[Violence and mental health issues among Mexican adolescents that have considered or attempted cross-border migration]. / Violencia y salud mental asociados a pensar o haber intentado emigrar internacionalmente por adolescentes mexicanos.

The aim of this study was to estimate the role of victimization by violence among Mexican adolescents that have considered or attempted migrating to the United States, including mental health variables (emotional self-esteem, self-esteem in school, depression, suicidal ideation, and attempted suicide) as mediators of the effects. The study used a cross-sectional design with a stratified cluster sample of 13,198 adolescents from the 2nd Mexican National Survey on Exclusion, Intolerance, and Violence in public schools in 2009. The analysis used the regression models proposed by Baron & Kenny. Prevalence of having considered or attempted cross-border migration was 23.1%. Mean age was 16.36 years. Female adolescents constituted 54.9% of the sample, and 56% were lower-income. Mental health variables that acted as partial mediators were suicidal ideation (35.9%), depression (19.2%), attempted suicide (17.7%), emotional self-esteem (6.2%), and self-esteem in school (3.4%) for moderate family violence, and emotional self-esteem (17.5%) for social rejection in school and suicidal ideation (8.1%) for physical harm in school. Female adolescents showed greater impact from mediators than men in considering or having attempted cross-border migration. The study discusses the importance of incorporating the prevention of violence in the social contexts studied here and incorporating mental health in dealing with violence in adolescents and in public health programs in transit areas for illegal migrants.

The Expanding Role of Education and Research in International Healthcare.

A recent report of the Lancet Commission on Global Surgery has continued to emphasize the importance of surgery in global health. Plastic surgeons have been involved in humanitarian care of children in developing countries for many years. The ability to repair children with cleft lip and palate in resource-poor settings has made this desirable for many plastic surgeons. A number of philanthropic plastic surgery organizations arose to deal with the problem in a more structured way. Dr. Donald Laub at Stanford established Interplast (now ReSurg) in 1969. Dr. Bill and Kathy Magee established Operation Smile in 1982, and many others have followed. The unifying theme of these organizations has been the desire to provide safe and effective surgical care to children who would otherwise be forced to live out their lives with deformity. Most care has been for children with clefts, but efforts have expanded to include hand surgery and burn reconstruction. The initial effort was provided through surgical missions. A paradigm shift has occurred as sustainability and local capacity have become paramount. Education and training of local colleagues and assistance in surgical safety infrastructure are expanding the reach of plastic surgical care around the globe. The inauguration of in-country permanent surgical centers allows high-volume outcomes research, as well as unique educational collaboration between plastic surgeons of both the developed and developing world.

Inequitable Access to Timely Cleft Palate Surgery in Low- and Middle-Income Countries.

BACKGROUND: Delayed cleft palate repair has significant implications for physical, mental, and social well-being and has been suggested to lead to an increased risk of infant and under-five mortality in low- and middle-income countries (LMICs). METHODS: Using medical records from Operation Smile international programs taking place in eleven different LMICs between March and May 2014, we performed a logistic regression assessing the relationship between delayed surgery access, defined as primary palatoplasty presentation after 24 months of age, and GDP per capita across 11 countries. RESULTS: Median age of presentation ranged from 13 to 24 months in upper-middle-income countries, 17 to 35 months in lower-middle-income countries, and 14 to 66 months in low-income countries. Our analysis demonstrated a 14 % increase in the odds of late surgery [OR = 0.88 (P < 0.001)] for every 1000 USD decrease of GDP per capita. In low- and lower-middle-income countries, this relationship was even stronger, with an OR of 0.59 (P < 0.001), indicating a 70 % increase in the odds of late surgery for every 1000 USD decrease in GDP per capita. CONCLUSIONS: There is a strong negative correlation between national income status and delayed access to primary cleft palate surgery, indicating a high degree of inequity in access to surgery, particularly in low- and lower-middle-income countries. As the importance of surgery in global health is increasingly recognized, an equity perspective must be included in the global dialog to ensure that the world's poor have fair and equitable access to essential surgical care.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part I: challenge and commitment.

BACKGROUND: With an estimated backlog of 4,000,000 patients worldwide, cleft lip and cleft palate remain a stark example of the global burden of surgical disease. The need for a new paradigm in global surgery has been increasingly recognized by governments, funding agencies, and professionals to exponentially expand care while emphasizing safety and quality. This three-part article examines the evolution of the Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) as an innovative model for sustainable cleft care in the developing world. METHODS: The GCCCC is the result of a unique public-private partnership between government, charity, and private enterprise. In 2009, Operation Smile, the Government of Assam, the National Rural Health Mission, and the Tata Group joined together to work towards the common goal of creating a center of excellence in cleft care for the region. RESULTS: This partnership combined expertise in medical care and training, organizational structure and management, local health care infrastructure, and finance. A state-of-the-art surgical facility was constructed in Guwahati, Assam which includes a modern integrated operating suite with an open layout, advanced surgical equipment, sophisticated anesthesia and monitoring capabilities, central medical gases, and sterilization facilities. CONCLUSION: The combination of established leaders and dreamers from different arenas combined to create a synergy of ambitions, resources, and compassion that became the backbone of success in Guwahati.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part II: program development and quality care.

BACKGROUND: The Guwahati Comprehensive Cleft Care Center (GCCCC) is committed to free medical and surgical care to patients afflicted with facial deformities in Assam, India. A needs-based approach was utilized to assemble numerous teams, processes of care, and systems aimed at providing world-class care to the most needy of patients, and to assist them with breaking through the barriers that prohibit them from obtaining services. METHODS: A team of international professionals from various disciplines served in Guwahati full time to implement and oversee patient care and training of local counterparts. Recruitment of local professionals in all disciplines began early in the scheme of the program and led to gradual expansion of all medical teams. Emphasis was placed on achieving optimal outcome for each patient treated, as opposed to treating the maximum number of patients. RESULTS: The center is open year round to offer full-time services and follow-up care. Along with surgery, GCCCC provides speech therapy, child life counseling, dental care, otolaryngology, orthodontics, and nutrition services for the cleft patients under one roof. Local medical providers participated in a model of graded responsibility commiserate with individualized skill and progress, and gradually assumed all leadership positions and now account for 92% of the workforce. Institutional infrastructure improvements positioned and empowered teams of skilled local providers while implementing systemized perioperative processes. CONCLUSION: This needs-based approach to program development in Guwahati was successful in optimization of quality and safety in all clinical divisions.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability.

BACKGROUND: The Guwahati Comprehensive Cleft Care Center (GCCCC) utilizes a high-volume, subspecialized institution to provide safe, quality, and comprehensive and cost-effective surgical care to a highly vulnerable patient population. METHODS: The GCCCC utilized a diagonal model of surgical care delivery, with vertical inputs of mission-based care transitioning to investments in infrastructure and human capital to create a sustainable, local care delivery system. Over the first 2.5 years of service (May 2011-November 2013), the GCCCC made significant advances in numerous areas. Progress was meticulously documented to evaluate performance and provide transparency to stakeholders including donors, government officials, medical oversight bodies, employees, and patients. RESULTS: During this time period, the GCCCC provided free operations to 7,034 patients, with improved safety, outcomes, and multidisciplinary services while dramatically decreasing costs and increasing investments in the local community. The center has become a regional referral cleft center, and governments of surrounding states have contracted the GCCCC to provide care for their citizens with cleft lip and cleft palate. Additional regional and global impact is anticipated through continued investments into education and training, comprehensive services, and research and outcomes. CONCLUSION: The success of this public private partnership demonstrates the value of this model of surgical care in the developing world, and offers a blueprint for reproduction. The GCCCC experience has been consistent with previous studies demonstrating a positive volume-outcomes relationship, and provides evidence for the value of the specialty hospital model for surgical delivery in the developing world.

Factores del abuso sexual en la niñez y la adolescencia en estudiantes de Morelos, México / Factors for sexual abuse during childhood and adolescence in students of Morelos, Mexico / Fatores de abuso sexual na infância e adolescência de estudantes de Morelos, México

OBJETIVO: Estimar la prevalencia y los factores asociados al abuso sexual en niñez y adolescencia. MÉTODOS: Estudio realizado en una muestra de estudiantes del estado de Morelos, México, en 2004-2005. Los participantes (n=1730) pertenecen a una cohorte de 13.293 estudiantes de 12 a 24 años. Los datos fueron colectados mediante la aplicación de un cuestionario conteniendo secciones de escalas validadas. Las variables analizadas fueron: factores sociodemográficos (sexo, zona de habitación, nivel socioeconómico); familiares (educación de los padres, adicciones de los padres, violencia entre padres); psicológicos individuales (autoestima - Inventario de Autoestima de Coopersmith, depresión, consumo de alcohol); violencia intrafamiliar (Escala de Strauss); y abuso sexual. Mediante regresión logística múltiple se evaluaron los factores asociados. Se obtuvieron Razones de Momios (RM) con intervalos de confianza al 95%. RESULTADOS: El 4.7% (n=80) de los (as) estudiantes presentaron intento de abuso y el 2.9% (n=50) fueron víctimas de abuso sexual consumado. Las mujeres tuvieron mayor prevalencia de intento (6.1%). El 3.6% de las mujeres y el 1.9% de los hombres fueron abusados sexualmente. Principal agresor en mujeres fue el novio y en hombres una persona desconocida. Edad promedio de 12.02 años en mujeres y 11.71 en hombres. Factores asociados al abuso: mayor consumo de alcohol padres (RM = 3.37; IC 95% 1.40;8.07); violencia hacia madre (RM=4.49; IC 95% 1.54;13.10); ser mujer (RM = 2.47; IC 95% 1.17;5.24); ser víctima de violencia intrafamiliar alta (RM=3.58; IC 95% 1.32;9.67). Autoestima alta fue un factor protector (RM=0.27; IC 95% 0.09;0.75). CONCLUSIONES: En promedio el abuso sexual se presenta a los 12 años de edad en ambos sexos, siendo más frecuente en el sexo femenino. La mayoría de víctimas no lo denuncia.

OBJECTIVE: To estimate the prevalence and factors associated with sexual abuse in childhood and adolescence.METHODS: Study conducted in a sample of students in the state of Morelos, Mexico, in 2004-2005. Participants (n=1730) were drawn from a cohort of 13,293 students aged 12 to 24 years. Data were collected by means of a questionnaire comprising parts of validated scales. The variables studied were: sociodemographic (gender, living area, socioeconomic status), family (parental education, parental addictions, violence between parents), individual psychological factors (self-esteem assessed using the Coopersmith Self-Esteem Inventory, depression, alcohol consumption), intrafamily violence (assessed through Strauss Scale) and sexual abuse. Multiple logistic regression assessed the risk factors associated. Odds ratios (OR) with 95% confidence intervals were estimated.RESULTS: Of all students studied, 4.7% (n=80) reported attempted sexual abuse and 2.9% (n=50) were victims of consummated sexual abuse. Women had higher prevalence of attempted (6.1%) abuse; 3.6% of females and 1.9% of men were sexually abused. Main perpetrators were boyfriends in women and a stranger in men. Mean age was 12.02 years old among females and 11.71 years old among men. Factors found to be associated with abuse: high parental alcohol consumption (OR = 3.37, 95% CI 1.40;8.07), violence toward the mother (OR = 4.49, 95% CI 1.54;13.10), female gender (OR = 2.47, 95% CI 1.17;5.24), being a victim of great domestic violence (OR = 3.58, 95% CI 1.32;9.67). High self-esteem was a protective factor (OR = 0.27, 95% CI 0.09;0.75). CONCLUSIONS: Overall sexual abuse occurs at the age of 12 in both males and females, and it is more frequent among females. Most victims do not report abuse.

OBJETIVO: Estimar a prevalência e fatores associados ao abuso sexual infantil e na adolescência. MÉTODOS: Estudo realizado em amostra de estudantes do estado de Morelos, México, entre 2004 e 2005. Os participantes (n=1730) pertencem a uma coorte de 13.293 estudantes de 12 a 24 anos. Os dados foram coletados por meio de questionário formado por partes de escalas validadas. As variáveis analisadas foram: fatores sociodemográficos (sexo, zona de residência, nível socioeconômico); familiares (educação dos pais, vícios dos pai, violência entre pais); psicológicos individuais (autoestima- Inventario de Autoestima de Coopersmith, depressão, consumo de álcool); violência intrafamiliar (Escala de Strauss); e abuso sexual. As variáveis dependentes analisadas foram a intenção e o abuso sexual consumado. Os fatores associados foram analisados por meio de regressão logística múltipla, com odds ratios e respectivos intervalos de 95% de confiança (IC 95%). RESULTADOS: Do total, 4,7% (n=80) dos alunos reportaram terem sofrido intenção de abuso e 2,9% foram vítimas de abuso sexual consumado. As mulheres relataram maior prevalência de intenção (6,1%). Foram abusados sexualmente 3,6% das mulheres e 1,9% dos homens. O principal agressor das mulheres foi o namorado e dos homens, uma pessoa desconhecida. A idade do abuso foi de 12,02 anos para mulheres e 11,71 para os homens. Os fatores associados ao abuso foi o maior consumo de álcool pelos pais (RM = 3.37; IC 95% 1.40;8.07); violência contra a mãe (OR=4.49; IC 95%1.54;13.10); ser mulher (OR= 2.47; IC 95%1.17;5.24); ser vítima de violência intrafamiliar alta (OR=3.58; IC 95%1.32;9.67). Autoestima alta foi um fator protetor (RM=0.27; IC 95% 0.09;0.75). CONCLUSÕES: A média de idade do abuso sexual foi de 12 anos em ambos os sexos, sendo mais freqüente entre as do sexo feminino. A maioria das vítimas não denuncia o abuso.

[Factors for sexual abuse during childhood and adolescence in students of Morelos, Mexico]. / Factores del abuso sexual en la niñez y la adolescencia en estudiantes de Morelos, México.

OBJECTIVE: To estimate the prevalence and factors associated with sexual abuse in childhood and adolescence. METHODS: Study conducted in a sample of students in the state of Morelos, Mexico, in 2004-2005. Participants (n=1730) were drawn from a cohort of 13,293 students aged 12 to 24 years. Data were collected by means of a questionnaire comprising parts of validated scales. The variables studied were: sociodemographic (gender, living area, socioeconomic status), family (parental education, parental addictions, violence between parents), individual psychological factors (self-esteem assessed using the Coopersmith Self-Esteem Inventory, depression, alcohol consumption), intrafamily violence (assessed through Strauss Scale) and sexual abuse. Multiple logistic regression assessed the risk factors associated. Odds ratios (OR) with 95% confidence intervals were estimated. RESULTS: Of all students studied, 4.7% (n=80) reported attempted sexual abuse and 2.9% (n=50) were victims of consummated sexual abuse. Women had higher prevalence of attempted (6.1%) abuse; 3.6% of females and 1.9% of men were sexually abused. Main perpetrators were boyfriends in women and a stranger in men. Mean age was 12.02 years old among females and 11.71 years old among men. Factors found to be associated with abuse: high parental alcohol consumption (OR = 3.37, 95% CI 1.40;8.07), violence toward the mother (OR = 4.49, 95% CI 1.54;13.10), female gender (OR = 2.47, 95% CI 1.17;5.24), being a victim of great domestic violence (OR = 3.58, 95% CI 1.32;9.67). High self-esteem was a protective factor (OR = 0.27, 95% CI 0.09;0.75). CONCLUSIONS: Overall sexual abuse occurs at the age of 12 in both males and females, and it is more frequent among females. Most victims do not report abuse.

Prevalence and correlates of adolescent dating violence: baseline study of a cohort of 7,960 male and female Mexican public school students.

INTRODUCTION: Factors correlated with adolescent dating violence have yet to be documented in most developing countries; this study assesses the prevalence and correlates of victimization with and perpetration of dating violence among Mexican youth. METHODS: This was the baseline measurement (1998-1999) of a cohort of 7960 public school students (11-24 years) developed to explore various health behaviors in Mexican youth. Multinomial logistic regression models were constructed with adolescent dating violence as the dependent variable. RESULTS: Prevalence of dating violence victimization was 9.37% (female) and 8.57% (male) for psychological violence; 9.88% (female) and 22.71% (male) for physical violence, and 8.63% (female) and 15.15% (male) for both psychological and physical violence. Prevalence of perpetration was 4.21% (female) and 4.33% (male) for psychological violence; 20.99% (female) and 19.54% (male) for physical violence; and 7.48% (female) and 5.51% (male) for both types of violence. Factors associated with dating violence victimization for both genders included: two or more lifetime sexual partners and intra-familial violence. Higher age, alcohol use and illegal drug use were significantly associated with victimization only among girls. The following were significantly associated with perpetration of dating violence in both genders: gang membership, illegal drug use, two or more lifetime sexual partners and intra-familial violence. Higher age and alcohol use were significantly associated with perpetration only among girls. High or middle socio-economic status was associated with perpetration only in boys. CONCLUSIONS: Future research on adolescent dating violence in Mexico should further explore severity and frequency of violent behaviors, include a focus on severe dating violence and take into account the context and meaning of dating violence. A longitudinal design that allows determination of causality will also be needed in order to develop prevention strategies.

[Validation of a questionnaire for measurement of beliefs about the climacteric]. / Validación de un cuestionario para la medición de las creencias sobre el climaterio.

OBJECTIVE: To design an instrument for measuring beliefs about the social, psychological, and physiological consequences of women's climacteric stage. MATERIAL AND METHODS: The study included 340 women affiliated to Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado (Institute for Social Services and Security for State Workers, ISSSTE) (age mean = 49.46, (SD 7.92). The mean number of pregnancies in the sample was 3.75 (SD 2.57), and the mean number of born children was 3.21 (SD 2.19); 48% of women were premenopausal, 10.9% perimenopausal, and 40.6% postmenopausal. The instrument consisted of 25 items. RESULTS: A factorial analysis with Varimax rotation was carried out. Four factors were confirmed: disadvantages (alpha = 0.769), advantages (alpha = 0.839), physiological (alpha = 0.659), and psychological (alpha = 0.711). CONCLUSION: This instrument shows good internal consistency, and measures four climacteric belief groups: a) beliefs on disadvantages, b) beliefs on advantages, c) beliefs on physiological ailments, and d) beliefs on psychological symptoms. All three confirmed dimensions of the climacteric phase have been proposed in other studies.

Validación de un cuestionario para la medición de las creencias sobre el climaterio / Validation of a questionnaire for measurement of beliefs about the climacteric

OBJECTIVE: To design an instrument for measuring beliefs about the social, psychological, and physiological consequences of women's climacteric stage. MATERIAL AND METHODS: The study included 340 women affiliated to Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado (Institute for Social Services and Security for State Workers, ISSSTE) (age mean = 49.46, (SD 7.92). The mean number of pregnancies in the sample was 3.75 (SD 2.57), and the mean number of born children was 3.21 (SD 2.19); 48 of women were premenopausal, 10.9 perimenopausal, and 40.6 postmenopausal. The instrument consisted of 25 items. RESULTS: A factorial analysis with Varimax rotation was carried out. Four factors were confirmed: disadvantages (alpha = 0.769), advantages (alpha = 0.839), physiological (alpha = 0.659), and psychological (alpha = 0.711). CONCLUSION: This instrument shows good internal consistency, and measures four climacteric belief groups: a) beliefs on disadvantages, b) beliefs on advantages, c) beliefs on physiological ailments, and d) beliefs on psychological symptoms. All three confirmed dimensions of the climacteric phase have been proposed in other studies.