Access to early diagnosis for attention-deficit/hyperactivity disorder among children and adolescents in Mexico City at specialized mental health services.

BACKGROUND: In Mexico, this pioneering research was undertaken to assess the accessibility of timely diagnosis of Dyads [Children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD) and their primary caregivers] at specialized mental health services. The study was conducted in two phases. The first phase involved designing an "Access Pathway" aimed to identify barriers and facilitators for ADHD diagnosis; several barriers, with only the teacher being identified as a facilitator. In the second phase, the study aimed to determine the time taken for dyads, to obtain a timely diagnosis at each stage of the Access Pathway. As well as identify any disparities based on gender and socioeconomic factors that might affect the age at which children can access a timely diagnosis. METHOD: In a retrospective cohort study, 177 dyads participated. To collect data, the Acceda Survey was used, based on the robust Conceptual Model Levesque, 2013. The survey consisted of 48 questions that were both dichotomous and polytomous allowing the creation of an Access Pathway that included five stages: the age of perception, the age of search, the age of first contact with a mental health professional, the age of arrival at the host hospital, and the age of diagnosis. The data was meticulously analyzed using a comprehensive descriptive approach and a nonparametric multivariate approach by sex, followed by post-hoc Mann-Whitney's U tests. Demographic factors were evaluated using univariable and multivariable Cox regression analyses. RESULTS: 71% of dyads experienced a late, significantly late, or highly late diagnosis of ADHD. Girls were detected one year later than boys. Both boys and girls took a year to seek specialized mental health care and an additional year to receive a formal specialized diagnosis. Children with more siblings had longer delays in diagnosis, while caregivers with formal employment were found to help obtain timely diagnoses. CONCLUSIONS: Our findings suggest starting the Access Pathway where signs and symptoms of ADHD are detected, particularly at school, to prevent children from suffering consequences. Mental health school-based service models have been successfully tested in other latitudes, making them a viable option to shorten the time to obtain a timely diagnosis.

Design and validation of indicators for the comprehensive measurement of quality of care for type 2 diabetes and acute respiratory infections in ambulatory health services.

Developing ambulatory health services (AHS) of optimal quality is a pending issue for many health systems at a global level, especially in middle- and low-income countries. An effective health response requires indicators to measure the quality of care that are context-specific and feasible for routine monitoring. This paper aimed to design and validate indicators for assessing the technical and interpersonal quality dimensions for type 2 diabetes (T2D) and acute respiratory infections (ARI) care in AHS. The study was conducted in two stages. First, technical and user-centered-based indicators of quality of care for T2D and ARI care were designed following international recommendations, mainly from the American Diabetes Association standards and the National Institute for Health and Care Excellence guidelines. We then assessed the validity, reliability, relevance, and feasibility of the proposed indicators implementing the modified Delphi technique. A panel of 17 medical experts from five countries scored the indicators using two electronic questionnaires, one for each reason for consultation selected, sent by email in two sequential rounds of rating. We defined the levels of consensus according to the overall median for each performance category, which was established as the threshold. Selected indicators included those with scores equal to or higher than the threshold. We designed 36 T2D indicators, of which 16 were validated for measuring the detection of risks and complications, glycemic control, pharmacological treatment, and patient-centered care. Out of the 22 indicators designed for ARI, we validated 10 for diagnosis, appropriate prescription of antimicrobials, and patient-centered care. The validated indicators showed consistency for the dimensions analyzed. Hence, they proved to be a potentially reliable and valuable tool for monitoring the performance of the various T2D and ARI care processes in AHS. Further research will be needed to verify the applicability of the validated indicators in routine clinical practice.

Trabajadoras comunitarias de salud: experiencias en el abordaje de la salud mental en zonas rurales de Chiapas.

OBJETIVO: Analizar, desde la perspectiva de las trabajadoras comunitarias de salud (TCS), los conocimientos y experiencias en la atención de la salud mental (SM) en comunidades rurales de Chiapas. Material y métodos. Se utilizó el enfoque fenomenológico descriptivo. Se realizaron 18 entrevistas semiestructuradas a TCS, las cuales fueron audiograbadas, transcritas, codificadas y analizadas utilizando como técnica, el análisis cualitativo de contenido con ayuda del software Atlas ti. RESULTADOS: Las TCS mental tienen una amplia comprensión de la cultura, el lenguaje y los problemas de sus comunidades, permitiéndoles fungir como enlace entre los servicios de salud y la población. Identifican que hay buena SM cuando "una persona tiene ánimo de realizar su trabajo diario" y enfermedad cuando "las personas sufren o tienen pensamientos chuecos". Sus experiencias de trabajo están ligadas con el acompañamiento individual (psico-educación) y el apoyo de actividades realizadas por profesionales de Compañeros En Salud (CES). Conclusión. Las TCS mental que trabajan con CES desarrollan un papel importante en la promoción de la SM, de riesgos y acompañamiento de pacientes con trastornos mentales. Estos hallazgos consolidan la evidencia e importancia del desarrollo de las intervenciones comunitarias en SM a través de este personal, en contextos de escasa disponibilidad de servicios de salud.

[Exploring facilitators and barriers to implementing expanded nursing roles in MexicoEstudo de facilitadores e barreiras para a implementação de funções ampliadas de enfermagem no México]. / Exploración de facilitadores y barreras para implementar los roles ampliados de enfermería en México.

Objective: To explore the perceptions of nursing professionals regarding facilitators and barriers to the implementation of expanded nursing functions in a state in central Mexico. Methods: Qualitative descriptive phenomenological study. During 2022, 18 semi-structured interviews were conducted with three types of informants: a) head nurses at state-level facilities; b) head nurses at local-level facilities; and c) heads of health units and operational nursing staff who have direct contact with patients. Results: The following facilitators were identified: willingness to adopt the strategy (seen as favorable by managers and acceptable by nursing staff); reorganization of functions (simplification of processes and analysis of the situation of health units); access to training; and characteristics of nursing staff (professionalization, work experience, and favorable attitude). Barriers included: conditions at the first level of care (personnel shortages, too many administrative activities, lack of physical space, materials, supplies, and consumables), resistance to change (professional jealousy of other disciplines and duplication of tasks), staff salaries, lack of training, not trusted with expanded duties, and attitude of patients (resistance to nursing care). Conclusions: By understanding the perceptions of nursing professionals, we can identify key elements for the successful expansion of nursing functions through expansion of the competencies of operational staff. Reorganization and proper management at different levels of decision-making will be necessary.

Objetivo: Explorar as percepções dos profissionais de enfermagem sobre os facilitadores e as barreiras à implementação de funções ampliadas de enfermagem em um estado do México. Métodos: Estudo qualitativo descritivo com abordagem fenomenológica. Em 2022, foram realizadas 18 entrevistas semiestruturadas com três tipos de informantes: a) chefes estaduais de enfermagem; b) chefes jurisdicionais de enfermagem; e c) chefes de unidades de saúde e profissionais de enfermagem que fazem atendimento direto aos pacientes. Resultados: Os seguintes facilitadores foram identificados: disposição para adotar a estratégia (atitude favorável dos gerentes e aceitação da equipe de enfermagem), reorganização das funções (simplificação dos processos e análise da situação das unidades de saúde) e acesso a capacitação e características da equipe de enfermagem (profissionalização, experiência de trabalho e atitude favorável). As barreiras encontradas incluem: contexto do primeiro nível de atenção (falta de pessoal, excesso de atividades administrativas, falta de espaço físico, falta de materiais, insumos e consumíveis), resistência à mudança (zelo profissional de outras disciplinas e duplicação de tarefas), salários do pessoal, falta de atualização, pouca confiança na expansão das funções e atitude dos pacientes (resistência ao atendimento por profissionais de enfermagem). Conclusões: Entender as percepções dos profissionais de enfermagem permite a identificação de elementos-chave para a expansão bem-sucedida das funções de enfermagem por meio da expansão das competências de trabalho dos profissionais que atendem pacientes; serão necessários reorganização e gerenciamento adequado nos diferentes níveis de tomada de decisão.

Understanding adherence of hypertensive patients in Mexico to an exercise-referral scheme for increasing physical activity.

Among the strategies developed thus far for promoting physical activity (PA), exercise-referral schemes (ERs) have gained in popularity as an effective means of preventing secondary health conditions such as hypertension. However, information on the factors affecting adherence to these programs is limited. Using a mixed-methods approach, we undertook the present study to determine the factors associated with adherence to a specific ER aimed at increasing PA among the hypertensive patients in a Social Security institution in Mexico. Data were obtained through semi-structured questionnaires and interviews as well as from the clinical records of participants. For the quantitative component, multinomial regression analysis estimated the factors behind the varying levels of adherence. For the qualitative component, we performed a content analysis based on the health belief model. According to our findings, 80% of participants who began the ER exhibited high levels of adherence. Older age and being female were the key demographic characteristics of those showing increased adherence. Meanwhile, financial issues, the investment of time required, low perception of the benefits of PA, lack of confidence in being able to achieve changes in lifestyle, and a reluctance to acknowledge the seriousness of their health condition were the principal factors among those who did not join the program or exhibited low levels of adherence. Our findings can serve as a basis for designing PA interventions that take into account individual, cultural and administrative elements in their efforts to improve adherence to PA programs for those suffering from chronic conditions such as hypertension.

Out-of-pocket and catastrophic expenses in households of patients with schizophrenia lacking social security

OBJECTIVE: To estimate the magnitude of out-of-pocket (OOP) and catastrophic health expenses as well as impoverishment experienced by households of schizophrenia patients lacking social security coverage. MATERIALS AND METHODS: We conducted a cross-sectional study of 96 individuals treated in outpatient consultation between February and December 2018 in a psychiatric hospital. RESULTS: All households sustained OOP health expenses; the median was 510 USD (95%CI: 456-628). The OOP expenses represented 28 and 4% of the capacity to pay in poor and rich households, respectively. 16% of households incurred catastrophic expenses and 6.6% have impoverishment for health reasons. CONCLUSIONS: Our results illustrate that pocket expenses and catastrophic expenses in patients with schizophrenia are higher than those reported for the general population. Therefore, it is necessary to rethink the financial protection policies aimed at patients with schizophrenia and their households.

Sedentarismo laboral en distintos contextos ocupacionales en México: prevalencia y factores asociados.

Objetivo. Analizar la prevalencia de sedentarismo laboral en diferentes contextos ocupacionales y estimar los factores asociados de acuerdo con el sector de actividad económica. Material y métodos. Análisis secundario de datos de la Encuesta Nacional de Ocupación y Empleo (ENOE); se identificó la ocupación y se clasificó en cuatro categorías. La variable dependiente fue el sedentarismo laboral; las variables independientes fueron sexo, edad, escolaridad, ingreso, zona de residencia urbana del trabajador, formalidad laboral y región socioeconómica. Los factores asociados se estimaron mediante regresión logística múltiple por sector de actividad económica. Resultados. La mayor prevalencia del seden-tarismo laboral se encontró en el sector de servicios (43%, IC95%: 42.3-43.6). Los factores asociados fueron nivel de estudios superior, mayores ingresos, ser mujer y trabajar en el sector formal. Conclusiones. La prevalencia de seden-tarismo laboral es alta en sectores productivos estratégicos, por lo que es necesario considerar los factores de riesgo identificados en este trabajo para establecer estrategias de mitigación.

Health care trajectories and barriers to treatment for patients with end-stage renal disease without health insurance in Mexico: a mixed methods approach.

BACKGROUND: Mexico has the sixth-highest premature death rate from chronic kidney disease (CKD) in the world. From 1990 to 2017, the age-standardized CKD mortality rate jumped from 28.7 to 58.1 per 100,000 inhabitants, making it the second-leading cause of death that year. Medical care for the disease is inequitable, as those without health insurance have limited access to renal replacement therapy (RRT). The objective of this study is to describe the healthcare trajectories of patients with end-stage renal disease (ESRD) in a public hospital in Mexico City and the barriers they face in receiving peritoneal dialysis and haemodialysis. METHODS: This study uses a convergent mixed methods approach and is predominantly qualitative. Patients completed 199 surveys, and 42 semi-structured interviews with patients having ESRD and their families were conducted. The quantitative data were analysed using descriptive statistics, and the qualitative data were processed using a phenomenological approach. RESULTS: It was found that 76.9% of the patients received peritoneal dialysis or haemodialysis as their first RRT. Over 30% began their treatment at least a month after a health professional prescribed it. Almost 50% had been hospitalized for complications related to the disease in the previous year, and 36% had uncertainties about their treatment. Close to 64% of the haemodialysis patients received treatment intermittently. Barriers to accessing treatment, information, contact with health services, and treatment availability were identified. Patients and their families encountered economic and emotional difficulties at every phase of their search for medical care and treatment. CONCLUSION: Mexico urgently needs to implement public policies related to CKD that are primarily directed at its prevention but should also implement policies directed at slowing its progression, reducing its complications, and providing funding for uninsured patients who require RRT. These policies must be based on the perspectives of human rights and equality, and the perspectives of patients, their families and the general population should be included in the policy creation process.

An Overview of Social Media Use in the Field of Public Health Nutrition: Benefits, Scope, Limitations, and a Latin American Experience.

Social media platforms are low-cost tools that can be used to address issues in public health nutrition, especially in countries where health-related institutions experience economic limitations. We aimed to emphasize the benefits of using social media to promote health that have been documented to date. To show social media's positive impact on population health literacy, we briefly describe an inexpensive systematic communication strategy implemented in our research center through 2 social media platforms, the lessons learned, and the strategy's short-term results. Because social media use in public health is a new field of study, this perspective also focuses on the current limitations and gaps in evidence that need to be addressed to translate the best practices into policy recommendations. In conclusion, the perspective highlights the role that health actors and governments should take to maximize the benefits of social media use.

[Pathway of access to an early diagnosis of attention deficit hiperactivity disorder (ADHD): A primary caregiver´s perspective.] / Trayectoria de acceso al diagnóstico oportuno del trastorno por déficit de atención e hiperactividad: una perspectiva del cuidador primario.

OBJECTIVE: To evaluate the access of an early diagnosis of the ADHD and to identify its barriers by means of a trajectory of facts from perceiving the symptoms until obtaining the formal diagnosis. MATERIALS AND METHODS: An integral conceptual model has been used - based on four dimensions (perceive, search, arrive and use) - and centered on the patient; this has allowed to trace a trajectory of facts lived by the dyads (patient and their primary caregiver). The survey was composed of five open and 143 dichotomous or polytomous questions. 177 dyads participated. RESULTS: Numerous barriers were identified to access the early diagnosis; the lack of perception of ADHD was key to initiate access. CONCLUSIONS: The lack of perception could be avoided with information to the caregivers so that they perceive the nuclear symptoms of ADHD as potential mental health problems.

OBJETIVO: Evaluar el acceso al diagnóstico oportuno del trastorno por déficit de atención e hiperactividad (TDAH) e identificar sus barreras mediante una trayectoria de hechos que va desde percibir los síntomas hasta obtener el diagnóstico forma. MATERIAL Y MÉTODOS: Se empleó un modelo conceptual integral (basado en cuatro dimensiones: percibir, buscar, llegar y usar) y centrado en el paciente. Ello permitió trazar una trayectoria de hechos vividos por las diadas (paciente y su cuidador primario), a partir de la cual se diseñó una cédula compuesta por 143 preguntas dicotómicas o politómicas, y cinco preguntas abiertas. Participaron 177 diadas. RESULTADOS: Se identificaron numerosas barreras para acceder al diagnóstico oportuno; la falta de percepción del TDAH resultó clave como bstáculo para el acceso inicial. CONCLUSIONES: La barrera de la falta de percepción podría evitarse brindando información a los cuidadores para que perciban los síntomas nucleares del TDAH como problemas potenciales de salud mental.

[Collateral effect of transnational migration: the transformation of medical habitus]. / Efecto colateral de la migración transnacional:la transformación del habitus médico.

OBJECTIVE: To analyze health practice transformations in health providers in Mexico. MATERIALS AND METHODS: . We used qualitative data to explore transnational health practices of men with migration experience to the US, healthcare professionals in Mexico from eight rural communities, and Mexican providers in US. Data used came from a study that explored transnational health practices in the context of migration. RESULTS: Healthcare professionals provided care to migrants through remote consultations or via a family member, and in-person during migrants' visits or by health-care professionals relocating to migrants' destination com-munities in the US. The remote consultations mainly caused three changes in the field of medical practice: providing care without a patient review or clinical examination, long-distance prescription of medications, and provision of care mediated by a family member. CONCLUSIONS: Changes in their medical practice shifted roles of healthcare professionals and of migrants as patients, transforming the hegemonic biomedical model in Mexico.

OBJETIVO: Analizar las transformaciones de la práctica médica en proveedores de salud en México. MATERIAL Y MÉTODOS: Se utilizaron datos cualitativos para explorar las prácticas de salud transnacionales de hombres con ex-periencia en migración a los Estados Unidos y profesionales de la salud en México de ocho comunidades rurales y pro-veedores mexicanos en Estados Unidos. RESULTADOS: Los profesionales de la salud brindan atención a los migrantes a través de consultas remotas o a través de un miembro de la familia, y en persona, durante las visitas de los migrantes o por profesionales de la salud que se trasladan a las comunidades de destino de los migrantes en los EU. Las consultas a distan-cia causaron principalmente tres cambios en el campo de la práctica médica: proporcionar atención sin una revisión del paciente o un examen clínico, la prescripción a larga distancia de medicamentos y la prestación de atención mediada por un miembro de la familia. CONCLUSIONES: Los cambios en la práctica médica modificaron el rol de los profesionales de la salud y los migrantes como pacientes, lo que ha transformado el modelo biomédico hegemónico en México.

[Quality of care in type 2 diabetes, progressand challenges from 2012 to 2018-19 forthe Mexican health system]. / Calidad de la atención en diabetes tipo 2, avances y retos de 2012 a 2018-19 para el sistema de salud de México.

OBJECTIVE: To estimate changes in the quality of process of care and its association with glycaemic control in adults with type 2 diabetes. MATERIALS AND METHODS: Changes in compliance of 14 process of care indicators for 9 038 adults with type 2 diabetes and glycaemic control in a subsample were estimated. Averages, weighted changes and associations without or controlling for other factors were estimated us-ing statistical weights for the combined data (Ensanut 2012 and Ensanut 2018-19). RESULTS: From 2012 to 2018-19, glycaemic control doubled. Early detection of complications and increased insuline use improved, but identification and treatment of cardiovascular risk factors decreased. The overall quality of care was associated with optimal glycaemic control. CONCLUSIONS: There are areas of opportunity for improvement of quality of care, that deserve comprehensive strategies and continuous monitoring.

OBJETIVO: Estimar cambios en la calidad del proceso de atención y su asociación con control glucémico en adultos con diabetes tipo 2. MATERIAL Y MÉTODOS: cambio en el cumplimiento de 14 indicadores del proceso de atención en 9 038 adultos con diabetes tipo 2 y del control glucémico en una submuestra. Se estimaron promedios, cam-bios ponderados y asociaciones crudas y ajustadas utilizando ponderaciones estadísticas para datos combinados (Ensanut 2012 y Ensanut 2018-19). RESULTADOS: De 2012 a 2018-19, el control glucémico se duplicó. Mejoró la detección tem-prana de complicaciones y aumentó el uso de insulina, pero disminuyó la identificación y tratamiento de factores de riesgo cardiovascular. La calidad global de la atención se asoció con el control glucémico óptimo. CONCLUSIONES: Existen áreas de oportunidad para la mejora de la calidad en la atención que ameritan estrategias integrales y monitorización continua.

Physicians and the pharmaceutical industry: impact on prescription attitudes and habits.

INTRODUCTION: The physician-pharmaceutical industry relationship has been identified as an ethical problem, due to conflicts of interest motivated by the benefits that doctors receive and that can affect their clinical judgment. OBJECTIVE: To identify the frequency of physicians participation in activities financed by the pharmaceutical industry (PI), their attitudes towards PI representatives (PIRs), their prescriptive behavior and the association between their characteristics and their workplace with their participation in activities financed by the PI. METHOD: Cross-sectional survey to internists and cardiologists. The questionnaire included characteristics of the doctors and their workplace, participation in activities financed by the PI, attitudes towards PIRs, and prescription behavior. RESULTS: 455 questionnaires were analyzed; 78.5 % of surveyed subjects were aware of the physician-PI relationship, the majority acknowledged meeting with PIRs, 30 % indicated having received financial subsidies and 10 % considered that gifts affect their prescription. Having prior knowledge of the physician-PI relationship was associated with less participation in PI-financed educational activities. CONCLUSION: Practices and preferences towards the PI show the need to design strategies to avoid inappropriate prescription. INTRODUCCIÓN: La relación médico-industria farmacéutica (IF) se ha identificado como un problema ético por favorecer conflictos de interés derivados de los beneficios que reciben los médicos y que pueden afectar su juicio clínico. OBJETIVO: Identificar la frecuencia de participación de médicos en actividades financiadas por la IF, las actitudes de estos profesionales hacia los representantes de la IF, su conducta prescriptiva y la asociación de sus características y del trabajo con la participación en actividades financiadas por la IF. MÉTODO: Encuesta transversal a médicos internistas y cardiólogos. El cuestionario incluyó características de los médicos y centro de trabajo, participación en actividades financiadas por la IF, actitudes hacia los representantes y conducta de prescripción. RESULTADOS: Se analizaron 455 cuestionarios, 78.5 % de los encuestados tuvo conocimiento de la relación médico-IF, la mayoría respondió reunirse con representantes de la IF, 30 % indicó haber recibido subsidios financieros y 10 % consideró que los obsequios afectan su prescripción. Tener conocimiento previo de la relación médico-IF se asoció con menor participación en actividades educativas financiadas por por la IF. CONCLUSIÓN: Las prácticas y preferencias hacia la IF muestran la necesidad de diseñar estrategias para evitar la prescripción inapropiada.

Socioeconomic inequalities in survival of children with acute lymphoblastic leukemia insured by social security in Mexico: a study of the 2007-2009 cohorts.

BACKGROUND: Although acute lymphoblastic leukemia (ALL) 5 years survival in minors has reached 90%, socioeconomic differences have been reported among and within countries. Within countries, the difference has been related to the socioeconomic status of the parents, even in the context of public health services with universal coverage. In Mexico, differences in the mortality of children with cancer have been reported among sociodemographic zones. The Instituto Mexicano del Seguro Social (IMSS), the country's main social security institution, has reported socioeconomic differences in life expectancy within its affiliated population. Here, the socioeconomic inequalities in the survival of children (< 15 years old) enrolled in the IMSS were analyzed. METHODS: Five-year survival data were analyzed in cohorts of patients diagnosed with ALL during the period 2007-2009 in the two IMSS networks of medical services that serve 7 states of the central region of Mexico. A Cox proportional risk model was developed and adjusted for the socioeconomic characteristics of family, community of residence and for the clinical characteristics of the children. The slope of socioeconomic inequality of the probability of dying within five years after the diagnosis of ALL was estimated. RESULTS: For the 294 patients studied, the 5 years survival rate was 53.7%; the median survival was 4.06 years (4.9 years for standard-risk diagnosis; 2.5 years for high-risk diagnosis). The attrition rate was 12%. The Cox model showed that children who had been IMSS-insured for less than half their lives had more than double the risk of dying than those who had been insured for their entire lives. CONCLUSIONS: We did not find evidence of socioeconomic inequalities in the survival of children with ALL associated with family income, educational and occupational level of parents. However, we found a relevant gradient related social security protection: the longer children's life insured by social security, the higher their probability of surviving ALL was. These results add evidence of the effectiveness of social security, as a mechanism of wealth redistribution and a promoter of social mobility. Extending these social security benefits to the entire Mexican population could promote better health outcomes.

Correction to: socioeconomic inequalities in survival of children with acute lymphoblastic leukemia insured by social security in Mexico: a study of the 2007-2009 cohorts.

Following publication of the original article [1], the author reported her name has been erroneously spelled as Blanca E. Pelcastre. The full name is Blanca E. Pelcastre-Villafuerte.

Frequency of ubiquitous connectivity and associated factors among Mexican adolescents.

BACKGROUND: There is limited information in Mexico - a middle-income country and a digital adopter with an important demographic bonus - regarding the potential use of technology and connectivity in health promotion among adolescent population. Therefore, the objective of this study was to determine the proportion of adolescents connected ubiquitously; and to identify its associated factors for the further development of mobile health interventions. METHODS: An online survey of adolescents from state of Morelos, Mexico, was conducted in 2016. Explored individual socio-educational and school technological infrastructure characteristics and habits of use of mobile technologies. A logistic regression model was fitted to identify variables associated with ubiquitous connectivity. RESULTS: One thousand three hundred thirty-six students were included and six questionnaires (0.45%) were eliminated due to duplication of information. Fifty-four percent of participants were female, and the mean age was 16.31 ± 0.84 years. In total, 47% of students were ubiquitously connected. Associated factors to ubiquitous connectivity included better academic performance, the need to use Internet-based technologies, engaging in ludic activities on the Web and living in the state capital. CONCLUSIONS: Ubiquitous connectivity it's a desirable condition for strengthening health promotion programs focused on young population. Strategies including digital technology tools with potential to increase adolescent engagement should be explored and evaluated. However, it is necessary to recognize that there are additional factors that may influence the success of health promotion interventions.

[Analysis and reflections on the 2019 initiative that reforms Mexico's Ley General de Salud]. / Análisis y reflexiones sobre la iniciativa de reforma a la Ley General de Salud de México 2019.

The initiative including an Act Project for reforming the Ley General de Salud of Mexico, submitted in 2019 to the Congress of the Union, proposes the creation of a system of universal and free access to health services and associated medicines for the population lacking of social security benefits, and the creation of the Instituto de Salud para el Bienestar. This article analyzes the substantive aspects of the project, with the aim of motivating the reflection of the proposed reform and its most important components, to contribute to achieving its aim. The conclusion is that the main themes of the Project require precision in relevant areas, such as the transformation of the financing scheme for care, the strengthening of stewardship and governance, the responsibility in the provision of services, and the regulation and access to medicines. The contributions of academics, decision makers and social organizations will be essential to create a public health policy based on evidence and social equity.

La iniciativa con Proyecto de Decreto por el que se reforma la Ley General de Salud de México presentada en 2019 ante el Congreso de la Unión propone la creación de un sistema de acceso universal y gratuito a los servicios de salud y a medicamentos asociados para la población sin seguridad social y la creación del Instituto de Salud para el Bienestar. Este artículo analiza algunos aspectos sustantivos del Proyecto de Decreto con el objetivo de motivar la reflexión sobre la reforma propuesta y sus componentes más importantes para contribuir a su propósito. Se concluye que los principales temas del proyecto requieren precisión en rubros relevantes, como la transformación del esquema de financiamiento para la atención, el fortalecimiento de la rectoría y gobernanza, la responsabilidad en la provisión de servicios y la regulación y acceso a medicamentos. Las aportaciones de académicos, tomadores de decisiones y organizaciones sociales serán indispensables para una política pública de salud basada en evidencia y con equidad social.

[Indigenous condition in health services: comparison of quality of care 2012-2018 for poor population.] / La condición indígena en los servicios de salud: comparación de la calidad en la atención 2012-2018 para la población en pobreza.

OBJECTIVE: To compare the perception of the quality of ambulatory care in users of health services in 2012 and 2018, by indigenous and non-indigenous condition. MATERIALS AND METHODS: With information from two population surveys (Encuesta Nacional de Salud y Nutrición [Ensanut] 2012 and Ensanut 100k) the quality of care was analyzed based on indicators of structure, process, health outcome and care satisfaction. RESULTS: Between 2012 and 2018, the use of private health services increased; favorable opinion about the conditions of the site, and perception of short waiting times decreased among non-indigenous people. In public health services, the supply of medicines remained high, the laboratory and Rx tests in the same care unit and pharma- cology treatment explanation decreased, particularly among non-indigenous patients. Perception of health improvement and satisfaction of care was adequate. CONCLUSIONS: An ambulatory care model aimed to response needs and expectations of the most vulnerable population, mainly the indigenous population, is a priority.

OBJETIVO: Comparar la percepción de la calidad de atención ambulatoria de servicios de salud en 2012 y 2018, por condición indígena y no indígena. MATERIAL Y MÉTODOS: Con información de dos encuestas poblacionales (Encuesta Nacional de Salud y Nutrición [Ensanut] 2012 y Ensanut 100k) se analizó la calidad de atención con indicadores de estructura, proceso, resultado en salud y satisfacción. RESULTADOS: Entre 2012 y 2018 aumentó la utilización de servicios privados, disminuyó la buena opinión sobre las condiciones del lugar y la percepción de tiempo de espera corto para utilizadores no indígenas. Para servicios públicos se mantuvo alto el surtimiento de medicamentos, disminuyó la realización de estudios de laboratorio y gabinete en la unidad de atención y la explicación del tratamiento farmacológico principalmente en no indígenas. La percepción de mejoría y la satisfacción fue buena. CONCLUSIONES: Es prioritario un modelo de atención ambulatoria acorde con las necesidades y expectativas de la población más vulnerable y, principalmente, indígena.

[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.

Perceptions of childcare staff for preventing overweight in Mexican preschool children: A SWOT analysis.

OBJECTIVE: To identify strengths, weaknesses, opportunities, and threats (SWOT) perceived by childcare staff for preventing childhood overweight. MATERIAL AND METHODS: Qualitative study using an interpretative phenomenological approach; 18 in-depth, semi-structured interviews and 12 focus groups with 89 key informants working in six Mexican public childcare centers (CCC) were conducted. Through content and SWOT analyses, experts further ranked fifty-nine recurrent perceptions regarding healthy feeding and physical activity (PA), using the Delphi method. RESULTS: Strengths: Acknowledgement of the CCC's responsibility in fostering healthy feeding, availability of organizational regulations, and access to PA infrastructure/indoor activities. Weaknesses: Disregard of preschool overweight as a health problem, nu- tritional misperceptions, and perceived risk of child injuries while conducting PA. Opportunities: Willingness to reduce children's access to junk foods, and parental active play with children during weekends. Threats: Limited family nutritional education, and restricted parental time/economic constraints/access to safe public spaces for PA. CONCLUSIONS: The identified SWOT must be considered when developing obesityprevention interventions targeted at CCC.