Estimating mortality and disability in Peru before the COVID-19 pandemic: a systematic analysis from the Global Burden of the Disease Study 2019.

Background: Estimating and analyzing trends and patterns of health loss are essential to promote efficient resource allocation and improve Peru's healthcare system performance. Methods: Using estimates from the Global Burden of Disease (GBD), Injuries, and Risk Factors Study (2019), we assessed mortality and disability in Peru from 1990 to 2019. We report demographic and epidemiologic trends in terms of population, life expectancy at birth (LE), mortality, incidence, prevalence, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by the major diseases and risk factors in Peru. Finally, we compared Peru with 16 countries in the Latin American (LA) region. Results: The Peruvian population reached 33.9 million inhabitants (49.9% women) in 2019. From 1990 to 2019, LE at birth increased from 69.2 (95% uncertainty interval 67.8-70.3) to 80.3 (77.2-83.2) years. This increase was driven by the decline in under-5 mortality (-80.7%) and mortality from infectious diseases in older age groups (+60 years old). The number of DALYs in 1990 was 9.2 million (8.5-10.1) and reached 7.5 million (6.1-9.0) in 2019. The proportion of DALYs due to non-communicable diseases (NCDs) increased from 38.2% in 1990 to 67.9% in 2019. The all-ages and age-standardized DALYs rates and YLLs rates decreased, but YLDs rates remained constant. In 2019, the leading causes of DALYs were neonatal disorders, lower respiratory infections (LRIs), ischemic heart disease, road injuries, and low back pain. The leading risk factors associated with DALYs in 2019 were undernutrition, high body mass index, high fasting plasma glucose, and air pollution. Before the COVID-19 pandemic, Peru experienced one of the highest LRIs-DALYs rates in the LA region. Conclusion: In the last three decades, Peru experienced significant improvements in LE and child survival and an increase in the burden of NCDs and associated disability. The Peruvian healthcare system must be redesigned to respond to this epidemiological transition. The new design should aim to reduce premature deaths and maintain healthy longevity, focusing on effective coverage and treatment of NCDs and reducing and managing the related disability.

Self-efficacy and Social Settings Matter for Fostering Healthy Eating in Mexican Schoolchildren.

OBJECTIVE: To identify differences in schoolchildren's self-efficacy for eating behaviors across social settings and self-efficacy sources favoring healthy and unhealthy eating. DESIGN: A cross-sectional, mixed-methods study using self-efficacy and demographic surveys, focus groups, and school environment semistructured observations. SETTING: Morelos, Mexico, Cuernavaca City school district, public elementary schools in the National School Lunch Program. PARTICIPANTS AND RECRUITMENT: We studied 274 fifth- and sixth-grade children from 8 elementary schools during the 2016-2017 school year. VARIABLES MEASURED: Children's self-efficacy for healthy and unhealthy eating across 3 settings (school cafeteria, recess, and home). Children's perceptions about sources of self-efficacy, which favor their healthy or unhealthy eating (performance accomplishments, behavior modeling, verbal persuasion, and emotional or physiological states). Sociodemographic information was obtained from parents. ANALYSIS: We performed a variance components analysis with school and students within schools as random effects with paired t tests (quantitative data) and content analysis on the basis of the Social Cognitive Theory (qualitative data). RESULTS: Schoolchildren's self-efficacy for healthy eating differed across social settings, being greater in the school cafeteria than at recess or home, except for drinking water. On average, self-efficacy for unhealthy eating was lower in the cafeteria than in other studied settings. Performance achievements and behavior modeling were key sources of self-efficacy for healthy and unhealthy eating. CONCLUSION AND IMPLICATIONS: Sources of self-efficacy and social settings matter to understanding schoolchildren's healthy and unhealthy eating. Future interventions might consider developing collective efficacy among the school community and boosting children's participation in home meal planning. Further research could explore locus of control and other intrapersonal dimensions influencing self-efficacy.

How do diverse low-income and middle-income countries implement primary healthcare team integration to support the delivery of comprehensive primary health care? A mixed-methods study protocol from India, Mexico and Uganda.

INTRODUCTION: Attainment of universal health coverage is feasible via strengthened primary health systems that are comprehensive, accessible, people-centred, continuous and coordinated. Having an adequately trained, motivated and equipped primary healthcare workforce is central to the provision of comprehensive primary healthcare (CPHC). This study aims to understand PHC team integration, composition and organisation in the delivery of CPHC in India, Mexico and Uganda. METHODS AND ANALYSIS: A parallel, mixed-methods study (integration of quantitative and qualitative results) will be conducted to gain an understanding of PHC teams. Methods include: (1) Policy review on PHC team composition, organisation and expected comprehensiveness of PHC services, (2) PHC facility review using the WHO Service Availability and Readiness Assessment, and (3) PHC key informant interviews. Data will be collected from 20, 10 and 10 PHCs in India, Mexico and Uganda, respectively, and analysed using descriptive methods and thematic analysis approach. Outcomes will include an in-depth understanding of the health policies for PHC as well as understanding PHC team composition, organisation and the delivery of comprehensive PHC. ETHICS AND DISSEMINATION: Approvals have been sought from the Institutional Ethics Committee of The George Institute for Global Health, India for the Indian sites, School of Medicine Research Ethics Committee at Makerere University for the sites in Uganda and the Research, Ethics and Biosecurity Committees of the Mexican National Institute of Public Health for the sites in Mexico. Results will be shared through presentations with governments, publications in peer-reviewed journals and presentations at conferences.

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.

Perceptions of childcare staff for preventing overweight in Mexican preschool children: A SWOT analysis / Percepciones del personal de guarderías sobre la prevención del sobrepeso en preescolares mexicanos: análisis FODA

Abstract: Objective: To identify strengths, weaknesses, opportunities, and threats (SWOT) perceived by childcare staff for preventing childhood overweight. Materials 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, nutritional 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. Conclusion: The identified SWOT must be considered when developing obesity-prevention interventions targeted at CCC.

Resumen: Objetivo: Identificar fortalezas, debilidades, oportunidades y amenazas (FODA) percibidas por personal de guarderías, para prevenir sobrepeso en preescolares. Material y métodos: Estudio cualitativo con enfoque fenomenológico interpretativo en seis guarderías públicas de la Ciudad de México. Se realizaron 18 entrevistas semiestructuradas a profundidad y 12 grupos focales con 89 directivos y trabajadores. Mediante análisis de contenido y FODA se identificaron 59 percepciones sobre alimentación y actividad física (AF), jerarquizadas por expertos mediante el método Delphi. Resultados: Fortalezas: Reconocimiento del potencial de guarderías en promover alimentación saludable, disponibilidad de reglamentos y acceso a infraestructura/práctica de AF en interiores. Debilidades: No se considera el sobrepeso infantil como un problema de salud, baja alfabetización nutricional y percepción de riesgo de lesiones al practicar AF. Oportunidades: Voluntad de limitar acceso a alimentos chatarra y estimular a padres e hijos a realizar juegos activos en fines de semana. Amenazas: Limitada orientación alimentaria y restricciones temporales/económicas/de acceso a espacios seguros para AF. Conclusión: Las FODA identificadas deben considerarse en las intervenciones para prevenir el sobrepeso en guarderías.

Development and validation of a Screening Questionnaire of Family Mistreatment against Older Adults for use in primary care settings in Mexico.

The abuse of older adults is a serious public health issue that can be difficult to identify at the first level of care. Medical and nursing personnel are sometimes unable to identify older adults who suffer family mistreatment. This can occur when victims feel shame or as a result of cultural factors. In the light of this, healthcare personnel require a screening tool that can be used to identify signs of mistreatment. The aim of this study was to develop and validate a screening tool for detecting the familial mistreatment of older adults in primary care settings. A mixed method cross-sectional study was carried out in three phases between 2009 and 2012 in Mexico. The formative phase involved using a qualitative methodology to identify terms that older adults use to identify practices defined as forms of mistreatment. On this basis, the second phase involved the design of a screening tool through the formation of items in collaboration with a panel of experts. These items were tested on older adults to ensure their intelligibility. Finally, validity and reliability levels were evaluated through the application of the screening tool to a sample of older adults at a primary care facility and at a legal centre. These findings were discussed with gerontologists, and the data were analysed through an exploratory factor analysis with orthogonal rotation and Cronbach's alpha using STATA v13. From the results, we generated a screening tool that is culturally and socially tailored to older adults in Mexico. The tool has a Cronbach's alpha of 0.89, a sensitivity value of 86% (p < .05) and a specificity value of 90% (p < .05) for positive answers to the tool's 15 items. Applying this tool at the first level of care could limit damage to older adults' health and could lower the frequency of emergency room use in hospitals.

Prevalence and factors associated with violence and abuse of older adults in Mexico's 2012 National Health and Nutrition Survey.

BACKGROUND: Factors associated with violence and the abuse of older adults are understudied and its prevalence in Mexico has not been reported. The aim of this study was to identify the prevalence and factors associated with violence and abuse of older adults in Mexico. METHODS: We used Mexico's 2012 National Health and Nutrition Survey, which included a sample of 8,894 individuals who are 60 years or older and who self-reported a negative health event related to robbery, aggression or violence in the previous 12 months. We used chi-squared test and Fisher's exact test to analyze the variables related to violence. Adjusted estimates were completed with multiple logistic regression models for complex surveys. RESULTS: The prevalence of violence was 1.7 % for both men and women. In 95 % of the cases, the aggression was from an unknown party. Verbal aggressions were the most prevalent (60 %). Among men, physical aggression was more common. Violence frequently occurred in the home (37.6 %); however, men were primarily assaulted in public places (42.4 %), in comparison to women (30.7 %). There were also differences in the risk factors for violence. Among men, risk was associated with younger age (60-64 years), higher education (secondary school or above) and higher socioeconomic status. Among women, risk was associated with depression, not being the head of the family, and region of the country. CONCLUSIONS: Violence against older adults presents differently for men and women, which means it is necessary to increase knowledge about the dynamics of the social determinants of violence, particularly in regards to the role of education among men. The relatively low prevalence found in this study may reflect the difficulty and fear of discussing the topic of violence. This may occur because of cultural factors, as well as by the perception of helplessness perpetuated by the scarce access to social programs that ensure protection and problem solving with regards to the complex social determinants of individual and family violence that this population group endures.

Public health services and their relationship with rapid HIV test utilization and access for key populations in Morelos, Mexico.

OBJECTIVE: In 2009, 4 749 rapid HIV tests were run in Morelos, Mexico, despite lacking evidence on their results. This article seeks to analyze how public health organization relates to utility of rapid HIV test among healthcare users. MATERIALS AND METHODS: Joint study: comparison of differences in applied test and positive results for each group with the Bonferroni statistical tool, observational study in 34 health subsystems, and 11 interviews with public healthcare users. RESULTS: Each subsystem processes influenced the use and usefulness of screening; for instance, primary care centers test only pregnant women and exclude men who have sex with men (MSM). That group shows significant differences (p<0.007) in the HIV-positive test with respect to other groups. CONCLUSIONS: Despite the availability of rapid detection tests and epidemiological evidence, the way public health services are organized impedes an efficient diagnosis in the group with higher risk, namely MSM. The distribution of rapid HIV tests was guided by stigmatization.

Public health services and their relationship with rapid HIV test utilization and access for key populations in Morelos, Mexico / La organización de los servicios de salud y su relación con la utilización y acceso a las pruebas rápidas para la detección del VIH en las poblaciones clave en Morelos, México

Objective. In 2009, 4 749 rapid HIV tests were run in Morelos, Mexico, despite lacking evidence on their results. This article seeks to analyze how public health organization relates to utility of rapid HIV test among healthcare users. Materials and methods. Joint study: comparison of differences in applied test and positive results for each group with the Bonferroni statistical tool, observational study in 34 health subsystems, and 11 interviews with public healthcare users. Results. Each subsystem processes influenced the use and usefulness of screening; for instance, primary care centers test only pregnant women and exclude men who have sex with men (MSM). That group shows significant differences (p<0.007) in the HIV-positive test with respect to other groups. Conclusions. Despite the availability of rapid detection tests and epidemiological evidence, the way public health services are organized impedes an efficient diagnosis in the group with higher risk, namely MSM. The distribution of rapid HIV tests was guided by stigmatization.

Objetivo. En 2009, 4 749 pruebas rápidas de detección de VIH fueron aplicadas en Morelos, México, sin evidencias de resultados. Se hace necesario analizar la distribución de estas pruebas y las consecuencias que la organización de los servicios de salud tuvo para el diagnóstico del VIH en las poblaciones clave. Material y métodos. Estudio mixto: comparación de diferencias en pruebas aplicadas y casos diagnosticados en grupos mediante la técnica de Bonferroni, observaciones en 34 subsistemas de salud y 11 entrevistas a usuarios. Resultados. Los procesos de cada subsistema incidieron en la utilización y utilidad del tamizaje: se focalizó en mujeres embarazadas y se excluyó a grupos en mayor riesgo (p<0.007) en hombres que tienen sexo con otros hombres (HSH). Conclusiones. A pesar de la disponibilidad de las pruebas y de información epidemiológica, la organización de los servicios impidió una mayor captación de HSH. La estigmatización influyó en las formas de distribuirlas.

[Human resources for health in the context of the reform of the health system in Mexico: professional training and labor market]. / Recursos humanos para la salud en el contexto de la reforma sanitaria en México: formación profesional y mercado laboral.

The role that human resources for health should play in future stages of the Mexican Health System reform is discussed. The following dimensions are considered to guide the discussion: the orientation of training, the institutions responsible for training, the mechanisms to link graduates to health institutions and the ways health workers should respond to the current managerial modifications. Changes should be based on a pre-defined strategic planning exercise based on institutional agreements which allow defining common objectives as well as clear procedures to attain those objectives.

Obesity determinants in Mexican preschool children: parental perceptions and practices related to feeding and physical activity.

BACKGROUND AND AIMS: Obesity represents a major public health problem worldwide. In Mexico, overweight and obesity have increased dramatically, affecting 26% of school-aged children. The aim of this study was to explore perceptions and practices of key obesity determinants among parents of preschool children attending child care centers. METHODS: We conducted five focus groups with 38 parents from six Mexico City child care centers. Inquiry topics were 1) childhood obesity causes and consequences; 2) child feeding practices at the child care center and home; 3) healthful and unhealthful foods for young children; 4) significance of physical activity in childhood; and 5) physical activity-promoting factors and barriers. We analyzed these data using content analysis. RESULTS: We identified a number of barriers to healthful eating, including parental time constraints, permissive feeding styles, unhealthful food preparation practices, lack of knowledge about nutrition, food advertisement, and high availability of unhealthful foods in public places. Facilitators to healthful eating included recognition of childhood overweight prevention and consequences, and healthy food choices. Main barriers to childhood physical activity included influence of young family members to play video games, parental time constraints, street safety, low access to sports facilities, and insufficient communication with child care centers. CONCLUSIONS: Understanding parental views and perceptions of the main factors influencing preschoolers' weight-related behavior can inform home-based or environmental interventions that support healthful eating and regular physical activity.

[Predominant organizational culture in nursing at a public hospital. Morelos, Mexico]. / Cultura organizacional de enfermería dominante en un hospital de la Secretaría de Salud de Morelos, México.

OBJECTIVE: To identify dominant and preferred organizational culture models at second level nursing services in Morelos. MATERIAL AND METHODS: A cross-sectional study was conducted between April and June, 2008. Nursing caregivers from Public Health Services of Morelos State participated. We gathered and analyzed data about socioeconomic characteristics and organizational culture, and we applied the Xi² and Kappa coefficient statistical tests using Stata version 10 software. RESULTS: We interviewed 30 nurses, randomly selected from a total of 397, with at least one year of seniority. It was identified that the dominant organizational culture is one of power and the preferred culture is one of performance. A Kappa positive coefficient of 0.17 (p = 0.047) was found between the dominant model and the preferred performance model. CONCLUSIONS: Identifying said organizational culture models helps to understand performance differences in the management of nursing care services currently provided to users of the hospital and to aspire to improvements in the service itself.

Cultura organizacional de enfermería dominante en un hospital de la Secretaría de Salud de Morelos, México / Predominant organizational culture in nursing at a public hospital. Morelos, Mexico

OBJETIVO: Identificar los modelos de cultura organizacional, dominante y preferido, en enfermería en el segundo nivel de atención a la salud. MATERIAL Y MÉTODOS: Entre abril y junio de 2008 se hizo un estudio transversal con personal de enfermería de los Servicios de Salud del Estado de Morelos. Se obtuvo información sobre los datos sociodemográficos y la cultura organizacional. Se hicieron pruebas de ji² y de correlación Kappa, y se usó Stata v.10. RESULTADOS: Se entrevistó a 30 enfermeras seleccionadas aleatoriamente de un total de 397, con al menos un año de antigüedad laboral. Se identificó que la cultura organizacional dominante es la del poder y la preferida es la del desempeño. El coeficiente Kappa positivo de 0.17 (p= 0.047) entre lo que domina y el modelo del desempeño que se prefiere. CONCLUSIONES: Identificar estos modelos de la cultura organizacional permite entender los diferenciales de desempeño en la gestión del cuidado enfermero a los usuarios hospitalarios y plantearse aspiraciones de mejoras en el propio servicio.

OBJECTIVE: To identify dominant and preferred organizational culture models at second level nursing services in Morelos. MATERIAL AND METHODS: A cross-sectional study was conducted between April and June, 2008. Nursing caregivers from Public Health Services of Morelos State participated. We gathered and analyzed data about socioeconomic characteristics and organizational culture, and we applied the Xi² and Kappa coefficient statistical tests using Stata version 10 software. RESULTS: We interviewed 30 nurses, randomly selected from a total of 397, with at least one year of seniority. It was identified that the dominant organizational culture is one of power and the preferred culture is one of performance. A Kappa positive coefficient of 0.17 (p = 0.047) was found between the dominant model and the preferred performance model. CONCLUSIONS: Identifying said organizational culture models helps to understand performance differences in the management of nursing care services currently provided to users of the hospital and to aspire to improvements in the service itself.

Estrategias para la enseñanza del autoexamen del seno a mujeres en edad reproductiva / Strategies for breast self-examination training to women of reproductive age

Objetivo. Disponer de una estrategia efectiva de enseñanza de conocimientos en cáncer de mama (CM) y en la técnica del autoexamen del seno (AES) para las mujeres mexicanas de entre 12 a 47 años de edad. Material y métodos. Entre abril de 1996 y julio de 1998, en la ciudad de Cuernavaca, Morelos, México, se diseñaron y evaluaron dos estrategias de enseñanza del AES y sus materiales didácticos con base en las propuestas de las mujeres participantes en el inicio de este estudio. Ambas estrategias consistieron en la presentación de un folleto y una cinta de video; en la primera, una enfermera en salud pública condujo la sesión; en la segunda, una sobreviviente de CM. Además, en la segunda estrategia se adicionaron unas diapositivas y unos modelos de senos de silicón. Ambas estrategias se compararon con una tercera que se extrajo de las normas de la Secretaría de Salud, consistente en la presentación de una hoja impresa y una cinta de video por parte de una enfermera. Participaron 149 mujeres, asignadas aleatoriamente a cada estrategia. La efectividad de éstas se evaluó por los cambios en los conocimientos en AES y CM, y en la destreza para identificar mayor número de abultamientos en un modelo de seno de silicón tamaño natural, medidos antes y después de la capacitación. Se realizaron para el análisis estadístico pruebas t de Student, análisis de varianza, c2 de McNemar, la de Pearson y regresión lineal múltiple. Resultados. Con las tres estrategias se elevaron aproximadamente 30 por ciento los conocimientos de las participantes sobre CM, AES y su destreza para identificar abultamientos. Sólo una de cada 20 mujeres fue capaz de identificar más de tres abultamientos en el modelo al inicio de su capacitación, posteriormente entre 3 y 4 de cada 10 mujeres, valores p<0.05. Se identificaron algunos determinantes del aprendizaje del AES, del CM y de la destreza para identificar abultamientos en esta población. Conclusiones. La enseñanza del AES con cualquiera de las estrategias evaluadas podría incluirse en un plan integral de prevención y detección temprana del cáncer mamario para las mujeres mexicanas. La práctica adecuada y mensual del AES se vincula tanto con la reducción del lapso entre el hallazgo de un signo sospechoso y la demanda de atención médica, como con la solicitud del examen clínico del seno, lo que implica identificar tumores de menor tamaño cuando se presenta el CM.