Health-care guidelines and policies during the COVID-19 pandemic in Mexico: A case of health-inequalities

Estimating the effect of realistic improvements of metformin adherence on COVID-19 mortality using targeted machine learning

Background

Type 2 diabetes elevates the risk of severe outcomes in COVID-19 patients, with multiple studies reporting higher case fatality rates. Metformin is a widely used medication for glycemic management. We hypothesize that improved adherence to metformin may lower COVID-19 post-infection mortality risk in this group. Utilizing data from the Mexican Social Security Institute (IMSS), we investigate the relationship between metformin adherence and mortality following COVID-19 infection in patients with chronic metformin prescriptions.

Methods

This is a retrospective cohort study consisting of 61,180 IMSS beneficiaries who received a positive polymerase chain reaction (PCR) or rapid test for SARS-CoV-2 and had at least two consecutive months of metformin prescriptions prior to the positive test. The hypothetical intervention is improved adherence to metformin, measured by proportion of days covered (PDC), with the comparison being the observed metformin adherence values. The primary outcome is all-cause mortality following COVID-19 infection. We defined the causal parameter using shift intervention, an example of modified treatment policies. We used the targeted learning framework for estimation of the target estimand.

Findings

Among COVID-19 positive patients with chronic metformin prescriptions, we found that a 5% and 10% absolute increase in metformin adherence is associated with a respective 0.26% (95% CI: -0.28%, 0.79%) and 1.26% (95% CI: 0.72%, 1.80%) absolute decrease in mortality risk.

Interpretation

Subject to the limitations of a real-world data study, our results indicate a causal association between improved metformin adherence and reduced COVID-19 post-infection mortality risk.

Gender health care inequalities in health crisis: when uncertainty can lead to inequality

BACKGROUND

In health crisis, inequalities in access to and use of health care services become more evident. The objective of this study is to analyse the existence and evolution of gender inequalities in access to and use of healthcare services in the context of the COVID-19 health crisis.

METHODS

Retrospective cohort study using data from all individuals with a confirmed COVID-19 infection from March 2020 to March 2022 in Aragón (Spain) (390,099 cases). Health care access and use was analysed by gender for the different pandemic waves. Univariate and multivariate analyses were conducted to evaluate the effect of sex in health care. Blinder-Oaxaca decomposition methods were performed to explain gender gaps observed.

RESULTS

The health care received throughout the COVID-19 pandemic differed between men and women. Women were admitted to hospital and intensive care units less frequently than men and their stays were shorter. Differences observed between men and women narrowed throughout the pandemic, but persisted even after adjusting for age, socioeconomic status, morbidity burden or the patient's place of residence. Differences in sociodemographic characteristics and morbidity burden could explain partially the gender inequalities found, mainly in the later phases of the pandemic, but not in the earlier waves.

CONCLUSIONS

There were gender inequalities in access to and use of health services during the COVID-19 pandemic. Inequalities were greater in the first waves of the pandemic, but did not disappear. Analysis of health crises must take into account an intersectional gender perspective to ensure equitable health care.

Health-care policies during the COVID-19 pandemic in Mexico: A continuous case of heterogeneous, reactive, and unequal response

Background

The pandemic in Mexico underlined pre-existing health-care system inequalities. Within the first six months of the COVID-19 pandemic, 154 health policies across health institutions were found to be uncoordinated and heterogeneous, leading to health inequalities in access and potential health outcomes.

Data & methods

Using a rapid qualitative research methodology, data was collected using purposive sampling of institutional policies published for public access on the official websites of the four public health institutions in Mexico from June 16th, 2020 to October 30th, 2021. This policy review used archival analysis to understand the differences in health-care policies during the COVID-19 pandemic in Mexico. These policies were classified under the RREAL framework and as a continuation of our first publication.

Results

During this study, categories of public health response and vaccination dominated the policies enacted. The SSA was the main author of publications. There seems to be a more unified policy response. However, health inequalities persist.

Conclusions

The Mexican government continued to be reactive to the increase in cases or the arrival of new variants, rather than preventative. Research and development of policies need to work together in soaring cases like COVID-19 to work more effectively against the economic and epidemiological burden of a pandemic. It is suggested that this "vaccination" should be included in the RREAL classification. Other sectors (i.e. the ministry of foreign affairs) should be considered relevant players in the future management of a pandemic.

State management of primary health care in response to COVID-19 in Bahia, Brazil

This is an analysis of state management of Primary Health Care in response to the COVID-19 pandemic in Bahia. It is a qualitative case study with interviews with managers and regulatory documents analyzed according to the categories of government project and government capacity. State PHC proposals were debated in the Bipartite Intermanagerial Commission and in the Public Health Operational Emergency Committee. The scope of the PHC project focused on the definition of specific actions to manage the health crisis with the municipalities. The institutional support of the state to the municipalities modulated inter-federative relations and was decisive in the elaboration of municipal contingency plans, training of teams and production and dissemination of technical standards. The capacity of the state government was dependent upon the degree of municipal autonomy and the availability of state technical references in the regions. The state strengthened institutional partnerships for dialogue with municipal managers, but mechanisms for articulation with the federal level and social control were not identified. This study contributes to the analysis of the role of states in the formulation and implementation of PHC actions mediated by inter-federative relationships in emergency public health contexts.

Households' basic needs satisfaction during the Coronavirus disease 19 (COVID-19) pandemic in Burkina Faso

The Coronavirus disease 19 (COVID-19) pandemic has profoundly affected economic and health systems around the world. This paper aims to assess household access to basic foods and health care and food security attainment during the COVID-19 pandemic in Burkina Faso. We use the COVID-19 High-Frequency Phone Survey 2020 panel data supported by the World Bank and conducted by Institut National de la Statistique et de la Démographie (INSD). The pooled multinomial logistic, the panel logistic, and the panel ordered logistic regressions are used to analyse the access to basic foods, the access to health care and the food security of the households, respectively. The results show that during COVID-19, female-headed households, poor households and farm households remain the most vulnerable in terms of access to basic foods, health services and food insecurity. Furthermore, the results indicate that households living outside the capital, particularly in the other urbans, experience fewer difficulties obtaining basic foods than those residing in the capital and are also unlikely to experience food insecurity. For more effective policy responses to the COVID-19 or similar shocks, the interventions should focus on household socioeconomic conditions and distinguish between urban and rural areas.

Pandemic iatrogenesis: exclusion and lag in non-COVID medical care in Mexico City

Abstract The paper analyzes, from a qualitative perspective, how the COVID-19 pandemic has significantly reduced medical care for chronic patients at the three levels of the Mexico City health sector due to community mitigation strategies, the perceived risk of infection of health personnel and patients, the focus on pandemic care, and how these processes are articulated with the previous underfunding conditions of the public health system. Thus, we adopted the Grounded Theory approach based on the description and analysis of the experiences of 42 doctors interviewed at the three care levels. The pandemic iatrogenesis concept is proposed to address the interrelation between the material and symbolic organization of the dominant model of medical care and specific structural and cultural dimensions of massive and systemic neglect since the arrival of the pandemic. We point out some strategies and possibilities to avoid similar future settings based on this theoretical proposal and the experiences of the doctors interviewed.

Iatrogenia pandémica: la exclusión y el rezago en la atención médica, no COVID, en la Ciudad de México

Resumen El artículo analiza, desde una perspectiva cualitativa, cómo la pandemia de COVID-19 ha reducido significativamente la atención médica de pacientes crónicos, en los tres niveles del sector salud de la Ciudad de México, debido a las estrategias de mitigación comunitaria; la percepción del riesgo de infección del personal de salud y los pacientes; la focalización en la atención a la pandemia, y a como estos procesos se articulan con las condiciones previas de desfinanciamiento del sistema público de salud. Para ello utilizamos el enfoque de la teoría fundamentada basándonos en la descripción y el análisis de las experiencias de 42 médicas y médicos entrevistados en los tres niveles de atención. Se propone el concepto de iatrogenia pandémica para abordar la interrelación entre la organización material y simbólica del modelo dominante de atención médica y ciertas dimensiones estructurales y culturales de la desatención masiva y sistémica desde la llegada de la pandemia. A partir de esta propuesta teórica y de las experiencias de las médicas y los médicos entrevistados, se señalan algunas estrategias y posibilidades para evitar escenarios futuros similares.

Rapid qualitative health research from the Global South: Reflections and learnings from Argentina, Brazil, Chile, and Mexico during the COVID-19 pandemic

The objective of this paper is to provide insights into our experiences undertaking qualitative rapid research in Latin American contexts based on fieldwork from Argentina, Brazil, Chile, and Mexico. We focus on the insights and learning processes that emerged from our research teamwork during the COVID-19 pandemic. Our research projects are part of an international collaboration led by the Rapid Research Evaluation and Appraisal Lab (RREAL) to explore the experiences of COVID-19 Frontline Healthcare Workers. The analyzed experiences not only rely on the local studies but also on our reflections as a group of Latin American researchers collaborating along with an international team. Qualitative research has an important and long-lasting tradition in Latin America. However, healthcare professionals are still reluctant to use these methods. We highlight tensions and dilemmas that have emerged from our own empirical experience: First, the time for research ethics committees to evaluate the protocols; second, the difficulties in accessing funding to undertake research due to the lack of financial opportunities; third, having to decide the language of our publications. That is just the tip of the iceberg that allows us to show inequalities in the conditions under which scientific knowledge is produced between the North and the Global South. Following these points, our text explores the tension between the urgency to conduct rapid research and the multiple difficulties when undertaking it during the pandemic. It is important to point out that the problems we faced already existed before the sanitary emergency, being magnified by the former. At last, our conclusions delve into the reflexive process we, as a team of female researchers, undertook to explore the differences and similarities of our experiences. This analysis allowed us to solve obstacles and dilemmas when doing research. The winding road we describe here serves as an example for other research teams when planning and undertaking rapid qualitative research during future pandemics.

The healthcare inequality among middle-aged and older adults in China: a comparative analysis between the full samples and the homogeneous population

BACKGROUND

In the Chinese population, the middle-aged and older adults are the two main segments that utilize a large portion of healthcare. With the fast growth of the two segments, the demands of healthcare services increases significantly. The issue related to inequality in utilization of healthcare emerges with the growth and it deserves more attention. Most existing studies discuss overall inequality. Less attention is paid to inequality among subdivisions, that is, relative inequality. This study focuses on the inequality of healthcare utilization among the homogeneous population and the inequality of the full samples in China.

METHODS

Data were obtained from four waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013, 2015 and 2018. First, the Concentration Index (CI) was used to measure the inequality of outpatient, inpatient and preventive care for the samples, and regression analysis was applied to decompose the contributing factors of inequality. Then SOM is introduced to identify homogeneous population through clustering and measure the inequality in three types of healthcare utilization among homogeneous population. Based on this, the difference between absolute inequalities and relative inequalities was discussed.

RESULTS

The preventive care is shown to have the highest degree of inequality inclined to the rich and has the largest increase (CI: 0.048 in 2011 ~ 0.086 in 2018); The inequality degree in outpatient care appears to be the smallest (CI: -0.028 in 2011 ~ 0.014 in 2018). The decomposition results show that age, education, income, chronic disease and self-reported health issues help explain a large portion of inequality in outpatient and inpatient care. And the contribution of socioeconomic factors and education to the inequality of preventive care is the largest. In regards to three types of healthcare among the homogeneous population, the degree of inequality seems to be higher among group with high socioeconomic status than those with lower socioeconomic status. In particular, for the people who are in the high socioeconomic group, the degree of inequality in preventive care is consistently higher than in outpatient and inpatient care. The inequality degree of preventive care in the low socioeconomic status group varies significantly with the flexibility of their response to policies.

CONCLUSIONS

Key policy recommendations include establishing a health examination card and continuously improving the fit of free preventive care with the needs of the middle-aged and older adults; developing CCB activities to avoid people's excessive utilization in the high socioeconomic status group or insufficient utilization in the low socioeconomic status group; reasonable control of reimbursement and out-of-pocket payments.

Towards a typology of social protection for migrants and refugees in Latin America during the COVID-19 pandemic

The COVID-19 health crisis has put to the test Latin America's already precarious social protection systems. This paper comparatively examines what type of social protection has been provided, by whom, and to what extent migrant and refugee populations have been included in these programmes in seven countries of the region during the COVID-19 pandemic, between March and December 2020. We develop a typology of models of social protection highlighting the assemblages of actors, different modes of protection and the emerging migrants' subjectification in Brazil, Chile, Colombia, Ecuador, Mexico, Peru, and Uruguay in relation to Non-Contributory Social Transfer (NCST) programmes and other actions undertaken by state and non-state actors. The analysis is based on 85 semi-structured interviews with representatives of national and local governments, International Organisations, Civil Society Organisations, and migrant-led organisations across 16 cities, and a systematic review of regulatory frameworks in the country-case studies. The proposed typology shows broad heterogeneity and complexity regarding different degrees of inclusion of migrant and refugee populations, particularly in pre-existing and new NCST programmes. These actions are furthering notions of migrant protection that are contingent and crisis-driven, imposing temporal limitations that often selectively exclude migrants based on legal status. It also brings to the fore the path-dependent nature of policies and practices of exclusion/inclusion in the region, which impact on migrants' effective access to social and economic rights, while shaping the broader dynamics of migration governance in the region.

In-Transit Migrants And Asylum Seekers: Inclusion Gaps In Mexico's COVID-19 Health Policy Response

During the COVID-19 pandemic, as immigration and asylum processes were delayed or interrupted, migrants and asylum seekers were stranded at Mexico's northern border. In-transit migrants and asylum seekers are an underserved population, and pandemic preparedness has seldom taken their needs into account. In this article we analyze public health policies developed in Mexico in response to the COVID-19 pandemic and describe how these policies have largely overlooked the needs of vulnerable mobile populations. We reviewed eighty publicly available documents issued by federal, state, and municipal authorities in Mexico between January and September 2020. Only seven policy documents explicitly considered in-transit migrants and asylum seekers and their health care needs. In addition, we identified six major gaps in these policies that, if addressed, would promote greater inclusion of persons in mobility in future pandemic response plans, to protect the health of migrant populations.

Habitability, Resilience, and Satisfaction in Mexican Homes to COVID-19 Pandemic

Following the 2020 confinement due to the COVID-19 pandemic, housing has become the only safe place and this has exposed inequity in habitability. This research on the reality of confined households and the perception of their homes in the Mexican republic is based on a mixed participatory study, combining quantitative and qualitative approaches. The online questionnaire consisted of 58 questions in the quantitative approximation. The qualitative part required the provision of an image of the workspace, with testimonies and personal reflections. During the lockdown, all participants saw an increase in overall energy consumption; more than half reported not being in thermal comfort; and a third declared deficiencies in noise insulation. Regarding the perception of the telework/tele-study space, we found the following categories: bedrooms, living/dining rooms, studies and others. In addition, respondents had often adapted the workspace for both individual and shared use. In general, the households were satisfied with the size of their houses but would like landscaped spaces or better views outside. Confinement made housing the protective element against the pandemic. The consequences will have an effect globally, so new architectural design paradigms need to be rethought.