Health-care coverage and access to health care in the context of type 2 diabetes and hypertension in rural Mexico: a systematic literature review

[Determinants of avoidable hospitalization for type2 diabetes. Narrative review]

OBJECTIVE

To identify the structural and intermediate determinants associated with avoidable hospitalizations (AH) of patients with type2 diabetes mellitus (T2DM).

DESIGN

Literature review based on narrative synthesis.

DATA SOURCES

Databases: PubMed, Science Direct, and Latin American and Caribbean Literature in Health Sciences (LILACS).

STUDY SELECTION

Documents were selected and analyzed under a critical literature review, considering inclusion and exclusion criteria.

DATA EXTRACTION

Information extracted from each selected article was synthesized based on the countries' income levels and the social determinants of health framework.

RESULTS

A total of 4,166 articles were relevant, 36 were selected for review. From this selection, 21 were publications conducted in high-income countries, 14 in upper-middle-income countries, and one in lower-middle-income countries. The review identified that the coverage of health services -mainly primary health care- and health insurance contribute to reducing the risk of AH for T2DM, while social inequalities tend to increase the risk.

CONCLUSIONS

The AH due to T2DM are susceptible to reduction through policies that contribute to increasing effective access to health services (availability, insurance), since they express social inequality, occurring to a greater extent in socioeconomically vulnerable populations. This review also provides evidence of the need to expand research on this topic in middle and low-income countries.

Determinants of Out-of-Pocket Health Spending in Households in Peru in the Times of the Pandemic (COVID-19)

In 2021, the expenses paid by households worldwide due to COVID-19 showed an increasing behavior and directly affected economic income since they were part of unforeseen expenses among households and became a factor that contributed to the increase in the levels of poverty mainly in households that were not part of the health system. The objective of this research was to establish the main determinants of out-of-pocket spending on health in Peruvian households in the times of the pandemic. A quantitative approach, of a nonexperimental type, with a descriptive and correlational methodological design was considered. The database of the National Household Survey of the National Institute of Statistics and Informatics for 2021 was used as a source of information, applying the binomial logit econometric model. Out-of-pocket expenses during the pandemic compared to normal periods were shared by the members of the households. Since they were part of unforeseen expenses, these expenses mainly impacted the heads of the households and strongly affected household budgets. For this reason, the type of insurance, the suffering of household members from a disease, the results of tests for COVID-19, the expenditure on individual health, the existence of permanent limitations to any member of the household, the presence of an older adult in the household, and the marital status of the head of the household determined and positively influenced out-of-pocket spending in households in Peru with 36.85, 8.48, 6.50, 0.0065, 23.73, 16.79, and 2.44 percentage units. However, the existence of a drinking water service in the household, educational level, and the area of residence determined and negatively influenced out-of-pocket spending in households in Peru with 4.81, 6.75, and 19.26 percentage units, respectively. The type of insurance, the suffering of an individual from a disease, the results of COVID-19 tests, health spending, the existence of permanent limitations, the presence of an older adult in the household, and the marital status of the head of the household positively determined out-of-pocket spending in households in Peru, while the existence of a potable water service, educational level, and the area of residence determined out-of-pocket expenses in a negative or indirect way.

Setbacks in the quest for universal health coverage in Mexico: polarised politics, policy upheaval, and pandemic disruption

2023 marks the 20-year anniversary of the creation of Mexico's System of Social Protection for Health and the Seguro Popular, a model for the global quest to achieve universal health coverage through health system reform. We analyse the success and challenges after 2012, the consequences of reform ageing, and the unique coincidence of systemic reorganisation during the COVID-19 pandemic to identify strategies for health system disaster preparedness. We document that population health and financial protection improved as the Seguro Popular aged, despite erosion of the budget and absent needed reforms. The Seguro Popular closed in January, 2020, and Mexico embarked on a complex, extensive health system reorganisation. We posit that dismantling the Seguro Popular while trying to establish a new programme in 2020-21 made the Mexican health system more vulnerable in the worst pandemic period and shows the precariousness of evidence-based policy making to political polarisation and populism. Reforms should be designed to be flexible yet insulated from political volatility and constructed and managed to be structurally permeable and adaptable to new evidence to face changing health needs. Simultaneously, health systems should be grounded to withstand systemic shocks of politics and natural disasters.

Life Satisfaction and Dental Visits in Adults Aged ≥50 Years and Living with Diabetes Mellitus: A Comparison between Urban and Rural Mexican

OBJECTIVE

To examine the association between low life satisfaction with past-year dental visits in a rural-urban national sample of 50-year-old Mexican adults with diabetes mellitus (DM).

METHODS

Data are drawn from the Mexican Health and Aging Study (MHAS), a cross-sectional study conducted in 2018 involving 3,592 older adults aged 50 years and older and living in urban and rural areas in Mexico. Life satisfaction was measured using the Satisfaction with Life Scale (SWLS) and past-year dental visits dichotomized as none and ≥1 dental visits. The Poisson regression analyses were used to assess the association, adjusting for confounders.

RESULTS

62.9% were women, mean age was 65.5 (±9.6), and 16.5% lived in a rural area, while the female subjects continue to present a higher probability of visiting a dentist (PR = 1.28 (95% CI 1.08-1.51)). In terms of age, the ≥70-year group presented 28% lower possibility of visiting a dentist (PR = 0.72 (95% CI 0.60-0.86)). The interaction showed that adults ≥50 years who reside in a rural area and have low life satisfaction were 40% less likely to have visited a dentist in the last year (PR = 0.60 (95% CI 0.37-0.98)) than adults ≥50 years who reside in an urban area and have high life satisfaction.

CONCLUSIONS

The present study highlights the association between low life satisfaction and past-year dental visits in rural populations. Therefore, rurality should be considered a possible confounder in analysis of life satisfaction in the older adult population.

Sex differences in the association between diabetes and depressive symptoms: findings from Mexican National Health and Nutrition Survey 2018-2019

AIMS

We set out to investigate the potential sex differences in the association between diabetes and depressive symptoms by conducting an interaction analysis, and to investigate whether sex mediates the effect of diabetes on depressive symptoms.

METHODS

We conducted analyses on cross-sectional data of adults aged 20 years or older in the Mexican National Health and Nutrition Survey 2018-2019 (ENSANUT 2018-2019). Diabetes was defined by self-reported medical diagnosis, and depressive symptoms were measured using the seven-item Centre for Epidemiologic Studies Depression scale. First, an unadjusted interaction analysis was conducted. Second, the inverse probability of treatment weighting was applied to account for imbalances and biases. Third, the four-way decomposition method was used to estimate the potential mediating effect of sex.

RESULTS

In the study population (N=43 074), the prevalence of diabetes was 9.3% for men and 11.7% for women. Depressive symptoms were more prevalent in women (19.0%) than in men (9.5%). Women with diabetes had the greatest odds of having depressive symptoms, compared with men without diabetes (ORwomen-diabetes3.49 (95% CI: 3.16 to 3.86)). The interaction analysis indicated that diabetes and sex interact on both, multiplicative and additive scales (ratio of ORs (95% CI) 1.22 (1.02 to 1.45), and relative excess risk due to interaction (95% CI) 0.99 (0.63 to 1.36)). The four-way decomposition analysis showed that the interaction effect between diabetes and sex is larger than the mediation effect.

CONCLUSIONS

We found a positive interaction between diabetes and sex in the odds of having depressive symptoms. Mental health and diabetes care services planning would benefit from adopting a sex-informed approach.

Medicinal plants used by rural communities in the arid zone of Viesca and Parras Coahuila in northeast Mexico

This study is the first record of medicinal plants in the southwest of the Coahuila state, an arid zone where extreme dry conditions prevail. One hundred twenty-two residents (in sixteen communities) were interviewed. The residents were questioned with a questionnaire-guided ethnomedical survey protocol about the various plants used. Seventy-seven species of medicinal plants belonging to 36 botanical families were cited. The highest use-value (UV) was calculated for Lippia graveolens Kunth (0.30); Aloe vera (L.) Burm.f. (0.20); Eucalyptus abdita Brooker & Hopper, Chamaemelum nobile (L.) All. (0.16); Mentha spicata L. (0.15) and Salvia officinalis L. (0.10). Informant consensus factor (ICF) about usages of medicinal plants ranges from 0.41 to 0.80; the highest level of agreement was determined between the informants and Respiratory System Diseases (0.80). The highest fidelity level (FL) values (100%) were identified in Flourensia cernua DC., Artisia ludoviciana Nutt., and Parthenium incanum Kunth to Gastro-intestinal System Diseases; Eucalyptus abdita Brooker & Hopper, Bougainvillea berberidifolia Heimerl, and Lippia graveolens Kunth to Respiratory System Diseases (RSD) and Cyclolepis genistoides D.Don and Ephedra antisyphilitica Berland. ex C.A.Mey. to Obstetrics, Gynecology and Urinary tract Diseases. These last two medicinal plant species ("palo azul" and "pitoreal") used by the rural communities in Viesca in the treatment of urinary tract infections and kidney stones have not been reported previously. These findings can provide new research directions for further phytochemical studies. The present study revealed that the residents are rich in ethno-medicinal knowledge and actively use medicinal plants to treat various diseases. New phytochemical and pharmacological research are needed to confirm the therapeutic potential and safety of the identified plants.

Diabetes-Related Excess Mortality in Mexico: A Comparative Analysis of National Death Registries Between 2017-2019 and 2020

OBJECTIVE

To estimate diabetes-related mortality in Mexico in 2020 compared with 2017-2019 after the onset of the coronavirus disease 2019 (COVID-19) pandemic.

RESEARCH DESIGN AND METHODS

This retrospective, state-level study used national death registries of Mexican adults aged ≥20 years for the 2017-2020 period. Diabetes-related death was defined using ICD-10 codes listing diabetes as the primary cause of death, excluding certificates with COVID-19 as the primary cause of death. Spatial and negative binomial regression models were used to characterize the geographic distribution and sociodemographic and epidemiologic correlates of diabetes-related excess mortality, estimated as increases in diabetes-related mortality in 2020 compared with average 2017-2019 rates.

RESULTS

We identified 148,437 diabetes-related deaths in 2020 (177 per 100,000 inhabitants) vs. an average of 101,496 deaths in 2017-2019 (125 per 100,000 inhabitants). In-hospital diabetes-related deaths decreased by 17.8% in 2020 versus 2017-2019, whereas out-of-hospital deaths increased by 89.4%. Most deaths were attributable to type 2 diabetes (130 per 100,000 inhabitants). Compared with 2018-2019 data, hyperglycemic hyperosmolar state and diabetic ketoacidosis were the two contributing causes with the highest increase in mortality (128% and 116% increase, respectively). Diabetes-related excess mortality clustered in southern Mexico and was highest in states with higher social lag, rates of COVID-19 hospitalization, and prevalence of HbA1c ≥7.5%.

CONCLUSIONS

Diabetes-related deaths increased among Mexican adults by 41.6% in 2020 after the onset of the COVID-19 pandemic, occurred disproportionately outside the hospital, and were largely attributable to type 2 diabetes and hyperglycemic emergencies. Disruptions in diabetes care and strained hospital capacity may have contributed to diabetes-related excess mortality in Mexico during 2020.

MIDO COVID: A digital public health strategy designed to tackle chronic disease and the COVID-19 pandemic in Mexico

Screening, prevention, and management of non-communicable diseases (NCDs, including obesity, hypertension, and type 2 diabetes) is the core function of Integrated Measurement for Early Detection (MIDO), a digital strategy developed by the Carlos Slim Foundation in Mexico. An extension of this strategy, MIDO COVID, was developed to address the need for an integrated plan in primary health care during the COVID-19 pandemic. MIDO COVID facilitates planning, surveillance, testing, and clinical management of SARS-CoV-2 infections and the major NCDs and their pre-disease states, to streamline the continuum of care. MIDO COVID screening was applied in 1063 Carso Group workplaces in 190 municipalities of the 32 Mexican states. Staff were trained to screen healthy workers for NCDs using a questionnaire, anthropomorphic measurements, and blood work; healthy individuals returning to work also received a SARS-CoV-2 antibody test. Between June 26 and December 31, 2020, 58,277 asymptomatic individuals underwent screening. The prevalence of obesity, hypertension, and type 2 diabetes was 32.1%, 25.7%, and 9.7% respectively. Only 2.2%, 8.8%, and 4.5% of individuals, respectively, were previously aware of their condition. Pre-obesity was identified in 38.6%, pre-hypertension in 17.4%, and prediabetes in 7.5% of the population. Risk of SARS-CoV-2 infection was highest for individuals with multiple NCDs. Many Mexicans are unaware of their health status and potentially increased risk of COVID-19 and serious complications. As a universal strategy implemented regardless of social factors, MIDO COVID promotes equity in access to health care prevention and early stage detection of NCDs; the information gained may help inform decisionmakers regarding prioritising vulnerable populations for immunisation.

Access and Use of Health Services by People with Diabetes from the Item Response Theory

The objective of this study was to analyze the indicators of access and use of health services in people with diabetes mellitus. This study used data from the National Health Survey, conducted in Brazil in 2013. The National Health Survey was carried out with adults aged 18 years or older residing in permanent private households in Brazil. Indicators from 492 individuals with self-reported diabetes mellitus living in the Central-West region of the country were analyzed. Item response theory was used to estimate the score for access to and use of health services. Multiple linear regression was used to analyze factors associated with scores of access and use of health services by people with diabetes mellitus. The mean score of access estimated by the item response theory and use estimated was 51.4, with the lowest score of zero (lowest access and use) and the highest 100 (highest access and use). Among the indicators analyzed, 74.6% reported having received medical care in the last 12 months and 46.4% reported that the last visit occurred in primary care. Only 18.9% had their feet examined and 29.3% underwent eye examinations. Individuals of mixed-race/skin color and those residing outside capital and metropolitan regions had lower access and use scores when compared to white individuals and residents of state capitals, respectively. The study shows several gaps in the indicators of access and use of health services by people with diabetes. People of mixed race/skin color and residents outside the capitals and metropolitan regions had lower scores for access and use, suggesting the need to increase health care in these groups.

A comparison of rural-urban differences in out-of-pocket expenses among older Mexicans with diabetes

Objective

To compare total out-of-pocket expenses for physician visits and medications among older adults living with diabetes in Mexico from urban, semi-urban, and rural areas.

Methods

The sample included 2,398 Mexicans aged 65 years and older with self-reported diabetes from the 2018 Mexican Health and Aging Study. Out-of-pocket expenses for physician visits and medications were regressed on locality, controlling for several factors.

Results

The profile of those with higher out-of-pocket medication expenditures included rural localities, higher education, unmarried, depressive symptoms, participation in Seguro Popular, and lacking insurance. In the multivariate analysis, rural older adults with diabetes paid a higher amount in medication expenditures compared with other localities.

Conclusion

Differences in locality are closely tied to the effective implementation of Seguro Popular. Although this program has improved access to care, participants have higher out-of-pocket expenditures for medications than those on employer-based plans across all localities. Among all groups, the uninsured bare the highest burden of expenditures, highlighting a continued need to address health inequities for the most underserved populations.

Longitudinal evidence on treatment discontinuation, adherence, and loss of hypertension control in four middle-income countries

Managing hypertension is a highly dynamic process, yet current evidence on hypertension control in middle-income countries (MICs) is largely based on cross-sectional data. Using multiple waves of population-based cohort data from four MICs (China, Indonesia, Mexico, and South Africa), we undertook a longitudinal investigation into how individuals with hypertension move through care over time. We classified adults aged 40 years and over (N = 8527) into care stages at both baseline and follow-up waves and estimated the probability of transitioning between stages using Poisson regression models. Over a 5- to 9-year follow-up period, only around 30% of undiagnosed individuals became diagnosed [Mexico, 27% (95% confidence interval: 23%, 31%); China, 30% (26%, 33%); Indonesia, 30% (28%, 32%); and South Africa, 36% (31%, 41%)], and one in four untreated individuals became treated [Indonesia, 11% (10%, 12%); Mexico, 24% (20%, 28%); China, 26% (23%, 29%); and South Africa, 33% (29%, 38%)]. The probability of reaching blood pressure (BP) control was lower [Indonesia, 2% (1%, 2%); China, 9% (7%, 11%); Mexico, 12% (9%, 14%); and South Africa, 24% (20%, 28%)] regardless of treatment status. A substantial proportion of individuals discontinued treatment [Indonesia, 70% (67%, 73%); China, 36% (32%, 40%); Mexico, 34% (29%, 39%); and South Africa, 20% (15%, 25%)], and most individuals lost BP control by follow-up [Indonesia, 92% (89%, 96%); Mexico, 77% (71%, 83%); China, 76% (69%, 83%); and South Africa 45% (36%, 54%)]. Our results highlight that policies solely aimed at improving diagnosis or initiating treatment may not lead to long-term hypertension control improvements in MICs.

Understanding of front of package nutrition labels: Guideline daily amount and warning labels in Mexicans with non-communicable diseases

One strategy for the prevention and treatment of non-communicable diseases (NCDs) is the implementation of the front-of-pack labeling (FoPL) in foods and beverages. In 2020, Mexico adopted the warning label system (WL) as a new public health policy, whose aim is to help consumers make healthier food choices. Previously, the Guideline Daily Amount (GDA) was the labelling used it. This paper aims to compare the understanding of two FoPL, the GDA and the WL, through the identification of unhealthy products in Mexicans with NCDs. We analyzed data from 14,880 Mexican adults older than 20 years old with NCDs (overweight-obesity (OW/O), self-reported diabetes mellitus 2 (DM2), or/and hypertension (HT), or/and dyslipidemia (Dys)). Participants were randomly assigned to one of two groups: the GDA labeling or WL. Each group had to respond to a survey and had to classify food products images as healthy or unhealthy according to the labelling system to which they were assigned. The correct classification was determined according to the criteria of Chile’s labeling nutrient profile stage 3. To evaluate the correct classification in each one of the groups we evaluated the differences in proportions. Logistic regression models were used to assess the likelihood to correctly classify the product according to participants’ number of diseases and WL information, taking GDA label as a reference. Participants who used the information contained in the GDA label misclassified food product labels in greater proportion (70%), mostly participants with three or more NCDs (participants with OW/O+ HT+ Dys, represent 42.3% of this group); compared with those who used WL (50%). The odds of correct classification of food products using WL image were two times greater compared to GDA image in participants with NCDs; being greater in participants with three or more NCDs. The study results highlight the usefulness of WL as it helps Mexicans with NCDs to classify unhealthy food products more adequately compared with GDA.

Ageing Perception as a Key Predictor of Self-Rated Health by Rural Older People—A Study with Gender and Inclusive Perspectives

This paper investigates positive perceptions of ageing in rural people aged 65 and over as a key predictor of the self-assessment of one’s health. Method: The sample covers a total of 3389 people from the ‘Survey of Health, Ageing and Retirement’ (SHARE), wave 6 (W6, 2015). This research analyses men and women who live in a rural environment. A linear regression model is proposed to consider the dependent variable ‘self-rated health’ and independent variables based on measures of quality of life in older adults. This study confirms that rural women perceive their health on the basis of factors different to those of their male contemporaries. The variable ‘How often do you feel/think that you can do the things that you want to do?’ is associated with women’s self-perceived health. In men, a high relationship (with p < 0.001) is obtained for the variables ‘How often do you feel/think look back on your life with a sense of happiness?’ and ‘How often do you feel/think that family responsibilities prevent you from doing what you want to do?’ Certain daily activities (e.g., leisure or care), along with a positive perception of life, influence one’s perceptions of one’s own health, especially in the case of women. In sum, rural older women make a positive evaluation of their own health and ageing, while rural older men relate self-rated health to passivity and reminiscing. There is a need for further research on psycho-social and socio-spatial issues from an intergenerational, technological and gender perspective for rural and territorial influences to attain better health and quality of life for rural older people in comparison to urban people.

Risk of chronic diseases in indigenous Totonacs from Mexico short running title: Risk of chronic diseases in indigenous Totonacs

AIM

The purpose of this study was to determine the risk of noncommunicable diseases (NCDs) development in four indigenous Totonac communities.

BACKGROUND

Poverty and low education levels increase the risk of unhealthy lifestyles, leading to a higher incidence of NCDs in indigenous communities. In addition, limited access to health services significantly reduces the opportune screening of risk factors.

METHODS

This was a cross-sectional observational study, in which we evaluated the incidence and/or the risk (%) to develop NCDs in adults from indigenous Totonac communities of Puebla State, Mexico. The sample consisted of 255 adults over 20 years old. Analysis of variance (ANOVA), Student's t-test, and Pearson's correlation were used for statistical analysis.

RESULTS

We found significant differences between communities regarding the risk of diabetes (p < 0.05) and hypertension (p < 0.01). However, there were no significant differences in terms of CVD risk (p > 0.05). Men were at higher risk for hypertension and CVD than women (37.8% vs 27.3% and 20.9% vs 12.2%, respectively), whereas women were at a higher risk of diabetes than men based on the FINDRISC score (11.7 vs 9.7, respectively).

CONCLUSION

The Zapotitlan community showed a higher risk of developing both diabetes and hypertension compared with the other communities. Men showed higher risks of hypertension and CVD compared with women. Women are at higher risk of diabetes than men.

Integrated Measurement for Early Detection (MIDO) as a digital strategy for timely assessment of non-communicable disease profiles and factors associated with unawareness and control: a retrospective observational study in primary healthcare facilities in Mexico

OBJECTIVES

The Carlos Slim Foundation implemented the Integrated Measurement for Early Detection (MIDO), a screening strategy for non-communicable diseases (NCDs) in Mexico as part of CASALUD, a portfolio of digital health services focusing on healthcare delivery and prevention/management of NCDs. We investigated the disease profile of the screened population and evaluated MIDO's contribution to the continuum of care of the main NCDs.

DESIGN

Using data from MIDO and the chronic diseases information system, we quantified the proportion of the population screened and diagnosed with NCDs, and measured care linkage/retention and level of control achieved. We analysed comorbidity patterns and estimated prevalence of predisease stages. Finally, we estimated characteristics associated with unawareness and control of NCDs, and examined efficacy of the CASALUD model in improving NCD control.

SETTING

Public primary health centres in 27/32 Mexican states.

PARTICIPANTS

Individuals aged ≥20 years lacking healthcare access.

RESULTS

From 2014 to 2018, 743 000 individuals were screened using MIDO. A predisease or disease condition was detected in ≥70% of the population who were unaware of their NCD status. The screening identified 38 417 new cases of type 2 diabetes, 53 133 new cases of hypertension and 208 627 individuals with obesity. Dyslipidaemia was found in 77.3% of individuals with available blood samples. Comorbidities were highly prevalent, especially in people with obesity. Only 5.47% (n=17 774) of individuals were linked with their corresponding primary health centre. Factors associated with unawareness of and uncontrolled NCDs were sex, age, and social determinants, for example, rural/urban environment, access to healthcare service, and education level. Patients with type 2 diabetes treated at clinics under the CASALUD model were more likely to achieve disease control (OR: 1.32, 95% CI: 1.09 to 1.61).

CONCLUSION

Patient-centred screening strategies such as MIDO are urgently needed to improve screening, access, retention and control for patients with NCDs.

Ethnic disparities in COVID-19 mortality in Mexico: A cross-sectional study based on national data

INTRODUCTION

Across the world, the COVID-19 pandemic has disproportionately affected racial and ethnic minorities. How ethnicity affects Indigenous peoples in Mexico is unclear. The aim of this cross-sectional study was to determine the mortality associated with ethnicity, particularly of Indigenous peoples, in a large sample of patients with COVID-19 in Mexico.

METHODS

We used open access data from the Mexican Ministry of Health, which includes data of all confirmed COVID-19 cases in the country. We used descriptive statistics to compare differences among different groups of patients. Logistic regression was used to calculate odds ratios while adjusting for confounders.

RESULTS

From February 28 to August 3, 2020, a total of 416546 adult patients were diagnosed with COVID-19. Among these, 4178 were Indigenous peoples. Among all patients with COVID-19, whether hospitalized or not, a higher proportion of Indigenous peoples died compared to non-Indigenous people (16.5% vs 11.1%, respectively). Among hospitalized patients, a higher proportion of Indigenous peoples died (37.1%) compared to non-Indigenous peoples (36.3%). Deaths outside the hospital were also higher among Indigenous peoples (3.7% vs 1.7%). A higher proportion of Indigenous peoples died in both the private and public health care sectors. The adjusted odds ratio for COVID-19 mortality among Indigenous peoples with COVID-19 was 1.13 (95% confidence interval 1.03 to 1.24). The adjusted odds ratio for COVID-19 mortality among Indigenous peoples with COVID-19 was higher among those who received only ambulatory care (1.55, 95% confidence interval 1.24 to 1.92).

DISCUSSION

In this large sample of patients with COVID-19, the findings suggest that Indigenous peoples in Mexico have a higher risk of death from COVID-19, especially outside the hospital. These findings suggest Indigenous peoples lack access to care more so than non-Indigenous people during the COVID-19 pandemic in Mexico.