Evaluation of Health Promotion Program at the Community Level in Mexico: Is the Program Efficient and Effective?

CONTEXT: Health promotion programs have been encouraged in the Americas since 1990. In Mexico, health program promotion at the community level was implemented by the Ministry of Health in 2001 to encourage community health status improvement. Despite the longtime of its implementation, evaluations of its efficiency and effectiveness are scarce. OBJECTIVE: To evaluate the efficiency of the Healthy Environments and Communities Program (HECP) through 2 means: (1) efficiency of the implementation and (2) technical efficiency, as well as to evaluate its effectiveness. SETTING: Target communities of the HECP of 32 Mexican states during 2013-2017. The HECP developed community interventions to improve community organization, health behaviors, and family and communitarian sanitation. METHODOLOGY: We conducted a cross-sectional study to evaluate the efficiency of HECP implementation and estimated the inclusion of target communities (focalization index), the retention of communities (continuity index), and the desertion of communities in the program (desertion index). To evaluate the adequate use of the program resources (technical efficiency), we used data-enveloped analysis and the Tobit regression model to identify external factors that can influence results. Finally, to evaluate the program's effectiveness, we estimated the index of the communities that improved their health indicators and were certified as healthy (community certification). RESULTS: The median rate of focalization was 3.44 (1.31-85.13); the continuity of communities' rate was 0.50 (0.16-2.67). Regarding technical efficiency to reach healthy communities, only 2 states reached the optimal efficiency (score 1); where the efficiency was adjusted for external factors, 6 states reached a score of 1. The median of global effectiveness was 0.19 (0.01-0.78). We found differences in efficiency and effectiveness scores among states. CONCLUSION: We found lower efficiency of the implementation and technical efficiency, as well as poor effectiveness of the program to reach healthy communities. To achieve HECP purpose, it is necessary to revise its guidelines, improve its strategies to work in communities, and establish the right mechanisms to monitor its implementation. It is essential to focus on the resources used to enhance technical efficiency and effectiveness at the community level.

Delaying sexual onset: outcome of a comprehensive sexuality education initiative for adolescents in public schools.

BACKGROUND: A common risk behavior in adolescence is the early initiation of unprotected sex that exposes adolescents to an unplanned pregnancy or sexually transmitted infections. Schools are an ideal place to strengthen adolescents' sexual knowledge and modify their behavior, guiding them to exercise responsible sexuality. The purpose of this article was to evaluate the knowledge of public secondary school teachers who received training in comprehensive education in sexuality (CES) and estimate the counseling's effect on students' sexual behavior. METHODS: Seventy-five public school teachers were trained in participatory and innovative techniques for CES. The change in teacher knowledge (n = 75) was assessed before and after the training using t-tests, Wilcoxon ranks tests and a Generalized Estimate Equation model. The students' sexual and reproductive behavior was evaluated in intervention (n = 650) and comparison schools (n = 555). We fit a logistic regression model using the students' sexual debut as a dependent variable. RESULTS: Teachers increased their knowledge of sexuality after training from 5.3 to 6.1 (p < 0.01). 83.3% of students in the intervention school reported using a contraceptive method in their last sexual relation, while 58.3% did so in the comparison schools. The students in comparison schools were 4.7 (p < 0.01) times more likely to start sexual initiation than students in the intervention schools. CONCLUSION: Training in CES improved teachers' knowledge about sexual and reproductive health. Students who received counseling from teachers who were trained in participatory and innovative techniques for CES used more contraceptive protection and delayed sexual debut.

Factores asociados con el auto-reporte de maltrato en adultos mayores en México / Factors associated with self-reporting of abuse in seniors citizens in Mexico

Objetivo: Identificar algunos factores sociodemográficos, de salud física y mental, apoyo social y de utilización de servicios de salud asociados con el auto-reporte de maltrato en una muestra de hombres y mujeres adultos mayores viviendo en colonias urbano-marginales de cuatro municipios de México. Método: Se llevó a cabo un estudio transversal entre junio del 2004 y agosto del 2005 con una muestra propositiva de 799 adultos mayores que residían en colonias urbanas, identificadas como de "muy alta" y "alta marginación" en los municipios de Cuernavaca, Chilpancingo, Guadalajara y Culiacán. Un cuestionario dirigido a los adultos mayores fue utilizado para explorar tanto la variable dependiente (auto-reporte de maltrato) como las variables asociadas: características sociodemográficas, estado de salud física y mental, apoyo social y familiar y utilización de servicios de salud. Para el análisis estadístico se emplearon pruebas no paramétricas así como un modelo multivariado de regresión logística. Resultados: En esta muestra de ancianos, el 23 por ciento de las mujeres y el 9 por ciento de los hombres reportaron haber sido maltratados como consecuencia de problemas familiares. Los resultados sugieren que los factores que se relacionan con el maltrato en los adultos mayores incluidos en este estudio son: sexo femenino (RM=3.73;IC=1.76-4.24), edad de 60 a 69 años (RM=1.61;IC=1.06-2.42), ser divorciado o separado (RM=2.28;IC=1.32-3.96), padecer un mayor número de enfermedades (RM=1.07;IC=1.01-1.17), presentar lesiones evidentes a la observación (RM= 2.89;IC=1.01-3.58), presentar sintomatología depresiva (RM=1.68;IC=1.04-2.72), y no contar con apoyo familiar adecuado RM=2.91;IC=1.86-4.55). Conclusión: Los sistemas de salud enfrentan un reto importante en el maltrato del adulto mayor debido, por un lado, al rápido aumento de este grupo poblacional y, por otro, a las carencias de recursos materiales y de recursos humanos especializados.

Objective: Identify some sociodemographic factors, in physical and mental health, social support and utilization of health services, associated with the self-reporting of abuse in a sample of male and female senior citizens living in urban, marginalized settlements in four municipalities of Mexico. Method: A cross sectional study was carried out between June of 2004 and August of 2005, with a purposive sample of 799 seniors who live in urban settlements identified as having "very high" or "high marginalization," in the municipalities of Cuernavaca, Chilpancingo, Guadalajara and Culiacán. A survey directed at seniors was used to explore the dependent variable (self-reporting of abuse) as well as the associated variables: sociodemographic characteristics, state of physical and mental health, social and family support and utilization of health services. For the statistical analysis non-parametric tests were used as well as a multivariate logistic regression model. Results: In this sample of seniors, 23 percent of the women and 9 percent of the men reported having been abused as a consequence of family problems. The factors included in this study that are related to abuse of seniors are: female gender (OR=3.73;CI=1.76-4.24), age of 60 to 69 (OR=1.61;CI=1.06-2.42), being divorced or separated (OR=2.28;CI=1.32-3.96), suffering from a higher number of diseases (OR=1.07;CI=1.01-1.17), presenting evident, observable injuries, (OR=2.89;CI=1.01-3.58), presenting depressive symptoms (OR=1.68;CI=1.04-2.72), and not having adequate family support (OR=2.91;CI=1.86-4.55). Conclusion: Health systems face an important challenge in abuse of seniors which is due, on one hand, to the rapid increase of this population, and on the other, a lack of material and specialized human resources.

Lesiones accidentales en adultos mayores: un reto para los sistemas de salud / Accidental injuries in older adults: a challenge for the health systems

OBJETIVO: Identificar los factores sociodemográficos, de salud y apoyo social relacionados con las lesiones accidentales en adultos mayores residentes de colonias urbanas marginales de las ciudades de Cuernavaca, Chilpancingo, Guadalajara y Culiacán. MATERIAL Y MÉTODOS: En 2004-2005 se llevó a cabo un estudio transversal; mediante muestra no probabilística, se entrevistó a 799 adultos mayores; se emplearon pruebas no paramétricas y un modelo multivariado de regresión logística. RESULTADOS: Del total de entrevistas, 37 por ciento notificaron lesiones y la causa principal fueron las caídas (54 por ciento). El hogar fue el sitio con mayor número de accidentes (52 por ciento). Los factores de riesgo asociados fueron edad avanzada, trabajar, mayor número de enfermedades, mayor consumo de medicamentos, remedios y bebidas alcohólicas, percepción de "mala salud", apoyo familiar inadecuado y ser cuidador de otros. CONCLUSIONES: La multicausalidad obliga, por una parte, a que toda la sociedad participe y, por la otra, a la intervención del área de la salud para prevenir y atender el problema.

OBJECTIVE: To identify factors (sociodemographic, health, and social support) associated with the presence of accidental injuries in older adults living in deprived urban neighborhoods in four Mexican municipalities. MATERIAL AND METHODS: Cross-sectional survey carried out in 2004-2005, with a non-probabilistic, intentional sample of 799 male and female elderly living in deprived urban areas in four Mexican municipalities. For the statistical analysis, non-parametric tests and multivariate logistic regression models were used. RESULTS: More than a third (37 percent) of the sample reported injuries; with falls being the main cause. Home was the venue where most accidents took place (52 percent). Risk factors for accidental injuries were: advanced age, working, greater number of illnesses, consumption of more medicines and remedies, self-perception of "poor" health , consumption of alcoholic beverages, inadequate family support and being a caretaker of others. CONCLUSIONS: The multi-causality of accidental injuries in older adults demands the participation of all sectors of society, and particularly public health interventions.