Nurses: the "front gate" to provide effective pediatric preventive care

The objective of this paper is to analyze the importance of nurses as key providers of preventive services for Mexican children and adolescents. Nurses represent a long-standing tradition as public health providers and are very close to the individual, the family and the community. Their contribution to the preventive care of patients of these age groups is explicit and tangible. Health needs for this segment of the population and the current conditions of the Mexican health care system call for further actions. Preventive care should be accessible, high quality and comprehensive. To accomplish these goals it is necessary to invest in the public health workforce. Also, the need to increase its efficiency and effectiveness of preventive services should prompt the Mexican health care system to support the skill mix and promote the presence of nurse practitioners in primary care facilities.

[Health needs in marginalized urban areas in Mexico]. / Necesidades de salud en áreas urbanas marginadas de México.

OBJECTIVE: To understand the health needs of the population living in Mexico's marginalized urban areas. METHODS: A population-based survey of families residing in poor, urban neighborhoods, in five geographic areas in Mexico (northern, central, southern, south-east, and Mexico City), selected through multistage sampling. Interviews were conducted and anthropometric measurements were taken in the home, and included all members of the participating family. Analysis was carried out on positive health factors, nutrition, reproductive health, health problems, and mental health, and results were disaggregated by age and sex. RESULTS: In all, 24,707 individuals participated. The interviewees were found to have minimal schooling (6 years or less). Only 46.8% had health care coverage, be it public or private. Among the children, 19.8% were malnourished; overweight was prevalent from adolescence onwards. Of adolescents 12-19 years of age, 15.7% were sexually active, but only 57.7% of the males and 41.9% of the females in this age group were using some method of contraception. Of the adults, 5.9% suffered from diabetes and 11.5%, from high blood pressure. In the sample of adolescents, adults, and elderly adults, tobacco use was 21.2%; alcohol consumption, 36.0%; illicit drug use, 9.5%; and depression, 20.2%. CONCLUSIONS: The health needs of people living in Mexico's marginalized urban areas proliferate in the context of a young population with weak ties and little support from family and health services. They face crisis and disease--infant malnutrition, high-risk pregnancy, and addictions--the byproducts of disparities in social progress. The rate of chronic conditions was similar to that of the general population of Mexico.

Necesidades de salud en áreas urbanas marginadas de México / Health needs in marginalized urban areas in Mexico

OBJETIVO: Evaluar las necesidades de salud de la población residente en áreas urbanas marginadas de México. MÉTODOS: Encuesta poblacional a familias residentes en colonias urbanas pobres de cinco regiones geográficas de México (Norte, Centro, Sur, Sureste y Ciudad de México), seleccionadas mediante un muestreo polietápico. Se realizaron entrevistas y mediciones antropométricas en sus domicilios a todos los integrantes de las familias seleccionadas y se analizaron las características de salud positiva, nutrición, salud reproductiva, daños a la salud y salud mental por grupos de análisis formados por edad y sexo. RESULTADOS: Participaron 24 707 personas. En los entrevistados se observó una baja escolaridad (6 años o menos) y solo 46,8 por ciento tuvo cobertura de servicios de salud, ya fuera en instituciones públicas o privadas. De los niños, 19,8 por ciento presentaba desmedro y el sobrepeso predominó a partir de la adolescencia. En los adolescentes de 12 a 19 años, 15,7 por ciento tenía vida sexual activa, pero solo 57,7 por ciento de los hombres y 41,9 por ciento de las mujeres de ese grupo de edad usaban algún método anticonceptivo. De los adultos, 5,9 por ciento padecía diabetes y 11,5 por ciento hipertensión arterial. En la muestra de adolescentes, adultos y adultos mayores, el tabaquismo fue de 21,2 por ciento, el consumo de alcohol de 36,0 por ciento, el uso de drogas de 9,5 por ciento y la depresión de 20,2 por ciento. CONCLUSIONES: La vulnerabilidad sanitaria de las personas que viven en las áreas urbanas marginadas de México se manifiesta en la existencia de una población joven, con pocas redes de apoyo familiar y de servicios de salud, que sufre trastornos y enfermedades, como la desnutrición infantil, el alto riesgo reproductivo y las adicciones en adolescentes y adultos, producto del rezago en el desarrollo social. La prevalencia de enfermedades crónicas fue similar a la de la población mexicana no marginada.

OBJECTIVE: To understand the health needs of the population living in Mexico's marginalized urban areas. METHODS: A population-based survey of families residing in poor, urban neighborhoods, in five geographic areas in Mexico (northern, central, southern, south-east, and Mexico City), selected through multistage sampling. Interviews were conducted and anthropometric measurements were taken in the home, and included all members of the participating family. Analysis was carried out on positive health factors, nutrition, reproductive health, health problems, and mental health, and results were disaggregated by age and sex. RESULTS: In all, 24 707 individuals participated. The interviewees were found to have minimal schooling (6 years or less). Only 46.8 percent had health care coverage, be it public or private. Among the children, 19.8 percent were malnourished; overweight was prevalent from adolescence onwards. Of adolescents 12-19 years of age, 15.7 percent were sexually active, but only 57.7 percent of the males and 41.9 percent of the females in this age group were using some method of contraception. Of the adults, 5.9 percent suffered from diabetes and 11.5 percent, from high blood pressure. In the sample of adolescents, adults, and elderly adults, tobacco use was 21.2 percent; alcohol consumption, 36.0 percent; illicit drug use, 9.5 percent; and depression, 20.2 percent. CONCLUSIONS: The health needs of people living in Mexico's marginalized urban areas proliferate in the context of a young population with weak ties and little support from family and health services. They face crisis and disease-infant malnutrition, high-risk pregnancy, and addictions-the byproducts of disparities in social progress. The rate of chronic conditions was similar to that of the general population of Mexico.

[Health risks for adolescents in underserved areas]. / Riesgos para la salud de los adolescentes en áreas marginadas.

Background: adolescent population is an important age group, with vulnerability and health needs not well known, especially for those living in urban slums. Our objective was to identify health risks for adolescents living in poor urban areas in five geographical regions of Mexico. Methods: a secondary data analysis from a nationwide adolescents ́ survey was carried out from population living in poor urban areas of the north, center, DF, south and southeast of Mexico. Cigarette smoking, alcohol and drug consumption, as well as frequency of accidents and violence, age at sexual initiation and use of contraception methods were analyzed. Results: the highest frequencies of consumption were: 27.8 % for cigarette smoking and 35.2 % for alcohol, both in adolescents from 16 to 19 years; accidents (5 %) and violence (1.7 %); age (median) at sexual initiation was 16 years, about 50 % of adolescents with regular sexual activity reported use of a contraception method. Conclusions: comparing our data with National Health Surveys; in poor urban areas, most adolescents health risks are higher than those found for same group age in the general population, however, presentation of accidents and violence are similar.

Introducción: : los adolescentes son un grupo con vulnerabilidad y necesidades de salud poco conocidas en México, principalmente en áreas de pobreza urbana. El objetivo de esta investigación fue identificar los riesgos para la salud de los adolescentes en las áreas urbanas marginadas en cinco regiones del país. Métodos: análisis secundario de una encuesta de salud para adolescentes realizada en áreas urbanas marginadas del Distrito Federal y regiones norte, centro, sur y sureste del país; se analizó consumo de tabaco, alcohol y drogas; historia de accidentes y violencias, edad de inicio de vida sexual y uso de métodos anticonceptivos; se calcularon frecuencias absolutas y relativas. Resultados: los consumos más altos fueron para tabaco (27.8 %) y alcohol (35.2 %), ambos en el grupo de 16 a 19 años de edad; 5 % sufrió algún accidente y 1.7 %, violencia; el inicio de la vida sexual tuvo una mediana de 16 años y 50 % utilizaba algún método anticonceptivo. Conclusiones: al comparar nuestros datos con los de otras encuestas nacionales, se encontró que los riesgos para la salud son mayores en los adolescentes de áreas urbanas marginadas que en adolescentes de la población general, sin embargo, la frecuencia de accidentes y violencias fue similar.

¿Qué se hace para no morir de hambre? Dinámicas domésticas y alimentación en la niñez en un área rural de extrema pobreza de México / What to do to avoid death by starvation? Domestic dynamics and childhood feeding practices in a rural area of extreme poverty in Mexico

OBJETIVO: Caracterizar y comparar, en términos de estructura, creencias y comportamiento en torno a la alimentación, la dinámica doméstica de hogares de niños y niñas menores de cinco años con y sin desnutrición. MATERIAL Y MÉTODOS: Estudio cualitativo con un diseño etnográfico basado en observación participante y entrevistas a profundidad a responsables del cuidado de menores e informantes clave bajo consentimiento informado verbal. El foco de observación fue el conjunto de prácticas relacionadas con el cuidado de los menores, con énfasis en las relacionadas con su alimentación, tanto al interior de los hogares como en la comunidad. Se realizaron dos estancias de campo, durante 2001, en tres comunidades rurales del Río Balsas, en el estado de Guerrero, México. RESULTADOS: Estructuras monoparentales, en etapa temprana del ciclo doméstico, generan condiciones que pueden propiciar la presencia de desnutrición de menores de cinco años. Las familias extensas representan, por su propia estructura, dinámicas domésticas más favorables. CONCLUSIONES: El problema de la desnutrición en ambientes de extrema pobreza resulta decisivamente influido por las estrategias nutricionales y las dinámicas sociales generadas en el interior de las familias.

OBJECTIVE: To describe and compare household dynamics in terms of structure, beliefs and nutrition-related behavior in the homes of malnourished and well-nourished children less than five years of age. MATERIAL AND METHODS: The authors carried out a qualitative ethnographic study using participant observation, and in depth interviews. Interviews were conducted with the child's caretaker or key informants, prior oral informed consent. Child care and childhood feeding practices at home and in the community were the focus of observations. The study included two periods of field work conducted in 2001, in three rural municipalities from the Río Balsas region, in Guerrero state, Mexico. The study's ethical and methodological aspects were approved by the National Research Commission of the Mexican Institute of Social Security. RESULTS: Households were differentially characterized by number of members, composition, type of relationship, source of income, and interactions among household members and with the community. CONCLUSION: Monoparental structures, in an early stage of the household cycle, give rise to conditions that render the child prone to malnutrition. Extended family structure represented more favorable household dynamics.

[Strategy of provision and assessment of preventive health services]. / Estrategia de prestación y evaluación de servicios preventivos.

This paper describes the strategy of provision and assessment of preventive health services that the Mexican Institute of Social Security (IMSS) established in 2002 and that for social communication purposes, was called PREVENIMSS. The strategy is composed by five programs: Children's Health, Adolescents' Health, Women's Health, Men's Health and Seniors' Health. The objectives of these programs are the following: to provide a group of actions to promote and protect health, according to their age, sex and risk factors; to incorporate new preventive actions in order to face demographic and epidemiologic transition; to promote the participation of population in health care; to integrate provision of preventive services in family medicine clinics, and to broaden their coverage and impact. The modernization process of the statistical information system is also described in this paper. It included several aspects, such as the establishment of an automated record of preventive actions, which allowed the generation of relevant and timely information to measure the coverage and both national and local impacts.

[ENCOPREVENIMSS 2003, 2004 and 2005. 1. Methodology and studied population]. / ENCOPREVENIMSS 2003, 2004 y 2005. 1. Metodología y población estudiada.

In order to assess the progress of preventive health programs by measuring the coverage and other health indicators, ENCOPREVENIMSS (Health National Surveys) 2003, 2004 and 2005 were carried out. These surveys were applied nationwide to population affiliated to the Mexican Institute of Social Security, and were representative at a state level. The sampling frame was stratified, with several stages, by clusters, and had a minimum sample of 328 people per program group in each delegation. The applied questionnaires were previously designed and evaluated through a pilot test. They included specific questions for each program component per age group. In 2004, two sections were added, based on validated instruments to evaluate frequency of food intake and physical activity. A total of 79,797 people were surveyed: 117,884 in 2004, and 122,380 in 2005. A third of the population was insured, while the rest was beneficiary; about half the population was between 20 and 59 years old, and the proportion of people older than 60 increased almost 2% from 2003 to 2005. More than 90% of those who claimed to have a paid job were factory workers or employees. More than 90% of the population were assigned to a family physician in all the assessed years. The information obtained from ENCOPREVENIMSS is a valuable tool to conduct institutional policies for public health.

[ENCOPREVENIMSS 2003, 2004 and 2005. 2. Advances in Children and Adolescents' Health Programs]. / ENCOPREVENIMSS 2003, 2004 y 2005. 2. Avances en los Programas de Salud del Niño y del Adolescente.

INTRODUCTION: the National Survey of Coverage of Integrated Health Programs (ENCOPREVENIMSS) are probabilistic population-based surveys with delegation representativeness of insured population of the Mexican Institute of Social Security, belonging to different age groups. OBJECTIVE: to evaluate the coverage of the Integrated Health Programs for Children and Adolescents during 2003-2005. MATERIAL AND METHODS: a descriptive analysis of ENCOPREVENIMSS 2003, 2004 and 2005 was carried out, with regard to the components of Children and Adolescents' Health Programs, in the 37 delegations (states) of IMSS. Through a home sample, information of sociodemographic characteristics, use of health services and coverage of the main components of PREVENIMSS, were collected. The concentration of information and the data analysis took place at the Coordination of Integrated Health Programs. RESULTS: from 2003 to 2005, the coverage of both groups increased, mainly in children. The advances of coverage were different for each activity. The ones with best results were the incorporation to protocols of preventive attention, and vaccination, as well as weight and height measurement. The actions with lowest achievement were the detection of visual problems and the nutritional evaluation. CONCLUSIONS: coverage analysis is useful to ascertain the degree of application of the different preventive activities and it is also a good basis for planning.

[ENCOPREVENIMSS 2003, 2004 AND 2005. 3. Advances in Women, Men and Seniors' Health Programs]. / ENCOPREVENIMSS 2003, 2004 y 2005. 3. Avances en los Programas de Salud de la Mujer, del Hombre y del Adulto Mayor.

This paper presents the results of the National Survey of Coverage of Integrated Health Programs (ENCOPREVENIMSS) 2003, 2004 and 2005, with regard to the coverage of Women, Men and Seniors' Health Programs. ENCOPREVENIMSS are nationwide probabilistic population-based surveys with delegation (state) representativeness of insured population of the Mexican Institute of Social Security. The sampling frame was stratified, with several stages, and by clusters. The surveys gathered information of sociodemographic characteristics, use of health services and coverage of the main components of the Health Integrated Programs (PREVENIMSS), as well as other complementary variables. For the purpose of this article, the main variables studied were those related to health promotion, weight, height and waist measurement, as well as other related to early detection of certain diseases. The results show an increase in the coverage during the period 2003-2005 in the three groups; however, the lowest were found in the group of men from 20 to 59 years old and the highest, in the group of seniors older than 59, except for those related to the detection of cervical and breast cancer, which were higher in women from 20 to 59 years old. Coverage analysis is useful to ascertain the degree of imposition of the different preventive activities and it is also a good basis for planning.

[ENCOPREVENIMSS 2003. Prevalence of low weight, overweight, general obesity and central obesity]. / ENCOPREVENIMSS 2003. 4. Prevalencia de peso bajo, sobrepeso, obesidad general y obesidad central.

OBJECTIVE: to estimate the prevalence of malnutrition in the population attending the Mexican Institute of Social Security. MATERIAL AND METHODS: we studied a 25% subset of the National Survey of Coverage of Integrated Health Programs performed in 2003 to estimate weight and height with standardized procedures; in adults over 20, waist circumference was also measured. We considered central obesity as waist circumferences larger than 88 cm for females and 102 cm for males. Based on weight and height, the prevalence of low weight, overweight and general obesity was estimated; based on waist circumference, central obesity was assessed. RESULTS: the prevalence of low weight in men and women was, respectively, of 5.3 and 6.4% in children; 6 and 8.2% in adolescents; almost none in adults, and of 11.7 and 3.6% in seniors. On the other hand, we observed that the prevalence of overweight and obesity increased progressively in both sexes since the first decade of life up to 87% in females between 50 and 59 years old and 82% in males between 40 and 49. The risk of central obesity was very high in women older than 20 in all decades of life (36.6 to 74.2%). In men, this risk had lower prevalence (12 to 31.7%). In the northern part of the country, women presented more central obesity, while in the southeast, men did. CONCLUSION: this report highlights the alarming prevalence of malnutrition in the Mexican Institute of Social Security population. This information is relevant for future strategies aiming to prevent these serious health problems.

[ENCOPREVENIMSS 2004. 5. Intake of healthy or potentially unhealthy food]. / ENCOPREVENIMSS 2004. 5. Consumo de alimentos saludables o con riesgo para la salud.

OBJECTIVE: to know the prevalence of healthy or potentially unhealthy food intake in the population insured by the Mexican Institute of Social Security. MATERIAL AND METHODS: food intake was obtained from frequency questionnaires classified as healthy (HF) or potentially unhealthy food (PUF), and according to its nature and frequency consumption. The prevalences according to age groups were obtained for <1 year old and every five years until 19; then, they were recorded by decades, sex, location and place of residence, with or without coast. RESULTS: in the first year of age, the consumption of HF is low, and the intake of PUF starts, with industrialized juices and soft drinks. Between the first and the ninth year of age, the consumption of HF increases; however, the intake of PUF increases too; there is not a significant intake of red meat, eggs and fish. Throughout adolescence, HF intake and diversity increases, although PUF consumption is higher too. In adults and senior citizens, the kind of HF most frequently consumed were cereals and leguminous plants, but they barely ate fruits and vegetables. The HF of greatest consumption were those of animal origin, and the riskiest ones were very greasy daily products with saturated fat, as well as soft drinks. We found that the population living in the Pacific coast consumes more sea food than the one living in the Gulf coast. We also found that, as people get older, the intake of PUF decreases. CONCLUSION: in the first years of life, the proper intake of meat, eggs and fish should be promoted, as well as the consumption of HF and the decrease of food with refined sugar, saturated fat or salt.

[Preventable diseases by vaccination. Coverage and impact]. / Enfermedades inmunoprevenibles. Coberturas e impactos de la vacunación.

OBJECTIVE: to evaluate the coverage and impacts of the vaccination component in Integrated Health Programs. MATERIAL AND METHODS: a descriptive study of secondary data analysis was carried out. We analyzed data generated by the Universal Vaccination Program (PROVAC) since 1991, the data compiled in the 2000 National Health Survey (ENSA) and the 2005 National Survey of Coverage of Integrated Health Programs (ENCOPREVENIMSS), as well as the IMSS Annual Epidemiological Gazettes since 1973. RESULTS: the coverage of the basic schemes of the Extended Immunization Program (PAI) in children from one to four years old increased from 46.0% in 1990 to 92.5% in 1992 and 98.2% in 2005. The coverage with booster doses was substantially lower, ranging between 57.0% and 97.3% depending on the type of vaccine and the number of doses. The coverage also varied, although to a lesser extent, among public healthcare institutions. In relation to the impact of the Universal Vaccination Program and the PREVENIMSS strategy among IMSS affiliates, we distinguished at least three situations: (1) illnesses in which a drop in incidence predates the Universal Vaccination Program: tuberculous meningitis, diphtheria, whooping cough, and tetanus; (2) illnesses in which the drop in incidence is clearly related to the program: measles, rubella, mumps, and meningitis due to H. influenzae b. (3) illnesses for which the impact has not yet been assessed: hepatitis B. In addition to a drop in the incidence of immunopreventable diseases, we observed changes in the age distribution of cases. CONCLUSIONS: the PREVENIMSS strategy has not interfered with, and in some case has helped to consolidate the achievements of the Universal Vaccination Program. The results of this investigation point to the need to modernize the current system of evaluating coverage and expanding vaccination schemes with booster doses.

[Mortality due to selected causes of infectious and chronic non-transmissible diseases, from 1991 to 2004]. / Mortalidad por causas seleccionadas de enfermedades infecciosas y crónicas no transmisibles, 1991-2004.

OBJECTIVE: to analyze the mortality behavior due to infectious diseases (acute diarrheal diseases, acute respiratory infections and lung tuberculosis) and chronic non-transmissible diseases (cervical cancer, breast cancer, diabetes mellitus and ischemic heart disease) in insured population of the Mexican Institute of Social Security (IMSS), in insured population user of the health services of IMSS and in uncovered population, from 1991 to 2004. MATERIAL AND METHODS: a descriptive study was carried out, in which the annual rates of national mortality for the selected causes were calculated by specific age groups in both insured and uninsured population. Death records were taken from the official registers of the National Institute of Statistics, Geography and Informatics and from the IMSS Mortality System. Population data were obtained from projections of the National Council of Population and IMSS records. RESULTS AND CONCLUSIONS: mortality due to acute diarrheal diseases, acute respiratory infections, lung tuberculosis and cervical cancer had a descending behavior, while breast cancer, diabetes mellitus and ischemic heart disease increased. Mortality for all causes analyzed was higher in uninsured population, except for diabetes mellitus, which was higher in insured population. This can be explained by the socioeconomic characteristics of the studied populations, as well as those of health services.

[Analysis of the decrease in mortality due to cervical cancer at the Mexican Institute of Social Security, from 1991 to 2005]. / Análisis del descenso de la mortalidad por cáncer cervicouterino en el IMSS, 1991-2005.

OBJECTIVE: to analyze the decrease in mortality due to cervical cancer in insured population of the Mexican Institute of Social Security (IMSS) and its relation to changes in the organization of the Program for Prevention and Control of Cervical Cancer (PCCaCu). MATERIAL AND METHODS: a descriptive study in which the annual rates of national mortality due to cervical cancer was analyzed from 1991 to 2005 was carried out. Information of deaths due to cervical cancer was obtained from the IMSS Mortality System (SISMOR), a database that identifies deaths occurred in insured population user of IMSS. The tendency was compared in three periods: I. 1991-1995, reorganization of the original program, II. 1996-2000, transition, and III. 2001-2005, incorporation to PREVENIMSS strategy. RESULTS: between 1991 and 2005, the mortality rate due to cervical cancer by 100 thousand women older than 24 years, decreased from 16.2 to 8.9 (45.1%). Between 1991 and 1995, the mortality rate increased 4.9%; between 1996 and 2000, it decreased 27% and in the last period, 2001-2005, it decreased 29.4%. The only differences that were statistically significant were the ones between the transition and the consolidation periods. The greatest decrease was registered when the PCCaCu was incorporated to PREVENIMSS strategy. CONCLUSIONS: the acceleration in the decrease of mortality rate due to cervical cancer can be explained by the reorganization and expansion of PCCaCu to target population and its incorporation to PREVENIMSS.