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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: This 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., Methods: We 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., Results: 25 745 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., Conclusion: Quality 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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Despite the substantial attention to primary care (PC), few studies have addressed the relationship between patients' experience with PC and their health status in low-and middle-income countries. This study aimed to (1) test the association between overall patient-centered PC experience (OPCE) and self-rated health (SRH) and (2) identify specific features of patient-centered PC associated with better SRH (i.e., excellent or very good SRH) in 6 Latin American and Caribbean countries., Methods and Findings: We conducted a secondary analysis of a 2013 public opinion cross-sectional survey on perceptions and experiences with healthcare systems in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama; the data were nationally representative for urban populations. We analyzed 9 features of patient-centered PC. We calculated OPCE score as the arithmetic mean of the PC features. OPCE score ranged from 0 to 1, where 0 meant that the participant did not have any of the 9 patient-centered PC experiences, while 1 meant that he/she reported having all these experiences. After testing for interaction on the additive scale, we analyzed countries pooled for aim 1, with an interaction term for Mexico, and each country separately for aim 2. We used multiple Poisson regression models double-weighted by survey and inverse probability weights to deal with the survey design and missing data. The study included 6,100 participants. The percentage of participants with excellent or very good SRH ranged from 29.5% in Mexico to 52.4% in Jamaica. OPCE was associated with reporting excellent or very good SRH in all countries: adjusting for socio-demographic and health covariates, patients with an OPCE score of 1 in Brazil, Colombia, El Salvador, Jamaica, and Panama were more likely to report excellent or very good SRH than those with a score of 0 (adjusted prevalence ratio [aPR] 1.61, 95% CI 1.37-1.90, p < 0.001); in Mexico, this association was even stronger (aPR 4.27, 95% CI 2.34-7.81, p < 0.001). The specific features of patient-centered PC associated with better SRH differed by country. The perception that PC providers solve most health problems was associated with excellent or very good SRH in Colombia (aPR 1.38, 95% CI 1.01-1.91, p = 0.046) and Jamaica (aPR 1.21, 95% CI 1.02-1.43, p = 0.030). Having a provider who knows relevant medical history was positively associated with better SRH in Mexico (aPR 1.47, 95% CI 1.03-2.12, p = 0.036) but was negatively associated with better SRH in Brazil (aPR 0.71, 95% CI 0.56-0.89, p = 0.003). Finally, easy contact with PC facility (Mexico: aPR 1.35, 95% CI 1.04-1.74, p = 0.023), coordination of care (Mexico: aPR 1.53, 95% CI 1.19-1.98, p = 0.001), and opportunity to ask questions (Brazil: aPR 1.42, 95% CI 1.11-1.83, p = 0.006) were each associated with better SRH. The main study limitation consists in the analysis being of cross-sectional data, which does not allow making causal inferences or identifying the direction of the association between the variables., Conclusions: Overall, a higher OPCE score was associated with better SRH in these 6 Latin American and Caribbean countries; associations between specific characteristics of patient-centered PC and SRH differed by country. The findings underscore the importance of high-quality, patient-centered PC as a path to improved population health., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: FG is an employee of the Inter-American Development Bank (IDB). MEK is a member of the Editorial Board of PLOS Medicine. All other authors have declared that no competing interests exist.

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., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

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 Measures: 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., (© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

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.

Background and Objectives: In Mexico, hypertension is among the top five causes for visits to primary care clinics; its complications are among the main causes of emergency and hospital care. The present study reports the effectiveness of a continuing medical education (CME) intervention to improve appropriate care for hypertension, on blood pressure control of hypertensive patients in primary care clinics., Methods: A secondary data analysis was carried out using data of hypertensive patients treated by family doctors who participated in the CME intervention. The evaluation was designed as a pre-/post-intervention study with control group in six primary care clinics. The effect of the CME intervention was analysed using multiple logistic regression modelling in which the dependent variable was uncontrolled blood pressure in the post-intervention patient measurement., Results: After the CME intervention, the net reduction of uncontrolled blood pressure between stages in the intervention group was 10.3%. The model results were that being treated by a family doctor who participated in the CME intervention reduced by 53% the probability of lack of control of blood pressure; receiving dietary recommendations reduced 57% the probability of uncontrolled blood pressure. Having uncontrolled blood pressure at the baseline stage increased the probability of lack of control in 166%, and per each unit of increase in body mass index the lack of control increased 7%., Conclusions: CME intervention improved the medical decision-making process to manage hypertension, thus increasing the probability of hypertensive patients to have blood pressure under control., (© 2010 Blackwell Publishing Ltd.)

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).

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.

Objective: To assess the health needs of the eligible public population of the Mexican Institute of Social Security (IMSS)., Design: Observational, descriptive, transversal study., Setting: Family Medicine Unit number 8 of the IMSS, in the city of Tlaxcala, Mexico., Participants: A sample of 1200 families using multi-stage sampling, between October 1999 and March 2000., Main Measurements: The designed and validated questionnaire on "Family health diagnosis" was used., Results: A 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., Conclusions: Identification 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.

A population-based case control study was conducted to ascertain whether the process of primary care can be a determinant of infant mortality due to Acute Respiratory Infection (ARI). Cases were 118 infants who died from ARI, individually matched with 118 infants who suffered an ARI episode and recovered. Information was gathered through interviewing mothers. Study variables were assembled into five subsets: children's characteristics; mothers' characteristics; access to medical services; process of primary care, and; sociodemographic variables. An index per subset was built to analyze the independent influence of each on ARI death risk. The index was constructed upon the weighted sum of the adjusted odds ratios (OR) within each subset. Then, the values of each index were collapsed into high/low values with the 50 percentile as a cut-off value. Next, by means of a conditional logistic regression procedure, an explanatory model of ARI mortality was obtained. The final multivariate model included the indexes that showed an independent effect: I) Process of care (OR 9.68, CI 95% 3.59-26.1): inadequate referral, attention provided by more than one physician and being attended by a private physician; II) children's characteristics (OR 7.22, CI 95% 2.35-22.2): perinatal history, lack of breast-feeding and incomplete immunization scheme; III) access to medical services (OR 5.27, CI 95% 2.02-13.7): geographic and economic barriers, lack of confidence in public health services, and; IV) mothers' characteristics (OR 4.03, CI 95% 1.18-13.8), mainly represented by untimely care seeking. We conclude that the management of the disease is a key determinant in which factors relating to the mother and the health services are strongly related. Our study reveals untimely care seeking, difficult access and inadequate disease treatment as important factors which deserve careful attention in the future. We also confirm the importance of biological determinants previously described. A main strategy to reduce infant mortality due to ARI should be to encourage training of primary care physicians, including private practitioners, focused on providing effective case management and emphasizing the education to mothers.

The operative Model of Primary Health Care, was developed to offer health services to a population living under conditions of extreme poverty in the municipality of Chimalhuacán, State of México. This article describes the theorical framework, organization and operationalization of an innovative model, changing the current paradigm of clinical practice to include allied health personnel with and especial training. At the core of the model is the Basic Unit of Primary Care that includes one physician and five allied health technicians for each 15,000 habitants. This model offer an alternative to improve the utilization of available personnel and infrastructure. Finally this paper emphasizes the importance of the permanece, surveillance and evaluation of the model.

To attend health requirements of a poor community nearby Mexico City, the Ministry of Health, implemented an innovative health services model, compounded by allied health personnel (AHP) and general practitioners. The main feature of this model is that the AHP had been involved to provide clinical services in five causes of consultation: upper acute respiratory infections, diarrheal disease, prenatal care, family planning and well-child program. In this paper, the authors analyze the patient's satisfaction and the productivity of this model compared with the conventional one. In order to evaluate patient's satisfaction, 500 patients were interviewed, 300 who were attended by innovative model and 200 who were attended by the traditional one. In both health services models a high percentage (98%) of the patients were satisfied with the attention they received. The productivity analysis showed that the number of consultations given for the five causes mentioned above and for other causes, was higher in the innovative model than in the traditional one. The relevance of the allied health personnel to provide primary care services is discussed.