Comparación de una intervención nutricional basada en la comunidad y una intervención nutricional convencional en localidades mayas de México / Comparison of a community-based nutritional intervention and a conventional nutritional intervention in Mayan communities in Mexico / Comparação entre uma intervenção nutricional baseada na comunidade e uma intervenção nutricional convencional em localidades maias de México

Las malas condiciones nutricionales en muchas localidades mayas de Yucatán, México, persisten, a pesar de que se han implementado diversos programas. El objetivo fue comparar los efectos de una intervención nutricional basada en la comunidad con enfoque intercultural (INBC) y una intervención nutricional convencional (INC), sobre el índice de masa corporal (IMC) y la dieta en mujeres de localidades mayas de Yucatán. Fueron incluidas mujeres adultas con IMC ≥ 25kg/m2 de dos pequeñas localidades rurales mayas vecinas. Ambas intervenciones fueron de tres meses y con 11 sesiones, siguiendo la normatividad vigente; en la INBC fue utilizada la herramienta intercultural, denominada Plato del Bien Comer Maya, además se incluyeron en la INBC estrategias diseñadas con base en información obtenida en una fase previa de estudio cualitativo con entrevistas. El grupo con la INBC (n = 7), en comparación con el grupo con la INC (n = 9), tuvo una mayor disminución de IMC (-0,58 ± 0,70 kg/m2 y +0,27 ± 0,64 kg/m2; p = 0,042), de la circunferencia de cintura (-2,15 ± 2,60 cm y -0,50 ± 0,75 cm; p = 0,042) y del consumo de grasas (-53,23 ± 21,92 gramos y -7,34 ± 25,77 gramos; p = 0,004), así como mayor incremento en las frecuencias semanales de consumo de algunos alimentos locales como nance (p = 0,012), tamarindo (p = 0,001) y chile (p = 0,004), la INBC fue la única que presentó una disminución significativa en el consumo diario de calorías (basal: 2.067 ± 91 kcal/día, a los tres meses: 1.474 ± 31 kcal/día; p = 0,018), hubo en ambos grupos disminuciones en el consumo de alimentos ultraprocesados, pero sin diferencias comparando los grupos; el grupo con la INBC obtuvo mejores resultados que el grupo con la INC.

Poor nutritional conditions persist in many Mayan communities in Yucatán, Mexico, even though various programs have been implemented. The study aimed to compare the effects of a community-based nutritional intervention with an intercultural focus versus a conventional nutritional intervention on body mass index (BMI) and diet in women in Mayan communities in Yucatán. The sample included adult women with BMI ≥ 25kg/m2 from neighboring rural Mayan villages. Both interventions lasted three months with 11 sessions and followed the prevailing guidelines. The community-based intervention used an intercultural tool called Good Mayan Food [Plato del Bien Comer Maya], besides strategies designed according to information obtained from a prior qualitative study phase using interviews. The group that received the community-based intervention (n = 7), compared to the conventional intervention group (n = 9), showed larger decreases in BMI (-0.58 ± 0.70 kg/m2 and +0.27 ± 0.64kg/m2; p = 0.042), waist circumference (-2.15 ± 2.60 cm and -0.50 ± 0.75 cm; p = 0.042), and consumption of fats (-53.23 ± 21.92 grams and -7.34 ± 25.77 grams; p = 0.004), as well as higher increases in weekly consumption of some local foods such as nance fruit (p = 0.012), tamarind (p = 0.001), and chili peppers (p = 0.004). The community-based intervention was the only one to show a significant decrease in daily calorie intake (baseline: 2,067 ± 91 kcal/day, at three months: 1,474 ± 31 kcal/day; p = 0.018), and both groups showed decreases in the consumption of ultra-processed foods, but without significant differences between the two groups. The community-based intervention group showed better results than the conventional intervention group.

As más condições nutricionais em muitas localidades maias de Yucatán (México) persistem apesar da implementação de diversos programas. O objetivo era comparar os impactos de uma intervenção nutricional baseada na comunidade com enfoque intercultural (INBC) e uma intervenção nutricional convencional (INC), sobre o índice de massa corporal (IMC) e a dieta de mulheres de localidades maias de Yucatán. Foram incluídas mulheres adultas com IMC ≥ 25kg/m2 de duas pequenas localidades rurais maias vizinhas. Ambas as intervenções duraram três meses e contaram com 11 sessões, conforme as normas vigentes; na INBC, foi utilizada a ferramenta intercultural denominada Prato de Comer Bem Maia [Plato del Bien Comer Maya], além de estratégias adicionais idealizadas com base em dados obtidos em uma fase prévia de estudo qualitativo com entrevistas. Em comparação com o grupo com a INC (n = 9), o grupo com a INBC (n = 7) teve maior diminuição de IMC (-0,58 ± 0,70 kg/m2 e +0,27 ± 0,64 kg/m2; p = 0,042), da circunferência abdominal (-2,15 ± 2,60 cm y -0,50 ± 0,75 cm; p = 0,042) e do consumo de gorduras (-53,23 ± 21,92 gramas y -7,34 ± 25,77 gramas; p = 0,004), bem como um aumento maior das frequências semanais de consumo de alguns alimentos locais como o murici (p = 0,012), o tamarindo (p = 0,001) e pimenta (p = 0,004). A INBC foi a única a apresentar uma diminuição significativa do consumo diário de calorias (inicial: 2.067 ± 91 kcal/dia, após três meses: 1.474 ± 31 kcal/dia; p = 0.018). Houve em ambos os grupos redução equivalente do consumo de alimentos ultraprocessados; o grupo com a INBC obteve melhores resultados que o grupo com a INC.

Los Grupos de Ayuda Mutua como posible estrategia de apoyo emocional para personas indígenas que padecen diabetes / Mutual Aid Groups as a possible emotional support strategy for indigenous people with diabetes

Resumen: Objetivo: Reflexionar sobre el apoyo emocional que los Grupos de Ayuda Mutua (GAM) dan a personas indígenas con diabetes y su importancia en el apego al tratamiento. Material y métodos: Estudio cualitativo: 25 entrevistas semiestructuradas; tres grupos focales (17 participantes); y observación no participante. Se realizó análisis de contenido con el apoyo del programa Atlas-ti. Resultados: Se identificaron expresiones emocionales relacionadas con el padecimiento. La opinión sobre el trabajo grupal fue positiva. El GAM es un espacio de catarsis, pero no funciona como soporte para enfrentar las restricciones del tratamiento y el impacto emocional en caso de complicaciones mayores. Conclusiones: Con la debida capacitación del personal de salud a cargo de los grupos, los GAM pueden llegar a ser espacios de soporte emocional para las personas indígenas y contribuir a su bienestar.

Abstract: Objective: To think about the emotional support that Mutual Aid Groups (MAG) offer up to indigenous people with diabetes and their importance in adherence to treatment. Materials and methods: Qualitative study: 25 semi-structured interviews; 3 focus groups (17 participants); and non-participant observation. Content analysis was carried out with the support of the Atlas-ti program. Results: We identified emotional expressions related to the disease. The opinion about MAGs and group work was positive. The MAG is a catharsis space, but it does not work as a support to face the restrictions of the treatment and the emotional impact in case of major complications. Conclusions: With proper training of the health personnel in charge of the groups, MAGs can become emotional support spaces for indigenous people and contribute to their well-being.

La vulnerabilidad y el riesgo: reflexiones a propósito de la pandemia del covid-19 / Vulnerabilidade e risco: reflexões sobre a pandemia de Covid-19 / Vulnerability and risk: reflections on the COVID-19 pandemic

RESUMEN A finales de diciembre 2019 se identificó el virus SARS-COV-2 como responsable de la pandemia de Covid-19. La rápida expansión de la transmisión puso al descubierto fallas estructurales de las sociedades modernas y de los sistemas de salud para prevenir y contener una amenaza sanitaria. La discusión científica se ha concentrado en la búsqueda de una vacuna, pero menos en comprender la respuesta social ante la amenaza globalizada actual y el temor a los rebrotes. En este ensayo reflexionamos, desde las ciencias sociales, sobre la importancia de vincular tres conceptos: vulnerabilidad-percepción-riesgo. Esto es necesario para desarrollar estrategias preventivas adecuadas a las circunstancias poblacionales, especialmente con la población más vulnerable, a favor de la equidad en salud.

RESUMO No final de dezembro de 2019, o vírus SARS-COV-2 foi identificado como responsável pela pandemia de Covid-19. A rápida propagação da transmissão expôs falhas estruturais das sociedades modernas e dos sistemas de saúde na prevenção e contenção de uma ameaça sanitária. A discussão científica tem se concentrado na busca por uma vacina, mas menos na compreensão da resposta social à atual ameaça global e ao medo de novos surtos. Neste ensaio refletimos, a partir das ciências sociais, sobre a importância de associar três conceitos: vulnerabilidade-percepção-risco. Isso é necessário para desenvolver estratégias preventivas adequadas às circunstâncias da população, principalmente junto à população mais vulnerável, em prol da equidade na saúde.

ABSTRACT At the end of December 2019, SARS-COV-2 virus was identified as responsible for the COVID-19 pandemic. The rapid spread of transmission exposed structural failures of modern societies and of the health systems in preventing and containing a health threat. Scientific discussion has focused on the search for a vaccine, but less on understanding the social response to the current global threat and fear of outbreaks. In this essay, we reflect, based on the social sciences, on the importance of linking three concepts: vulnerability-perception-risk. This is necessary to develop preventive strategies appropriate to population circumstances, especially with the most vulnerable population, in favor of health equity.

Opiniones de adolescentes sobre el Plato del Bien Comer Maya como herramienta de promoción de la salud / Adolescents opinions regarding Plato del Bien Comer Maya as nutrition health promotion tool

Resumen: Objetivo: Conocer opiniones sobre el Plato del Bien Comer Maya de adolescentes de Cholul, Yucatán, para mejorar la herramienta comunicativa y utilizarla en actividades de promoción de la salud. Material y métodos: Estudio cualitativo, de investigación formativa. Se realizaron tres grupos focales, participaron 28 adolescentes de secundaria: 12-16 años. Criterios de inclusión: pertenecer a alguno de los tres grados de la escuela y tener familias originarias del poblado. El análisis de los datos se realizó manualmente. Resultados: En comparación con el Plato del Bien Comer nacional, el Plato Maya fue mejor identificado por tener elementos locales a los que pueden acceder fácilmente y con costos menores. Se identificó la palabra fruto como una variación lingüística que representa en ese contexto tanto a las frutas como a las verduras. Conclusiones: Para tener mejores resultados en intervenciones nutricionales es necesario diseñar estrategias educativo-comunicativas acordes con la cultura local.

Abstract : Objective: To know opinions of adolescents from Cholul, Yucatán, about Plato del Bien Comer Maya in order to improve it as health promotion tool. Materials and methods: Qualitative study, formative research. Three focus groups were carried out, participating 28 adolescents: 12-16 years old. Criteria of inclusion: studying middle school; to have native family from the town. Analysis of the data made manually. Results: Comparatively with the national Plato del Bien Comer, the Plato Maya was better identified because have local food products easier to obtain and cheaper. The principal finding was to understand Fruto is a linguistic variation word which represents in Maya context both fruits and vegetables. This might be an important key to improve health promotion activities with that population. Conclusions: In order to have better results in nutritional interventions, it is necessary to design educational-communicative strategies in accordance with the local culture.

La desigualdad en salud de grupos vulnerables de México: adultos mayores, indígenas y migrantes / Health inequality among vulnerable groups in Mexico: older adults, indigenous people, and migrants

La vulnerabilidad en salud se refiere a la falta de protección de grupos poblacionales específicos que presentan problemas de salud particulares, así como a las desventajas que enfrentan para resolverlos, en comparación con otros grupos de población. Las causas de este importante problema de salud pública son muchas y de diversa índole, incluidas la insuficiencia de personal de salud capacitado y la falta de apoyo familiar, social, económico e institucional para obtener atención y minimizar los riesgos de salud. La vulnerabilidad en salud es una condición dinámica que resulta de la conjunción de varios determinantes sociales. En el presente trabajo se busca describir la situación de salud de tres grupos vulnerables (GV) de México -adultos mayores, indígenas y migrantes- y analizar las medidas que podrían contribuir al diseño e implementación de políticas públicas de salud más acordes a sus necesidades, partiendo de reconocer e identificar las necesidades propias de cada GV.

Health vulnerability refers to a lack of protection for specific population groups with specific health problems, as well as the disadvantages they face in solving them in comparison with other population groups. This major public health problem has multiple and diverse causes, including a shortage of trained health care personnel and the lack of family, social, economic, and institutional support in obtaining care and minimizing health risks. Health vulnerability is a dynamic condition arising from the confluence of multiple social determinants. This article attempts to describe the health situation of three vulnerable groups in Mexico-older adults, indigenous people, and migrants-and, after defining the needs of each, explore measures that could contribute to the design and implementation of public health policies better tailored to their respective needs.

Barreras y oportunidades para la regulación de la publicidad de alimentos y bebidas dirigida a niños en México / Barriers and opportunities for the regulation of food and beverage advertising to children in Mexico

Objetivos. Identificar barreras y oportunidades para la regulación de la publicidad de alimentos y bebidas para niños. Material y métodos. Estudio cualitativo. Se entrevistó a catorce informantes clave del ámbito legislativo, sector privado, funcionarios de la Secretaría de Salud y académicos involucrados en el tema de la regulación de la publicidad. Resultados. Barreras identificadas: concepción de la obesidad como problema individual, minimización de los efectos negativos sobre la salud, definición de la vulnerabilidad de la niñez acotada a su desarrollo cognitivo. Facilitadores: apoyo de varios sectores de la sociedad, a favor de la regulación, una amplia discusión científica acerca del tema, una experiencia exitosa similar con la industria del tabaco y sus lecciones. Conclusión. México cuenta con elementos clave para lograr una regulación eficaz de la publicidad.

Objective. To identify barriers and opportunities for the regulation of food and beverage advertising to children. Materials and methods. A qualitative study. Fourteen key informants from the congress, private sector, officials from the ministry of health and academics involved in the issue of regulation of advertising were interviewed. Results. Barriers identified: conception of obesity as an individual problem, minimization of the negative effects on health, definition of the vulnerability of children bounded to their cognitive development. Facilitators support from various sectors of society regulation, extensive scientific discussion on the subject, successful experience and its lessons on tabacco industry. Conclusion. Mexico has key elements for achieving effective regulation on advertising.

Experiencias de mujeres mexicanas migrantes indocumentadas en California, Estados Unidos, en su acceso a los servicios de salud sexual y reproductiva: estudio de caso / Experiences of undocumented Mexican migrant women when accessing sexual and reproductive health services in California, USA: a case study / Experiências de mulheres mexicanas migrantes sem documentação na Califórnia, Estados Unidos, no acesso aos serviços de saúde sexual e reprodutiva: estudo de caso

This study focuses on the experience of Mexican women migrants in California, USA, with the use of formal health services for sexual and reproductive health issues. The authors used a qualitative interpretative approach with life histories, interviewing eight female users of healthcare services in California and seven key informants in Mexico and California. There were three main types of barriers to healthcare: immigration status, language, and gender. Participants reported long waiting times, discriminatory attitudes, and high cost of services. A combination of formal and informal healthcare services was common. The assessment of quality of care was closely related to undocumented immigration status. Social support networks are crucial to help solve healthcare issues. Quality of care should take intercultural health issues into account.

El objetivo de este estudio fue conocer la experiencia de mujeres mexicanas migrantes en California, Estados Unidos, en torno a la utilización de los servicios formales de salud para resolver problemas relacionados con su salud sexual y reproductiva. El diseño fue cualitativo, con enfoque teórico metodológico de antropología interpretativa. Las técnicas utilizadas fueron historias de vida con mujeres usuarias de los servicios de salud en California y entrevistas breves con informantes clave. Se encontraron tres tipos de barreras principales para el acceso al sistema de salud: condición migratoria, idioma y género. Los tiempos de espera, actitudes discriminatorias y costo del servicio se expresaron como características que más incomodaron a las migrantes. La percepción de calidad de atención estuvo relacionada con la condición de ilegalidad migratoria. La red de apoyo tanto en México, como en California, colabora en la resolución de enfermedades. Se debe incorporar la perspectiva intercultural en los servicios.

O objetivo deste estudo foi conhecer a experiência de mulheres imigrantes mexicanas na Califórnia, Estados Unidos, sobre a utilização de serviços formais de saúde para resolver problemas relacionados com a saúde sexual e reprodutiva. O desenho foi qualitativo, com enfoque teórico-metodológico da Antropologia Interpretativa. As técnicas utilizadas foram relatos de histórias de vida de mulheres usuárias dos serviços de saúde na Califórnia e entrevistas breves com informantes-chave. Encontraram-se três tipos de barreiras principais para o acesso ao serviço de saúde: condições de imigração, idioma e gênero. Tempo de espera, atitudes discriminatórias e custo do serviço foram as características que mais incomodaram as imigrantes. A percepção de qualidade da atenção esteve relacionada com a condição de ilegalidade migratória. A rede de apoio, tanto no México quanto na Califórnia, colabora na resolução das enfermidades. Deve-se incorporar a perspectiva intercultural nos serviços de saúde.

Participación social y calidad en los servicios de salud: la experiencia del aval ciudadano en México / Social participation and quality of health care: the experience of citizens' health representatives in Mexico / Participação social e qualidade nos serviços de saúde: a experiência do aval ciudadano no México

OBJETIVO: Analizar la experiencia del aval ciudadano en el sistema de salud mexicano en la mejora de los servicios de salud. METODOS: Estudio de corte cualitativo en ocho estados de México en 2008. Se evaluaron diferentes aspectos del programa nacional para mejorar la calidad de los servicios de salud. Se compara la estrategia de México con otras experiencias en América Latina. RESULTADOS: Se exponen los avances y problemas del funcionamiento del aval ciudadano, figura que promueve la participación social en salud de la población. CONCLUSIONES: El aval ciudadano es una figura con gran potencial para representar a los usuarios en los servicios de salud y transmitir sus demandas de mejora de la calidad de la atención médica.

OBJECTIVE: This article describes the experience of the aval ciudadano "Citizens' Representative" (CR) in improving the Mexican health care system. METHODS: This is a qualitative study which took place in eight Mexican states in 2008. It evaluates different aspects of a nationwide program to increase the quality of health care services (National Crusade for Quality in Health Services). The Mexican strategy is compared with experiences in other Latin American countries. RESULTS: In this paper, there is the description of achievements and problems encountered by the CR in promoting social participation in the health of the population. CONCLUSIONS: The CR has great influence when representing health service users and passing on their demands for improvements to health care quality.

OBJETIVO: Analisar a experiência do aval ciudadano (reforço cidadão) no sistema de saúde mexicano na melhora dos serviços de saúde. MÉTODOS: Estudo de coorte qualitativo em oito estados mexicanos, em 2008. Foram avaliados diferentes aspectos do programa nacional para melhora de qualidade nos serviços de saúde. Compara-se a estratégia no México com outras experiências na América Latina. RESULTADOS: Foram expostos os avanços e problemas de funcionamento do aval ciudadano (reforço cidadão), figura que promove a participação social na saúde da população. CONCLUSÕES: O aval ciudadano (reforço cidadão) é uma figura com grande potencial para representar os usuários dos serviços de saúde e transmitir suas exigências de melhorias na qualidade da atenção médica.

Percepción de los usuarios sobre la calidad de la atención ambulatoria en servicios de salud en México / Users' perception about of quality ambulatory healthcare services in Mexico

Objetivo. Identificar la percepción de los usuarios de los servicios de salud ambulatorios en México sobre la calidad de atención y los factores asociados con dicha percepción. Material y métodos. De los datos obtenidos por las Encuestas Nacionales de Salud y Nutrición 2006 y 2012 se analizó la percepción de la atención recibida y de mejoría en salud después de la atención; se elaboró un modelo multivariado para identificar los factores de los servicios asociados con la percepción de mejoría. Resultados. La buena percepción de atención se elevó de 82 a 85%, y la de mejoría del estado de salud, de 79 a 81%, entre los años 2006 y 2012. La explicación sobre la enfermedad y tratamiento, la consulta sin cita previa, la oportunidad de elegir el servicio de salud y menor tiempo de espera se asociaron con la percepción de mejoría. Conclusiones. Existen avances en la calidad de atención percibida en la atención ambulatoria en México. Es necesario fortalecer estrategias organizacionales para brindar atención con mayor oportunidad y responder a las expectativas de los usuarios.

Objective. To identify users' perception about ambulatory healthcare services quality and associated factors in Mexico. Materials and methods. Analysis of the 2006 and 2012 National Surveys of Health and Nutrition that included users' perception of healthcare services and improvement in health status. A multivariate regression analysis allowed identifying the associated factors with the perception of improved health status. Results. Between 2006 and 2012, users' positive perception of healthcare services increased from 82 to 85%, and user report of improvement in health status increased from 79 to 81%. Health status improvement, explanations about the disease and treatment, being attended without appointment, freedom to choose the provider and short waiting time were associated with a perception of better quality of care. Conclusions. Users' perception about the quality of care in ambulatory healthcare settings has improved, yet it is still neccessary to strengthen organizational strategies to provide healthcare when needed and to improve fulfillment of users' expectations.

Género y trabajo: experiencia de las prestadoras de las casas de salud de mujeres indígenas de Guerrero y Oaxaca / Gender and work: the experience of providers of health services

OBJETIVO: Identificar, a través del discurso de prestadoras de servicio de las Casas de Salud de las Mujeres Indígenas de México en Ometepec, Guerrero y Matías Romero, Oaxaca, el papel de género en el desempeño de su rol como trabajadoras. METODOLOGÍA: Estudio cualitativo, basado en un análisis secundario de las entrevistas realizadas como parte del proyecto "Rescatando la experiencia de la Casa de la Mujer Indígena: sistematización y evaluación del proceso". RESULTADOS: Se identificó un importante valor al trabajo y compromiso hacia la comunidad. La culpa aparece como producto de la tensión entre el trabajo fuera del hogar y las responsabilidades como madres y esposas. La posibilidad de ayudar a otras mujeres es fuente de gratificación que disipa estos conflictos; el prestigio y el reconocimiento se suman a las ganancias de su rol. CONCLUSIONES: La experiencia laboral de las mujeres trabajadoras en la "casa de la mujer indígena" de Matías Romero, Oaxaca, y Ometepec, Guerrero, descrita en este trabajo muestra que tiene características muy específicas de difícil replicación en otras regiones del país. En estudios futuros es necesario considerar los diferentes contextos de vulnerabilidad.

The scope of this paper was to identify the role of gender for women as workers, through the perception and discourse of health service providers at the 'Health Centers for Indigenous Women' ("Casas de Salud de las Mujeres Indígenas") in Ometepec, Guerrero and Matías Romero, Oaxaca, Mexico. It is a qualitative study, based on a secondary analysis of the interviews conducted as part of the "Rescatando la experiencia de la Casa de la Mujer Indígena: sistematización y evaluación del proceso" project. A strong sense of the value of work and a strong commitment towards the community were identified. Guilt appears as the result of tension between work outside the home and the responsibilities as mothers and wives. The possibility of helping other women is a source of gratification that dissipates these conflicts; prestige and recognition are added to the benefits of their role. The labor experience of female workers in the "Casas de Salud de las Mujeres Indígenas" of Matías Romero, Oaxaca and Ometepec, Guerrero, described in this paper, reveals that it has very specific characteristics, which are difficult to replicate in other regions of the country. In future studies it is necessary to consider the different contexts of vulnerability.

La atención de los enfermos y discapacitados en el hogar: Retos para el sistema de salud mexicano / Household care for ill and disabled persons: challenges for the Mexican health care system

OBJETIVO: Identificar el patrón de dedicación de tiempo y analizar los mecanismos de atención que utilizan los miembros de familias con enfermos y discapacitados en el hogar. MATERIAL Y MÉTODOS: Para cumplir con el primer objetivo se analizó la base de datos de la Encuesta Nacional de Uso de Tiempo 2002. Para cumplir con el segundo objetivo se levantó información a través de entrevistas en profundidad y grupos focales en Coahuila, Sinaloa, Zacatecas, Jalisco, Oaxaca, Yucatán y el Distrito Federal de junio a diciembre de 2004. RESULTADOS: Se estima que 1 738 756 personas dedicaron tiempo a cuidar enfermos y que 1 496 616 se encargaron de cuidar discapacitados, la semana anterior al levantamiento de la encuesta. Existen diferencias importantes por género y nivel de escolaridad en la dedicación de horas a estas actividades. Por otra parte, los hogares tienden a reorganizarse para ofrecer atención a enfermos y discapacitados. En el hogar, son las mujeres quienes asumen la mayor responsabilidad en el cuidado. Existen diferencias importantes en la atención a enfermos y discapacitados en términos del desgaste físico y emocional que sufre el cuidador. CONCLUSIONES: Las implicaciones de los resultados en la atención a enfermos y discapacitados son enormes para un futuro cercano. El envejecimiento de la población y el aumento de las enfermedades crónicas requieren de una mayor articulación entre el ámbito institucional de atención y el ámbito del hogar, a fin de que ambos puedan complementar sus capacidades.

OBJECTIVE: To identify the pattern of time devoted by members of Mexican households to providing care to ill and disabled family members. To analyze the mechanisms used by families to provide care to an ill or disabled member. MATERIAL AND METHODS: The database of the 2002 National Survey of Time Use was explored to accomplish the first objective. The second objective was accomplished by collecting primary data through in-depth interviews and focal groups in Coahuila, Sinaloa, Zacatecas, Jalisco, Oaxaca and Yucatán from June to December 2004. RESULTS: It was estimated that 1 738 756 persons spent time providing care to ill persons and 1 496 616 to disabled persons, over the reference period of the survey. There are important differences in the dedication of hours by gender and education level. Moreover, households tend to reorganize their structure to provide care to ill and disabled members. Women tend to have more responsibilities in the process. There are important differences in the care of ill and of the disabled in terms of the physical and emotional stress produced in the caregiver. CONCLUSIONS: The implications of results in the care of ill and disabled populations are highly relevant for the future of the Mexican health care system. Population aging and the increase of chronic diseases call for a reinforced relationship between institutional and household care so as to complement capacities, a situation already taking place in other countries.

Violencia de género y otros factores asociados a la salud emocional de las usuarias del sector salud en México / Gender violence and other factors associated with emotional distress in female users of public health services in Mexico

OBJETIVO: Identificar los factores asociados al malestar emocional en una muestra nacional de usuarias de servicios de salud del sector público: Secretaría de Salud (SSA), Instituto Mexicano del Seguro Social (IMSS), Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE). MATERIAL Y MÉTODOS: Se utilizó la base de datos de la Encuesta Nacional de Violencia contra las Mujeres en México, donde se aplicaron 26 042 encuestas a usuarias de los servicios de salud de la SSA. Se utilizó la Escala de Salud Personal (ESP) para medir malestar emocional,; también se usó una escala de 19 reactivos que explora tipos de violencia y severidad de la misma. Mediante un modelo de regresión logística binaria se determinó la relación entre la presencia de malestar y la violencia de género, condiciones socioeconómicas y otras variables demográficas. RESULTADOS: Entre los más relevantes está la identificación de la prevalencia de malestar emocional (15.3 por ciento) entre las mujeres que acuden a solicitar servicios de salud al sector público, y la relación de este malestar emocional generalizado con la experiencia de diferentes tipos de violencia de género. Los resultados sugieren que los factores asociados con el malestar emocional de la mujeres que recurren a los servicios de salud fueron: la edad (26 años o >); la actividad (jornalera o peona), y las horas laborales (71 a la semana o >);el consumo de alcohol (mayor consumo); el maltrato en la infancia (frecuencia y diversos tipos de maltrato); la severidad de la violencia de pareja (violencia severa), el estrato socioeconómico (muy bajo) y el tipo de localidad de residencia (localidades urbanas). CONCLUSIONES: El predictor más importante del malestar emocional entre las usuarias del sector salud fue sufrir la violencia de pareja, sobre todo cuando ésta es severa, seguida de la violencia en la niñez. Así entonces, se propone utilizar herramientas de tamizaje en los servicios de salud, tanto de malestar emocional como de violencia intrafamiliar. Además, se propone diseñar y poner en marcha programas de atención y referencia de casos de malestar emocional femenino y de violencia intrafamiliar.

OBJECTIVE: To identify and describe the factors associated with emotional distress in a national sample of women users of public health services in Mexico, such a Secretaria de Salud (SSA), Instituto Mexicano del Seguro Social (IMSS), Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE). MATERIAL AND METHODS: This research study was conducted using the database of the National Survey of Violence against Women that consisted of the responses of a total of 26 042 female users of health care services provided by the Mexican government health agencies. The Personal Health Scale (ESP per its initials in Spanish) was used to assess emotional distress. To measure violence a 19-item scale which explores different types of violence as well as severity was used. The relationship between emotional distress and gender violence was determined through a binary logistic regression model, as were economic status and demographic variables. RESULTS: One of the most important findings of this study is the high prevalence of emotional distress (15.3 percent) among women seeking health care services from the public sector and the relationship of such emotional distress with the experience of marital physical, psychological, and sexual violence. Factors associated with emotional distress among female users of health care services were age (26 and older); activity (laborer); working hours (71 hours a week or more); alcohol intake (greater intake); abuse during childhood (frequency and types of abuse); severity of marital violence (severe violence); socioeconomic status (very low SES); and type of dwelling (urban). CONCLUSIONS: The principal predictor of emotional distress was intimate partner abuse, especially in severe expression. The next predictor was violence in childhood. Taking into consideration these predictors it is recommended to use screening instruments to identify emotional distress and gender violence in health setting. It is important to design and implement attention and reference programs in public health services for women suffering from emotional distress and gender violence.

Del riesgo a la vulnerabilidad. Bases metodológicas para comprender la relación entre violencia sexual e infección por VIH/ITS en migrantes clandestinos

resumen está disponible en el texto completo

Summary In the past, the epidemic of Acquired Immune Deficiency Syndrome (AIDS) was not conceived originally as a public health problem, and was attributed instead to individuals enacting social roles related to lifestyles considered as transgressions from hegemonic sexuality (heterosexual, reproductive and monogamous). The epidemiological analysis was upheld by clinical notions which reinforced the stigma of population groups historically discriminated, such as homosexuals and the Afro-American population. The study of the epidemic based on the concept of risk gave rice to the category of groups at risk, so that the phenomenon was explained from a moral point of view, as it also became apparent that the deaths associated with AIDS were a consequence of sexual preferences. This then impeded the analysis of the epidemic from the standpoint of the structural components of public health. Once it was possible to isolate and identify the Human Immune Deficiency virus (HIV) as the causal agent of AIDS, the epidemiology ceased referring to risk groups and incorporated the notion of risk practices. Even though, in the beginning potential infection with HIV by means of bodily fluids, such as blood, semen, and uterine cervical fluid was recognized, the clinical discourse still reinforced the stigmatization of infected people. The only innovation was the invention of the sexual worker as a new likely victim of the epidemic. At this moment, epidemiology recognizes the importance of speaking about contexts of risk instead of groups or practices at risk. Notwithstanding, the global dynamics of the epidemic tends to reinforce the idea that migrants are a new group at risk. This implies going backwards in the conceptual thinking of HIV/ AIDS because it suggests that migrants are a new hazard for public health, just like homosexuals and commercial sex workers. The mobile populations play a role in the transmission of HIV, especially in regions where international borders are shared between countries with unequal economies. For this, it is necessary to consider that the infections of HIV exist in cultural, political, and economical contexts. In this kind of regions, the epidemic can not be analyzed thinking of migrants as the responsible actors in the prevalence growth. The human traffic and the sexual aggressions, for example, are social phenomena linked to the structural conditions of the geographical stations of the mobile populations. In addition, it is necessary to consider that the worldwide dynamics of poverty and migration are produced as a result of disintegration of rural economies (disasters, wars, structural poverty). The relation between migration and poverty can be focused as that of contexts of sexual violence and discrimination. This point of view allows for the exploration of the conditions of HIV/STD infection among persons whose dignity is less respected. The relationship between international clandestine migration and HIV/AIDS has been studied scarcely. With the aim of proposing a different epistemological focus for this problem, in this article we reflect on the possibility of analyzing the notion of vulnerability placing it in a category which takes into account the historical, cultural, social and economic contexts. We propose to analyze vulnerability as a condition that may be transformed in space and time, and that is socially diverse because of this. From this, it follows that vulnerability is acquired in the process of interaction between migrants and the societies through which they move in transit. In this sense, vulnerability can be expressed as a way of being and living, linked to social roles and the course of the personal lives of the people who accompany migrants at the time of their territorial migration. Thus vulnerability is modified according to the historical and social conditions of their places of origin, the places they pass through, and the places of their destination, but also varies according to age, sex, education and social norms which direct sexual identity, as well as the reasons migrants have for displacing themselves. This perspective also permits us to observe that in ethnographic terms, vulnerability can be studied by taking into account the social capital of the clandestine migrant which, when translated into terms of their access to social networks in the places of origin, transit and destination, may either bring them nearer to or further away from situations of isolation, depression and sexual violence. The concept of vulnerability that we propose allows for the explanation of the ruralization of the HIV/AIDS epidemic as a phenomenon related to four socio-historic aspects: poverty, disintegration of agricultural zones, sexual violence and clandestine migration to the United States. We also suggest to include the fact that the HIV/AIDS epidemic occurs in contexts where the violation of human rights is associated with sexual aggression, which can also cause new HIV/STD. For this reason, the impact of poverty acquires a specific influence on this process presenting itself as the way of life of the migrant who transfers him-herself without documents and without authorization and who is especially fragile because he/she faces circumstances in which he/she has no social power. We thus consider that in order to understand in depth the phenomenon concerning the vulnerability of populations who move without legal papers, it is necessary to include both the life histories of the individuals and a study of the social context in which these take place, as a mean of analyzing their vulnerability. The objective of this essay consists in demonstrating the instrumental potential of the concept of vulnerability and its methodological implications for the study of international clandestine migration, as well as sexual aggressions as indicators of violation of human rights and infection with HIV/STD, respectively.

La percepción del apoyo social en mujeres con experiencia de violencia conyugal

resumen está disponible en el texto completo

Summary 1. Introduction Social support and social networks are related to social science studies and both topics are related to protective factors in models predicting differential responsiveness to problems of individuals of a social network. In the mental health area, populations with stress were reported. Infant mortality and poverty are social problems that have been subject to social support and to social networks´ research approach. Social networking is a factor that emerges as fundamental in the life of individuals. Conjugal violence (from now on, CV) is defined as a violent or abusive relationship, where interaction occurs in an imbalanced power-struggle situation. The aim of the present anthropological screening is to give light on the social construction of meanings and repercussions of CV on the heterosexual couple. This paper accounts solely for women´s perceived social support -among informants- and for their rationalization in regard to the CV experience. 2. Materials and methods Analysis was based on discursive interpretation of CV among 28 women, 14 of them attending to rural and urban health care centers, 14 attending a non governmental organization. Field work was fulfilled in one period between November 2000 and August 2001. The main inclusion criteria was to have lived or being living in prolonged cycles of CV. Research was conceived within the interpretative-hermeneutic approach. Research techniques employed pertain to the ethnographic method. In order to proccess information, a data matrix of seven categories and 22 subcategories was designed in the Ethnograph 4.0 software. 3. Results Two clearly defined groups were found: First Group: Women perceiving themselves as lacking any social support: informants with a diluted social support network Socioeconomic characteristics Seven women constitute this group; five come from rural settings and are health care center assisted. Of the urban informants, one is assisted in a non governmental organization and the other, in a state managed center for CV victims attention. In this group, age average is 24.5 years old, with an average of three children and an educative level of three elementary school grades. Two of these women have a job, the rest are economically dependant on their emotional partners. Five have a non marital relationship, one was married and the other, divorced. Duration of CV ocurrence in this group was between one and 12 years. Five of this seven women grew in a hostile familiar atmosphere, witnessing traumatic events in their originary families. Two out of the group had been subjects of sexual abuse by male relatives during their infancy. Six out of seven had had other sentimental couples, four of them had children born from these relationships. Perceived lack of support and the feeling of loneliness "¿Why is it that they feel alone and unsupported to cope with their problems?" The informants that come from a rural setting show a relationship pattern where physical violence and excesive control of spouse on everyday actions and social relations is established, a pattern which is manifested in physical and emotional violence. Upon this pattern, the women construct their subjectiveness on a disappointing general outlook of life, which seems logical because the partner control of social contacts results in isolation, a reality enhanced by the symbolical perception of their dependance. The social support map typical of this group shows that they perceive family as the limit to their social relations, and that they do not recognize their close relatives as a source of support. As to friendship and laboral relations quadrants, in contrast, whit the quadrant of communitary relationships, health care center personnel appears as significative stressing, the fact that health care institutions should be integrated in preventive strategies against CV. Second Group: Women perceiving themselves as having social support to cope with CV: informants with an established social support network. Socioeconomic characteristics 21 women constitute this group; 10 come from rural and urban settings and are health care center assisted. Of 21, ten are assisted in a non governmental organization and one, in a state managed center for CV victims attention. In this group, age average is 34.8 years old, with an average of two children and an educative level of secondary school; 12 of them have a job, the rest were economically dependant on their emotional partners or their families. Five had a non marital relationship, one was married and the other, divorced. Duration of CV ocurrence in this group was between several months and 36 years. This group reported their perceptions of a social group that supported them in several ways. The social support map typical of this group shows that they perceive the presence of much more significative persons in their social relations, a fact that results in a discursive construction less prone to suffering. Women of this group that were assisted by self help support groups reported having found significative frienships among their peers. As to the laboral relationships quadrant, women with a job found their laboral sphere as a protective factor. 4. Discussion Social support and social networks Two aspects of the debate are stressed: a conceptual difference between social support and social networks. a controversy regarding the relation between socioeconomical status and social support. As to the findings of the present screening, the definition of social support of Wethington y Kessler is employed. In the absence of a social network, the notion of social support is evidently lacking of tides, since the perception of support is founded in reciprocity, a relevant factor in cases of CV. Findings from several authors, stress the importance of the social stratification variable in the personal representation of social support. Regarding the present findings, this conceptualization would exclude the possibility of getting social support for populations with low economical resources, what would put an end to the cycle of the so called culture of poverty. In the narration of our informants about their CV experiences, we found significant aspects closer to the Dressler model, with an ideal cultural model of social support. Based on perceptions on what the informants perceive should be the expected kind of support from families and acquaintances, a cultural trait which excedes the boundaries of social stratification. On both groups, it is clear that reinforcing the social network depends on the standardization of cultural practices on certain activities such as personal counseling, or suggestions for problem-solving; this moral practice is obviously based on ethic notions of right and wrong, and thus secondary to moral judgments upon a given frame of reference. Based on the context of CV, the evidence generated by the present study should be aknowledged to understand the apparent paradox posed by the fact that familiar and close acquaintance networks may contribute, without making it conscious, to the cultural reproduction of violence.