The scope and sustainability of, and data about, utilization of embedded research: qualitative evidence from Latin America and the Caribbean.

Objectives: This paper describes and analyzes embedded implementation research and the empirical processes of planning for utilization, strategies to promote utilization and the sustainability of utilization of results from research led by decision-makers in Latin America and the Caribbean. Methods: This qualitative, descriptive and interpretive study is based on the findings from semistructured interviews with members of teams working under the Embedding Research for the Sustainable Development Goals initiative (2018-2019) as well as their responses to a self-assessment follow-up questionnaire 1 year after the project was completed. Results: Altogether 13 teams from 11 countries participated in the Initiative. Nine teams had a core team composed of a decision-maker as the principal investigator assisted by a researcher as co-principal investigator. Four teams included more than one co-principal investigator; and in five teams, the originally assigned principal investigator was replaced. There was an interesting relationship between the expected utilization of research results, the utilization strategies, the sustainability of research uptake and the teams' collaboration modalities. When decision-makers and co-principal investigators were active participants, the intention to use the results and strategies for utilization were clearly oriented to improve implementation. In teams with basically a formal collaboration between the two principals, plans for utilization were unclear or focused on producing academic knowledge. The participation of implementers below the rank of principal investigator decision-maker may be relevant. Conclusions: Embedded implementation research is an innovative tool that may foster the utilization of research and strengthen health programs and services. Considering the internal dynamics of such research teams will enhance planning and strategies for research utilization as well as the sustainability of practical and actionable findings.

Misinformation messages shared via WhatsApp in Mexico during the COVID-19 pandemic: an exploratory study.

Little is known about the role of WhatsApp in spreading misinformation during the start of the COVID-19 pandemic in Mexico. The aim of this study is to analyze the message content, format, authorship, time trends and social media distribution channels of misinformation in WhatsApp messages in Mexico. From March 18 to June 30, 2020 the authors collected all WhatsApp messages received via their personal contacts and their social networks that contained information about COVID-19. Descriptive and inferential statistics were used to analyze the scientifically inaccurate messages and the relationship between variables, respectively. Google image and video searches were carried out to identify sharing on other social media. Out of a total of 106 messages, the most frequently mentioned COVID-19 related message topics were prevention (20.0%), conspiracy (18.5%), therapy (15.4%) and origin of the virus (10.3%), changing throughout the pandemic according to users' concerns. Half of all WhatsApp messages were either images or videos. WhatsApp images were also shared on Facebook (80%) and YouTube (~50%). Our findings indicate that the design of information and health promotion campaigns requires to be proactive in adapting to the changes in message content and format of misinformation shared through encrypted social media.

As an encrypted social media platform with hardly accessible content, little is known about the role of WhatsApp in spreading misinformation messages (either false or misleading information) during the COVID-19 pandemic in Mexico. In this study, researchers studied the content, format, time and channel of distribution of WhatsApp messages containing information about COVID-19 collected via their personal contacts and their social networks from March 18 to June 30, 2020. Half of all messages were visually-appealing and the content changed according to the population´s concerns. WhatsApp messages were also distributed in several other social media platforms. Understanding the format and content of misinformation may help to design dynamic health information and promotion campaigns against it. Regulations of public social media such as Youtube can have a positive impact on WhatsApp.

Relevance and quality of implementation research proposals to face the challenges of public health in Latin-America and the Caribbean.

OBJECTIVES: To analyse the relevance and quality of the research proposals submitted to the 2016 call for proposals for the initiative Improving Programme Implementation through Embedded Research (iPIER-2016) to address current public health challenges in Latin America and the Caribbean. METHODS: We performed a cross-sectional study using information from 108 research proposals using quantitative and qualitative methods. We used three frameworks to analyse the relevance of the proposals: The Global Burden of Disease, the WHO Health Systems Conceptual Framework and the Sustainable Development Goals proposed in 2015 by the United Nations. We performed an index to analyse the relevance and quality of the proposals. RESULTS: Twenty seven percent of the proposals have very good relevance, one third of the proposals have quality flaws. This means their research questions are not related to implementation research or their methods are insufficient or inadequate to respond to the objective. CONCLUSIONS: The response to this call is proof of health authorities' interest in research as a tool to improve the implementation of health programs in the region. However, proposals show important variations in terms of relevance and quality among countries and training health staff in programme implementation seems a central requirement.

Replacement of core team members on embedded implementation research teams: experiences from Latin America and the Caribbean.

Objective: To understand how replacement of decision-makers (DMs) serving as principal investigators (PI) or co-PIs on research teams may affect the feasibility and value of embedded implementation research (EIR) used to improve health policies, programs, and services in Latin America and the Caribbean. Methods: This was a descriptive qualitative study based on 39 semistructured interviews with 13 embedded research teams selected by financing agencies to explore team composition, interaction among members, and research results. Interviews were conducted at three points during the study period from September 2018 to November 2019; data were analyzed from 2020 to 2021. Results: Research teams were found to be operating in one of three situations: (i) permanent core team (no change) with either active DM or inactive DM participation; (ii) replacement of DM-PI or co-PI that did not affect EIR research; and (iii) replacement of DM-PI that affected EIR. Conclusions: To ensure EIR continuity and stability, research teams should include high-level DMs together with more technical staff performing essential implementation activities. This structure could improve collaboration among professional researchers and ensure greater embeddedness of EIR to strengthen the health system.

Collaboration between health system decision makers and professional researchers to coproduce knowledge, a scoping review.

BACKGROUND: Recent literature uses different terms and approaches to the collaboration between researchers and health system decision-makers in the research process. In 2012, the World Health Organisation proposed to "Embed research within decision-making processes". Yet, important contributions use other terms and perspectives for the same issue. This scoping review aimed to identify these terms, approaches, their application and eventual influence on the utilization of evidence. METHODS: We searched papers published between January 2000 and February 2019 in English, Spanish, French and Portuguese in the databases of PubMed, Scielo, Google Scholar and EBSCOhost, thus accessing MedicLatina, MEDLINE Complete and eBook Collection. Our main inclusion criterion was the participation of health personnel in non-clinical research activities. We considered three domains for in depth analysis: Definition, name and description of the participation of decision makers and health staff; Forms of collaboration and actual/effective participation of health staff in research; Eventual influence on the utilization of research results. RESULTS: We identified 607 articles and selected 74 for full text analysis. Nineteen different terms are currently used in twelve countries to describe the participation of health decision-makers and staff in research activities. Most publications refer to Integrated Knowledge Translation or Embedded Research, and were published in Canada and the United Kingdom. Forty-five papers discuss the participation of health staff in research activities; 20 leading the whole process and 21 as collaborators. CONCLUSIONS: The identification of the different terms and approaches to the close collaboration of health staff and decision-makers with professional researchers is essential to promote its effective application and influence on the utilization of evidence. Yet, it is also necessary to insist in their co-participation throughout the whole investigation process as a relevant way to improve research results uptake, strengthen health systems and advance towards universal health coverage.

Health care workers' perceptions of episiotomy in the era of respectful maternity care: a qualitative study of an obstetric training program in Mexico.

BACKGROUND: Episiotomy in Mexico is highly prevalent and often routine - performed in up to 95% of births to primiparous women. The WHO suggests that episiotomy be used in selective cases, with an expected prevalence of 15%. Training programs to date have been unsuccessful in changing this practice. This research aims to understand how and why this practice persists despite shifts in knowledge and attitudes facilitated by the implementation of an obstetric training program. METHODS: This is a descriptive and interpretative qualitative study. We conducted 53 pre and post-intervention (PRONTO© Program) semi-structured interviews with general physician, gynecologists and nurses (N = 32, 56% women). Thematic analysis was carried out using Atlas-ti© software to iteratively organize codes. Through interpretive triangulation, the team found theoretical saturation and explanatory depth on key analytical categories. RESULTS: Themes fell into five major themes surrounding their perceptions of episiotomy: as a preventive measure, as a procedure that resolves problems in the moment, as a practice that gives the clinician control, as a risky practice, and the role of social norms in practicing it. Results show contradictory discourses among professionals. Despite the growing support for the selective use of episiotomy, it remains positively perceived as an effective prophylaxis for the complications of childbirth while maintaining control in the hands of health care providers. CONCLUSIONS: Perceptions of episiotomy shed light on how and why routine episiotomy persists, and provides insight into the multi-faceted approaches that will be required to affect this harmful obstetrical practice.

Embedding research into health services in Latin America and the Caribbean: experiences and challenges of the Technical Support Center.

This article describes the main models for embedding research and the successful experiences and challenges faced in joint work by researchers and decisionmakers who participated in the Embedding Research for the Sustainable Development Goals (ER-SDG) initiative, and the experience of the Technical Support Center. In June 2018, funding was granted to 13 pre-selected research projects from 11 middle- and low-income countries in Latin America and the Caribbean (Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Paraguay, and Peru). The projects focused on the system-, policy-, or program-level changes required to improve health and build on the joint work of researchers and decisionmakers, with a view to bringing together evidence production and decision-making in health systems and services. The Technical Support Center supported and guided the production of quality results useful for decision-making. This experience confirmed the value of initiatives such as ER-SDG in consolidating bridges between research on the implementation of health policies, programs, and systems, and the officials responsible for operating health-related programs, services, and interventions. It highlighted the importance of both respecting and taking advantage of each context-and the specific arrangements and patterns in the relationships between researchers and decisionmakers-through incentives for embedded research.

En este artículo se describen los principales modelos de integración, las experiencias de éxito y los retos del trabajo conjunto de los investigadores y los tomadores de decisiones participantes en la iniciativa Incorporación de la Investigación para Avanzar en el Cumplimiento de los Objetivos de Desarrollo Sostenible (ER-SDG), y la experiencia del Centro de Apoyo Técnico (CAT). En junio de 2018 se otorgó financiamiento, previa selección, a 13 proyectos de investigación de 11 países de ingresos medios y bajos de América Latina y el Caribe (Argentina, Bolivia, Brasil, Colombia, Ecuador, Guatemala, Guyana, Haití, Paraguay, Perú y República Dominicana). Los proyectos debían estar centrados en los cambios que se requieren a nivel de sistema, políticas o programas para mejorar la salud y basarse en el trabajo conjunto de investigadores y tomadores de decisiones, a fin de acercar la generación de evidencias a la toma de decisiones en los sistemas y servicios de salud. El CAT apoyó y orientó la producción de resultados de calidad y de utilidad para la toma de decisiones. La experiencia confirmó el valor de iniciativas como ER-SDG en la consolidación de puentes entre el mundo de la investigación sobre implementación de políticas, programas y sistemas de salud, y el mundo de los funcionarios encargados de operar esos programas, servicios e intervenciones relacionadas con la salud. Se resalta la necesidad de respetar y aprovechar cada contexto, y los arreglos y patrones específicos de relación entre investigadores y tomadores de decisiones, mediante incentivos para la integración.

Neste artigo são descritos os principais modelos de integração, as experiências de êxito e os desafios do trabalho conjunto de pesquisadores e responsáveis por tomar decisões que participam da iniciativa Incorporação da Pesquisa para Avançar no Cumprimento dos Objetivos de Desenvolvimento Sustentável (Embedding Research for the Sustainable Development Goals, ER-SDG) e da experiência do Centro de Apoio Técnico (CAT). Em junho de 2018, realizou-se a concessão de financiamento e pré-seleção de 13 projetos de pesquisa provenientes de 11 países de baixa e média renda da América Latina e Caribe (Argentina, Bolívia, Brasil, Colômbia, Equador, Guatemala, Guiana, Haiti, Paraguai, Peru e República Dominicana). Os projetos deveriam enfocar as mudanças necessárias no sistema, políticas ou programas para melhorar a saúde e fundar-se no trabalho conjunto de pesquisadores e responsáveis por tomar decisões visando aproximar a produção de evidências à tomada de decisão nos sistemas e serviços de saúde. O CAT forneceu suporte e orientação à produção de resultados úteis e de qualidade para a tomada de decisão. A experiência confirmou o valor de iniciativas como a ER-SDG para consolidar pontes entre o mundo da pesquisa voltada à implementação de políticas, programas e sistemas de saúde e o mundo dos encarregados de gerir estes programas, serviços e intervenções de saúde. Deve-se enfatizar a necessidade de respeitar e aproveitar cada contexto e os arranjos e padrões próprios da relação entre pesquisadores e responsáveis por tomar decisões criando incentivos à integração.

[Embedding research into health services in Latin America and the Caribbean: experiences and challenges of the Technical Support CenterExperiências e desafios do Centro de Apoio Técnico na pesquisa integrada aos serviços na América Latina e Caribe]. / Experiencias y retos del Centro de Apoyo Técnico en la investigación integrada en los servicios en América Latina y el Caribe.

This article describes the main models for embedding research and the successful experiences and challenges faced in joint work by researchers and decisionmakers who participated in the Embedding Research for the Sustainable Development Goals (ER-SDG) initiative, and the experience of the Technical Support Center. In June 2018, funding was granted to 13 pre-selected research projects from 11 middle- and low-income countries in Latin America and the Caribbean (Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Paraguay, and Peru). The projects focused on the system-, policy-, or program-level changes required to improve health and build on the joint work of researchers and decisionmakers, with a view to bringing together evidence production and decision-making in health systems and services. The Technical Support Center supported and guided the production of quality results useful for decision-making. This experience confirmed the value of initiatives such as ER-SDG in consolidating bridges between research on the implementation of health policies, programs, and systems, and the officials responsible for operating health-related programs, services, and interventions. It highlighted the importance of both respecting and taking advantage of each context-and the specific arrangements and patterns in the relationships between researchers and decisionmakers-through incentives for embedded research.

Neste artigo são descritos os principais modelos de integração, as experiências de êxito e os desafios do trabalho conjunto de pesquisadores e responsáveis por tomar decisões que participam da iniciativa Incorporação da Pesquisa para Avançar no Cumprimento dos Objetivos de Desenvolvimento Sustentável (Embedding Research for the Sustainable Development Goals, ER-SDG) e da experiência do Centro de Apoio Técnico (CAT). Em junho de 2018, realizou-se a concessão de financiamento e pré-seleção de 13 projetos de pesquisa provenientes de 11 países de baixa e média renda da América Latina e Caribe (Argentina, Bolívia, Brasil, Colômbia, Equador, Guatemala, Guiana, Haiti, Paraguai, Peru e República Dominicana). Os projetos deveriam enfocar as mudanças necessárias no sistema, políticas ou programas para melhorar a saúde e fundar-se no trabalho conjunto de pesquisadores e responsáveis por tomar decisões visando aproximar a produção de evidências à tomada de decisão nos sistemas e serviços de saúde. O CAT forneceu suporte e orientação à produção de resultados úteis e de qualidade para a tomada de decisão. A experiência confirmou o valor de iniciativas como a ER-SDG para consolidar pontes entre o mundo da pesquisa voltada à implementação de políticas, programas e sistemas de saúde e o mundo dos encarregados de gerir estes programas, serviços e intervenções de saúde. Deve-se enfatizar a necessidade de respeitar e aproveitar cada contexto e os arranjos e padrões próprios da relação entre pesquisadores e responsáveis por tomar decisões criando incentivos à integração.

Tuberculosis care cascade for the indigenous population in Colombia: an operational research study.

OBJECTIVE: Construct and evaluate the care cascade for pulmonary tuberculosis in the indigenous population of the department of Cauca (Colombia) and identify existing gaps. METHODS: Mixed-methods sequential explanatory design. In the first phase, the pulmonary tuberculosis care cascade for the indigenous population of Cauca was evaluated. Data were obtained from secondary sources and all cases diagnosed from 1 January 2016 to 31 December 2017 were included. In the second phase, semi-structured interviews were done with nine program coordinators and 11 nursing auxiliaries to explain identified gaps. Absolute and percentage values were estimated for each of the steps and gaps in the care cascade. Quantitative and qualitative results were triangulated. RESULTS: In 2016 and 2017, an estimated 202 patients with respiratory symptoms were expected to be positive and 106 cases of pulmonary tuberculosis were reported among the indigenous population of the department of Cauca. A gap of 47.5% was found for diagnosis, since only 52.5% of subjects were diagnosed in health services. This gap was explained by poor quality of samples and flawed smear techniques; flaws in correct identification of patients with respiratory symptoms; limited access to diagnostic methods, such as culture and molecular tests; and limited training and high turnover of personnel in health service provider institutions. CONCLUSIONS: The tuberculosis control program should focus actions on bridging the gap in case detection in the indigenous population.

Analysis of implementation outcomes of quality improvement initiatives in Haiti: the fingerprint initiative.

OBJECTIVE: To assess the process and outcomes of the implementation of an electronic fingerprint initiative as part of quality improvement in three health facilities in the Northern Department of Haiti, in terms of its acceptability, adoption, feasibility, fidelity, and sustainability. In Haiti, poor attendance of the healthcare workforce is a nationwide problem, closely related to the quality of care. Three health institutions have tried to implement an electronic fingerprint system to monitor and improve attendance. METHODS: An exploratory and qualitative descriptive study of the implementation outcomes of the fingerprint initiative. It was based on semi-structured interviews and one group discussion using purposeful sampling techniques to recruit participants, and an open coding system and deductive approach to analyze the data using ATLAS.ti 8. RESULTS: The fingerprint initiative was successfully implemented in a non-governmental organization supported health facility but, despite some planning, it was never implemented in the public health facilities. The acceptability of the implementation was high in the not-for-profit organization and low in the public settings, mostly in relation to the presence of champions and the leadership at each health facility. CONCLUSIONS: We recommend more involvement of the leadership of health facilities in the different phases of the implementation process in order to guarantee acceptability, adoption, fidelity and sustainabiliy. More research is needed to articulate this technology-driven initiative in the Haitian health system.

[Tuberculosis care cascade for the indigenous population in Colombia: an operational research studyCascata de atenção da tuberculose para os povos indígenas na Colômbia: pesquisa operacional]. / Cascada de atención de la tuberculosis para la población indígena en Colombia: una investigación operativa.

OBJECTIVE: Construct and evaluate the care cascade for pulmonary tuberculosis in the indigenous population of the department of Cauca (Colombia) and identify existing gaps. METHODS: Mixed-methods sequential explanatory design. In the first phase, the pulmonary tuberculosis care cascade for the indigenous population of Cauca was evaluated. Data were obtained from secondary sources and all cases diagnosed from 1 January 2016 to 31 December 2017 were included. In the second phase, semi-structured interviews were done with nine program coordinators and 11 nursing auxiliaries to explain identified gaps. Absolute and percentage values were estimated for each of the steps and gaps in the care cascade. Quantitative and qualitative results were triangulated. RESULTS: In 2016 and 2017, an estimated 202 patients with respiratory symptoms were expected to be positive and 106 cases of pulmonary tuberculosis were reported among the indigenous population of the department of Cauca. A gap of 47.5% was found for diagnosis, since only 52.5% of subjects were diagnosed in health services. This gap was explained by poor quality of samples and flawed smear techniques; flaws in correct identification of patients with respiratory symptoms; limited access to diagnostic methods, such as culture and molecular tests; and limited training and high turnover of personnel in health service provider institutions. CONCLUSIONS: The tuberculosis control program should focus actions on bridging the gap in case detection in the indigenous population.

OBJETIVO: Elaborar e avaliar a cascata de atenção da tuberculose pulmonar na população indígena do Departamento de Cauca (Colômbia) e identificar as lacunas existentes. MÉTODOS: Metodologia mista com desenho sequencial explicativo. Na primeira fase, avaliamos a cascata de atenção da tuberculose pulmonar para a população indígena de Cauca. Os dados foram obtidos de fontes secundárias, incluindo todos os casos diagnosticados entre 1 de janeiro de 2016 e 31 de dezembro de 2017. Na segunda fase, realizamos entrevistas semiestruturadas com nove coordenadores do programa e 11 auxiliares de enfermagem para explicar as lacunas identificadas. Estimamos os valores absolutos e percentuais em cada uma das etapas e as lacunas na cascata de atenção. Os resultados quantitativos e qualitativos foram triangulados. RESULTADOS: Nos anos de 2016 e 2017, foi estimada a ocorrência de 202 casos com sintomas respiratórios com diagnóstico esperado positivo; no entanto, os serviços de saúde só diagnosticaram e notificaram 106 casos de tuberculose pulmonar na população indígena do Departamento de Cauca. Portanto, identificamos uma lacuna diagnóstica de 47,5%, já que apenas 52,5% dos casos receberam um diagnóstico nos serviços de saúde. As explicações para esta lacuna foram a má qualidade das amostras e falhas na técnica de esfregaço, falhas na identificação correta dos sintomas respiratórios, acesso limitado aos métodos de diagnóstico, tais como cultura e testes moleculares, bem como capacitação deficiente e alta rotatividade de pessoal nas instituições de saúde. CONCLUSÕES: As ações do programa de controle da tuberculose devem se concentrar em reduzir a lacuna na detecção de casos na população indígena.

[Occupational health and safety: educational intervention for cleaning workers in research sectors]. / Salud y seguridad laboral: intervención educativa en trabajadores de limpieza en áreas de investigación.

OBJECTIVE: To evaluate the results of educational interven- tion on health and safety regarding principles of biosafety in cleaning workers of a health institution. MATERIALS AND METHODS: Using concurrent mixed methods, we evaluated a total of 31 workers on their knowledge, attitudes, and practices of biosafety and risk perception. We conducted baseline measurements and two follow-ups. Fractional logistic regression models were fitted with study stage as covariate. Additional models included interactions of study stage with key workers characteristics. Thematic qualitative analysis and triangulation was developed. RESULTS: The knowledge (+33.3 points, scale 0-100), attitudes (+10.6), and practices (+23.5) increased significantly in the first follow-up; knowledge de- creased in the second follow-up (p<0.001). The qualitative findings revealed an improvement in risk prevention attitudes and practices, framed by experiences of vulnerability, stigma, and discrimination. CONCLUSIONS: The study provides key elements for biosafety research related to vulnerable groups and it is effective in promoting the health of a disadvantaged and invisible sector.

OBJETIVO: Evaluar los resultados de una intervención educativa sobre salud y seguridad laboral bajo principios de bioseguridad en trabajadores y trabajadoras de limpieza de una institución de salud. MATERIAL Y MÉTODOS: Evaluación con métodos mixtos concurrentes sobre conocimientos, actitudes y prácticas en bioseguridad y percepción de riesgos, con medición basal y dos seguimientos, en 31 trabajadores y trabajadoras. Se realizaron modelos fraccionales separados para estimar interacciones de las mediciones. Se hizo análisis cualitativo temático y triangulación metodológica. RESULTADOS: Los conocimientos (+33.3 puntos, escala 0 - 100), actitudes (+10.6) y prácticas (+23.5) incrementaron signifi- cativamente en el primer seguimiento; los conocimientos disminuyeron en el segundo seguimiento (p<0.001). Los ha- llazgos cualitativos revelaron mejora en actitudes y prácticas de prevención frente al riesgo, enmarcados por experiencias de vulnerabilidad, estigma y discriminación. CONCLUSIONES: El estudio aporta elementos clave para la investigación en bioseguridad relacionada con grupos vulnerables y es efectivo para la promoción de la salud de un sector desfavorecido e invisibilizado.

[The health of Mexicans living in localities with less than 100 000 inhabitants]. / La salud de los mexicanos que habitan en localidades de menos de 100 000 habitantes.

OBJECTIVE: To describe the health and nutritional status of Mexican population living in localities under 100 000 inhabitants (100k) in year 2018 in comparison it with a sample of similar characteristics in 2012. MATERIALS AND METHODS: The more relevant results analyzed in 19 articles about health and nutrition of the population are presented. This included information on access and utilization of health services, health and nutrition status by age groups and households affected by food insecurity (FI). RESULTS: Information was obtained about the health and nutrition status of the population from <100k localities, which is characterized by its higher poverty levels. CONCLUSIONS: Great inequities prevails the health and nutrition conditions of the Mexican population. The findings are useful for the devel- opment of public policies capable of reducing health inequities conditions, in order to achieve social equity.

OBJETIVO: Describir la situación de salud y nutrición de la población mexicana que habita en localidades de menos de 100 000 habitantes (100k) para el año 2018 y compararla con una muestra con características similares en 2012. MATERIAL Y MÉTODOS: Se presentan los resultados sobre la salud y nutrición de la población, analizados en 19 artículos sobre el acceso y utilización de los servicios de salud, la situación de salud y nutrición por grupos de edad y sobre los hogares afectados por inseguridad alimentaria. RESULTADOS: Se obtuvo información de salud y nutrición a nivel nacional en población de localidades <100k, caracterizada por tener mayores con- diciones de pobreza. CONCLUSIONES: En México prevalecen desigualdades en las condiciones de salud y nutrición de la po- blación. Los hallazgos son de utilidad para desarrollar políticas públicas capaces de reducir las desigualdades en salud, con el objeto de lograr la equidad social.

[Inequalities in access to services, basis for policies to reduce the health gap]. / Desigualdades en el acceso a servicios, base de las políticas para la reducción de la brecha en salud.

OBJECTIVE: To estimate inequalities in access to health services among Mexican population living in localities of 100 000 or less inhabitants. MATERIALS AND METHODS: Cross-sectional analysis using the National Health and Nu- trition Survey 100k 2018 survey data. Access was estimated using health insurance and care for the last health condition. As inequality measure, we estimated the concentration index using an imputation of household per capita income. RESULTS: Among studied population, health insurance was 82.42% and access to care 60.03%. We identified inequalities in both indicators; marginal and pro-poor for insurance and pro-rich for access to care. CONCLUSIONS: In Mexico, even within the popuation living in poverty there are inequalities in access to health care. More granular public interventions are needed to address inequalities in an effective way.

OBJETIVO: Estimar la desigualdad en acceso a servicios de salud en poblaciones de localidades menores de 100 000 habitantes en México. MATERIAL Y MÉTODOS: Análisis de la Encuesta Nacional de Salud y Nutrición 100k 2018. Se estimó el acceso con base en la afiliación a un esquema de aseguramiento (acceso potencial) y la atención para el más reciente problema de salud (acceso a atención) mediante el índice de concentración, utilizando una imputación del ingreso per cápita. RESULTADOS: La afiliación a algún esquema de ase- guramiento en salud fue de 82.42% y el acceso a atención de 60.03%. Se identificaron desigualdades en ambos indicadores, marginales para acceso potencial y con mayor concentración entre la población de menor ingreso; para acceso a atención se encontró desigualdad con mayor concentración entre la población de mayor ingreso. CONCLUSIONES: En México prevalecen desigualdades en acceso a servicios de salud para la población en condiciones de pobreza. Es necesario desarrollar intervenciones públicas con mayor granularidad para incidir de forma efectiva en la desigualdad.

An explanatory analysis of economic and health inequality changes among Mexican indigenous people, 2000-2010.

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.

Hospital accreditation in Mexico fails to improve the quality of healthcare: lessons from an impact evaluation.

Healthcare quality in low- and middle-income countries poses a significant challenge, contributing to heightened mortality rates from treatable conditions. The accreditation of health facilities was part of the former health reform in Mexico, proposed as a mechanism to enhance healthcare quality. This study assesses the performance of hospital accreditation in Mexico, utilizing indicators of effectiveness, efficiency, and safety. Employing a longitudinal approach with controlled interrupted time series analysis (C-ITSA) and fixed effects panel analysis, administrative data from general hospitals in Mexico is scrutinized. Results reveal that hospital accreditation in Mexico fails to enhance healthcare quality and, disconcertingly, indicates deteriorating performance associated with increased hospital mortality. Amidst underfunded health services, the implemented accreditation model proves inadequately designed to uplift care quality. A fundamental redesign of the public hospital accreditation model is imperative, emphasizing incentives for structural enhancement and standardized processes. Addressing the critical challenge of improving care quality is urgent for Mexico's healthcare system, necessitating swift action to achieve effective access as a benchmark for universal healthcare coverage.

Migration Decision-Making among Mexican Youth: Individual, Family, and Community Influences.

We explored migration decisions using in-depth, semi-structured interviews with male and female youth ages 14 to 24 (n=47) from two Mexican communities, one with high and one with low U.S. migration density. Half were return migrants and half were non-migrants with relatives in the U.S. Migrant and non-migrant youth expressed different preferences, especially in terms of education and their ability to wait for financial gain. Reasons for migration were mostly similar across the two communities; however, the perceived risk of the migration journey was higher in the low density migration community while perceived opportunities in Mexico were higher in the high density migration community. Reasons for return were related to youths' initial social and economic motivations for migration. A greater understanding of factors influencing migration decisions may provide insight into the vulnerability of immigrant youth along the journey, their adaptation process in the U.S., and their reintegration in Mexico.

Tuberculosis screening indicators in indigenous population in Colombia: a mixed methods research.

This study aims to evaluate, via a mixed methods study, the implementation of the screening process for pulmonary tuberculosis (PTB) within indigenous population of the Department of Cauca, Colombia, during the 2016-2018 period. Indicators assessing the PTB screening process were elaborated and estimated. Subsequently, an evaluation of the indicators were performed based on a sampling process from health care providers of the municipalities with the highest and lowest PTB incidence and from key agents' perspective. Screening indicators were estimated and thematic analysis was performed based on the interviews conducted with key agents. Finally, a triangulation of quantitative and qualitative findings was performed. From the total population expected to have respiratory symptomatics (n = 16,711), the health care providers were able to identify 42.3% of them. Out of the individuals identified as respiratory symptomatics (n = 7,064), they were able to examine 93.2% (n = 6,585) with at least one acid-fast bacilli smear test. The reported positivity index from acid-fast bacilli smear test was 1.87%. The explanations from key agents revolved around the possibility of an overestimated targeted amount of respiratory symptomatics; insufficient personnel for the search of symptomatic individuals; high costs for the search in areas of difficult access; the need to request permissions from indigenous authorities; culturally ingrained stigma; use of traditional medicine and self-medication; and patient's personal beliefs. This study revealed barriers in the implementation of the screening process for PTB within the indigenous population from the Department of Cauca, mainly in the identifying process of the respiratory symptomatics.

Embedded implementation research determinants in Latin American health systems.

OBJECTIVE: To assess the determinants of embedded implementation research (EIR) conduct in seven Latin American and Caribbean countries. METHODS: This qualitative interpretative study conducted and analyzed 14 semi-structured interviews based on a grounded theory approach using Atlas-ti© 7.5.7. We grouped the conditions appointed by interviewees as determinants of EIR conduct into six domains. RESULTS: The participation of high-level engaged decision makers as research co-producers is an important EIR determinant that fosters research use. Nevertheless, EIR faces challenges such as dealing with key personnel changes and fluctuating political contexts. CONCLUSIONS: Despite its limitations, EIR is effective in creating a sense of ownership of research results among implementers, which helps bridge the gap between research and decision-making in health systems.

Impact of the 'Seguro Médico Siglo XXI' medical insurance programme on neonatal and infant mortality in Mexico, 2006-14: an ecological approach to estimation.

The 'Seguro Médico Siglo XXI' (SMSXXI), a universal coverage medical insurance programme for children under 5 years of age, started in 2006 to help avoid catastrophic health expenditures in poor families without social security in Mexico. The study used information from the National Health Information System for the 2006-14 period. An ecological approach was followed with a panel of the 2457 municipalities of Mexico as the units of analysis. The outcome variables were the municipality-level neonatal mortality and infant mortality rates in population without access to social security. The programme variable was the coverage of the SMSXXI programme at the municipality level, expressed as a proportion. Demographic and economic variables defined at the municipality level were included as covariates. Impact was estimated by fitting a fixed-effects negative binomial regression model. Results reveal that the SMSXXI significantly reduced both infant and neonatSal mortality in the target population, although in a non-linear fashion, with minimum mortality levels found around the 70% coverage range. The effect is mostly given by the transition from the first quintile to the fourth quintile of coverage (<13% vs 70.5-93.7% coverage), and it is attenuated significantly at coverage levels very close to or at 100%. The observed risk reduction amounted to an estimated total of 11 358 infant deaths being avoided due to the SMSXXI during the 2006-14 period, of which 48% were neonatal. In conclusion, we found a significant impact of the SMSXXI programme on both infant mortality and neonatal mortality. An attenuation of the effect of the insurance on mortality rates at levels close to 100% coverage may reflect the saturation of health units in detriment of the quality of care.