Health needs of indigenous Mayan older adults in Mexico and health services available.

Current data indicate that inequitable health service access is one of the major problems faced by indigenous people in Mexico and around the world. The aim of this study was to analyse the perceived health needs of indigenous older adults in a Mayan region of Mexico and the health services provided to address these needs. It used a qualitative design which explored health needs, perceptions of well-being, experiences with public health services and obstacles in accessing services through semi-structured interviews with 20 older adults, nine traditional healers and seven public healthcare providers from Mayan municipalities in southeastern Mexico during 2013-2014. We identified that cultural differences related to the language, values, beliefs and worldview of indigenous populations are ignored or incorporated only minimally by health services. The provision of services does not correspond to the health needs of indigenous Mayan older adults, and wide gaps still undermine their human rights and health status; despite the establishment of favourable regulations, healthcare services are organised for the non-indigenous population. The conditions of social vulnerability affecting indigenous older adults require that healthcare institutions incorporate an intercultural approach in order to improve the quality of care according to the necessities of the population.

Enfermagem e políticas públicas para reduzir a mortalidade materna em Morelos, Mèxico / Enfermería y políticas públicas para reducir la mortalidad materna en Morelos, México / Nursing and public policies to reduce maternal mortality in Morelos, Mexico

Objectives: to identify the public policy mechanisms for reducing maternal mortality and to analyze the participation of nursing personnel in such mechanisms. Method: qualitative study, for the data collection semi-structured interviews were carried out with the administrative staff, nurses from public health services and pregnant women in Mexico. The interviews were audio-recorded, transcribed, and thematically analyzed. Results: the public policy mechanisms designed to reduce maternal mortality in Morelos include the national "Even Start in Life" program, prenatal care delivered by nursing professionals, and basic information regarding maternal mortality delivered to women, to reduce the maternal mortality. The primary challenges to properly delivering these services include a general lack of coordination between relevant committees and stakeholders, and barriers that women face accessing care. Conclusions: there are very limited actions in the design of public policies for reducing maternal mortality led by nursing personnel.(AU)

Objetivos: identificar os mecanismos de políticas públicas para redução da mortalidade materna e analisar a participação da equipe de enfermagem em tais mecanismos. Método: estudo qualitativo, para a coleta de dados foram realizadas entrevistas semiestruturadas com gestores, enfermeiras dos serviços públicos de saúde e gestantes, no México. As entrevistas foram gravadas em áudio, transcritas e analisadas tematicamente. Resultados: os mecanismos de políticas públicas projetados para reduzir a mortalidade materna em Morelos incluem o programa nacional "Even Start in Life", atendimento pré-natal prestado por profissionais de enfermagem e informações básicas às mulheres para reduzir a mortalidade materna. Os principais desafios para prestação adequada desses serviços incluem uma falta geral de coordenação entre os comitês relevantes e as partes interessadas e as barreiras que as mulheres enfrentam ao acessar os cuidados. Conclusões: existem ações muito limitadas no desenho de políticas públicas para redução da mortalidade materna lideradas pela equipe de enfermagem.(AU)

Objetivos: identificar los dispositivos de política pública para reducir la mortalidad materna y analizar la participación del personal de enfermería en estas acciones. Método: estudio cualitativo con entrevistas semiestructuradas a personal directivo, enfermeras de servicios públicos de salud y mujeres embarazadas, en México. Las entrevistas fueron grabadas en audio, transcritas y analizadas temáticamente. Resultados: los dispositivos de política pública diseñados para reducir la mortalidad materna en Morelos incluyen el programa nacional "Arranque Parejo en la Vida", control prenatal por enfermería e información básica a mujeres para reducir mortalidad materna. Los principales obstáculos para la implementación de estas acciones incluyen la falta de coordinación general entre los comités responsables y las partes interesadas y las barreras que enfrentan las mujeres para el acceso a servicios de salud. Conclusiones: existen acciones muy limitadas en el diseño de políticas públicas para reducir la mortalidad materna lideradas por el personal de enfermería.(AU)

Certificación de establecimientos de atención médica en México: análisis de los incentivos para su continuidad / Certification of medical care facilities in Mexico: analysis of the incentives for its continuity

Resumen: Objetivo: Analizar el posible efecto de los modelos de certificación y de los incentivos implementados en la participación de establecimientos de atención médica (EAM) en la certificación del Consejo de Salubridad General entre 1999-2017. Material y métodos: Se colectaron documentos oficiales, impresos y en línea, sobre la certificación de EAM y se solicitó información a diversas instancias relacionadas mediante mecanismos de transparencia. Se analizó la participación de EAM en los períodos político-administrativos entre 1999-2017. Resultados: El promedio anual de participación entre 1999-2000 fue de 259.5 EAM; entre 2013-2016, de 72.5. La participación de EAM públicos es decreciente. En 2017, los EAM certificados eran <1%. Conclusiones: No se identificaron efectos positivos ni sostenidos de ajustes al modelo, ni de los incentivos implementados. Se observa disminución de la participación en los distintos periodos político-administrativos. Debe evaluarse profundamente el Sistema Nacional de Certificación de EAM y su posible efecto en la calidad clínica.

Abstract: Objective: To analyze the possible effect of certification models and healthcare organizations' (HOs) participation incentives in the General Health Council certification process in the 1999-2017 period. Materials and methods: Official printed and online documents about HOs' certification were collected. Information from instances related to the process was requested through transparency mechanisms. Health organizations' participation in political-administrative periods between 1997-2017 was analyzed. Results: The annual average participation in the certification process during the 1999-2000 period was 259.5 HOs; during the 2013-2016 period, the average was 72.5. Public units' participation in this process has been decreasing. In 2017, certified HO were <1%. Conclusions: No positive effects of adjustments to the certification model or the incentives applied were identified. Conversely, there is decreasing participation in the different political-administrative periods. The National HO Certification System and its possible effect on clinical quality must be thoroughly evaluated.

Promoting fruit, vegetable and simple water consumption among mothers and teachers of preschool children: An Intervention Mapping initiative.

For preschool children, mothers and teachers are the principal models and promoters of fruit, vegetable and simple water consumption at home and school, respectively. However, the daily intake of these food and drink items falls below recommended standards among Mexican adults, posing a high risk of non-communicable diseases such as overweight and obesity across all age groups in the country. The objective of this article is to describe the design, implementation and evaluation of an educational initiative conducted in a Mexican locality with the aim of promoting the consumption of fruits, vegetables (FVs) and simple water (SW) among preschoolers through the influence of their mothers and teachers. We used the Intervention Mapping methodology with qualitative and quantitative components. Mothers attended eight theoretical and practical sessions and two school meetings, while teachers were offered two workshops. Our results revealed positive changes among both groups: participants took greater interest in healthy nutrition, increased their purchase, preparation and intake of FVs and SW and promoted their consumption. This confirms that it is possible to achieve favorable changes in eating habits among those who participate in educational initiatives in Mexico.

[Certification of medical care facilities in Mexico: analysis of the incentives for its continuity.] / Certificación de establecimientos de atención médica en México: análisis de los incentivos para su continuidad.

OBJECTIVE: To analyze the possible effect of certification models and healthcare organizations' (HOs) participation incentives in the General Health Council certification process in the 1999-2017 period. MATERIALS AND METHODS: Official printed and online documents about HOs' certification were collected. Information from instances related to the process was requested through transparency mechanisms. Health organizations' participation in political-administrative periods between 1997-2017 was analyzed. RESULTS: The annual average participation in the certification process during the 1999-2000 period was 259.5 HOs; during the 2013-2016 period, the average was 72.5. Public units' participation in this process has been decreasing. In 2017, certified HO were <1%. CONCLUSIONS: No positive effects of adjustments to the certification model or the incentives applied were identified. Conversely, there is decreasing participation in the different political-administrative periods. The National HO Certification System and its possible effect on clinical quality must be thoroughly evaluated.

OBJECTIVE: Analizar el posible efecto de los modelos de certificación y de los incentivos implementados en la participación de establecimientos de atención médica (EAM) en la certificación del Consejo de Salubridad General entre 1999-2017. MATERIALS AND METHODS: Se colectaron documentos oficiales, impresos y en línea, sobre la certificación de EAM y se solicitó información a diversas instancias relacionadas mediante mecanismos de transparencia. Se analizó la participación de EAM en los períodos político-administrativos entre 1999-2017. RESULTS: El promedio anual de participación entre 1999-2000 fue de 259.5 EAM; entre 2013-2016, de 72.5. La participación de EAM públicos es decreciente. En 2017, los EAM certificados eran <1%. CONCLUSIONS: No se identificaron efectos positivos ni sostenidos de ajustes al modelo, ni de los incentivos implementados. Se observa disminución de la participación en los distintos periodos político-administrativos. Debe evaluarse profundamente el Sistema Nacional de Certificación de EAM y su posible efecto en la calidad clínica.

Experiences and perceptions of people who use heroin: public health lessons from Hermosillo, Mexico.

Heroin consumption in Mexico is low compared with its use in the United States; however, this practice is more common in the northern region of Mexico than in the rest of the country, being documented only in cities that are located exactly at the Mexico-U.S. border. The Mexican legal framework is focused on rehabilitation, but its effects on the lives of users are unknown. The objective of this research was to analyze how the regulatory Mexican framework is conceptualized and practiced in the daily life of a group of heroin users from a northern city, where consumption has recently spread and has not been documented. We collected the official registered data from users and conducted a qualitative study in Hermosillo, Sonora. A research on the legal framework was conducted, as well as on the city's context. Data on heroin users can be found at HIV health center, as there is no other source of such records. The Mexican legal framework aims at rehabilitation and at avoiding criminalization; however, the daily life of users drives them towards crime circuits: people commit crimes to stay in prison, where they can control the addiction and get heroin, in case of abstinence. The Mexican State has no empirical information to improve its programs and laws related to the use of heroin. The daily practices of users become not only epidemiological but social risks to the community and to the users themselves. Also, the lack of access due to stigmatization, criminalization and violence, increases the inequities, creating a cycle that reproduces poverty and suffering as part of a social structure. Therefore, changes are needed in the justice system.

Procesos educativos sobre enfermedad de Chagas con escolares de nivel básico de escuelas públicas de México / Educational processes on Chagas disease in schoolchildren from public schools in Mexico

Se presentan los cambios en conocimientos y prácticas sobre el vector y la enfermedad de Chagas con escolares de México posterior a una intervención educativa. La identificación del vector aumentó posterior a las sesiones educativas (pre=36,15% vs post=79,30%). Aumentaron los conocimientos acerca de la enfermedad de Chagas (30,90% vs 64,72%, valor de p< 0,0001) y de las acciones preventivas para evitar que el vector habite dentro de sus entornos (14,29% vs 61,81%, valor de p< 0,0001). Los escolares pueden jugar un papel fundamental en la prevención de esta problemática(AU)

Experiences and perceptions of people who use heroin: public health lessons from Hermosillo, Mexico / Experiencias y percepciones de personas que usan heroína: lecciones de salud pública desde Hermosillo, México / As experiências e percepções de usuários de heroína: lições de saúde pública de Hermosillo, México

Abstract: Heroin consumption in Mexico is low compared with its use in the United States; however, this practice is more common in the northern region of Mexico than in the rest of the country, being documented only in cities that are located exactly at the Mexico-U.S. border. The Mexican legal framework is focused on rehabilitation, but its effects on the lives of users are unknown. The objective of this research was to analyze how the regulatory Mexican framework is conceptualized and practiced in the daily life of a group of heroin users from a northern city, where consumption has recently spread and has not been documented. We collected the official registered data from users and conducted a qualitative study in Hermosillo, Sonora. A research on the legal framework was conducted, as well as on the city's context. Data on heroin users can be found at HIV health center, as there is no other source of such records. The Mexican legal framework aims at rehabilitation and at avoiding criminalization; however, the daily life of users drives them towards crime circuits: people commit crimes to stay in prison, where they can control the addiction and get heroin, in case of abstinence. The Mexican State has no empirical information to improve its programs and laws related to the use of heroin. The daily practices of users become not only epidemiological but social risks to the community and to the users themselves. Also, the lack of access due to stigmatization, criminalization and violence, increases the inequities, creating a cycle that reproduces poverty and suffering as part of a social structure. Therefore, changes are needed in the justice system.

Resumen: El consumo de heroína en México es bajo si se compara con su consumo en EE.UU.; no obstante, esta práctica es más común en la zona norte de México que en el resto del país, estando documentada solamente en ciudades que están localizadas exactamente en la frontera entre México y EE.UU. El marco legal mexicano está centrado en la rehabilitación, sin embargo sus efectos en las vidas de los consumidores son desconocidos. El objetivo de esta investigación fue analizar cómo se conceptualiza el marco regulatorio mexicano, y cómo se hace realidad en la vida diaria de un grupo de personas usuarias de heroína, procedentes de una ciudad del norte, donde recientemente el consumo se ha extendido y no se ha documentado. Nosotros recogimos datos oficiales registrados de consumidores y realizamos un estudio cualitativo en Hermosillo, Sonora. Se realizó una investigación sobre el marco legal, así como del contexto de la ciudad. Los datos sobre los consumidores de heroína sólo se pueden encontrar en centros de salud especializados en VIH, pues que no existe otra fuente para tales registros. El marco legal mexicano pretende la rehabilitación y evitar la criminalización; sin embargo, la vida diaria de los consumidores les conduce hacia los circuitos del crimen: la gente comete delitos para estar en prisión, donde pueden controlar la adicción y conseguir heroína, en caso de abstinencia. El estado mexicano no cuenta con información empírica para mejorar los programas y leyes relacionadas con el consumo de heroína. Las prácticas diarias de los consumidores se han convertido no sólo en riesgos epidemiológicas, sino tambiém en riesgos sociales para la comunidad y los propios consumidores. Asimismo, la falta de acceso debido a la estigmatización, la criminalización y la violencia, incrementa las inequidades, creando un círculo vicioso que reproduce la pobreza y el sufrimiento, como parte de la estructura social. Por ello, es necesario que se produzcan cambios en el sistema judicial.

Resumo: O consumo da heroína é baixo no México, comparado ao uso nos Estados Unidos, porém essa prática é mais comum na região Norte do México em comparação com o resto do país, sendo documentada apenas nas cidades localizadas justamente na fronteira com os Estados Unidos. A legislação mexicana visa principalmente a reabilitação, mas seus efeitos sobre a vida dos usuários não são conhecidos. Este estudo teve como objetivo analisar a maneira pela qual o arcabouço regulatório mexicano é conceituado e praticado na vida diária de um grupo de usuários de heroína de um município no Norte do México, onde o consumo tem sido disseminado recentemente, mas sem ter sido documentado até então. Foram coletados os dados oficiais sobre usuários, seguido por um estudo qualitativo em Hermosillo, no Estado de Sonora. Foram estudados a legislação pertinente e o contexto local em Hermosillo. Os dados sobre os usuários de heroína foram encontrados nos centros de atendimento a pessoas com HIV, uma vez que não existe outra fonte desses registros. A legislação mexicana visa a reabilitação dos usuários, evitando sua criminalização, mas sua vida cotidiana os empurra para os circuitos do crime. Assim, os indivíduos cometem crimes para permanecer na prisão, onde conseguem controlar a dependência e obter a droga em casos de síndrome de abstinência. O governo mexicano não dispõe de dados empíricos para melhorar os programas e leis relacionados ao uso da heroína. As práticas diárias dos usuários se transformam em riscos, não apenas epidemiológicos como também sociais, tanto para a comunidade quanto para os próprios usuários. Além disso, a falta de acesso a serviços, em função da combinação de estigmatização, criminalização e violência, aumenta as desigualdades, criando um ciclo que reproduz e o sofrimento enquanto parte de uma estrutura social. Portanto, são necessárias mudanças urgentes no sistema de justiça.

Género y actividad física en mujeres mexicanas con experiencia migratoria a Estados Unidos de América / Gender and physical activity in Mexican women with experience of migration to the USA

Objetivo Analizar la influencia de la categoría de género en la práctica de actividad física en mujeres de zonas rurales con experiencia migratoria a Estados Unidos de América. Métodos Diseño cualitativo con métodos de la teoría fundamentada; la información fue obtenida a través de entrevistas en profundidad a 19 mujeres que habitan en localidades rurales de la zona central de México Resultados A través del análisis emergió como categoría central la crítica social a la actividad física. Las mujeres con pareja no realizan actividad física porque de acuerdo con las normas sociales es mal visto que la efectúen, y son los hombres quienes toman ladecisión de permitirla. El género, la identidad femenina y la crítica social son elementos que contribuyen a la comprensión de la inactividad física en estas mujeres. Conclusión Es necesario que los programas sanitarios que promueven la actividad física dirigidos a mujeres adultas en zonas rurales, se diseñen tomando como base la perspectiva de género y el contexto de la población.(AU)

Objective To analyze the influence of gender on the practice of physical activity, in women with experiences of migration to the U.S.A. Methods Qualitative design with methods based on grounded theory. The information was obtained through in-depth interviews of 19 women living in rural localities in the central zone of Mexico. Results Through this analysis, a core category arose: social criticism of physical exercise. The results show that married women do not perform physical exercise because, due social norms, it is socially frowned upon and men are responsible for making the decision to permit it. Gender, female identity, women's role as subordinates to men, and social criticism are elements that contribute to understanding the lack of physical activity among these women. Conclusion We suggest that healthcare programs be designed to promote physical activity among adult women in rural areas, taking gender perspective and the population's context into account.(AU)

[Gender and physical activity in Mexican women with experience of migration to the USA]. / Género y actividad física en mujeres mexicanas con experiencia migratoria a Estados Unidos de América.

OBJECTIVE: To analyze the influence of gender on the practice of physical activity, in women with experiences of migration to the U.S.A. METHODS: Qualitative design with methods based on grounded theory. The information was obtained through in-depth interviews of 19 women living in rural localities in the central zone of Mexico. RESULTS: Through this analysis, a core category arose: social criticism of physical exercise. The results show that married women do not perform physical exercise because, due social norms, it is socially frowned upon and men are responsible for making the decision to permit it. Gender, female identity, women's role as subordinates to men, and social criticism are elements that contribute to understanding the lack of physical activity among these women. CONCLUSION: We suggest that healthcare programs be designed to promote physical activity among adult women in rural areas, taking gender perspective and the population's context into account.

[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.

[Identification of meeting places of sexual partners in 2 cities of the Southern Mexican borders, using the PLACE method]. / Identificación de sitios de encuentro de parejas sexuales en dos ciudades de la frontera sur de México, mediante el método PLACE.

OBJECTIVE: To identify the meeting sites of new sexual partners in two Southern border cities in Mexico. MATERIAL AND METHODS: A descriptive epidemiologic study was carried out in May 2001, by surveying key informants in two border cities. Each reported site was visited to interview a resident subject. Subjects socializing in a subsample of sites were also interviewed. RESULTS: The key informants of the community reported 134 meeting sites in Chetumal and 111 in Ciudad Hidalgo. Both sites had scarce HIV/AIDS prevention activities. Characteristics were obtained for 89 sites in Chetumal and 42 in Ciudad Hidalgo. Almost 21% of interviewees reportedly met a new sexual partner in these sites in the past four weeks. CONCLUSIONS: Preventive actions are needed in meeting sites of new sexual partners. This method may provide information to plan for future interventions. The English version of this paper is available too at:http://www.insp.mx/salud/index.html.

Identificación de sitios de encuentro de parejas sexuales en dos ciudades de la frontera sur de México, mediante el método PLACE / Identification of meeting sites of new sexual partners in two Southern border cities in Mexico using the PLACE method

OBJETIVO: Identificar sitios de encuentro de nuevas parejas sexuales en dos ciudades de la frontera sur de México. MATERIAL Y MÉTODOS: En un estudio epidemiológico descriptivo se encuestó, en mayo de 2001, a informantes clave de la comunidad en dos ciudades fronterizas del sur de México para identificar sitios de encuentro de nuevas parejas. Se visitó cada sitio reportado y se encuestó a una persona del lugar. De una submuestra de sitios, se encuestó a personas que socializaban en los mismos. RESULTADOS: Los informantes clave de la comunidad reportaron 134 sitios en Chetumal y 111 en Ciudad Hidalgo. Se obtuvo información de las características de 89 sitios en Chetumal y 42 en Ciudad Hidalgo, ambos con escasas actividades preventivas del VIH/SIDA. Cerca de 21 por ciento de usuarios encuestados reportaron haber conocido una nueva pareja en los sitios en las últimas cuatro semanas. CONCLUSIONES: Son necesarias acciones de prevención en los sitios de encuentro de nuevas parejas sexuales. Este método puede proveer información para planificar futuras intervenciones.

Identificación de lesiones mamarias malignas en México / identification of malignant breast lesions in Mexico

Objetivo. Evaluar la forma en que se detectan las lesiones mamarias malignas en la ciudad de México y estimar el número de pacientes que son diagnosticadas en etapas avanzadas de dicho tumor. Material y métodos. Estudio transversal realizado en 256 mujeres entre 1994 y 1996, a quienes se les hizo un diagnóstico histopatológico de cáncer mamario en tres hospitales públicos de tercer nivel en la ciudad de México. Se les entrevistó personalmente y se obtuvo información acerca de sus características reproductivas, clínicas y la forma en la que fue detectado el cáncer mamario. Se calcularon porcentajes y razones de momios, con un intervalo de confianza de 95 por ciento. Resultados. El 90 por ciento de las mujeres identificaron por sí mismas la presencia de un abultamiento en el seno. Del total de las pacientes, sólo 10 por ciento fueron diagnosticadas con tumores en estadio I y 27 casos fueron identificados por el médico; estos últimos resultaron con tumores de estadios II B en adelante. Conclusiones. La situación actual sugiere que la mortalidad por cáncer mamario en la ciudad de México mantendrá su tendencia al incremento, a menos de que se logre aumentar la proporción de mujeres diagnosticadas en la etapa de los tumores in situ, para lo cual se requieren cambios en el funcionamiento de los servicios y un vasto esfuerzo educativo entre la población susceptible de desarrollar la enfermedad. El texto completo en inglés de este artículo está disponible en: http://www.insp.mx/salud/index.html