Search

Mexico ranks among the OECD countries with the highest prevalence of teenage pregnancies, exhibiting a fertility rate of 70.6 births for every 1000 adolescents. Mexican adolescents with a history of pregnancy are twice as likely to lag behind in their studies as those who have not been pregnant. Research on adolescent maternity and its explanatory mechanisms is required as a basis for implementing policies and programs that effectively curb teenage pregnancy-related behaviors, prevent educational gaps, and reduce the intergenerational transmission of poverty. Based on quasi-experimental methodology and a non-recursive structural equation model with instrumental variables, this paper analyzed the intergenerational transmission of teenage pregnancy from mothers to daughters, as well as the relationship between teenage pregnancy and educational attainment. Using data from the 2009 National Survey of Demographic Dynamics in Mexico, our estimated model indicated a unidirectional relationship from teenage pregnancy to educational attainment. An association was observed between teenage pregnancy and an increased probability of a moderate or severe educational gap (≥ 1 year) by 21% ± 5 and a severe educational gap (≥ 2 years) by 33% ± 8. Adolescents whose mothers reported teenage pregnancy at 15 years of age were approximately 84% more likely to experience teenage pregnancy themselves than other adolescents. Relevant explanatory mechanisms included low socioeconomic status and a low level of education in the household. Mexico needs to formulate, implement, and expand comprehensive and early prevention strategies as well as teenage pregnancy care throughout its most vulnerable regions. Efforts should be made at the individual, family, and community levels; incorporate alliances with teenage networks; actively engage parents, teachers, and health care providers; and reinforce educational initiatives on sexual and reproductive health for adolescents. It would be convenient for the Government to implement public policies that emphasize the results obtained. There is no better instrument than to show the evidence of the gradual deterioration of human capital in Mexico associated with adolescent pregnancy.

This study determined the efficiency of two different models of diabetes care (traditional units and multidisciplinary units), estimated quality levels, and identified management practices associated with better quality and efficiency of both models in Mexico. A random sample consisting of 40 units (20 for each type of unit), allowed us to estimate technical efficiency using data envelopment analysis (DEA) after we calculated quality scores (performance and competence). We mapped the relationship between efficiency and quality score, and using a positive deviance approach, we studied managerial determinants of best performance in terms of both efficiency and quality. We found that efficiency in multidisciplinary units was higher than in traditional units; traditional units scored very low in terms of efficiency. Likewise, in terms of the different quality metrics, the multidisciplinary units were much better evaluated than the traditional units. We found important differences in the quality scores for the different health care models. Two-thirds of the multidisciplinary units were in the best-performing group (above-median efficiency and above-median performance), and almost half of them were mapped to the high-competence quadrant. On the other hand, only 10% of the traditional units managed to position themselves in the best performance quadrant. Managerial characteristics were positively correlated with the probability of belonging to the group with the highest performance. Our findings indicate that multidisciplinary medical care can lead to better outcomes for patients with diabetes compared to traditional medical care. In both types of units, however, there is substantial opportunity to improve efficiency and quality levels.

To slow the spread of COVID-19, most countries implemented stay-at-home orders, social distancing, and other nonpharmaceutical mitigation strategies. To understand individual preferences for mitigation strategies, we piloted a web-based Respondent Driven Sampling (RDS) approach to recruit participants from four universities in three countries to complete a computer-based Discrete Choice Experiment (DCE). Use of these methods, in combination, can serve to increase the external validity of a study by enabling recruitment of populations underrepresented in sampling frames, thus allowing preference results to be more generalizable to targeted subpopulations. A total of 99 students or staff members were invited to complete the survey, of which 72% started the survey (n = 71). Sixty-three participants (89% of starters) completed all tasks in the DCE. A rank-ordered mixed logit model was used to estimate preferences for COVID-19 nonpharmaceutical mitigation strategies. The model estimates indicated that participants preferred mitigation strategies that resulted in lower COVID-19 risk (i.e. sheltering-in-place more days a week), financial compensation from the government, fewer health (mental and physical) problems, and fewer financial problems. The high response rate and survey engagement provide proof of concept that RDS and DCE can be implemented as web-based applications, with the potential for scale up to produce nationally-representative preference estimates.

Pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV but requires sustained adherence. Conditional economic incentives (CEIs) can improve medication-taking behaviors, yet preferences for programs that employ CEIs to increase PrEP use among male sex workers (MSWs) have not been investigated. We conducted a discrete choice experiment in Mexico City to elicit stated preferences for a CEI-based PrEP adherence program among MSWs. Respondents expressed their preferences for different program characteristics: incentive amount; incentive format; incentive type; and adherence-verification method. We used a random utility logit model to estimate the relative importance of each attribute and estimated willingness-to-pay. MSWs preferred a higher, fixed incentive, with PrEP adherence measured via hair sampling. MSWs were willing to forego up to 21% of their potential maximum CEI amount to ensure receipt of a fixed payment. MSWs are highly willing to accept a CEI-based intervention for PrEP adherence, if offered along with fixed payments.La profilaxis previa a la exposición (PrEP) es muy eficaz para prevenir el VIH, pero requiere una adherencia sostenida. Los incentivos económicos condicionales (IEC) pueden mejorar los comportamientos de toma de medicamentos, sin embargo, no se han investigado las preferencias por los programas que emplean IEC para aumentar el uso de PrEP entre los trabajadores sexuales masculinos (TSM). Realizamos un experimento de elección discreta con TSM en la Ciudad de México para obtener preferencias declaradas para un programa de adherencia a la PrEP basado en IEC. Los participantes expresaron sus preferencias en cuanto a diferentes características: monto del incentivo; formato del incentivo; tipo de incentivo; y método de verificación de la adherencia. Utilizamos un modelo logit de utilidad aleatoria para estimar la importancia relativa de cada atributo y la disposición a pagar estimada (DAP). Los TSM prefirieron un incentivo fijo más alto, con la adherencia a la PrEP medida a través de muestras de cabello. Los TSM estaban dispuestos a renunciar hasta el 21% de su monto máximo potencial de IEC para garantizar la recepción de un pago fijo. Los TSM están muy dispuestos a aceptar una intervención basada en IEC para la adherencia a la PrEP, si se ofrece junto con pagos fijos.

Background The ImPrEP México demonstration project is the first to distribute free HIV pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM) and transgender women living in Mexico. In Mexico City, MSM who are also male sex workers (MSWs) face a disproportionately high risk of HIV infection. PrEP is highly effective for HIV prevention, yet “real-life” implementation among MSWs is a challenge due to the unique adherence barriers faced by this population. Methods This study uses the RE-AIM implementation science framework to characterize the unique barriers to and facilitators of PrEP uptake among MSWs in Mexico City. We conducted 9 in-depth key informant interviews and 2 focus group discussions with MSWs across 5 clinic and community sites. Qualitative data were analyzed using inductive, open coding approaches from grounded theory. We supplemented findings from the primary qualitative analysis with quantitative indicators derived from ImPrEP program records to describe the current Reach of the ImPrEP program among MSWs in Mexico City and the potential for wider PrEP Adoption among other high-risk populations in Mexico. Results The Reach of the ImPrEP program was 10% of known HIV-negative MSWs in Mexico City. Program Reach was lowest among MSWs who were street-based sex workers, of lower socioeconomic status, migrants from other states and self-identified as heterosexual. Barriers to program Reach included limited PrEP knowledge, HIV-related stigma, and structural barriers; facilitators included in-person program recruitment, patient-centered care, and spread of information through word of mouth among MSWs. Two out of the four eligible institutions had adopted the ImPrEP protocol. Barriers to wider program Adoption included HIV- and sexual identity– related stigma, protocol limitations, and lack of a national policy for PrEP distribution; facilitators of Adoption included existing healthcare infrastructure, sensitized providers, and community support from non-governmental organizations. Conclusions Increasing the ImPrEP program’s Reach among MSWs will depend on improving PrEP education and addressing HIV-related stigma and access barriers. Future Adoption of the ImPrEP program should build on existing clinical infrastructure and community support. Creation of a national policy for PrEP distribution may improve the Reach and Adoption of PrEP among highest-risk populations in Mexico.

Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

Introduction: Male sex workers are at high-risk for acquisition of sexually transmitted infections, including human immunodeficiency virus. We quantified incidence rates of sexually transmitted infections and identified their time-varying predictors among male sex workers in Mexico City. Methods: Male sex workers recruited from the largest human immunodeficiency virus clinic and community sites in Mexico City were tested for chlamydia, gonorrhea, syphilis, hepatitis, and human immunodeficiency virus at baseline, 6-months, and 12-months. Incidence rates with 95% bootstrapped confidence limits were calculated. We examined potential time-varying predictors using generalized estimating equations for a population averaged model. Results and Discussion: Among 227 male sex workers, median age was 24 and baseline human immunodeficiency virus prevalence was 32%. Incidence rates (per 100 person-years) were as follows: human immunodeficiency virus (5.23; 95% confidence interval [CI]: 2.15, 10.31), chlamydia (5.15; 95% CI: 2.58, 9.34), gonorrhea (3.93; 95% CI: 1.88, 7.83), syphilis (13.04; 95% CI: 8.24, 19.94), hepatitis B (2.11; 95% CI: 0.53, 4.89), hepatitis C (0.95; 95% CI: 0.00, 3.16), any sexually transmitted infection except human immunodeficiency virus (30.99; 95% CI: 21.73, 40.26), and any sexually transmitted infection including human immunodeficiency virus (50.08; 95% CI: 37.60, 62.55). In the multivariable-adjusted model, incident sexually transmitted infections (excluding human immunodeficiency virus) were lower among those who reported consistently using condoms during anal and vaginal intercourse (odds ratio = 0.03, 95% 0.00, 0.68) compared to those who reported inconsistently using condoms during anal and vaginal intercourse. Conclusions: Incidence of sexually transmitted infections is high among male sex workers in Mexico City. Consistent condom use is an important protective factor for sexually transmitted infections, and should be an important component of interventions to prevent incident infections.

OBJECTIVE Diabetes mellitus is an important risk factor for severe COVID-19, but little is known about the marginal effect of additional risk factors for severe COVID-19 among individuals with diabetes. We tested the hypothesis that sociodemographic, access to healthcare, and presentation to care characteristics among individuals with diabetes in Mexico confer an additional risk of hospitalization with COVID-19. RESEARCH DESIGN AND METHODS We conducted a cross-sectional study using public data from the General Directorate of Epidemiology of the Mexican Ministry of Health. We included individuals with laboratory-confirmed SARS-CoV-2 between March 1st and July 31st, 2020. The primary outcome was the predicted probability of hospitalization, inclusive of 8.5% of patients who required intensive care unit (ICU) admission. RESULTS Among 373,963 adults with COVID-19, 16.1% [95% CI: 16.0-16.3] self-reported diabetes. The predicted probability of hospitalization was 38.4% [37.6-39.2] for patients with diabetes only and 42.9% [42.2-43.7] for patients with diabetes and one or more comorbidities (obesity, hypertension, cardiovascular disease, and chronic kidney disease). High municipality-level of social deprivation and low state-level healthcare resources were associated with a 9.5% [6.3-12.7] and 17.5% [14.5-20.4] increased probability of hospitalization among patients with diabetes, respectively. In age-, sex-, and comorbidity-adjusted models, living in a context of high social vulnerability and low healthcare resources was associated with the highest predicted probability of hospitalization. CONCLUSIONS Social vulnerability contributes considerably to the probability of hospitalization among individuals with COVID-19 and diabetes with associated comorbidities. These findings can inform mitigation strategies for populations at the highest risk of severe COVID-19.

OBJECTIVE Diabetes is an important risk factor for severe coronavirus disease 2019 (COVID-19), but little is known about the marginal effect of additional risk factors for severe COVID-19 among individuals with diabetes. We tested the hypothesis that sociodemographic, access to health care, and presentation to care characteristics among individuals with diabetes in Mexico confer an additional risk of hospitalization with COVID-19. RESEARCH DESIGN AND METHODS We conducted a cross-sectional study using public data from the General Directorate of Epidemiology of the Mexican Ministry of Health. We included individuals with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 between 1 March and 31 July 2020. The primary outcome was the predicted probability of hospitalization, inclusive of 8.5% of patients who required intensive care unit admission. RESULTS Among 373,963 adults with COVID-19, 16.1% (95% CI 16.0–16.3) self-reported diabetes. The predicted probability of hospitalization was 38.4% (37.6–39.2) for patients with diabetes only and 42.9% (42.2–43.7) for patients with diabetes and one or more comorbidities (obesity, hypertension, cardiovascular disease, and chronic kidney disease). High municipality-level of social deprivation and low state-level health care resources were associated with a 9.5% (6.3–12.7) and 17.5% (14.5–20.4) increased probability of hospitalization among patients with diabetes, respectively. In age-, sex-, and comorbidity-adjusted models, living in a context of high social vulnerability and low health care resources was associated with the highest predicted probability of hospitalization. CONCLUSIONS Social vulnerability contributes considerably to the probability of hospitalization among individuals with COVID-19 and diabetes with associated comorbidities. These findings can inform mitigation strategies for populations at the highest risk of severe COVID-19.

We describe associations of pretreatment drug resistance (PDR) with clinical outcomes such as remaining in care, loss to follow-up (LTFU), viral suppression, and death in Mexico, in real-life clinical settings. We analyzed clinical outcomes after a two-year follow up period in participants of a large 2017–2018 nationally representative PDR survey cross-referenced with information of the national ministry of health HIV database. Participants were stratified according to prior ART exposure and presence of efavirenz/nevirapine PDR. Using a Fine-Gray model, we evaluated virological suppression among resistant patients, in a context of competing risk with lost to follow-up and death. A total of 1823 participants were followed-up by a median of 1.88 years (Interquartile Range (IQR): 1.59–2.02): 20 (1%) were classified as experienced + resistant; 165 (9%) naïve + resistant; 211 (11%) experienced + non-resistant; and 1427 (78%) as naïve + non-resistant. Being ART-experienced was associated with a lower probability of remaining in care (adjusted Hazard Ratio(aHR) = 0.68, 0.53–0.86, for the non-resistant group and aHR = 0.37, 0.17–0.84, for the resistant group, compared to the naïve + non-resistant group). Heterosexual cisgender women compared to men who have sex with men [MSM], had a lower viral suppression (aHR = 0.84, 0.70–1.01, p = 0.06) ART-experienced persons with NNRTI-PDR showed the worst clinical outcomes. This group was enriched with women and persons with lower education and unemployed, which suggests higher levels of social vulnerability.

Men who have sex with men (MSM) face a disproportionate burden of HIV incidence and HIV prevalence, particularly young men who have sex with men. The aim of this article was to analyze the relation between a psychological temporal perspective and HIV/sexually transmitted infection (STI) risk behaviors among male sex workers (MSWs), a potentially highly present-oriented group of MSM. A total sample of 326 MSWs were included and responded to a validated psychological scale: the Zimbardo’s Time Perspective Inventory; they also reported how frequently they engaged in protective behaviors against HIV and other STI risks behaviors, including condom use with casual and regular partners, as well as prior HIV testing. We adjusted structural equation models to analyze the relation between a psychological temporal perspective and HIV/STI risk behaviors. We found that orientation toward the past was correlated with decreased condom use with casual partners (β = − 0.18; CI95% − 0.23, − 0.12). Future orientation was not associated with condom use with casual partners. Regarding condom use with regular partners, past and present orientation were related to lower likelihood of condom use (β = − 0.23; CI95% − 0.29, − 0.17; β = − 0.11; CI95% − 0.19, − 0.02), whereas future orientation increased the likelihood of condom use with regular partners (β = 0.40; CI95% 0.31, 0.50). Time orientation (past, present, or future) did not predict the probability of having an HIV test. The design of HIV/STI prevention programs among vulnerable populations, such as MSM and MSWs, should consider specific time-frame mechanisms that can importantly affect sexual risk behavior decisions.

Randomized controlled pilot evaluated effect of conditional economic incentives (CEIs) on number of sex partners, condom use, and incident sexually transmitted infections (STIs) among male sex workers in Mexico City. Incentives were contingent on testing free of new curable STIs and/or clinic attendance. We assessed outcomes for n = 227 participants at 6 and 12 months (during active phase with incentives), and then at 18 months (with incentives removed). We used intention-to-treat and inverse probability weighting for the analysis. During active phase, CEIs increased clinic visits (10-13 percentage points) and increased condom use (10-15 percentage points) for CEI groups relative to controls. The effect on condom use was not sustained once CEIs were removed. CEIs did not have an effect on number of partners or incident STIs. Conditional incentives for male sex workers can increase linkage to care and retention and reduce some HIV/STI risks such as condomless sex, while incentives are in place.

To describe the temporal and geographical patterns of the continuum of maternal health care in Mexico, as well as the sociodemographic characteristics that affect the likelihood of receiving this care.We conducted a pooled cross-sectional analysis using the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics, collating sociodemographic and obstetric characteristics of 93 745 women aged 12-54 years at last delivery. We defined eight variables along the antenatal-postnatal continuum, both independently and conditionally. We used a pooled fixed-effects multivariable logistic model to determine the likelihood of receiving the continuum of care for various properties. We also mapped the quintiles of adjusted state-level absolute change in continuum of care coverage during 1994-2018.We observed large absolute increases in the proportion of women receiving timely antenatal and postnatal care (from 48.9% to 88.2% and from 39.1% to 68.7%, respectively). In our conditional analysis, we found that the proportion of women receiving adequate antenatal care doubled over this period. We showed that having social security and a higher level of education is positively associated with receiving the continuum of care. We observed the largest relative increases in continuum of care coverage in Chiapas (181.5%) and Durango (160.6%), assigned human development index categories of low and medium, respectively.Despite significant progress in coverage of the continuum of maternal health care, disparities remain. While ensuring progress towards achievement of the health-related sustainable development goal, government intervention must also target underserved populations.Décrire les schémas géographiques et temporels de la continuité des soins de santé maternelle au Mexique, ainsi que les caractéristiques sociodémographiques qui déterminent la probabilité de recevoir de tels soins.Nous avons effectué une analyse transversale combinée fondée sur les éditions 1997, 2009, 2014 et 2018 de l'Enquête nationale sur la dynamique démographique, et compilé les données sociodémographiques et obstétriques de 93 745 femmes âgées de 12 à 54 ans lors de leur dernier accouchement. Nous avons identifié huit variables au fil de la continuité prénatale et postnatale, tant de manière indépendante que conditionnelle. Puis nous avons employé un modèle logistique multivarié à effets fixes combinés pour déterminer la probabilité de bénéficier de cette continuité des soins pour diverses propriétés. Enfin, nous avons cartographié les quintiles d'écart absolu ajusté au niveau national dans la continuité de la couverture durant la période comprise entre 1994 et 2018.Nous avons observé d'importantes augmentations réelles dans le pourcentage de femmes faisant l'objet de soins prénatals et postnatals au moment opportun (de 48,9% à 88,2% et de 39,1% à 68,7% respectivement). Notre analyse conditionnelle a révélé que la proportion de femmes ayant reçu des soins prénatals adaptés a doublé au cours de cette période. Nous avons démontré que le fait d'avoir une sécurité sociale et un niveau d'éducation plus élevé était associé à une amélioration de l'accès à la continuité des soins. Ce sont les États de Chiapas (181,5%) et de Durango (160,6%) qui ont connu les plus grandes augmentations relatives en matière de continuité des soins, le premier appartenant à la catégorie faible de l'indice de développement humain, et le second à la catégorie moyenne.Malgré les progrès considérables réalisés dans la couverture d'une continuité des soins de santé maternelle, des inégalités subsistent. Le gouvernement doit continuer à tendre vers l'objectif de développement durable lié à la santé tout en focalisant son intervention sur les populations mal desservies.Describir los patrones temporales y geográficos de la continuidad de la atención sanitaria materna en México, así como las características sociodemográficas que afectan a la probabilidad de recibir esta atención.Realizamos un análisis transversal conjunto utilizando las curvas de 1997, 2009, 2014 y 2018 de la Encuesta Nacional de la Dinámica Demográfica (ENADID), cotejando las características sociodemográficas y obstétricas de 93.745 mujeres de 12 a 54 años en el último parto. Definimos ocho variables a lo largo de la continuidad prenatal-postnatal, tanto de forma independiente como condicionada. Utilizamos un modelo logístico multivariable de efectos fijos combinados para determinar la probabilidad de recibir la continuidad de la atención para diversas propiedades. También trazamos un mapa de los quintiles de cambio absoluto ajustado a nivel estatal en la cobertura de la continuidad de la atención durante 1994-2018.Observamos grandes aumentos absolutos en la proporción de mujeres que reciben atención prenatal y postnatal oportuna (del 48,9% al 88,2% y del 39,1% al 68,7%, respectivamente). En nuestro análisis condicional, encontramos que la proporción de mujeres que reciben atención prenatal adecuada se duplicó durante este período. Demostramos que tener seguridad social y un mayor nivel de educación está positivamente asociado con la recepción de la atención continua. Observamos los mayores incrementos relativos en la cobertura de la continuidad de atención en Chiapas (181,5%) y Durango (160,6%), a los que se asignaron las categorías de índice de desarrollo humano de bajo y medio, respectivamente.A pesar de los importantes progresos realizados en la cobertura de la continuidad de la atención sanitaria materna, siguen existiendo disparidades. Al tiempo que se garantiza el progreso hacia el logro del objetivo de desarrollo sostenible relacionado con la salud, la intervención del gobierno también debe dirigirse a las poblaciones desatendidas.الغرض وصف الأنماط الزمنية والجغرافية لاستمرارية الرعاية الصحية للأم في المكسيك، فضلاً عن الخصائص الاجتماعية السكانية التي تؤثر على احتمالية تلقي هذه الرعاية. الطريقة قمنا بإجراء تحليل مقطعي مجمع باستخدام موجات من المسح الوطني للديناميكيات السكانية في أعوام 1997 و2009 و2014 و2018، وجمع الخصائص الاجتماعية السكانية والخصائص التوليدية لعدد 93745 امرأة تتراوح أعمارهن بين 12 و54 عاماً عند آخر عملية ولادة. قمنا بتحديد ثمانية متغيرات بامتداد الفترة المتصلة قبل الولادة وبعدها، بشكل مستقل ومشروط. ثم استخدمنا نموذج لوجيستي متعددة المتغيرات ذي تأثيرات محددة ومجمعة، لتحديد احتمالية الحصول على استمرارية الرعاية لمختلف الظروف. قمنا أيضًا بتعيين فئات خمسية للتغير المطلق المعدل على مستوى الولاية في استمرار تغطية الرعاية خلال الفترة من 1994 إلى 2018. النتائج لاحظنا زيادات مطلقة كبيرة في نسبة النساء اللواتي يحصلن على الرعاية قبل الولادة وبعدها في الوقت المناسب (من 48.9% إلى 88.2%، ومن 39.1% إلى 68.7% على الترتيب). وفي هذا التحليل الشرطي، وجدنا أن نسبة النساء اللواتي يحصلن على رعاية مناسبة قبل الولادة، قد تضاعفت خلال هذه الفترة. لقد أوضحنا أن الحصول على الأمان الاجتماعي ومستوى أعلى من التعليم، يرتبط بشكل إيجابي بالحصول على رعاية مستمرة. لاحظنا أن أكبر الزيادات النسبية في استمرارية تغطية الرعاية في تشياباس (181.5%)، ودورانجو (160.6%)، كانت حيث تم تعيين فئات مؤشر التنمية البشرية بأنها منخفضة ومتوسطة، على الترتيب. الاستنتاج على الرغم من التقدم الملموس في تغطية الرعاية الصحية المستمرة للأم، إلا أنه لا تزال هناك فوارق قائمة. مع ضمان التقدم نحو تحقيق هدف التنمية المستدامة المتعلق بالصحة، يجب أن يستهدف التدخل الحكومي أيضاً الفئات السكانية المحرومة من الخدمات.旨在描述墨西哥孕产妇连续保健服务在时间和地理层面的分布状况，以及影响享受这种保健服务的社会人口学特征。.我们采用 1997 年、2009 年、2014 年和 2018 年全国人口动态调查的数据开展了横断面调查汇总分析，并整理了 93,745 名年龄介于 12 至 54 岁之间的妇女上一次分娩时的社会人口学和产科特征。我们采用独立和条件分析围绕产前–产后连续性定义了八个变量。我们运用汇总的固定效应多元 Logistic 回归模型来确定各属性接受连续护理的可能性。同时还划分了 1994 年至 2018 年期间连续护理覆盖率调整后的国家层面变化绝对值的五分位点。.我们发现，及时接受产前和产后护理的妇女比例大幅增加（分别从 48.9% 增至 88.2% 以及从 39.1% 增至 68.7%）。根据我们的条件分析，我们发现，在此期间充分接受产前护理的孕妇比例翻了一番。分析显示，拥有社会保障和较高教育水平与获得连续护理呈正相关。根据我们的观察，恰帕斯 (181.5%) 和杜兰戈 (160.6%) 的连续护理覆盖率相对增幅最大，分别属于较低和中等人类发展指数类别。.尽管孕产妇连续保健服务的覆盖率取得了显著进展，但仍存在明显差异。确保在实现健康相关可持续发展目标方面取得进展的同时，政府还必须针对服务匮乏地区的人口采取干预措施。.Описать временные и географические закономерности системы бесперебойного и непрерывного оказания помощи матерям в Мексике, а также социально-демографические характеристики, которые влияют на вероятность получения таких услуг.Авторы провели объединенный перекрестный анализ с использованием волн Национального обследования демографической динамики за 1997, 2009, 2014 и 2018 годы, сопоставив социально-демографические и акушерские характеристики для 93 745 женщин в возрасте от 12 до 54 лет на момент последних родов. Были определены восемь переменных в системе бесперебойного и непрерывного оказания помощи в дородовой и послеродовой период, как независимых, так и условных. Авторы использовали объединенную многомерную логистическую модель с фиксированными эффектами, чтобы определить вероятность бесперебойного и непрерывного оказания помощи для различных свойств. На уровне отдельных штатов была также составлена карта квинтилей скорректированных абсолютных изменений в системе бесперебойного и непрерывного оказания помощи за период 1994–2018 гг.Авторы наблюдали значительный абсолютный прирост доли женщин, получающих своевременную дородовую и послеродовую помощь (с 48,9 до 88,2% и с 39,1 до 68,7% соответственно). В своем условном анализе авторы обнаружили, что доля женщин, получающих надлежащую дородовую помощь, за этот период удвоилась. Показано, что наличие социального обеспечения и более высокий уровень образования положительно связаны с получением бесперебойной и непрерывной помощи. Наибольшее относительное увеличение охвата услугами системы бесперебойного и непрерывного оказания медицинской помощи наблюдалось в штатах Чьяпас (181,5%) и Дуранго (160,6%), которым были присвоены категории низкого и среднего индекса гуманитарного развития соответственно.Несмотря на значительный прогресс в системе бесперебойного и непрерывного оказания помощи матерям, неравенство все еще сохраняется. Наряду с обеспечением прогресса в достижении цели в области устойчивого развития, связанной со здоровьем, вмешательство государства также должно быть направлено и на малообеспеченные слои населения.

Background Over the last two decades, the Mexican government has released several efforts to achieve universal health coverage (UHC), based on the principles of fairness and social protection, to reduce the inequities in utilization, access, and quality of care existing in the health system. Two of the most important social public policies that have targeted the population without access to social security include the 1997 conditional cash transfers (CCT) program known as Prospera (formerly Oportunidades or Progresa) and the Seguro Popular de Salud (SPS by its Spanish initials), launched in 2003. These two programs, so far, have survived changes in the federal administrations being the most longstanding social programs targeting poor (or unprotected) populations ever in the history of modern Mexico. We tested the existence of positive synergies between demand-side (or CCT-Prospera) and supply-side (or Seguro Popular de Salud, SPS) social programs in the achievement of effective coverage (EC) of maternal-child health interventions in Mexico. Methods We performed a retrospective-cohort analysis to 6413 women aged 12-49 years who participated in a probabilistic survey conducted in 2012. We calculated EC as the product of three indexes: need, utilization and quality of health care. Correlates of EC were identified estimating a logistic regression model. We also presented adjusted EC by specific women groups. Results EC among beneficiaries of both programs was similar to estimates in Social Security affiliates (54%). For those not affiliated to any of the programs or those who received benefits for only one of them, the EC was 47.6% and 45.5% respectively. Adjusted estimates of EC suggest that overall, having both programs (Prospera + SPS) has a positive effect on maternal and child care coverage, which makes the observed differences in EC not statistically significant between those affiliated to both programs in comparison with the observed in the population with social security. Conclusions Results support positive synergies between Prospera and SPS in the reduction of the gaps in EC. The most vulnerable population groups need to be reached by the combination of these programs so that public health efforts translate into greater EC of maternal health services and better maternal-child outcomes.

Conditional economic incentives are a theoretically grounded approach for eliciting behavior change. The rationale stems from present-biased preferences, by which individuals attach greater value to benefits in the present and heavily discount long-term health. A growing literature documents the use of economic incentives in the HIV field. Small and frequent conditional economic incentives offered to vulnerable populations can contribute to behavior change. Economic incentives accompanied with other strategies can help overcome obstacles to access health services and in general seem to improve linkage to HIV care, prevention interventions, and adherence to HIV treatment. Future identification of promising combinations of intervention components, modalities, and strategies may yield maximum impact.

Aims We sought to investigate whether individuals with diabetes have a higher likelihood of testing positive for SARS-CoV-2, as a proxy for infection risk, than individuals without diabetes. Methods We conducted a cross-sectional study of publicly available data among a Mexican population, totaling 2,314,022 adults ≥ 18 years who underwent SARS-CoV-2 testing between March 1 and December 20, 2020. We used 1:1 nearest neighborhood propensity score matching by diabetes status to account for confounding among those with and without diabetes. Results In the overall study population, 1,057,779 (45.7%) individuals tested positive for SARS-CoV-2 and 270,486 (11.7%) self-reported diabetes. After propensity score matching, patient characteristics were well-balanced, with 150,487 patients in the diabetes group (mean [SD] age 55.9 [12.7] years; 51.3% women) and 150,487 patients in the no diabetes group (55.5 [13.3] years; 50.3% women). The strictest matching algorithm (1:1 nearest neighbor) showed that compared to individuals without diabetes, having diabetes was associated with 9.0% higher odds of having a positive SARS-CoV-2 test (OR 1.09 [95% CI: 1.08–1.10]). Conclusions Presence of diabetes was associated with higher odds of testing positive for SARS-CoV-2, which could have important implications for risk mitigation efforts for people with diabetes at risk of SARS-CoV-2 infection.

Dating violence is a significant problem in Mexico. National survey data estimated 76 % of Mexican youth have been victims of psychological aggression in their relationships; 15.5 % have experienced physical violence; and 16.5 % of women have been the victims of sexual violence. Female adolescents perpetrate physical violence more frequently than males, while perpetration between genders of other types of violence is unclear. Furthermore, poor, marginalized youth are at a higher risk for experiencing dating violence. “Amor… pero del Bueno” (True Love) was piloted in two urban, low-income high schools in Mexico City to prevent dating violence. The intervention consisted of school-level and individual-level components delivered over 16 weeks covering topics on gender roles, dating violence, sexual rights, and strategies for coping with dating violence. The short-term impact was assessed quasi-experimentally, using matching techniques and fixed-effects models. A sample of 885 students (381 students exposed to the classroom-based curriculum of the individual-level component (SCC, IL-1) and 540 exposed only to the school climate component (SCC)) was evaluated for the following: changes in dating violence behaviors (psychological, physical and sexual), beliefs related to gender norms, knowledge, and skills for preventing dating violence. We found a 58 % (p

Objective In 2007, the Ministry of Health (MoH) in Mexico implemented a multidisciplinary health-care model (MHC) for patients with type-2 diabetes (T2D), which has proven more effective in controlling this condition than the conventional health-care model (CHC). Research design and methods We compared the cost-effectiveness of the MHC vs. the CHC for patients with T2D using a quasi-experimental, retrospective design. Epidemiologic and cost data were obtained from a randomly selected sample of health-care units, using medical records as well as patient- and facility-level data. We modelled the cost-effectiveness of the MHC at one, 10 and 20 years using a simulation model. Results The average cumulative costs per patient at 20 years were US$4,225 for the MHC and US$4,399 for the CHC. With a willingness to pay one gross domestic product (GDP) per capita per quality-adjusted life year (QALY) (US$8,910), the incremental net benefits per patient were US$1,450 and US$3,737 at 10 and 20 years, respectively. The MHC was cost-effective from the third year onward; however, increasing coverage to 500 patients per year rendered it cost-effective at year one. Conclusions The MHC is cost-effective at 10 and 20 years. Cost-effectiveness can be achieved in the short term by increasing MHC coverage.

In Mexico City, male sex workers (MSWs) are up to 126 times more likely to be living with HIV than the general public. We conducted interviews with 23 MSWs in Mexico City to examine their subjective understandings about their sexual risk behaviors and explore opportunities about HIV pre-exposure prophylaxis (PrEP) as a prevention approach in this group. Despite knowledge about sexual HIV risks, most participants reported condomless anal sex with clients. There was very little prior knowledge about PrEP, but very high interest in using a daily pill for prevention. Several participants expected an increase in condomless anal sex if taking PrEP, because of monetary incentives from clients or a perceived increase in pleasure. Additionally, seasonal sex workers expressed interest in using PrEP only during months when they were performing sex work. PrEP implementation efforts through Mexico’s healthcare system should recognize the varying needs and sexual risk behaviors of MSWs.

Aim To estimate the annual burden of gestational diabetes mellitus (GDM) in Mexico. Methods A model was built to conduct estimates from a healthcare system perspective, namely, the incremental costs of GDM pregnancy compared with non-GDM pregnancy from the first trimester until childbirth. The model used probabilities from the literature and surveys, and costs obtained from the Ministry of Health and national healthcare institutions. Scenario analyses were performed to estimate the GDM burden at different levels of incidence. Results Although a non-GDM pregnancy cost on average USD 1880.6 (low risk was USD 1043.9 and high risk was USD 1673.5), a pregnancy with GDM cost USD 2934.9. Therefore, the total additional cost was USD 1576.2 per case. Given the considerable variability of the GDM incidence in Mexico, the total burden could range from USD 86.8 to USD 827.4 million per year. Conclusions GDM is one of the most frequent complications of pregnancy, but research has been insufficient regarding its epidemiological and economic burden in Latin America. This paper shows that the GDM economic burden in Mexico is substantial despite only accounting for short-term medical costs. Further research to assess the GDM incidence and evaluate its long-term consequences from a broader societal perspective in Mexico is recommended.

New and innovative approaches are needed to improve the prevention, diagnosis, and treatment of HIV in low-income and middle-income countries. Several trials use conditional economic incentives (CEIs) to improve HIV outcomes. Most CEI interventions use a traditional economic theory approach, although some interventions incorporate behavioural economics, which combines traditional economics with insights from psychology. Incentive interventions that are appropriately implemented can increase HIV testing rates and voluntary male circumcision, and they can improve other HIV prevention and treatment outcomes in certain settings in the short term. More research is needed to uncover theory-based mechanisms that increase the duration of incentive effects and provide strategies for susceptible individuals, which will help to address common constraints and biases that can influence health-related decisions.

Livia Dainelli,1 Alberto Prieto-Patron,1 Irma Silva-Zolezzi,1 Sandra G Sosa-Rubi,2 Salvador Espino y Sosa,3 Enrique Reyes-Muñoz,4 Ruy Lopez-Ridaura,5 Patrick Detzel1 1Nestlé Research Center, Lausanne, Switzerland; 2Health Economics Department, National Institute of Public Health, Cuernavaca, Morelos, Mexico; 3Clinical Research Branch, National Institute of Perinatology Isidro Espinosa de los Reyes, Mexico City, CDMX, Mexico; 4Endocrinology Department, National Institute of Perinatology Isidro Espinosa de los Reyes, Mexico City, CDMX, Mexico; 5Center for Research on Population Health, National Institute of Public Health, Cuernavaca, Morelos, Mexico Purpose: To identify the most common practices implemented for the screening and treatment of gestational diabetes mellitus (GDM) and to estimate the GDM clinician-reported proportion as a proxy of the incidence in Mexico. Materials and methods: Three hundred fifty-seven physicians in four major cities were asked about their practices regarding GDM screening, treatment, clinical exams, and health care staff involved in case of GDM diagnosis, as well as the percentage of women with GDM they care for. Data management and statistical analyses were done with Stata 13. Results: The overall GDM clinician-reported proportion was 23.7%. Regional differences were expected and consistent with the data on the epidemiology of the obesity in the country. The most common screening test was the oral glucose tolerance test 75 g one step (46.6% of total cases). Diet and exercise were sufficient to treat GDM in 40.6% of cases; the rest of the sample relied on some form of medication, especially oral hypoglycemic agents (63.0% of cases), insulin (22.0%), or a combination of these (13.0%). To educate women on how to measure glycemia and eventually take medications, an average of 2–3 hours were necessary. The three most common prenatal screening tests were the “no stress”, the “Doppler ultrasound”, and the “biophysical profile”, respectively, taken at least once by 70%, 60%, and 45% of women. Among women who were prescribed insulin, only 37% managed to keep the initial prescribed dose during the whole pregnancy. Conclusion: The survey confirmed the expected incidence and gave interesting results on the treatment of GDM. The current Mexican guidelines seem to have been partially implemented in practice, and a coherent national strategy for GDM is still missing. More studies are encouraged to investigate this topic, with the aim to better understand the importance of the monetary cost of GDM, which is currently underestimated. Keywords: GDM incidence, pharmacological treatment, prenatal test

Mexico has a concentrated HIV epidemic, with male sex workers constituting a key affected population. We estimated annual HIV cumulative incidence among male sex workers' partners, and then compared incidence under three hypothetical intervention scenarios: improving condom use; and scaling up HIV treatment as prevention, considering current viral suppression rates (CVS, 60.7 %) or full viral suppression among those treated (FVS, 100 %). Clinical and behavioral data to inform model parameterization were derived from a sample (n = 79) of male sex workers recruited from street locations and Clínica Condesa, an HIV clinic in Mexico City. We estimated annual HIV incidence among male sex workers' partners to be 8.0 % (95 % CI: 7.3-8.7). Simulation models demonstrated that increasing condom use by 10 %, and scaling up HIV treatment initiation by 50 % (from baseline values) would decrease the male sex workers-attributable annual incidence to 5.2, 4.4 % (CVS) and 3.2 % (FVS), respectively. Scaling up the number of male sex workers on ART and implementing interventions to ensure adherence is urgently required to decrease HIV incidence among male sex workers' partners in Mexico City.

Objective. Understand and quantify the relationship between socio-economic and health insurance profiles and the use of outpatient medical services in the context of universal health care in Mexico. Materials and methods. Using ENSANUT 2012 multinomial regression models were estimated to analyze the use of outpatient services and associated factors. Results. Population with greater poverty levels, lower educational level and living in highly marginalized areas have lower odds to use outpatient health services. In contrast, health insurance and higher income increase the odds to use health services and influence the choice of provider. Conclusions. Barriers to access to health care related to poverty and social protection persist. However, there is space to lower the effect of these barriers by addressing constraints linked to the supply and the perceived quality of healthcare services.

The objective of this study was to measure willingness-to-accept (WTA) reductions in risks for HIV and other sexually transmitted infections (STI) using conditional economic incentives (CEI) among men who have sex with men (MSM), including male sex workers (MSW) in Mexico City. A survey experiment was conducted with 1,745 MSM and MSW (18-25 years of age) who received incentive offers to decide first whether to accept monthly prevention talks and STI testing; and then a second set of offers to accept to stay free of STIs (verified by quarterly biological testing). The survey used random-starting-point and iterative offers. WTA was estimated with a maximum likelihood double-bounded dichotomous choice model. The average acceptance probabilities were: 73.9% for the monthly model, and 80.4% for the quarterly model. The incentive-elasticity of participation in the monthly model was 0.222, and it was 0.515 in the quarterly model. For a combination program with monthly prevention talks, and staying free of curable STI, the implied WTA was USD$288 per person per year, but it was lower for MSW: USD$156 per person per year. Thus, some of the populations at highest risk of HIV infection (MSM & MSW) seem well disposed to participate in a CEI program for HIV and STI prevention in Mexico. The average willingness-to-accept estimate is within the range of feasible allocations for prevention in the local context. Given the potential impact, Mexico, a leader in conditional cash transfers for human development and poverty reduction, could extend that successful model for targeted HIV/STI prevention.

For three decades, psychological science has been the foundation for public health efforts to prevent human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) cases (Coates, Temoshok, Mandel, 1984). In the absence of biomedical interventions, especially in the early phases of HIV/AIDS, public health programs relied on psychological theories of behavior change to design strategies for reducing HIV risk behaviors (Fishbein, 2000). Previous literature reviews have summarized the evidence for the efficacy of behavioral HIV prevention programs (Noar, 2007; Pequegnat & Stover, 2000), showing that interventions based on psychological theory have contributed to significant increases in condom use, reductions in number of partners, reduction in incidence of sexually transmitted infections (STIs) other than HIV, and increases in knowledge and attitudes that favor safer sex. Despite these successes, the number of new HIV infections has continued to rise in the past decade, revealing limitations to psychological approaches to HIV prevention. In 2009 alone, there were an estimated 2.6 million new HIV infections globally, primarily in settings characterized by poverty (UNAIDS, 2010). An estimated 56,000 new infections occurred annually in the United States since 2006, with sexual and ethnic minority populations disproportionately at risk for infection (White House Office of National AIDS Policy, 2010). The burden of HIV/AIDS in disadvantaged groups brings attention to structural and economic factors that might elude psychological theories of behavior change. Criticism of the body of existing behavioral interventions highlights a need for new approaches to HIV prevention that extend beyond psychology-focused frameworks (Philipps & Pirkle, 2011). HIV prevention research has recently become energized by insights from behavioral economics. As a hybrid of economics and psychology, behavioral economics introduces unique theoretical understandings about the conditions under which risky decisions are amenable to intervention. A notable contribution of behavioral economics to HIV prevention is the emergence of conditional economic incentive (CEI) programs for changing HIV-related behavioral outcomes. Similar to contingency management (CM) programs developed by psychologists for treating individual-level substance use problems, CEIs operate as policy and structural-level interventions by providing financial rewards to individuals who engage in behaviors that facilitate positive health outcomes - such as school attendance, clinic visits, and proper nutrition. Community-level effects of CEI programs on child and family health have been observed in many parts of the world (Attanasio, Meghir, & Santiago, 2011). Providing economic incentives to individuals for changing sexual risk behaviors associated with HIV transmission presents a compelling extension of this framework. The aims of this paper are twofold. First, we briefly describe the literature on psychological and behavioral economics approaches to HIV prevention. Second, we describe the convergence of theoretical orientations through the example of CEI programs for addressing HIV, and we explore the empirical evidence for the effects of illustrative CEI programs on HIV prevention outcomes.

Although commercial sex transactions related to men who have sex with men have particular importance for HIV/AIDS prevention, the economic literature analyzing male sex workers is limited. A handful of studies have been published, first with descriptive analyses of specific markets and more recently taking advantage of Internet resources and larger surveys. The theoretical economic models have not yet been fully customized to fit all the nuance and specificity of this particular trade. This chapter gives a general overview of economic models relevant for the analysis of male-sex-worker transactions; it then presents a summary of relevant themes in the economics literature, with additional insights from other social sciences, and concludes with suggestions for future research, particularly combining psychosocial issues in the framework of behavioral and health economics.

Objective: We estimate facility-level average annual costs per client along the HIV testing and counselling (HTC) and prevention of mother-to-child transmission (PMTCT) service cascades. Design: Data collected covered the period 2011–2012 in 230 HTC and 212 PMTCT facilities in Kenya, Rwanda, South Africa, and Zambia. Methods: Input quantities and unit prices were collected, as were output data. Annual economic costs were estimated from the service providers’ perspective using micro-costing. Average annual costs per client in 2013 United States dollars (US$) were estimated along the service cascades. Results: For HTC, average cost per client tested ranged from US$5 (SD US$7) in Rwanda to US$31 (SD US$24) in South Africa, whereas average cost per client diagnosed as HIV-positive ranged from US$122 (SD US$119) in Zambia to US$1367 (SD US$2093) in Rwanda. For PMTCT, average cost per client tested ranged from US$18 (SD US$20) in Rwanda to US$89 (SD US$56) in South Africa; average cost per client diagnosed as HIV-positive ranged from US$567 (SD US$417) in Zambia to US$2021 (SD US$3210) in Rwanda; average cost per client on antiretroviral prophylaxis ranged from US$704 (SD US$610) in South Africa to US$2314 (SD US$3204) in Rwanda; and average cost per infant on nevirapine ranged from US$888 (SD US$884) in South Africa to US$2359 (SD US$3257) in Rwanda. Conclusion: We found important differences in unit costs along the HTC and PMTCT service cascades within and between countries suggesting that more efficient delivery of these services is possible.

OBJETIVO: Presentar y analizar informacion de costo-efectividad de intervenciones propuestas por la Iniciativa Mesoamericana de Salud (IMS) en las areas de nutricion infantil, inmunizaciones, paludismo, dengue y salud materno-infantil y reproductiva. MATERIAL Y METODOS: Se llevo a cabo una revision sistematica de la literatura de evaluaciones economicas publicadas entre el ano 2000 y agosto 2009 sobre intervenciones en las areas de la salud mencionadas, en los idiomas ingles y espanol. RESULTADOS: Las intervenciones en nutricion y de salud materno-infantil mostraron ser altamente costo-efectivas (con rangos menores a US$200 por ano de vida ajustado por discapacidad [AVAD] evitado para nutricion y US$100 para materno-infantil). En dengue solo se encontro informacion sobre la aplicacion de larvicidas, cuya razon de costo efectividad estimada fue de US$40.79 a US$345.06 por AVAD evitado. Respecto al paludismo, las intervenciones estudiadas resultaron costo-efectivas (

OBJETIVO. Estimar el efecto del Seguro Popular (SP) sobre la incidencia del gasto catastrófico en salud (GCS) y sobre el gasto de bolsillo en salud (GBS) en el mediano plazo. MATERIAL Y MÉTODOS. Con base en la Encuesta de Evaluación del Seguro Popular (2005-2008), se analizaron los resultados del efecto del SP en la cohorte rural para dos años de seguimiento (2006 y 2008) y en la cohorte urbana para un año (2008). RESULTADOS. A nivel conglomerado no se detectaron efectos del SP. A nivel hogar se encontró que el SP tiene un efecto protector en el GCS y en el GBS en consulta externa y hospitalización en zonas rurales; y efectos significativos en la reducción de GBS en consulta externa en zonas urbanas. CONCLUSIONES. El SP se muestra como un programa efectivo para proteger a los hogares contra gastos de bolsillo por motivos de salud en el mediano plazo.OBJECTIVE. To estimate the effect of "Seguro Popular" (SP) on the incidence of catastrophic health expenditure (CHE) and out-of-pocket (OOP) health expenditure in the medium term. MATERIAL AND METHODS. We used the 'Encuesta de Evaluación del SP' -SP Survey Evaluation- (2005-2008). We analyzed the SP effect on the rural cohort during two years of follow-up (2006 and 2008) and in the urban cohort during one year of follow-up (2008). RESULTS. At the local level (regional clusters) we did not find an effect of the SP. At the household level we found a protective effect of SP on CHE and the OOP health payments in outpatient and hospitalization in rural areas; and a significant effect on the reduction of OOP health payments in outpatient services in urban zones. CONCLUSIONS. SP seems to be an effective program to protect poor household against out-of-pocket health expenditures in the medium term.

OBJETIVO: Describir algunos de los modelos estadísticos para el estudio de variables expresadas como un conteo en el contexto del uso de los servicios de salud. MATERIAL Y MÉTODOS: Con base en la Encuesta de Evaluación del Seguro Popular (2005-2006) se calculó el efecto del Seguro Popular sobre el número de consultas externas mediante el uso de los modelos de regresión Poisson, binomial negativo, binomial negativo cero-inflado y Hurdle binomial negativo. Se utilizó el criterio de información de Akaike (AIC) para definir el mejor modelo. RESULTADOS: La mejor opción estadística para el análisis del uso de los servicios de salud resultó ser el modelo Hurdle, de acuerdo con sus presuposiciones y el valor del AIC. DISCUSIÓN: La modelación de variables de conteo requiere el empleo de modelos que incluyan una medición de la dispersión. Ante la presencia de exceso de ceros, el modelo Hurdle es una opción apropiada.OBJECTIVE: To describe some of the statistical models for the study of count variables in the context of the use of health services. MATERIAL AND METHODS: We used the Seguro Popular Evaluation Survey to estimate the effect of Seguro Popular on the frequency of use of outpatient health services, using Poisson regression models and negative binomial, zero-inflated negative binomial and the hurdle negative binomial models. We used the Akaike Information Criterion (AIC) to define the best model. RESULTS: Results show that the best statistical approach to model the use of health services is the hurdle model, taking into account both the main theoretical assumptions and the statistical results of the AIC. DISCUSSION: The modelling of count data requires the application of statistical models to model data dispersion; in the presence of an excess of zeros, the hurdle model is an appropriate statistical option.

The goal of Seguro Popular (SP) in Mexico was to improve the financial protection of the uninsured population against excessive health expenditures. This paper estimates the impact of SP on catastrophic health expenditures (CHE), as well as out-of-pocket (OOP) health expenditures, from two different sources. First, we use the SP Impact Evaluation Survey (2005–2006), and compare the instrumental variables (IV) results with the experimental benchmark. Then, we use the same IV methods with the National Health and Nutrition Survey (ENSANUT 2006). We estimate naïve models, assuming exogeneity, and contrast them with IV models that take advantage of the specific SP implementation mechanisms for identification. The IV models estimated included two-stage least squares (2SLS), bivariate probit, and two-stage residual inclusion (2SRI) models. Instrumental variables estimates resulted in comparable estimates against the “gold standard.” Instrumental variables estimates indicate a reduction of 54% in catastrophic expenditures at the national level. SP beneficiaries also had lower expenditures on outpatient and medicine expenditures. The selection-corrected protective effect is found not only in the limited experimental dataset, but also at the national level.

OBJETIVO: Analizar la práctica de mastografías y Papanicolaou y el seguimiento de resultados anormales entre mujeres de áreas rurales en México. MATERIAL Y MÉTODOS: Se realizó un estudio de corte transversal con la Encuesta de Evaluación de los Hogares Rurales (ENCEL 2007) - Oportunidades levantada entre julio y noviembre del año 2007. Se utilizó un modelo logístico multinivel para modelar la realización de mastografías y Papanicolaou. RESULTADOS: Se encontró una baja frecuencia en la ejecución de mastografías en mujeres de 30 a 39 años (12%) y de 40 a 49 años (16%), además de un bajo informe de seguimiento médico (60%) en los grupos de edad de alto riesgo y con resultados anormales. Estos factores se relacionaron con la falta de acceso a recursos médicos y la condición indígena de las mujeres. CONCLUSIÓN: Se recomienda fortalecer el acceso a exámenes de mastografía y Papanicolaou entre mujeres de alto riesgo en áreas rurales y el seguimiento adecuado de casos anormales para reducir la letalidad del cáncer de mama (CaMa) y el cáncer cervicouterino (CaCu).

Despite the high-profile support for combination prevention programmes (CPPs) since 2008, there is little rigorous evidence on their impact and cost-effectiveness. In 2010, Mexico received funds from the Global Fund to implement a series of behavioural, biomedical, and structural interventions over 3 years targeted to men who have sex with men. The aims of the study were to estimate the impact of the programme across a range of outcomes and cost-effectiveness.A quasi-experiment was designed before the implementation of the CPP, in which 24 cities were randomly selected for impact evaluation and 12 pairs of cities were matched. In practice, though, implementation of the programme was staggered over 1 year. Therefore, we used two different approaches to estimate impact: a difference-in-difference estimation comparing both groups and a dose-response approach using time exposure to the programme at the city level.Results from the difference-in-difference estimation showed modest impact on condom use. However, the dose–response findings revealed a 7.5% increase in HIV testing per additional year exposed to the programme, relative to baseline coverage; an increase in awareness of HIV status among HIV-positive individuals of 6.3%; a 6.7% increase in HIV-positive individuals on treatment; and a 7% reduction in the perception of stigma/discrimination from healthcare personnel. The cost per person not exposed to an untreated HIV-positive individual was gauged to be US$400.The study provides evidence of the effectiveness and cost of a CPP along the HIV treatment cascade: access to HIV tests, awareness of HIV status, and antiretroviral therapy initiation.

This article examines the role of components of adequate antenatal care (ANC) in disparities in birth weight between indigenous and non-indigenous women in Mexico. We estimate the potential for added weight gain among indigenous infants if their mothers received timely, frequent ( ≥4 visits) and complete ANC (≥75% of recommended processes of care). We used population-based survey data (2012;N= 6612 women 12-49). We applied quantile regression to examine heterogeneity of the association between adequate ANC, indigenous ethnicity and birth weight across quantiles of the birth weight distribution. A greater proportion of indigenous women reported a low-birth weight infant (

ideas that PWAs have supernatural powers that can be obtained by ingesting their body parts, and that having sexual intercourse with females with albinism can cure HIV/AIDS. Improving awareness of albinism is an integral step towards improving quality of life of PWAs in Tanzania. We developed a program to evaluate the use of community health workers (CHWs) to spread awareness of albinism and the challenges faced by this marginalized population in Tanzania. Structure/Method/Design: We developed an educational program consisting of a video, PowerPoint presentation, and discussion topics and taught it to 33 CHWs trained by Empower Tanzania, an NGO with an infrastructure designed to disseminate public health practices in rural Tanzania. These CHWs delivered the presentation at schools and community gatherings in a rural district of Tanzania throughout February 2014. We administered questionnaires to program attendees before and after the presentation. We also gave questionnaires throughout the community before and after the month-long intervention. These questionnaires were used to assess baseline views about albinism, to evaluate the program’s success, and to obtain additional feedback. Outcomes & Evaluation: A total of 12,007 participants attended presentations. Questionnaires randomly administered to 426 participants demonstrated significantly higher knowledge about albinism after the presentations than before, and indicated that participants intended to share what they had learned with friends and family members. Community questionnaires administered to 896 randomlyselected community members in January and 743 additional community members in March suggested retained, community-wide gains in knowledge about albinism and the unique challenges faced by PWAs. Data analysis revealed the knowledge gains varied based on selected demographic characteristics. We conclude the program to be an effective means to improve awareness of and knowledge about albinism. We hope these knowledge gains can reduce the associated discrimination and stigma towards PWAs in Tanzania. Going Forward: The UN has identified improving knowledge at a community level as a priority in addressing violence towards Tanzanians with albinism. Public health interventions utilizing CHWs are an effective tool to improve health outcomes in rural populations. Our program demonstrates a promising approach to alleviate the challenges faced by a marginalized population and supports the utility of CHW programs to enact cultural change. This program will continue to be used by Empower Tanzania to maintain the observed gains in knowledge. Potential applications of our findings include dissemination of this program to other areas of Tanzania and utilization of this CHWbased approach to develop interventions addressing other social determinants of health in developing countries. Funding: Peterson Family Foundation Abstract #: 01ETC098

Much of Latin America has experienced steep declines in fertility over the past three decades: The mean total fertility rate for the regionA dropped from 5.1 children in the mid-1970s to 2.5 children in 2005.2 Mexico, which has had an explicit population policy since the 1970s, has followed this trend.3 Despite progress at the national level, disparities persist in Mexico, with poor, rural and indigenous women having lower contraceptive use rates and higher fertility rates than do more affluent, urban and nonindigenous women, respectively.B Furthermore, adolescent fertility has not declined at the same pace as overall fertility. Age-specific fertility rates indicate that the contribution to total fertility by women aged 15–19 has risen in some Latin American countries, with a disproportionally high burden of early fertility among rural adolescents.4 Early pregnancy is associated with adverse health outcomes for women and children,6 increased total fertility7 and poverty.8 Reducing unintended early fertility is a key strategy to decrease poverty and improve women’s health. One approach to poverty reduction is through Conditional cash transfer programs,9 which is a form of performance-based payment—generally targeted toward poor households or individuals—in exchange for complying with a set of behavioral requirements or conditionalities, such as school attendance or health service utilization.19 Conditional cash transfer programs have been implemented in several countries in Latin America and Sub-Saharan Africa, as well as in India, Bangladesh, Nepal and the United States,10–16 and have been shown to increase utilization of conditionalities;9,17,18 however, evidence about programs’ effects on short- and long-term health outcomes has been mixed.18,19,63 Programs vary widely in structure,19 and it is not clear which program structures, conditionalities or components are most influential, although studies comparing conditional and unconditional cash transfers20 suggest that incentives are more effective with short-term behavior changes than with longer-term outcomes.21 The causal pathway for observed effects of conditional cash transfer programs is not fully understood.17

Introduction Mexico faces important problems concerning income and health inequity. Mexico’s national public agenda prioritizes remedying current inequities between its indigenous and non-indigenous population groups. This study explores the changes in social inequalities among Mexico’s indigenous and non-indigenous populations for the time period 2000 to 2010 using routinely collected poverty, welfare and health indicator data. Methods We described changes in socioeconomic indicators (housing condition), poverty (Foster-Greer-Thorbecke and Sen-Shorrocks-Sen indexes), health indicators (childhood stunting and infant mortality) using diverse sources of nationally representative data. Results This analysis provides consistent evidence of disparities in the Mexican indigenous population regarding both basic and crucial developmental indicators. Although developmental indicators have improved among the indigenous population, when we compare indigenous and non-indigenous people, the gap in socio-economic and developmental indicators persists. Conclusions Despite a decade of efforts to promote public programs, poverty persists and is a particular burden for indigenous populations within Mexican society. In light of the results, it would be advisable to review public policy and to specifically target future policy to the needs of the indigenous population.

This study provides evidence for those working in the maternal health metrics and health system performance fields, as well as those interested in achieving universal and effective health care coverage. Based on the perspective of continuity of health care and applying quasi-experimental methods to analyse the cross-sectional 2009 National Demographic Dynamics Survey (n = 14 414 women), we estimated the middle-term effects of Mexico's new public health insurance scheme, Seguro Popular de Salud (SPS) (vs women without health insurance) on seven indicators related to maternal health care (according to official guidelines): (a) access to skilled antenatal care (ANC); (b) timely ANC; (c) frequent ANC; (d) adequate content of ANC; (e) institutional delivery; (f) postnatal consultation and (g) access to standardized comprehensive antenatal and postnatal care (or the intersection of the seven process indicators). Our results show that 94% of all pregnancies were attended by trained health personnel. However, comprehensive access to ANC declines steeply in both groups as we move along the maternal healthcare continuum. The percentage of institutional deliveries providing timely, frequent and adequate content of ANC reached 70% among SPS women (vs 64.7% in the uninsured), and only 57.4% of SPS-affiliated women received standardized comprehensive care (vs 53.7% in the uninsured group). In Mexico, access to comprehensive antenatal and postnatal care as defined by Mexican guidelines (in accordance to WHO recommendations) is far from optimal. Even though a positive influence of SPS on maternal care was documented, important challenges still remain. Our results identified key bottlenecks of the maternal healthcare continuum that should be addressed by policy makers through a combination of supply side interventions and interventions directed to social determinants of access to health care.