Design and validation of indicators for the comprehensive measurement of quality of care for type 2 diabetes and acute respiratory infections in ambulatory health services.

Developing ambulatory health services (AHS) of optimal quality is a pending issue for many health systems at a global level, especially in middle- and low-income countries. An effective health response requires indicators to measure the quality of care that are context-specific and feasible for routine monitoring. This paper aimed to design and validate indicators for assessing the technical and interpersonal quality dimensions for type 2 diabetes (T2D) and acute respiratory infections (ARI) care in AHS. The study was conducted in two stages. First, technical and user-centered-based indicators of quality of care for T2D and ARI care were designed following international recommendations, mainly from the American Diabetes Association standards and the National Institute for Health and Care Excellence guidelines. We then assessed the validity, reliability, relevance, and feasibility of the proposed indicators implementing the modified Delphi technique. A panel of 17 medical experts from five countries scored the indicators using two electronic questionnaires, one for each reason for consultation selected, sent by email in two sequential rounds of rating. We defined the levels of consensus according to the overall median for each performance category, which was established as the threshold. Selected indicators included those with scores equal to or higher than the threshold. We designed 36 T2D indicators, of which 16 were validated for measuring the detection of risks and complications, glycemic control, pharmacological treatment, and patient-centered care. Out of the 22 indicators designed for ARI, we validated 10 for diagnosis, appropriate prescription of antimicrobials, and patient-centered care. The validated indicators showed consistency for the dimensions analyzed. Hence, they proved to be a potentially reliable and valuable tool for monitoring the performance of the various T2D and ARI care processes in AHS. Further research will be needed to verify the applicability of the validated indicators in routine clinical practice.

[Job conditions and precarious work among Mexican physicians: an analysis based on a national survey]. / Condiciones de empleo y precariedad laboral de los médicos de México: análisis basado en una encuesta nacional.

The study aimed to describe the socioeconomic characteristics and job conditions of medical personnel in Mexico. This was a cross-sectional study based on the Mexican National Occupational and Employment Survey (ENOE) for all four quarters of 2019 and the first quarter of 2020. We included all physicians who had concluded their university training. The variable "cumulative precarious labor" was constructed as the sum of five binary variables related to minimum wage, workweek, and lack of employment contract, job security, and labor benefits. Using this unweighted sum, we classified their labor conditions as absence of (0) or low (1), medium (2 to 3), or high (4 to 5) precarious labor. In the public sector, 13.4% and 3.3% of physicians were engaged in medium or high precarious labor, respectively; the percentages were higher in the private sector, with 38.5% and 7.7% (p < 0.01), respectively, due mainly to the lack of formal contracts and medical insurance. These conditions were exacerbated in women working in medical offices in private-sector companies, where 75.2% and 6% worked in medium or high precarious conditions, respectively, while the proportions in men were 15.6% and 7.7%, respectively (p < 0.01). Precarious labor exists in the Mexican health sector; labor conditions for physicians are more precious in the private sector than in the public sector, especially in private-sector offices where female physicians are more exposed to precarious employment.

El objetivo fue describir las características socioeconómicas y condiciones de empleo del personal médico en México. Estudio transversal con base en la Encuesta Nacional de Ocupación y Empleo (ENOE) de México, de los 4 trimestres de 2019 y el primer trimestre de 2020. Incluimos a todos los médicos con estudios universitarios concluidos. La variable precariedad laboral acumulada fue construida como la suma de cinco variables binarias relacionadas con el salario mínimo, jornada laboral, carencias de contrato, de seguridad y de prestaciones sociales. Con esta suma no ponderada, clasificamos las condiciones laborales en baja (1), media (2 a 3), alta (4 a 5), y ausencia de precariedad laboral (0). En el sector público, 13,4% y 3,3% de los médicos tienen precariedad laboral media y alta, respectivamente; los porcentajes son mayores en el sector privado, 38,5% y 7,7% (p < 0,01), respectivamente, debido principalmente a las carencias de contrato escrito y seguro médico. Estas condiciones se exacerban en las mujeres que trabajan en los consultorios médicos de las empresas del sector privado donde 75,2% y 6% de ellas tienen precariedad media y alta, respectivamente, mientras que en los hombres los porcentajes son 15,6 y 7,7%, respectivamente, (p < 0,01). Existe precariedad laboral en el sector salud mexicano; las condiciones laborales de los médicos del sector privado son más precarias que en el sector público, particularmente en los consultorios del sector privado, donde las mujeres están más expuestas a empleos precarios.

O objetivo era descrever as características socioeconômicas e as condições de emprego dos médicos no México. Estudo transversal com base na Pesquisa Nacional de Ocupação e Emprego (ENOE) do México, nos quatro trimestres de 2019 e no primeiro trimestre de 2020. Incluímos todos os médicos com estudos universitários concluídos. A variável da precariedade laboral acumulada foi construída como a soma de cinco variáveis binárias relacionadas com o piso salarial, a jornada de trabalho, a falta de contrato, segurança e benefícios sociais. Com esta soma não ponderada, classificamos as condições de trabalho em baixa (1), média (2 a 3), alta (4 a 5), e ausência de precariedade laboral (0). No setor público, 13,4% e 3,3% dos médicos estão em situação de precariedade laboral média e alta, respectivamente; os percentuais são mais elevados no setor privado, com 38,5% e 7,7% (p < 0,01), respectivamente, devido principalmente à inexistência de contrato escrito e de seguro médico. Estas condições se agravam para as mulheres que trabalham nos consultórios médicos das empresas do setor privado, onde 75,2% e 6% delas sofrem precariedade média e alta, respectivamente, ao passo que para os homens, os percentuais são de 15,6% e 7,7%, respectivamente, (p < 0,01). Existe precariedade laboral no setor da saúde mexicano; as condições de trabalho dos médicos do setor privado são mais precárias do que no setor público, em especial, nos consultórios do setor privado onde as mulheres estão mais expostas a empregos precários.

Condiciones de empleo y precariedad laboral de los médicos de México: análisis basado en una encuesta nacional / Job conditions and precarious work among Mexican physicians: an analysis based on a national survey / Condições de emprego e precariedade laboral dos médicos do México: análise baseada em pesquisa nacional

El objetivo fue describir las características socioeconómicas y condiciones de empleo del personal médico en México. Estudio transversal con base en la Encuesta Nacional de Ocupación y Empleo (ENOE) de México, de los 4 trimestres de 2019 y el primer trimestre de 2020. Incluimos a todos los médicos con estudios universitarios concluidos. La variable precariedad laboral acumulada fue construida como la suma de cinco variables binarias relacionadas con el salario mínimo, jornada laboral, carencias de contrato, de seguridad y de prestaciones sociales. Con esta suma no ponderada, clasificamos las condiciones laborales en baja (1), media (2 a 3), alta (4 a 5), y ausencia de precariedad laboral (0). En el sector público, 13,4% y 3,3% de los médicos tienen precariedad laboral media y alta, respectivamente; los porcentajes son mayores en el sector privado, 38,5% y 7,7% (p < 0,01), respectivamente, debido principalmente a las carencias de contrato escrito y seguro médico. Estas condiciones se exacerban en las mujeres que trabajan en los consultorios médicos de las empresas del sector privado donde 75,2% y 6% de ellas tienen precariedad media y alta, respectivamente, mientras que en los hombres los porcentajes son 15,6 y 7,7%, respectivamente, (p < 0,01). Existe precariedad laboral en el sector salud mexicano; las condiciones laborales de los médicos del sector privado son más precarias que en el sector público, particularmente en los consultorios del sector privado, donde las mujeres están más expuestas a empleos precarios.

The study aimed to describe the socioeconomic characteristics and job conditions of medical personnel in Mexico. This was a cross-sectional study based on the Mexican National Occupational and Employment Survey (ENOE) for all four quarters of 2019 and the first quarter of 2020. We included all physicians who had concluded their university training. The variable "cumulative precarious labor" was constructed as the sum of five binary variables related to minimum wage, workweek, and lack of employment contract, job security, and labor benefits. Using this unweighted sum, we classified their labor conditions as absence of (0) or low (1), medium (2 to 3), or high (4 to 5) precarious labor. In the public sector, 13.4% and 3.3% of physicians were engaged in medium or high precarious labor, respectively; the percentages were higher in the private sector, with 38.5% and 7.7% (p < 0.01), respectively, due mainly to the lack of formal contracts and medical insurance. These conditions were exacerbated in women working in medical offices in private-sector companies, where 75.2% and 6% worked in medium or high precarious conditions, respectively, while the proportions in men were 15.6% and 7.7%, respectively (p < 0.01). Precarious labor exists in the Mexican health sector; labor conditions for physicians are more precious in the private sector than in the public sector, especially in private-sector offices where female physicians are more exposed to precarious employment.

O objetivo era descrever as características socioeconômicas e as condições de emprego dos médicos no México. Estudo transversal com base na Pesquisa Nacional de Ocupação e Emprego (ENOE) do México, nos quatro trimestres de 2019 e no primeiro trimestre de 2020. Incluímos todos os médicos com estudos universitários concluídos. A variável da precariedade laboral acumulada foi construída como a soma de cinco variáveis binárias relacionadas com o piso salarial, a jornada de trabalho, a falta de contrato, segurança e benefícios sociais. Com esta soma não ponderada, classificamos as condições de trabalho em baixa (1), média (2 a 3), alta (4 a 5), e ausência de precariedade laboral (0). No setor público, 13,4% e 3,3% dos médicos estão em situação de precariedade laboral média e alta, respectivamente; os percentuais são mais elevados no setor privado, com 38,5% e 7,7% (p < 0,01), respectivamente, devido principalmente à inexistência de contrato escrito e de seguro médico. Estas condições se agravam para as mulheres que trabalham nos consultórios médicos das empresas do setor privado, onde 75,2% e 6% delas sofrem precariedade média e alta, respectivamente, ao passo que para os homens, os percentuais são de 15,6% e 7,7%, respectivamente, (p < 0,01). Existe precariedade laboral no setor da saúde mexicano; as condições de trabalho dos médicos do setor privado são mais precárias do que no setor público, em especial, nos consultórios do setor privado onde as mulheres estão mais expostas a empregos precários.

Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups.

Influenza vaccination coverage in countries of Latin America is low among priority risk groups, ranging from 5 to 75% among older people. This paper aims to describe and analyze the determinants of influenza vaccination hesitancy through the lens of the 3C model of confidence, complacency and convenience among middle-class, urban risk group populations in Brazil, Chile, Paraguay, Peru, Uruguay, countries in South America with contrasting vaccination coverage. Focus groups were conducted among four risk groups: pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥60 years in samples of urban residents. Adults with risk factors expressed the most detailed perceptions about confidence in the vaccine. A wide range of perceptions regarding complacency were expressed across risk groups and countries, with pregnant women and mothers showing greater concerns while convenience had a narrower and generally more positive range of perceptions. Participants from Chile and Paraguay expressed the most contrasts regarding confidence and complacency. Information and communication strategies need to be tailored for risk groups while confidence and complacency should be addressed in synergy.

Diabetes care innovation in the Mexican Institute for Social Insurance: Scaling up the preventive chronic disease care model to address critical coverage constraints.

BACKGROUND: With diabetes prevalence in Mexico at 11.3% of adults, the Mexican Institute of Social Insurance (IMSS) is piloting the Chronic Disease Preventive Model (CDPM). CDPM includes intensive patient education, care by multidisciplinary teams and risk management in primary care. The objective of this article is to determine CDPM coverage bottlenecks and to explore facilitators and barriers to implementation. METHODS: The National Health and Nutrition Survey 2018 was processed to identify key diabetes prevalence, coverage, quality and outcome indicators. Key IMSS informant interviews and document content analyses were undertaken following the Tanahashi coverage decay model and the Consolidated Framework for Implementation Research (CFIR). RESULTS: IMSS screens 49% of adult beneficiaries for diabetes but only 26% with presumptive diagnosis proceed to confirmation. Out of 4.1 million adults with diabetes, IMSS diagnoses 94% and treats 85%. Medications are received by 90% of patients but only 63% of those requiring insulin receive it. The overall quality of care indicator attains 37% of potential. Coverage of diabetes education, monitoring with HbA1c and interdisciplinary care are 20%, 15% and 3%, respectively. Among IMSS beneficiaries treated by the institute 38.1% have HbA1c levels below 7% and 26.1% have levels above 9%. CDPM facilitators are the perceived threat of uncontrolled diabetes, compatibility of innovation values and willingness for institutional learning. Barriers are centralized decision making, functional differentiation across managers and practitioners and lack of incentives, resource shortages and the lack of measures to ensure fidelity. CONCLUSIONS: CDPM scale-up has to address organizational and process barriers while ensuring the necessary resources for sustainability.

The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru.

Influenza vaccination has been available under Peru's national immunization program since 2008, but vaccination coverage has decreased lately. Surveys and focus groups were conducted among four risk groups (pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥65 years) to identify factors affecting influenza vaccine hesitancy in Peru. The 3Cs model (Confidence, Complacency, and Convenience) was used as a conceptual framework for the study. Most pregnant women and mothers of young children (70.0%), but less than half (46.3%) of older adults and adults with risk factors were vaccinated against influenza. Vaccine confidence and complacency were positively associated with educational level. Complacency was the most deficient of the 3Cs. Pregnant women and mothers were the most informed and least complacent among risk groups. Focus groups revealed the misconceptions behind the high level of complacency observed, including the perception of influenza risk and the role assigned to vaccination in preventing the disease. Interviews with officials identified that most strategies are directed to vaccination availability and hence to convenience, with opportunities for strategies to improve vaccination uptake and community engagement. The results highlight the importance of implementing in Peru communication strategies to increase perceptions of vaccine safety and effectiveness thus improving confidence and reducing complacency. The establishment of explicit incentives should also be considered to increase vaccination uptake, particularly to health personnel.