Tattoo discrimination in Mexico motivates interest in tattoo removal among structurally vulnerable adults.

Tattoos are less prevalent in Mexico and tattooed persons are frequently stigmatized. We examine the prevalence and correlates of interest in receiving tattoo removal services among 278 tattooed Mexican adults living in Tijuana, Mexico who responded to interviewer-administered surveys, including open-ended questions. Overall, 69% of participants were interested in receiving free tattoo removal services, 31% reported facing employment barriers due to their tattoos, and 43% of respondents regretted or disliked some of their tattoos. Having a voter identification card, reporting moderate/severe depression symptoms and believing that tattoo removal would remove employment barriers were independently associated with interest in tattoo removal. Our findings suggest that there is substantial interest in tattoo removal services. Publicly financed tattoo removal services may help disadvantaged persons gain access to Mexico's labor market and it may positively impact other life domains such as mental well-being and interactions with law enforcement.

Tattoo Removal as a Resettlement Service to Reduce Incarceration Among Mexican Migrants.

In Mexico, tattooed migrants face discrimination and are at high-risk of incarceration, thus, we assessed whether receiving laser tattoo removal affected the likelihood of incarceration. In 2015-2016, 89 adults ages ≥ 18 years with visible tattoos were recruited at a free-clinic to receive laser tattoo removal or assigned to the wait-list; all completed baseline and 6-month questionnaires. Overall, 97.8% of participants ever migrated to the USA. In multivariate analyses restricted to migrants (n = 87), those receiving laser tattoo removal [Adjusted Odds Ratio (AOR) 0.27, 95% CI 0.07-0.89] and possessing a Mexican Voting card (AOR 0.14; 95% CI 0.03-0.58) were significantly less likely than wait-list participants to be incarcerated at 6-months. Previously incarcerated participants were significantly more likely to be incarcerated at follow-up. Tattoo removal may reduce incarceration among Mexican migrants. Future studies can assess other health and social benefits of tattoo removal for migrants/deportees returning to Mexico.

Cost-Effectiveness of a Technology-Enhanced Diabetes Care Management Program in Mexico.

BACKGROUND: The prevalence of diabetes has increased substantially in Mexico over the last 40 years, leading to significant impacts on population health and the healthcare system. Technology-based solutions may improve diabetes outcomes in areas where lack of efficient transportation creates barriers to care. OBJECTIVES: To estimate the lifetime cost-effectiveness of a technology-based diabetes care management program from the perspective of the Mexican healthcare system. METHODS: Clinical outcomes and cost data from a 3-arm randomized clinical trial of Dulce Wireless Tijuana, a diabetes care management program incorporating short-term mobile technology, were used as inputs in a validated simulation model for type 2 diabetes. Study arms included a control group (CG), Project Dulce diabetes care management (PD), and Project Dulce with technology enhancement (PD-TE). RESULTS: Intervention costs were $1448 for PD and $1740 for PD-TE compared with $740 for CG. Both intervention arms increased quality-adjusted life-years and costs. The incremental cost-effectiveness ratio for PD was $1635 and for PD-TE was $2220, both compared with CG. The incremental cost-effectiveness ratio for PD-TE versus PD was $4299. The results were sensitive to the time horizon. The PE and PD-TE interventions were cost-effective under time horizons of 15 to 20 years, but were not cost-effective under time horizons of 5 to 10 years. CONCLUSIONS: Both the PD and PD-TE were highly cost-effective from a Mexican health system perspective. Considering the economic impact of the diabetes epidemic and the widespread use of cellular technology in Mexico, implementation of PD-TE is warranted.

Association of Adverse Childhood Experiences with Depression in Latino Migrants Residing in Tijuana, Mexico.

CONTEXT: Physical, sexual, and emotional abuse in childhood-adverse childhood experiences (ACEs)-are associated with poor mental and physical health. OBJECTIVE: To determine the prevalence of ACEs and their relationship to depression among Latino migrants in Mexico, which has not been previously examined. METHODS: A total of 110 Latinos aged 18 years and older residing in Tijuana, Mexico, completed interviewer-administered questionnaires, including the ACE scale (range = 0 to 10 items), at baseline in 2015. We studied the prevalence of ACEs (score on the ACE scale) and the presence of depressive symptoms (Patient Health Questionnaire-9). Multivariate logistic regression models were used to estimate the association between the ACE score and depressive symptoms. RESULTS: Overall, 82% of participants were men, and 82% reported being deported from the US. At least 1 ACE was reported by 64% of participants, and 33% reported 3 or more ACEs. Those who reported ever being incarcerated were significantly more likely to have 3 or more ACEs compared with no ACEs (56% vs 28%; p = 0.039). Symptoms of mild, moderate, or severe depression were identified in 14% of participants. In multivariate analyses, for each additional ACE item reported, participants were significantly more likely to meet criteria for depressive symptoms (adjusted odds ratio = 1.42; 95% confidence interval = 1.13-1.78; p = 0.002). CONCLUSION: Among Latino migrants residing in the US-Mexico border region, ACEs were pervasive and associated with depression symptoms. Programs and policies targeting migrants in this region should consider addressing both ACEs and depression.

The Health Frontiers in Tijuana Undergraduate Internship Program: A Novel Global Health Experience in Mexico for Pre-medical/Pre-health Undergraduates.

We describe the creation of the Health Frontiers in Tijuana (HFiT) Undergraduate Internship Program (UIP), a novel global health experience for U.S. and Mexican undergraduate students based at the binational HFiT student-run free clinic. The UIP introduces students to a diverse underserved patient population, and U.S.-Mexico border public health.

Dulce Wireless Tijuana: A Randomized Control Trial Evaluating the Impact of Project Dulce and Short-Term Mobile Technology on Glycemic Control in a Family Medicine Clinic in Northern Mexico.

BACKGROUND: The global epidemic of diabetes calls for innovative interventions. This study evaluated the effectiveness of the Project Dulce model, with and without wireless technology, on glycemic control and other clinical and self-reported outcomes in patients with poorly controlled type 2 diabetes in Mexico. SUBJECTS AND METHODS: Adults with type 2 diabetes and a glycated hemoglobin A1c (HbA1c) level of ≥8% were recruited from Family Medical Unit #27 of the Instituto Mexicano del Seguro Social (IMSS) in Tijuana, México, and randomly assigned to one of three groups: Project Dulce-only (PD); Project Dulce technology-enhanced with mobile tools (PD-TE); or IMSS standard of care/control group (CG). Clinical and self-reported outcomes were assessed at baseline, Month 4, and Month 10. Time-by-group interactions and within-group changes were analyzed. RESULTS: HbA1c reductions from baseline to Month 10 were significantly greater in PD-TE (-3.0% [-33 mmol/mol]) and PD (-2.6% [-28.7 mmol/mol]) compared with CG (-1.3% [-14.2 mmol/mol]) (P = 0.009 and 0.001, respectively). PD-TE and PD also exhibited significant improvement in diabetes knowledge when compared with CG (P < 0.05 for both). No statistically significant differences were detected between PD and PD-TE on these indicators (P = 0.54 and 0.86, respectively). Several within-group improvements were observed on other clinical and self-report indicators but did not vary significantly across groups. CONCLUSIONS: Project Dulce with and without wireless technology substantially improved glycemic control and diabetes knowledge in high-risk patients with type 2 diabetes in a Mexican family medical unit, suggesting that integrating peer-led education, nurse coordination, and 3G wireless technology is an effective approach for improving diabetes outcomes in high-risk populations.

Risk of violence in drug rehabilitation centers: perceptions of people who inject drugs in Tijuana, Mexico.

BACKGROUND: In 2009, Mexico reformed its health law to partially decriminalize drug possession considered for personal use and to increase mandatory referrals to certified drug rehabilitation centers in lieu of incarceration. Concurrently, news media reported violent attacks perpetrated by drug cartels against Mexican drug rehabilitation centers and instances of human rights violations by staff against people who inject drugs (PWID) in treatment. In many cases, these violent situations took place at "Peer Support" (Ayuda Mutua) drug rehabilitation centers that house a large number of drug-dependent PWID. In an effort to understand barriers to treatment uptake, we examined prevalence and correlates of perceived risk of violence at drug rehabilitation centers among PWID in Tijuana, Mexico. METHODS: Secondary analysis of baseline data collected between March 2011 and May 2013 of PWID recruited into a prospective cohort study in Tijuana. Interviewer-administered surveys measured perceived risk of violence at drug rehabilitation centers by asking participants to indicate their level of agreement with the statement "going to rehabilitation puts me at risk of violence". Logistic regression was used to examine factors associated with perceived risk of violence. RESULTS: Of 733 PWID, 34.5 % perceived risk of violence at drug rehabilitation centers. In multivariate analysis, reporting ever having used crystal methamphetamine and cocaine (separately), having a great or urgent need to get help for drug use, and ever receiving professional help for drug/alcohol use were negatively associated with perceived risk of violence at drug rehabilitation centers, while having been told by law enforcement that drug rehabilitation attendance is mandatory was positively associated with perceived risk of violence. All associations were significant at a 0.05 alpha level. CONCLUSION: The perception of violence at drug rehabilitation centers among PWID does not represent the lived experience of those PWID who attended professionalized services, reported a great or urgent need to get help for their drug use and had a history of using crystal and cocaine. Professionalizing service delivery and engaging law enforcement in their new role of decriminalization and service referral for PWID could address the perceptions of violence at drug rehabilitation centers. Similarly, health authorities should expand periodic inspections at drug rehabilitation centers to guarantee quality service provision and minimize PWIDs' concerns about violence.

Depressive symptoms among patients at a clinic in the Red Light District of Tijuana, Mexico.

Little is known about depression among structurally vulnerable groups living in Tijuana (e.g., migrants, deportees, substance users, sex workers, homeless) who may be at high risk for poor mental health. This study investigates the prevalence and correlates of depressive symptoms among vulnerable patients receiving services at a free clinic in Tijuana, Mexico. A convenience sample of 584 adult Mexican patients completed an interviewer-administered questionnaire in English or Spanish that included the 8-item NIH PROMIS depression short form and measures of individual, social, and structural factors affecting health. The prevalence of clinically significant depressive symptoms in our sample was 55%. In the multivariate analysis, female gender, poor/fair self-rated health, recent illicit drug use (past six months), feeling rejected (past six months), history of forced sex, and history of violence were independently associated with increased odds of experiencing depressive symptoms. When stratified by gender, we found important differences in significant factors, including recent illicit drug use in men and deportation in women. Among study participants, prevalence of depressive symptoms exceeds prevalence rates reported elsewhere in the U.S.-Mexico border region. These findings suggest that public health efforts to support mental health services in the border region are needed.

Acculturative trajectories descriptions and implications for health among 12 Mexican deported women who inject drugs / Descripción de trayectorias aculturativas y sus implicaciones en salud en 12 mujeres deportadas que se inyectan drogas

INTRODUCTION: Between 1999-2007, the U.S. deported 4.8 million migrants to Mexico; of these, 1.1 million migrants were deported to the border city of Tijuana, Baja California. Deportees are often returned to unfamiliar communities where they may experience emotional and socioeconomic stressors that may raise their risk for engaging in unsafe behaviors. OBJECTIVE: This exploratory study describes adaptation to the post-deportation environment among Mexican-born injection drug-using women. METHOD: In 2008, we conducted qualitative interviews in Tijuana with 12 women reporting U.S. deportation. Our analytic framework focused on acculturation stress, adaptation and social capital in relation to HIV risk, considering a gender perspective. RESULTS: We found that the stress caused by the deportation experience and acclimating to the post-deportation community may have contributed to the women's participation in high-risk HIV behaviors (e.g., unprotected sex, sex work). Female deportees reported limited access to post-deportation social capital resources (e.g., social support, healthy social networks). Social factors (e.g., discrimination, lack of a government identification) challenged women's resettlement and likely contributed to economic and health vulnerabilities. DISCUSSION AND CONCLUSION: These preliminary findings suggest that deportees may benefit from organized services at repatriation, including mental health screening. Macro-level interventions that address stigma and facilitate deportees' economic integration may help stem engagement in risk behaviors.

INTRODUCCIÓN: Entre 1999-2007, EE.UU. deportó a 4.8 millones de migrantes a México; de éstos, 1.1 millones fueron deportados a la ciudad fronteriza de Tijuana, B.C. Los deportados a menudo son devueltos a comunidades desconocidas donde pueden experimentar factores estresantes, emocionales y económicos, que pueden aumentar la probabilidad de involucrarse en conductas de riesgo. OBJETIVO: Este estudio exploratorio describe las experiencias de mujeres mexicanas que se inyectan drogas en su proceso de adaptación y su ambiente posterior a su deportación. MÉTODO: En 2008, se realizaron entrevistas cualitativas en Tijuana a 12 mujeres deportadas de EE.UU. El marco teórico utilizado para el análisis de las entrevistas fue el estrés aculturativo y el capital social relacionado con el riesgo para adquirir VIH tomando en cuenta la perspectiva de género. RESULTADOS: Encontramos que la experiencia del estrés aculturativo causado por la deportación de las mujeres entrevistadas pudo condicionar su participación en conductas de alto riesgo para VIH (ejemplo: sexo sin protección, trabajo sexual). Las mujeres reportaron posteriormente, a su deportación un acceso limitado para apoyo social y redes sociales sanas. La discriminación o la falta de una identificación oficial desafiaron el reasentamiento de las mujeres y probablemente contribuyeron a sus vulnerabilidades económicas y de salud. DISCUSIÓN Y CONCLUSIÓN: Estos resultados preliminares sugieren que los deportados podrían beneficiarse de los servicios organizados de repatriación, incluidos los exámenes de salud mental. Intervenciones a nivel macro que aborden el estigma y faciliten la integración económica de los deportados podrían ayudar a impedir su participación en conductas de riesgo.

Supporting the minority physician pipeline: providing global health experiences to undergraduate students in the United States-Mexico border region.

BACKGROUND: The sizeable US Latino population calls for increasing the pipeline of minority and bilingual physicians who can provide culturally competent care. Currently, only 5.5% of US providers are Hispanic/Latino, compared with 16% of the US population (i.e., >50.5 million persons). By 2060, it is predicted that about one-third of all US residents will be of Latino ethnicity. ACTIVITIES AND OUTCOMES: This article describes the Health Frontiers in Tijuana Undergraduate Internship Program (HFiT-UIP), a new quarterly undergraduate internship program based at a US-Mexico binational student-run free clinic and sponsored by the University of California, San Diego School of Medicine and the Universidad Autónoma de Baja California in Tijuana, Mexico. The HFiT-UIP provides learning opportunities for students and underrepresented minorities interested in medical careers, specifically Latino health. DISCUSSION: The HFiT-UIP might serve as a model for other educational partnerships across the US-Mexico border region and may help minority and other undergraduates seeking academic and community-based enrichment experiences. The HFiT-UIP can also support students' desires to learn about Latino, border, and global health within resource-limited settings.

Molecular characterization of Mycobacterium bovis isolates from patients with tuberculosis in Baja California, Mexico.

The incidence of tuberculosis (TB) from Mycobacterium bovis in humans is likely to be underestimated and in some cases even ignored in most developing countries. This may be due to the difficulty of differentiating TB caused by either Mycobacteriumtuberculosis or M. bovis. Our objectives were to determine the prevalence of M. bovis human disease among the patients referred for study to the Tuberculosis Laboratory of the Tijuana General Hospital in Baja California, Mexico and to characterize molecularly the clinical isolates using 8 loci of MIRU-VNTR. A cross-sectional analysis of all culture-proven cases of tuberculosis was conducted during the period from January 1, 2011 through June 30, 2013. Clinical isolates that exhibited resistance to pyrazinamide (Z) were submitted for molecular analysis. A total of 2699 clinical samples were cultured during the study period and 600 (22%) that tested positive were processed for drug susceptibility for first line drugs. Sixty-four (10.7%) of the tested isolates tested were resistant to Z, and 27 (4.5%) of those were subsequently identified molecularly as M. bovis. Three of the M. bovis isolates were polyresistant to Z, isoniazid (H), ethambutol (E) and rifampicin (R) (Z+H+E, Z+E and Z+R); the rest were only resistant only to Z. VNTR typing, based on the 8 VNTR loci commonly tested for M.bovis, detected 12 allelic profiles (genotypes). The real burden of M. bovis cases among the total reported human tuberculosis cases can only be known from especially designed studies in which, during a specific period, all specimens submitted to tuberculosis diagnosis in one or more laboratories are cultured on the appropriate media and the isolated mycobacteria are analyzed to differentiate M. bovis from M. tuberculosis and other Mycobacterium species.

Establishing a binational student-run free-clinic in Tijuana, Mexico: a model for US-Mexico border states.

In 2011, a bi-national student-run free clinic for the underserved, known as "Health Frontiers in Tijuana" (HFiT), was created in Tijuana, Mexico. Students and faculty from one Mexican and one US medical school staff the clinic and attend patients on Saturdays. Students from both medical schools enroll in a didactic course during the quarter/semester that they attend the free clinic. The course addresses clinical, ethical, cultural, population-specific issues and the structure, financing and delivery of medical care in Mexico. The clinic implements an electronic medical record and is developing telemedicine for consulting on complex cases. Despite challenges related to sustaining adequate funding, this program may be replicated in other border communities.

Correlates of unprotected anal sex among men who have sex with men in Tijuana, Mexico.

BACKGROUND: Although men who have sex with men (MSM) are disproportionately affected by HIV/AIDS in Mexico, data on current risk behaviors in this population are lacking. This study investigated the prevalence and correlates of unprotected anal intercourse (UAI) in a sample of 260 MSM in Tijuana, Mexico. METHODS: In June 2010, men attending a gay pride celebration were invited to complete a sexual risk survey. Men who reported UAI with a male partner in the past year were compared with men who reported only protected anal sex during the same period. RESULTS: Mean age of participants was 29.7; 54% had a high school diploma or less; and 43% were unemployed. In the past year, 55% had been tested for HIV, 21% reported using illicit drugs before or during sex, and 94% had sex only with men. Overall, 50% reported having UAI with another male in the past year. Factors independently associated with UAI in the past year were unemployment (AOR = 1.87), attending adult movie theaters (AOR = 2.21), using illicit drugs before or during sex (AOR = 2.43), and not having a recent HIV test (AOR = 1.85). CONCLUSIONS: Interventions to promote HIV testing and condom use among men who have sex with men may want to consider venue-specific approaches, as well as focus on drug-use issues in the context of unsafe sex.

Profiles, perceptions and motivations of Community Health Workers of NGOs in a border city of US-Mexico.

To analyze the profile, perceptions and motivations of Community Health Workers (CHWs) from non-governmental organizations (NGOs) in the border city of US-Mexico and to describe the type of community interventions they perform. we surveyed 121 CHWs from 9 NGOs participating in a monthly meeting between May and July of 2009. Each participating CHW answered a structured questionnaire. Furthermore, two focus groups were held, in which 10 and 8 CHWs participated, respectively. Qualitative and quantitative analyses were carried out on the data obtained. 70% of the CHWs had 9 years or less of formal education. With respect to community work, 61% volunteered between 1 and 5 h weekly; only 40% received some form of economic support. The most commonly reported activities were distribution of informational materials (59.5%) and promotion of health fairs (52.9%). Analysis of focus group discussions lead to the development of four conceptual categories: personal development, motivation, perception of their community participation and institutional relationship, some of the testimonies are "…just because the people do not respond does not mean we give up. No, we must work, persist, promote and raise awareness of the people…", "…when they compensate us, it is not really a payment. We are there because we get results, we do it happily… It is voluntary…" CHWs are an important human resource for communities. Institutions focusing on primary care should view these community players as social capital, which could improve the effectiveness of prevention strategies and achieve greater coverage of health services.