robson system classifies all deliveries into one of ten groups on the basis of five parameters: obstetric history, onset of labour, fetal lie, number of neonates, and gestational age. Methods: We studied deliveries in 287 facilities in 21 countries that were included in both the WHO Global Survey of Maternal and Perinatal Health (WHOGS; 2004–08) and the WHO Multi-Country Survey of Maternal and Newborn Health (WHOMCS; 2010–11). We used the data from these surveys to establish the average annual percentage change (AAPC) in caesarean section rates per country. Countries were stratified according to Human Development Index (HDI) group (very high/high, medium, or low) and the Robson criteria were applied to both datasets. We report the relative size of each Robson group, the caesarean section rate in each Robson group, and the absolute and relative contributions made by each to the overall caesarean section rate. Findings: The caesarean section rate increased overall between the two surveys (from 26·4% in the WHOGS to 31·2% in the WHOMCS, p=0·003) and in all countries except Japan. Use of obstetric interventions (induction, prelabour caesarean section, and overall caesarean section) increased over time. Caesarean section rates increased across most Robson groups in all HDI categories. Use of induction and prelabour caesarean section increased in very high/high and low HDI countries, and the caesarean section rate after induction in multiparous women increased significantly across all HDI groups. The proportion of women who had previously had a caesarean section increased in moderate and low HDI countries, as did the caesarean section rate in these women. Interpretation: Use of the Robson criteria allows standardised comparisons of data across countries and timepoints and identifies the subpopulations driving changes in caesarean section rates. Women who have previously had a caesarean section are an increasingly important determinant of overall caesarean section rates in countries with a moderate or low HDI. Strategies to reduce the frequency of the procedure should include avoidance of medically unnecessary primary caesarean section. Improved case selection for induction and prelabour caesarean section could also reduce caesarean section rates. Funding: None.

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.OBJETIVO: Describir algunos de los resultados del Estudio de VPH en Morelos. El objetivo principal del Estudio de VPH en Morelos es evaluar el uso de la prueba del virus de papiloma humano (VPH), en relación con la prueba de Papanicolaou, para el tamizaje de cáncer cervical. MATERIAL Y MÉTODOS: El Estudio de VPH en Morelos actualmente se está llevando a cabo en México, para examinar la posibilidad de usar la prueba de VPH para la detección de cáncer cervical. Se evaluó el uso de la prueba de VPH en muestras auto-tomadas vaginales y en muestras cervicales tomadas por un clínico. Se comparó la aceptabilidad del uso de la prueba de VPH en muestras auto-tomadas al uso del Papanicolaou. También se realizó un análisis de costo-efectividad y de costo-beneficio. RESULTADOS: Los resultados del Estudio de VPH en Morelos indican que la prueba de VPH tiene una mayor sensibilidad para detectar los casos de neoplasia intraepitelial cervical 2/3 y cáncer cervical que la prueba de Papanicolaou. Los resultados también indican una aceptabilidad menor al uso de la prueba de Papanicolaou que al uso de la prueba de VPH auto-tomada. Los resultados del análisis de costo-efectividad y el análisis de costo-beneficio indican que el tamizaje con la prueba de VPH en mujeres de 20-80 años de edad siempre es más costo-efectivo que el tamizaje con el Papanicolaou. CONCLUSIONES: Nuestros resultados sugieren que la prueba del VPH (ya sea auto-tomada o clínica) podría ser utilizada en los programas de detección y prevención de cáncer cervical, como un complemento o un sustituto efectivo de la prueba de Papanicolaou.

Objetivo. Identificar las estrategias familiares de vida asociadas con desnutrición en niños menores de dos años. Material y métodos. Estudio de casos y controles efectuado en 1998 en el municipio de Teolocholco, estado de Tlaxcala, México, para estudiar familias con niños de 6 a 23 meses de edad. La muestra estuvo conformada por 105 casos y 210 controles. Las estrategias familiares de vida se agruparon en cinco tipos: formación de la familia, obtención y organización de recursos familiares, colaboración intra o extrafamiliar y preservación de la vida. La desnutrición se identificó de acuerdo con la talla para la edad. Para el análisis de los datos se hizo estimación de razones de momios, con intervalos de confianza al 95% y se construyeron modelos de regresión logística no condicionada. Resultados. Se obtuvieron datos de 605 unidades familiares, 445 controles y 160 casos. El modelo predictivo estuvo integrado por la escolaridad de la madre, hacinamiento, intervalo entre nacimientos, ingreso per capita mensual y el tiempo destinado para actividades de crianza/cuidado de los niños. Conclusiones. Las estrategias familiares de vida son determinantes para la ocurrencia desnutrición. Las características de la vida familiar deben considerarse en programas dirigidos a abatir el padecimiento en este grupo.Objective. To identify the role of family life strategies on malnutrition in children aged 6-23 months of age. Material and Methods. This case-control study was conducted in 1998 in the municipality of Teolocholco, State of Tlaxcala, Mexico, among families with children aged 6-23 months of age. The sample was conformed by 105 cases and 210 controls. Family life strategies were grouped into five types: family composition, means and distribution of family income, family and social networks, and life preservation strategies. Malnutrition was classified according to height for age. Data were analyzed using logistic regression to obtain odds ratios and 95% confidence intervals. Results. Data were collected from 605 families, for a total of 445 controls and 160 cases. The predictive model included mother's schooling, overcrowding, time elapsed between childbirths, per capita monthly income, and time devoted to child-rearing activities. Conclusions. Family life strategies determine children's nutritional status; understanding the influence of the family on the children's health status is necessary to develop effective programs aimed at improving the nutritional status of children.

OBJETIVO: Analizar el impacto de los servicios de salud, el saneamiento y la alfabetización en la mortalidad de menores de cinco años en dos estados con diferentes características socioculturales: Chiapas y Nuevo León. MATERIAL Y MÉTODOS: Se realizó un estudio ecológico con base en el análisis secundario de datos publicados por la Secretaría de Salud, el Instituto Nacional de Estadística, Geografía e Informática y el Consejo Nacional de Población, relativos a las tendencias de la mortalidad de menores de cinco años y a cambios de diversos indicadores, correspondientes al periodo de 1990-1997. Mencionar al tratamiento estadístico de los datos. Se realizó un estudio ecológico con base en el análisis secundario de datos publicados por la Secretaría de Salud, el Instituto Nacional de Estadística e Informática y el Consejo Nacional de Población, relativos a las tendencias de MMCA y a cambios de diversos indicadores, correspondientes al periodo de 1990-1997. Para ambos estados se calcularon las variaciones registradas y se determinaron las tendencias mediante análisis de regresión lineal simple, en el que la variable independiente correspondió a los años de estudio. Se hizo también análisis de correlación parcial entre las diversas tendencias de mortalidad estudiadas y entre éstas y los indicadores seleccionados. RESULTADOS: En el periodo estudiado se registró un marcado descenso de la mortalidad de menores de cinco años que fue más acentuado en Chiapas; en ambas entidades se relacionó principalmente con la disminución de mortalidad por enfermedad diarreica, aunque también con la de sarampión e infecciones respiratorias agudas. En Chiapas los indicadores que correlacionaron más significativamente con este descenso fueron las coberturas de vacunación y el alfabetismo; en Nuevo León, el aumento en el número de enfermeras, las coberturas de vacunación, el alfabetismo y las viviendas con agua entubada. CONCLUSIONES: En el periodo estudiado se redujo el diferencial en las tasas de mortalidad de menores de cinco años entre Chiapas y Nuevo León; para mantener o acelerar tal descenso es necesario continuar con los programas analizados y, en Chiapas o estados similares, ampliar en forma más acelerada la infraestructura en salud.OBJECTIVE: To analyze differences of the impact of health care services, sanitation and literacy on the mortality rates of children under five years of age, in two Mexican states with marked socioeconomic differences: Chiapas and Nuevo Leon. MATERIAL AND METHODS: The study design was ecologic, based on a retrospective analysis of data published by the Health Ministry (Secretaría de Salud), National Institute of Statistics, Geography and Informatics (Instituto Nacional de Estadística, Geografía e Informática) and the National Population Council (Consejo Nacional de Población), on the tendencies of mortality among children under five years and on the changes of selected indicators corresponding to the period 1990-1997. Study design: ecologic study. This was based on a retrospective analysis of data published by Secretaría de Salud, Instituto Nacional de Estadística e Informática and Consejo Nacional de Población, about the tendencies of mortality among children under five years, and about the changes of selected indicators. The analysis was carried out in the period comprised between 1990-1997. For both states the registered variations were calculated and the trends were determined through analysis of simple linear regression; the independent variable corresponded to the study years. Partial correlation analysis between the various mortality trends studies and between and the selected indicators, were calculated. RESULTS: During the studied period there was a steady decline of children mortality, which was more marked in Chiapas. In both entities, this decrease was closely related to the decline in mortality due to acute diarrhea, and also correlated with a descent in measles and acute respiratory infections. In Chiapas, the indicators which correlated more significantly with this decline in mortality were vaccination coverage and literacy. In Nuevo Leon, the indicators with greater correlation were the increase in the number of nurses, of lodgings with piped water and vaccination coverage. CONCLUSIONS: During the analyzed period, the mortality rate of children under five years of age decreased in the states of Chiapas and Nuevo Leon. To sustain or accelerate the decline in childhood mortality it is mandatory to continue with the currently implemented programs, and in Chiapas, and similar states, to increase the available infrastructure to provide health care.

The first evaluation of the Medical Insurance for a New Generation program (SMNG) was conducted in 2009. A mixed-method approach was used to obtain a comprehensive picture of SMNG members and the program itself. The evaluation comprised: 1) Program design; 2) Social and health conditions of its members; 3); Evaluation of SMNG's performance by measuring coverage, productivity and efficiency; 4) Families health expenditures. The lessons learned for the program are that SMNG is focused on a vulnerable segment of the population with pervasive unmet health needs; prevalence of malnutrition, anemia and other conditions remains high. Further efforts are necessary to deploy the program where it is most needed, particularly in rural areas; most of its members are urban dwellers. However, more needs to be done to educate members about the importance of preventive care and to build the capability of health providers to provide high quality care. Families are still experiencing hardship to provide medical care to their children, so additional efforts are needed to decrease out-of-pocket and catastrophic expenditures. The lessons learned for the evaluation allow concluding that this first evaluation set the groundwork for better-targeted subsequent interventions and evaluations aimed at showing the impact of SMNG to bridge existing gaps in equity, access, coverage, and health status of Mexican children.La primera evaluación del Seguro Médico para una Nueva Generación (SMNG) se llevó a cabo en 2009. La evaluación utilizó métodos mixtos para obtener una imagen completa de los miembros del SMNG y del programa. La evaluación comprendió: 1) el diseño del programa, 2) las condiciones sociales y de salud de los miembros, 3) acceso y uso de los servicios de salud, 4) la calidad de los servicios de atención ambulatoria y hospitalaria y 5) el efecto en los gastos de salud de las familias. El SMNG está enfocado a la población vulnerable con necesidades de salud no satisfechas, donde persiste la prevalencia de la desnutrición, anemia y otras enfermedades. Son necesarios esfuerzos adicionales para aumentar la cobertura del programa en zonas rurales donde la necesidad es mayor; pues la mayoría de sus miembros habitan en áreas urbanas, también es indispensable fortalecer la atención preventiva y fortalecer la capacidad de los proveedores de salud para proporcionar atención de alta calidad. Las familias todavía están experimentando dificultades para prestar atención a sus hijos, son necesarios esfuerzos adicionales para disminuir los gastos de bolsillo y catastrófico. Esta primera evaluación establece las bases para intervenciones y evaluaciones posteriores sustentadas en objetivos mejor definidos y enfocados a demostrar que SMNG está disminuyendo las brechas existentes en equidad, acceso, cobertura y estado de salud de la niñez mexicana.

OBJECTIVE: To describe the utilization and associated factors for preventive and curative care utilization among children affiliated to the Medical Insurance for a New Generation (SMNG). MATERIALS AND METHODS: Data from the 2009 National Survey of SMNG was analyzed. RESULTS: The analysis represented 1 316 867 children; 25% of urban and 37.5% of rural mothers that took their children to well-child visits. Covariates associated with preventive care utilization were children 35 years, mother's literacy level of bachelor degree, housewife, attendance at >7 antenatal care visits, and living in a rural area. Curative care: 12% attended emergency room services, 5.4% were hospitalized and 66% received ambulatory care. Covariates associated with curative care utilization: child history of frequent diseases, mother living with husband/partner, mother's literacy level of bachelor degree, attendance >7 antenatal care visits and having paid work. CONCLUSION: It is needed to reinforce the programs encouraging mothers to seek preventive care regularly.OBJETIVO: Describir el uso y factores asociados para la atención preventiva y curativa de niños afiliados al Seguro Médico para una Nueva Generación (SMNG). MATERIAL Y MÉTODOS: Análisis de la información de la Encuesta Nacional SMNG 2009. RESULTADOS: El análisis representó 1316867 niños; 25% de madres urbanas y 37,5% de rurales que llevaron a sus hijos para atención preventiva. Variables asociadas con atención preventiva regular: niños 35 años, escolaridad licenciatura, ama de casa, asistencia a >7 visitas de atención prenatal y vivienda en zona rural. 12% acudió a servicios de urgencias, 5,4% fueron hospitalizados y 66% recibió atención ambulatoria. Antecedentes de enfermedades infecciosas, madre que vive con su esposo o pareja, escolaridad licenciatura, asistencia a >7 visitas prenatales y tener un trabajo remunerado se asociaron con la utilización de servicios curativos. CONCLUSIÓN: Es indispensable fomentar que las madres lleven a sus hijos regularmente a atención preventiva.

OBJECTIVE: To describe the Medical Insurance for a New Generation (SMNG) as key public policy aimed at improving health care services for children under the age of five years in Mexico. MATERIALS AND METHODS: This paper analyzes interrelated aspects of public policies to provide health care to Mexican children: a) the demographic and health status of children, with emphasis on the wide disparities between children of varying demographics; b) the relationship of the main functions of a health care system: financing, equity, access and quality, with the provision of health care for children; c) the architecture of the Medical Insurance for a New Generation. CONCLUSION: SMNG is a program that can be instrumental in lowering infant mortality and alleviating the burden of families to care for sick children by improving access, quality of care and equity.OBJETIVO: Describir la importancia del Seguro Médico para una Nueva Generación (SMNG) como un elemento clave de las políticas públicas mexicanas destinadas a mejorar los servicios de salud para los niños menores de cinco años. MATERIAL Y MÉTODOS: Este artículo analiza aspectos interrelacionados con la salud de los niños mexicanos: a) las disparidades del estado de salud entre los niños con distintas características demográficas, b) la relación de las funciones del sistema de salud: finaciamiento, equidad, acceso y calidad, con la provisión de servicios de salud para los niños, c) El diseño del Seguro Médico para una Nueva Generación como herramienta para disminuir las brechas de desigualdad en la niñez mexicana. CONCLUSIÓN: El SMNG es un programa cuyo principal objetivo es fortalecer los servicios de salud desde el lado de la demanda. SMNG puede contribuir a reducir la morbilidad y mortalidad en los menores de cinco años y aliviar la carga de las familias para el cuidado de sus niños enfermos, mejorando el acceso, la calidad de los servicios de salud y la equidad.

OBJECTIVE: To describe the mixed-method approach to evaluate the Medical Insurance for a New Generation (Seguro Médico para una Nueva Generación, SMNG). MATERIALS AND METHODS: The program has been comprehensively evaluated. It has four key domains: 1) SMNG design; 2) children's health status and socio-demographic characteristics; 3) performance by measuring coverage, efficiency and productivity; 4) family health expenditure. Quantitative and qualitative research approaches have been used. This included reviews of existing databases and clinical charts, collection of empirical data through in-depth interviews with healthcare providers, and a nation-wide household survey. CONCLUSION: The results should serve as baseline data of the health status of SMNG children and the current staus of the program.OBJETIVO: Describir el abordaje de métodos mixtos que se utilizó para evaluar el SMNG Seguro Médico para una Nueva Generación. MATERIAL Y MÉTODOS: la evaluación integral del Programa se llevó a cabo en cuatro áreas clave: 1) el diseño del SMNG, 2) el estado de salud y las características sociodemográficas de los niños afiliados, 3) el desempeño del SMNG mediante la medición de la cobertura y de procesos clave, 4) los gastos en salud de la familia. La metodología mixta combina enfoques de investigación cuantitativa y cualitativa y la recolección y análisis de datos. La evaluación incluyó la revisión de bases de datos y de expedientes clínicos y la recolección de datos empíricos mediante entrevistas a profundidad con actores clave, una encuesta de hogares en todo el país y cuestionarios a personal de salud. CONCLUSIÓN: Los resultados sirven como referencia sobre el estado de salud de los niños afiliados al SMNG y de las condiciones actuales del programa; además permiten identificar áreas clave que pueden abordarse para mejorar la calidad, eficiencia y eficacia del SMNG.

OBJETIVO: Evaluar el efecto en la prescripción de hipoglucémicos de un programa de educación médica continua en unidades de medicina familiar (UMF). MATERIAL Y MÉTODOS: Se realizó un estudio observacional que comparó dos grupos (con y sin programa) con dos cortes transversales (antes y después). La unidad de análisis fue la consulta. El periodo de análisis comprendió seis meses anteriores y seis posteriores a la institución del programa. La principal variable de resultado fue la prescripción adecuada, evaluada mediante dos criterios: elección e indicación correctas. El análisis incluyó modelos de regresión logística, se aplicó la técnica de dobles diferencias y se ajustó por variables relativas al paciente, la consulta y la UMF; las más relevantes fueron sexo, obesidad, otras afecciones, número de consultas, número de medicamentos, tamaño de la clínica, grupo y etapa. RESULTADOS: Se obtuvo un incremento atribuible al programa de 0.6% en la probabilidad de prescripción adecuada y de 11% en la elección correcta en pacientes obesos.OBJECTIVE: To evaluate the impact of a continuing medical education program on family doctors to improve prescription of hypoglycemic drugs. MATERIAL AND METHODS: An observational study was conducted with two groups of comparison (with-without program) and before-after periods. The unit of analysis was the visit. The period of evaluation comprised six months before and six after implementing the program. The outcome variable was the appropriateness of prescription that was based upon two criteria: appropriate selection and proper indication of the drug. Logistic regression models and the double differences technique were used to analyze the information. Models were adjusted by independent variables related with the patient, the visit and the PCC, the more relevant ones were: sex, obesity, conditions other than diabetes, number of visits in the analyzed period, number of drugs prescribed, size of the PCC and period. RESULTS: the program increases 0.6% the probability of appropriate prescription and 11% the probability of appropriate choice of the hypoglycemic drug in obese patients.