Evaluating Access to Health Care in Mothers and Caregivers of Children under Five Years of Age in Rural Communities of Yucatán, Mexico.

Populations in rural communities have more limited access to health care and attention than urban populations. The present study aimed to evaluate barriers to access to health care in mothers and caregivers of children under five years of age, twelve months after an educational intervention. The study was carried out from February to September 2022, and 472 mothers from eight communities in the state of Yucatán, in the southeast of the United Mexican States, participated. A comparative analysis was carried out on help-seeking times, obstacles to reaching it, and illnesses in children. The results revealed that the main barriers to access to care were long times to decide to seek help, lack of financial resources to pay for the transfer to another health unit, lack of someone to accompany the mother or caregiver when the child needed be transferred, and lack of transportation for the transfer. Disease knowledge remained at different levels in the eight communities; the significant differences occurred in four communities, one specifically for heart defects. It was concluded that, in the rural populations studied, there are barriers to access to health care which have to do with neglected social determinants, such as those related to conditions of gender, income, social support network, and the health system. Access to health care must be universal, so public health interventions should be aimed at reducing the barriers that prevent the population from demanding and using services in a timely manner.

Impact of the Salud Mesoamerica Initiative on delivery care choices in Guatemala, Honduras, and Nicaragua.

BACKGROUND: The Salud Mesoamérica Initiative (SMI) is a public-private collaboration aimed to improve maternal and child health conditions in the poorest populations of Mesoamerica through a results-based aid mechanism. We assess the impact of SMI on the staffing and availability of equipment and supplies for delivery care, the proportion of institutional deliveries, and the proportion of women who choose a facility other than the one closest to their locality of residence for delivery. METHODS: We used a quasi-experimental design, including baseline and follow-up measurements between 2013 and 2018 in intervention and comparison areas of Guatemala, Nicaragua, and Honduras. We collected information on 8754 births linked to the health facility closest to the mother's locality of residence and the facility where the delivery took place (if attended in a health facility). We fit difference-in-difference models, adjusting for women's characteristics (age, parity, education), household characteristics, exposure to health promotion interventions, health facility level, and country. RESULTS: Equipment, inputs, and staffing of facilities improved after the Initiative in both intervention and comparison areas. After adjustment for covariates, institutional delivery increased between baseline and follow-up by 3.1 percentage points (ß = 0.031, 95% CI -0.03, 0.09) more in intervention areas than in comparison areas. The proportion of women in intervention areas who chose a facility other than their closest one to attend the delivery decreased between baseline and follow-up by 13 percentage points (ß = - 0.130, 95% CI -0.23, - 0.03) more than in the comparison group. CONCLUSIONS: Results indicate that women in intervention areas of SMI are more likely to go to their closest facility to attend delivery after the Initiative has improved facilities' capacity, suggesting that results-based aid initiatives targeting poor populations, like SMI, can increase the use of facilities closest to the place of residence for delivery care services. This should be considered in the design of interventions after the COVID-19 pandemic may have changed health and social conditions.

Factors associated with delays in the search for care in under-5 deaths in Yucatán, Mexico / Factores asociados con demoras en la búsqueda de atención en muertes de menores de cinco años en Yucatán, México

Abstract: Objective: We examined delays during the search for care and associations with mother, child, or health services characteristics, and with symptoms reported prior to death. Materials and methods: Cross-sectional study comprising household interviews with 252 caregivers of children under-5 who died in the state of Yucatán, Mexico, during 2015-2016. We evaluated the three main delays: 1) time to identify symptoms and start search for care, 2) transport time to health facility, and 3) wait time at health facility. Results: Children faced important delays including a mean time to start the search for care of 4.1 days. The mean transport time to the first facility was longer for children enrolled in Seguro Popular and there were longer wait times at public facilities, especially among children who also experienced longer travel time Conclusions: Providing resources to enable caregivers to access health services in a timely manner may reduce delays in seeking care.

Resumen: Objetivo: Analizar las demoras en la búsqueda de atención y su asociación con características de la madre, del niño y los servicios de salud, así como con los síntomas reportados antes de la defunción. Material y métodos: Diseño transversal con entrevistas a 252 cuidadores que se encargaron de niños menores de cinco años que fallecieron en el estado de Yucatán, México, durante 2015-2016. Se evaluaron tres demoras: 1) tiempo en identificar la complicación e iniciar el proceso de búsqueda; 2) tiempo de transporte; y 3) tiempo de espera en la unidad de salud. Resultados: Los niños enfrentaron demoras importantes en la búsqueda de atención. La media de tiempo para iniciar la búsqueda de atención fue de 4.1 días. La media de tiempo de transporte a la primera unidad de atención fue mayor para niños inscritos en el Seguro Popular y hubo tiempos de espera más largos en unidades de salud del sector público, especialmente entre niños que tuvieron tiempos de transporte largos. Conclusión: Proporcionar recursos que permitan a los cuidadores acceder a los servicios de salud de manera oportuna puede reducir las demoras en la búsqueda de atención.

Factors associated with delays in the search for care in under-5 deaths in Yucatán, Mexico.

OBJECTIVE: We examined delays during the search for care and associations with mother, child, or health services characteristics, and with symptoms reported prior to death. MATERIALS AND METHODS: Cross-sectional study compris-ing household interviews with 252 caregivers of children under-5 who died in the state of Yucatán, Mexico, during 2015-2016. We evaluated the three main delays: 1) time to identify symptoms and start search for care, 2) transport time to health facility, and 3) wait time at health facility. RESULTS: Children faced important delays including a mean time to start the search for care of 4.1 days. The mean transport time to the first facility was longer for children enrolled in Seguro Popular and there were longer wait times at public facilities, especially among children who also experienced longer travel time. CONCLUSIONS: Providing resources to enable caregiv-ers to access health services in a timely manner may reduce delays in seeking care.

Assessing multidimensional care coverage for pre-eclampsia in the era of universal health coverage: A pre-post evaluation of the Salud Mesoamérica Initiative.

OBJECTIVE: To compare a multidimensional care package for pre-eclampsia/eclampsia in Central American health facilities, before and after implementation of the Salud Mesoamérica Initiative. METHODS: An evaluation study was conducted at 67 basic- and comprehensive-level health facilities serving the poorest areas in Honduras, Nicaragua, and Belize. Cases of severe pre-eclampsia or eclampsia were randomly sampled and relevant quality of care data extracted from medical records at baseline (n=111) from January 1, 2011, to March 31, 2013, and at second-phase follow-up (n=249) from June 1, 2015, to September 30, 2017. The primary outcome was evidence of the delivery of multidimensional care for the management of pre-eclampsia/eclampsia. RESULTS: The care of 360 women with severe pre-eclampsia or eclampsia was analyzed. Odds of multidimensional care for pre-eclampsia management (P=0.271) increased (although not significantly) in the second-phase follow-up compared to baseline. Multidimensional care was significantly associated with training (P<0.001), basic-level facilities (P<0.001), and higher in Honduras (P=0.001) and Belize (P=0.024) than the reference country of Nicaragua. CONCLUSION: Multidimensional care for pre-eclampsia management increased across all facility types, countries, and severity of disease. The Salud Mesoamérica Initiative is a promising model for achieving such quality of care interventions in the era of universal health coverage.

Access and use of oxytocin for postpartum haemorrhage prevention: a pre-post study targeting the poorest in six Mesoamerican countries.

OBJECTIVES: Haemorrhage remains the leading cause of maternal mortality in Central America. The Salud Mesoamérica Initiative aims to reduce such mortality via performance indicators. Our objective was to assess the availability and administration of oxytocin, before and after applying Salud Mesoamérica Initiative interventions in the poorest health facilities across Central America. DESIGN: Pre-post study. SETTING: 166 basic-level and comprehensive-level health facilities in Belize, Guatemala, Honduras, Mexico, Nicaragua and Panama. PARTICIPANTS: A random sample of medical records for uncomplicated full-term deliveries (n=2470) per International Classification of Diseases coding at baseline (July 2011 to August 2013) and at first-phase follow-up (January 2014 to October 2014). INTERVENTIONS: A year of intervention implementation prior to first-phase follow-up data collection focused on improving access to oxytocin by strengthening supply chains, procurement, storage practices and pharmacy inventory monitoring, using a results-based financing model. PRIMARY AND SECONDARY OUTCOME MEASURES: Oxytocin availability (primary outcome) and administration (secondary outcome) for postpartum haemorrhage prevention. RESULTS: Availability of oxytocin increased from 82.9% to 97.6%. Oxytocin administration increased from 83.6% to 88.4%. Significant improvements were seen for availability of oxytocin (adjusted OR (aOR)=8.41, 95% CI 1.50 to 47.30). Administration of oxytocin was found to be significantly higher in Honduras (aOR=2.96; 95% CI 1.00 to 8.76) in reference to Guatemala at follow-up. CONCLUSION: After interventions to increase health facility supplies, the study showed a significant improvement in availability but not administration of oxytocin in poor communities within Mesoamerica. Efforts are needed to improve the use of oxytocin.

Results-based aid with lasting effects: sustainability in the Salud Mesoamérica Initiative.

BACKGROUND: The Salud Mesoamérica Initiative is a public-private partnership aimed at reducing maternal and child morbidity and mortality for the poorest populations in Central America and the southernmost state of Mexico. Currently at the midpoint of implementation and with external funding expected to phase out by 2020, SMI's sustainability warrants evaluation. In this study, we examine if the major SMI components fit into the Dynamic Sustainability Framework to predict whether SMI benefits could be sustainable beyond the external funding and to identify threats to sustainability. METHODS: Through the 2016 Salud Mesoamérica Initiative Process Evaluation, we applied qualitative methods including document review, key informant interviews, focus group discussions, and a social network analysis to address our objective. RESULTS: SMI's design continuously evolves and aligns with national needs and objectives. Partnerships, the regional approach, and the results-based aid model create a culture that prioritizes health care. SMI's sector-wide approach and knowledge-sharing framework strengthen health systems. Evidence-based practice promotes policy dialogue and scale-up of interventions. CONCLUSION: Most SMI elements fit within the Dynamic Sustainability Framework, suggesting a likelihood of sustainability after external funding ceases, and subsequent application of lessons learned by the global community. This includes a flexible design, partnerships and a culture of prioritizing healthcare, health systems strengthening mechanisms, policy changes, and scale-ups of interventions. However, threats to sustainability, including possible transient culture of prioritizing health care, dissipation of reputational risk and financial partnerships, and personnel turnover, need to be addressed.