Integrative health care model for climacteric stage women: design of the intervention.

BACKGROUND: Climacteric stage women experience significant biological, psychological and social changes. With demographic changes being observed in the growing number of climacteric stage women in Mexico, it is important to improve their knowledge about the climacteric stage and its potential associated problems, encourage their participation in screening programs, and promote the acquisition of healthy lifestyles.At Mexican health care institutions the predominant health care model for climacteric stage women has a biomedical perspective. Medical doctors provide mostly curative services and have limited support from other health professionals. This study aims to design an integrative health care model (IHCM: bio-psycho-social, multidisciplinary and women-centered) applicable in primary care services aimed at climacteric stage women. METHODS/DESIGN: We present the design, inclusion criteria and detailed description of an IHCM. The IHCM consists of collaborative and coordinated provision of services by a health team, which is involves a family doctor, nurse, psychologist, and the woman herself. The health team promotes the empowerment of women through individual and group counseling on the climacteric stage and health related self-care. The intervention lasts three months followed by a three-month follow-up period to evaluate the effectiveness of the model. The effectiveness of the model will be evaluated through the following aspects: health-related quality of life (HR-QoL), empowerment, self-efficacy and knowledge regarding the climacteric stage and health-related self-care activities, use of screening services, and improvement in lifestyles (regular leisure time physical activity and healthy diet). DISCUSSION: Participation in preventive activities should be encouraged among women in Mexico. Designing and evaluating the effectiveness of an integrative health care model for women at the climacteric stage, based on the empowerment approach and focus on health-related self-care to improve their HR-QoL is pertinent for current health conditions of this age group. TRIAL REGISTRATION: The study is registered at the ClinicalTrials.gov (NCT01272115).

Strengthening preventive care programs: a permanent challenge for healthcare systems; lessons from PREVENIMSS México.

BACKGROUND: In 2001, the Instituto Mexicano del Seguro Social (IMSS) carried out a major reorganization to provide comprehensive preventive care to reinforce primary care services through the PREVENIMSS program. This program divides the population into programmatic age groups that receive specific preventive services: children (0-9 years), adolescents (10-19 years), men (20-59 years), women (20-59 years) and older adults (> = 60 years). The objective of this paper is to describe the improvement of the PREVENIMSS program in terms of the increase of coverage of preventive actions and the identification of unmet needs of unsolved and emergent health problems. METHODS: From 2003 to 2006, four nation-wide cross-sectional probabilistic population based surveys were conducted using a four stage sampling design. Thirty thousand households were visited in each survey. The number of IMSS members interviewed ranged from 79,797 respondents in 2003 to 117,036 respondents in 2006. RESULTS: The four surveys showed a substantial increase in coverage indicators for each age group: children, completed schemes of vaccination (> 90%), iron supplementation (17.8% to 65.5%), newborn screening for metabolic disorders (60.3% to 81.6%). Adolescents, measles - rubella vaccine (52.4% to 71.4%), hepatitis vaccine (9.3% to 46.2%), use of condoms (17.9% to 59.9%). Women, measles-rubella vaccine (28.5% to 59-2%), cervical cancer screening (66.7% to 75%), breast cancer screening (> 2.1%). Men, type 2 diabetes screening (38.6% to 57.8%) hypertension screening (48-4% to 64.0%). Older adults, pneumococcal vaccine (13.2% to 24.9%), influenza vaccine (12.6% to 52.9) Regarding the unmet needs, the prevalence of anemia in children was 30% and a growing prevalence of overweight and obesity, type 2 diabetes, and hypertension was found in men, women and older adults. CONCLUSION: PREVENIMSS showed an important increase in the coverage of preventive services and stressed the magnitude of the old and new challenges that this healthcare system faces. The unsolved problems such as anemia, and the emerging ones such as overweight, obesity, among others, point out the need to strength preventive care through designing and implementing innovative programs aimed to attain effective coverage for those conditions in which prevention obtains substandard results.

An international trial of antioxidants in the prevention of preeclampsia (INTAPP).

OBJECTIVE: We sought to investigate whether prenatal vitamin C and E supplementation reduces the incidence of gestational hypertension (GH) and its adverse conditions among high- and low-risk women. STUDY DESIGN: In a multicenter randomized controlled trial, women were stratified by the risk status and assigned to daily treatment (1 g vitamin C and 400 IU vitamin E) or placebo. The primary outcome was GH and its adverse conditions. RESULTS: Of the 2647 women randomized, 2363 were included in the analysis. There was no difference in the risk of GH and its adverse conditions between groups (relative risk, 0.99; 95% confidence interval, 0.78-1.26). However, vitamins C and E increased the risk of fetal loss or perinatal death (nonprespecified) as well as preterm prelabor rupture of membranes. CONCLUSION: Vitamin C and E supplementation did not reduce the rate of preeclampsia or GH, but increased the risk of fetal loss or perinatal death and preterm prelabor rupture of membranes.

Una mirada desde los servicios de salud a la nutrición de la niñez mexicana: IV Prevención de los problemas de nutrición de los niños, de rezago y emergentes / Health services perspective of the nutrition of Mexican children: IV. Prevention of shortage and emerging nutritional problems during childhood

Para contender con los problemas de la nutrición de los niños, los de rezago y emergentes, se enfatiza la importancia de que los niños pequeños sean amamantados e ingieran mayor cantidad de alimentos complementarios de origen animal. Asimismo, se recomienda utilizar el índice de masa corporal para detectar oportunamente problemas nutricios de déficit o exceso. La prevención del peso bajo al nacer requiere otorgar a la madre una atención prenatal de calidad, favorecer el acceso a los servicios de salud y una atención profesional del nacimiento. Para prevenir la anemia carencial se destaca la importancia de una correcta orientación alimentaria, eliminar los factores que ocasionan microsangrado gastrointestinal, adicionar hierro a los alimentos de consumo popular, aumentar las reservas al nacimiento y dar a los niños suplementos con sales específicas de hierro y ácido fólico. Para disminuir el retardo de la talla para la edad, que se encuentra vinculado a la deficiencia de cinc, se considera que la forma más eficaz de aportar este micro nutrimento es con suplementos que lo contengan y con alimentos de origen animal, además de productos del mar. De los problemas emergentes se menciona sólo la prevención de la obesidad por sus graves repercusiones. Ante la dificultad actual para decidir qué medidas son costo-efectivas, y ante el elevado fracaso terapéutico, se destaca la prevención como estrategia para su contención. Se enfatiza que es un problema de salud que estrictamente no es una responsabilidad médica o de los sistemas de salud, pero se proponen acciones alrededor de la ecuación del balance energético, abarcando desde la gestación a la edad escolar, en la que deben participar los individuos, los padres de familia, escuelas, maestros, productores de alimentos, publicistas y funcionarios públicos para modificar factores de riesgo como la cantidad y composición de los alimentos, además de la necesidad de eliminar el sedentarismo como forma de bienestar.

To demonstrate childhood nutritional problems, both those that are a consequence of underdevelopment (stunted and micronutrient deficiencies) and those emerging problems (overweight and obesity), we stress the importance of promoting breastfeeding along with appropriate complementary feeding. It is also recommended to measure body mass index to detect timely childhood growth deviations. To prevent low birth weight, high-quality antenatal care must be offered to mothers in accessible health facilities that are equipped to resolve pregnancy-related complications including newborn delivery by healthcare professionals. Several measures are helpful for preventing iron deficiency anemia such as increasing the iron reserves of pregnant women, retarding clamping of the umbilical cord that, in turn, increases the iron reserves of the newborn. We must eliminate risk factors for iron loss through the gastrointestinal tract and provide iron supplementation for at-risk infants. Folie acid also must be included in the supplement. Prevalence of stunting in poor communities is generally associated with zinc deficiency. Sufficient portions of animal and seafood products should be included in the daily diet, and supplements with this micronutrient should be provided in order to help prevent its deficiency. Regarding the emergent nutritional problems, we discuss the prevention of obesity due to its severe health consequences. Currently, there is no consensus about the most cost-effective interventions. In addition to the high proportion of therapeutic failures, several actions using as a model the energy balance equation from gestation to the child's age are proposed. We discuss about the amount of food and food composition as risk factors for obesity, along with the need to disregard a sedentary lifestyle. Obesity is not strictly a medical or health system responsibility but a problem shared by parents, families, schools, food producers and mass media as well as public authorities who, as social leaders, do not realize that we all are living in an obesogenic environment.

Atención integral de pacientes diabéticos e hipertensos con participación de enfermeras en medicina familiar / Comprehensive diabetic and hypertensive patient care involving nurses working in family practice

OBJETIVOS: Evaluar la efectividad de la participación de enfermeras de atención primaria en la atención integral a pacientes con hipertensión arterial (HTA) y diabetes mellitus tipo 2 (DM2). MÉTODOS: Se realizó un estudio cuasi-experimental antes-después, sin grupo control, en ocho clínicas de medicina familiar. Enfermeras capacitadas otorgaron atención integral en coordinación con un equipo formado por médico familiar, nutricionista, trabajadora social y estomatólogo. La intervención duró siete meses y utilizó como variables de resultado cambios en el índice de masa corporal, glucemia en ayunas, presión arterial, autopercepción del estado de salud, adherencia terapéutica y solicitud de servicios de urgencias. El cambio se determinó comparando la medición basal y final mediante entrevistas y registro de las variables de interés. RESULTADOS: 1 131 pacientes completaron el seguimiento, de los cuales 44,9 por ciento fue diagnosticado con HTA, 27 por ciento con DM2 y 28,1 por ciento con ambos padecimientos. La proporción de pacientes atendidos coordinadamente por el equipo de salud aumentó; se observó incremento de casos con peso normal y sobrepeso, reducción en la proporción de obesos (P < 0,05) y aumento de hipertensos con presión arterial < 130/80mmHg (P < 0,05). No se modificó la proporción de diabéticos con glucemia < 140 mg/dl; 18,2 por ciento notificó mejoría en la autopercepción del estado de salud (P < 0,05); hubo mejoría en la adherencia terapéutica (P < 0,05) y reducción de solicitud de atención a urgencias en las clínicas (-4,5 por ciento) y en los hospitales (-6,8 por ciento) (P < 0,05). CONCLUSIONES: La atención integral a pacientes con enfermedades crónicas mediante la participación de enfermeras contribuye a mejorar los resultados de salud en servicios de atención primaria.

OBJECTIVES: To evaluate the effectiveness of involving primary care nurses in comprehensive care of patients with hypertension and diabetes mellitus type II (DM2). METHODS: A quasi-experimental, before-and-after study was conducted, without a control group, in eight family-practice clinics. Trained nurses offered comprehensive care in conjunction with a team made up of a family doctor, a nutritionist, a social worker, and a dentist. The intervention lasted seven months and its outcome variables were changes in body mass index, fasting blood glucose, blood pressure, self-perceived health status, treatment compliance, and emergency services requests. Any change was determined by comparing the baseline to the final measurement through interviews and recording the variables of interest in a spreadsheet. RESULTS: In all, 1 131 patients completed the follow-up, of which 44.9 percent were diagnosed with hypertension, 27 percent with DM2, and 28.1 percent with both conditions. The proportion of patients seen by the coordinated health teams increased; there was a rise in cases of normal weight and overweight; a decrease in the proportion of obese (P < 0.05); and an increase in hypertensives with high blood pressure (< 130/ 80mmHg) (P < 0.05). There was no change in the proportion of diabetics with high blood glucose (< 140 mg/dl); 18.2 percent reported improved self-perceived health status (P < 0.05); there was improved treatment compliance (P < 0.05); and a decrease in requests for emergency services at the clinics (-4.5 percent) and at the hospitals (-6.8 percent) (P < 0.05). CONCLUSIONS: Comprehensive care for chronically ill patients through the involvement of nurses contributes to improved health outcomes in primary care.

A multifaceted education intervention for improving family physicians' case management.

BACKGROUND AND OBJECTIVES: The Mexican Institute of Social Security (IMSS) is the largest public health care system in Mexico. IMSS family physicians' management of clinical problems is frequently not consistent with published evidence. This study aimed to evaluate the effects of a multifaceted educational intervention to improve management of acute respiratory infections (ARI) by IMSS family physicians. METHODS: A non-randomized pre-post intervention with comparison group design was conducted in eight IMSS family medicine clinics in which 106 family physicians practiced. An evidence-based clinical guideline for ARI management was developed, and clinical tutors were trained. The three-stage intervention comprised interactive workshops, individual tutorials, and round-table peer-review sessions. The main outcome was appropriate ARI case management. The intervention effect was calculated by using the differences-in-differences model, adjusting for cluster of physicians. RESULTS: In the intervention group, the difference in mean proportion of improvement compared with baseline evaluation was 22.6% (95% confidence interval [CI]=10.3 to 34.9) for appropriate prescription of antibiotics, 29.8% (95% CI=17.2 to 42.4) for indication of worsening signs, and 19.6% (95% CI=11.2 to 28.0) for overall appropriate case management. The comparison group showed no significant changes. CONCLUSIONS: The educational intervention improved ARI management. Further studies are needed to analyze organizational implications, cost, sustainability, and effects on health outcomes.

[Comprehensive diabetic and hypertensive patient care involving nurses working in family practice]. / Atención integral de pacientes diabéticos e hipertensos con participación de enfermeras en medicina familiar.

OBJECTIVES: To evaluate the effectiveness of involving primary care nurses in comprehensive care of patients with hypertension and diabetes mellitus type II (DM2). METHODS: A quasi-experimental, before-and-after study was conducted, without a control group, in eight family-practice clinics. Trained nurses offered comprehensive care in conjunction with a team made up of a family doctor, a nutritionist, a social worker, and a dentist. The intervention lasted seven months and its outcome variables were changes in body mass index, fasting blood glucose, blood pressure, self-perceived health status, treatment compliance, and emergency services requests. Any change was determined by comparing the baseline to the final measurement through interviews and recording the variables of interest in a spreadsheet. RESULTS: In all, 1 131 patients completed the follow-up, of which 44.9% were diagnosed with hypertension, 27% with DM2, and 28.1% with both conditions. The proportion of patients seen by the coordinated health teams increased; there was a rise in cases of normal weight and overweight; a decrease in the proportion of obese (P < 0.05); and an increase in hypertensives with high blood pressure (< 130/ 80mmHg) (P < 0.05). There was no change in the proportion of diabetics with high blood glucose (< 140 mg/dl); 18.2% reported improved self-perceived health status (P < 0.05); there was improved treatment compliance (P < 0.05); and a decrease in requests for emergency services at the clinics (-4.5%) and at the hospitals (-6.8%) (P < 0.05). CONCLUSIONS: Comprehensive care for chronically ill patients through the involvement of nurses contributes to improved health outcomes in primary care.

Frequency and determinants of vitamin A deficiency in children under 5 years of age with pneumonia.

BACKGROUND: Vitamin A deficiency (VAD) has been closely related to acute respiratory infections (ARI), although information is still incomplete; for example, the frequency of VAD in children <5 years of age with pneumonia is not known, and the conditions associated with VAD have not been identified. This study was conducted to gain insight into the status of vitamin A in children with pneumonia. A secondary objective was to identify the sociodemographic, individual, and nutritional factors associated with VAD in these children. METHODS: A cross-sectional study was conducted in the Mexican state of Hidalgo, one of the poorest in the country. Children with community-acquired pneumonia treated at nine public hospitals were included. Information was obtained by interviewing mothers, and ascertainment of vitamin A status was performed with relative-dose-response (RDR) test. RESULTS: A total of 422 cases were included. VAD was identified in 17.8% of children; 50.3% showed normal results, 24.6% had liver reserve depletion, and 7.3% showed results attributable to the infectious process. Variables associated with VAD were as follows: age <2 months (OR 3.44, 95% CI: 1.84-9.24); children >6 months of age fed with formula (OR 0.37, 95% CI: 0.15-0.91), and affiliation with the Mexican Social Security Institute (IMSS) health system (OR 0.40, 95% CI: 0.22-0.72). CONCLUSIONS: The frequency of VAD in children with community-acquired pneumonia confirms that the problem of deficiency persists in Mexico. The associated factors for VAD found in this study can be taken into account when planning and evaluating vitamin A supplementation activities in populations with high risk for deficiency.