Global Assessment of Palliative Care Need: Serious Health-Related Suffering Measurement Methodology

Inequities and gaps in palliative care access are a serious impediment to health systems especially low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions. In this paper, an updated methodology - SHS2.0 - is presented building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions. The updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. Detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, is also shared, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS. The discussion encompasses opportunities for applying SHS to future policy making assessment of future research priorities particularly in light of the dearth of data from low- and middle-income countries, and sharing of directions for future work to develop SHS 3.0.

Non-pharmaceutical interventions to combat COVID-19 in the Americas described through daily sub-national data

This dataset covers national and subnational non-pharmaceutical interventions (NPI) to combat the COVID-19 pandemic in the Americas. Prior to the development of a vaccine, NPI were governments' primary tools to mitigate the spread of COVID-19. Variation in subnational responses to COVID-19 is high and is salient for health outcomes. This dataset captures governments' dynamic, varied NPI to combat COVID-19 for 80% of Latin America's population from each country's first case through December 2021. These daily data encompass all national and subnational units in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru. The dataset includes individual and aggregate indices of nine NPI: school closures, work suspensions, public event cancellations, public transport suspensions, information campaigns, local travel restrictions, international travel controls, stay-at-home orders, and restrictions on the size of gatherings. We also collected data on mask mandates as a separate indicator. Local country-teams drew from multiple data sources, resulting in high-quality, reliable data. The dataset thus allows for consistent, meaningful comparisons of NPI within and across countries during the pandemic.

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.

Can You Hear Us Now? Equity in Global Advocacy for Palliative Care

Evidence-based advocacy underpins the sustainable delivery of quality, publicly guaranteed, and universally available palliative care. More than 60 million people in low- and middle-income countries (LMICs) have no or extremely limited access to either palliative care services or essential palliative care medicines (e.g., opioids) on the World Health Organization Model List. Indeed, only 12% of the global palliative care need is currently being met. Palliative care advocacy works to bring this global public health inequity to light. Despite their expertise, palliative care practitioners in LMICs are rarely invited to health policymaking tables - even in their own countries - and are underrepresented in the academic literature produced largely in the high-income world. In this paper, palliative care experts from Bangladesh, Colombia, Egypt, Sudan, Uganda, and Zambia affiliated with the International Association for Hospice & Palliative Care Advocacy Focal Point Program articulate the urgent need for evidence-based advocacy, focusing on significant barriers such as urban/rural divides, cancer-centeredness, service delivery gaps, opioid formulary limitations, public policy, and education deficits. Their advocacy is situated in the context of an emerging global health narrative that stipulates palliative care provision as an ethical obligation of all health systems. To support advocacy efforts, palliative care evaluation and indicator data should assess the extent to which LMIC practitioners lead and participate in global and regional advocacy. This goal entails investment in transnational advocacy initiatives, research investments in palliative care access and cost-effective models in LMICs, and capacity building for a global community of practice to capture the attention of policymakers at all levels of health system governance.

Strengthening Health Systems To Face Pandemics: Subnational Policy Responses To COVID-19 In Latin America

Nonpharmaceutical interventions such as stay-at-home orders continue to be the main policy response to the COVID-19 pandemic in countries with limited or slow vaccine rollout. Often, nonpharmaceutical interventions are managed or implemented at the subnational level, yet little information exists on within-country variation in nonpharmaceutical intervention policies. We focused on Latin America, a COVID-19 epicenter, and collected and analyzed daily subnational data on public health measures in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru to compare within- and across-country nonpharmaceutical interventions. We showed high heterogeneity in the adoption of these interventions at the subnational level in Brazil and Mexico; consistent national guidelines with subnational heterogeneity in Argentina and Colombia; and homogeneous policies guided by centralized national policies in Bolivia, Chile, and Peru. Our results point to the role of subnational policies and governments in responding to health crises. We found that subnational responses cannot replace coordinated national policy. Our findings imply that governments should focus on evidence-based national policies while coordinating with subnational governments to tailor local responses to changing local conditions.

The feminization of medicine in Latin America: 'More-the-merrier' will not beget gender equity or strengthen health systems

This viewpoint addresses the lack of gender diversity in medical leadership in Latin America and the gap in evidence on gender dimensions of the health workforce. While Latin America has experienced a dramatic change in the gender demographic of the medical field, the health sector employment pipeline is rife with entrenched and systemic gender inequities that continue to perpetuate a devaluation of women; ultimately resulting in an under-representation of women in medical leadership. Using data available in the public domain, we describe and critique the trajectory of women in medicine and characterize the magnitude of gender inequity in health system leadership over time and across the region, drawing on historical data from Mexico as an illustrative case. We propose recommendations that stand to disrupt the status quo to more appropriately value women and their representation at the highest levels of decision making for health. We call for adequate measurement of equity in medical leadership as a matter of national, regional, and global priority and propose the establishment of a regional observatory to monitor and evaluate meaningful progress towards gender parity in the health sector as well as in medical leadership.

Optimizing the Global Nursing Workforce to Ensure Universal Palliative Care Access and Alleviate Serious Health-Related Suffering Worldwide

CONTEXT

Palliative care access is fundamental to the highest attainable standard of health and a core component of universal health coverage. Forging universal palliative care access is insurmountable without strategically optimizing the nursing workforce and integrating palliative nursing into health systems at all levels. The COVID-19 pandemic has underscored both the critical need for accessible palliative care to alleviate serious health-related suffering and the key role of nurses to achieve this goal.

OBJECTIVES

1) Summarize palliative nursing contributions to the expansion of palliative care access; 2) identify emerging nursing roles in alignment with global palliative care recommendations and policy agendas; 3) promote nursing leadership development to enhance universal access to palliative care services.

METHODS

Empirical and policy literature review; best practice models; recommendations to optimize the palliative nursing workforce.

RESULTS

Nurses working across settings provide a considerable untapped resource that can be leveraged to advance palliative care access and palliative care program development. Best practice models demonstrate promising approaches and outcomes related to education and training, policy and advocacy, and academic-practice partnerships.

CONCLUSION

An estimated 28 million nurses account for 59% of the international healthcare workforce and deliver up to 90% of primary health services. It has been well-documented that nurses are often the first or only healthcare provider available in many parts of the world. Strategic investments in international and interdisciplinary collaboration, as well as policy changes and the safe expansion of high-quality nursing care, can optimize the efforts of the global nursing workforce to mitigate serious health-related suffering.

Punt Politics as Failure of Health System Stewardship: Evidence from the COVID-19 Pandemic Response in Brazil and Mexico

We present a new concept, Punt Politics, and apply it to the COVID-19 non-pharmaceutical interventions (NPI) in two epicenters of the pandemic: Mexico and Brazil. Punt Politics refers to national leaders in federal systems deferring or deflecting responsibility for health systems decision-making to sub-national entities without evidence or coordination. The fragmentation of authority and overlapping functions in federal, decentralized political systems make them more susceptible to coordination problems than centralized, unitary systems. We apply the concept to pandemics, which require national health system stewardship, using sub-national NPI data that we developed and curated through the Observatory for the Containment of COVID-19 in the Americas to illustrate Punt Politics in Mexico and Brazil. Both countries suffer from protracted, high levels of COVID-19 mortality and inadequate pandemic responses, including little testing and disregard for scientific evidence. We illustrate how populist leadership drove Punt Politics and how partisan politics contributed to disabling an evidence-based response in Mexico and Brazil. These cases illustrate the combination of decentralization and populist leadership that is most conducive to punting responsibility. We discuss how Punt Politics reduces health system functionality, providing lessons for other countries and future pandemic responses, including vaccine rollout.

A partisan pandemic: state government public health policies to combat COVID-19 in Brazil

INTRODUCTION

To present an analysis of the Brazilian health system and subnational (state) variation in response to the COVID-19 pandemic, based on 10 non-pharmaceutical interventions (NPIs).

MATERIALS AND METHODS

We collected daily information on implementation of 10 NPI designed to inform the public of health risks and promote distancing and mask use at the national level for eight countries across the Americas. We then analyse the adoption of the 10 policies across Brazil's 27 states over time, individually and using a composite index. We draw on this index to assess the timeliness and rigour of NPI implementation across the country, from the date of the first case, 26 February 2020. We also compile Google data on population mobility by state to describe changes in mobility throughout the COVID-19 pandemic.

RESULTS

Brazil's national NPI response was the least stringent among countries analysed. In the absence of a unified federal response to the pandemic, Brazilian state policy implementation was neither homogenous nor synchronised. The median NPI was no stay-at-home order, a recommendation to wear masks in public space but not a requirement, a full school closure and partial restrictions on businesses, public transportation, intrastate travel, interstate travel and international travel. These restrictions were implemented 45 days after the first case in each state, on average. Rondônia implemented the earliest and most rigorous policies, with school closures, business closures, information campaigns and restrictions on movement 24 days after the first case; Mato Grosso do Sul had the fewest, least stringent restrictions on movement, business operations and no mask recommendation.

CONCLUSIONS

The study identifies wide variation in national-level NPI responses to the COVID-19 pandemic. Our focus on Brazil identifies subsequent variability in how and when states implemented NPI to contain COVID-19. States' NPIs and their scores on the composite policy index both align with the governors' political affiliations: opposition governors implemented earlier, more stringent sanitary measures than those supporting the Bolsonaro administration. A strong, unified national response to a pandemic is essential for keeping the population safe and disease-free, both at the outset of an outbreak and as communities begin to reopen. This national response should be aligned with state and municipal implementation of NPI, which we show is not the case in Brazil.

Domestic violence during the COVID-19 pandemic - Evidence from a systematic review and meta-analysis

PURPOSE

The aim of this review was to estimate the effect of COVID-19-related restrictions (i.e., stay at home orders, lockdown orders) on reported incidents of domestic violence.

METHODS

A systematic review of articles was conducted in various databases and a meta-analysis was also performed. The search was carried out based on conventional scientific standards that are outlined in the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) and studies needed to meet certain criteria.

RESULTS

Analyses were conducted with a random effects restricted maximum likelihood model. Eighteen empirical studies (and 37 estimates) that met the general inclusion criteria were used. Results showed that most study estimates were indicative of an increase in domestic violence post-lockdowns. The overall mean effect size was 0.66 (CI: 0.08-1.24). The effects were stronger when only US studies were considered.

CONCLUSION

Incidents of domestic violence increased in response to stay-at-home/lockdown orders, a finding that is based on several studies from different cities, states, and several countries around the world.

Access to paediatric cancer care treatment in Mexico: responding to health system challenges and opportunities

In Mexico, paediatric cancer is the leading cause of death for children aged 0-18 years. This study analyses the main challenges for paediatric cancer care from the perspective of three key health systems functions: stewardship, financing and service delivery. The study used a mixed methods approach comprised of: (1) a scoping literature review, (2) an analysis of 2008-18 expenditures on paediatric cancer by the Fund for Protection against Catastrophic Expenditures (FPGC) of Seguro Popular and (3) a nation-wide survey of the supply capacity of 59 Ministry of Health (MoH) and 39 Mexican Institute of Social Security (IMSS) hospitals engaged in paediatric cancer care. The study found that while Mexico has made substantial progress towards universal health coverage (UHC) for paediatric cancer treatment, serious gaps persist. FPGC funds for paediatric cancer increased from 2008 to 2011 to reach US$36 million and then declined to US$13.6 million in 2018, along with the number of covered cases. The distribution of health professionals and paediatric oncology infrastructure is uneven between MoH and IMSS hospitals and across Mexican regions. Both institutions share common barriers for continuous and co-ordinated health care and lack monitoring activities that cripple their capacity to apply uniform standards for high-quality cancer care. In conclusion, achieving universal and effective coverage of paediatric cancer treatment is a critical component of UHC for Mexico. This requires periodic and ongoing assessment of health system performance specific to paediatric cancer to identify gaps and propose strategies for continued investment and improvement of access to care and health outcomes for this important cause of premature mortality.

Self-identity, lived experiences, and challenges of breast, cervical, and prostate cancer survivorship in Mexico: a qualitative study

Background

Qualitative research on cancer patients’ survivor-identity and lived experiences in low- and middle-income countries is scarce. Our study aimed at exploring the concept and experience of survivorship for Mexicans living with breast, cervical, and prostate cancer.

Methods

We conducted a qualitative study in Mexico City, Morelos, Nuevo León, and Puebla. The participants were breast, cervical, and prostate cancer patients ≥18 years of age with completed primary cancer treatment. Data were collected via in-depth interviews and analyzed using an inductive thematic approach.

Results

The study included 22 participants with a history of breast, 20 cervical, and 18 prostate cancer. Participants accepted the term “cancer survivor” as a literal interpretation of being alive, medical confirmation of treatment completion, or achievement of a clinical result possibly indicative of cure. The majority of respondents perceived that the future is out of their control and under God’s will. They linked cure to divine intervention and did not demonstrate the sense of empowerment that is often associated with the survivorship term. The principal themes of their narratives encompass: 1) adverse physical and sexual experiences; 2) emotional problems; 3) cancer-related stigma; 4) challenges to obtaining health-related information; 5) financial hardship; and 6) experience of strengthening family ties in order to provide them with support. In addition, women with breast cancer reported distress caused by changes in body image and positive experience with support groups.

Conclusion

In Mexico, cancer patients report complex survivorship experiences that demand post-treatment follow-up and support. There is the need to implement comprehensive, culturally-relevant survivorship programs focused on emotional, informational, and in-kind support and empowerment of cancer patients.

Psychometric validation of a Patient-Centred Quality of Cancer Care Questionnaire in Mexico

OBJECTIVES

To develop and validate a Patient-Centred Quality of Cancer Care Questionnaire in Spanish (PCQCCQ-S) appropriate to the Mexican context.

DESIGN

Psychometric validation of a questionnaire.

SETTING

Two public oncology hospitals in Mexico City.

PARTICIPANTS

1809 patients with cancer aged ≥18 years.

SOURCE OF INFORMATION

Cross-sectional survey.

METHODS

The validation procedures comprised (1) content validity through a group of experts and patients; (2) item reduction and evaluation of the factor structure, through an exploratory factor analysis based on the polychoric correlation matrix; (3) internal consistency using Cronbach's alpha; (4) convergent validity between the PCQCCQ-S and supportive care needs scale; (5) correlation analysis between the PCQCCQ-S and quality of life scale by calculating Spearman's rank-correlation coefficient; and (6) differentiation by 'known groups' through the Wilcoxon rank-sum test.

RESULTS

The PCQCCQ-S has 30 items with the following five factors accounting for 96.5% of the total variance: (1) timely care; (2) clarity of the information; (3) information for treatment decision-making; (4) activities to address biopsychosocial needs; and (5) respectful and coordinated care. Cronbach's alpha values ranged from 0.73 to 0.90 among the factors. PCQCCQ-S has moderate convergent validity with supportive care needs scale, revealing that higher quality is correlated with lower patient needs. PCQCCQ-S has acceptable ability to differentiate by 'known groups', showing that older patients and those with low levels of education perceived lower total quality of care as compared with their counterparts.

CONCLUSION

PCQCCQ-S has acceptable psychometric properties and can be used to measure quality of patient-centred cancer care in Mexico and serve as a reference to develop PCQCCQ-S in other Spanish-speaking countries.

Avoidable Mortality: The Core of the Global Cancer Divide

Purpose

The incidence of infection-associated cancers and lethality of cancers amenable to treatment are closely correlated with the income of countries. We analyzed a core part of this global cancer divide—the distribution of premature mortality across country income groups and cancers—applying novel approaches to measure avoidable mortality and identify priorities for public policy.

Methods

We analyzed avoidable cancer mortality using set lower- and upper-bound age limits of 65 and 75 years (empirical approach), applying cancer-specific and country income group–specific ages of death (feasibility approach), and applying cancer-specific ages of death of high-income countries to all low- and middle-income countries (LMICs; social justice approach). We applied these methods to 2015 mortality data on 16 cancers for which prevention is possible and/or treatment is likely to result in cure or significant increase in life expectancy.

Results

At least 30% and as much as 50% of cancer deaths are premature, corresponding to between 2.6 and 4.3 million deaths each year, and 70% to 80% are concentrated in LMICs. Using the feasibility approach, 36% of cancer deaths are avoidable; with the social justice approach, 45% of cancer deaths are avoidable. Five cancer types—breast, colorectal, lung, liver, and stomach—account for almost 75% of avoidable cancer deaths in LMICs and worldwide.

Conclusion

Each year, millions of premature cancer deaths could be avoided with interventions focused on four priority areas: infection-associated cancers, lifestyle and risk factors, women’s cancers, and children’s cancers. Our analysis of the global burden and the specific cancer types associated with avoidable cancer mortality suggests significant opportunities for health systems to redress the inequity of the global cancer divide.

Solving the Global Crisis in Access to Pain Relief: Lessons From Country Actions

Annually, more than 61 million people worldwide experience about 6 billion days of serious health-related suffering that could be alleviated with access to palliative care and pain relief. However, palliative care is limited or nonexistent in most parts of the world. The access abyss is so stark that 50% of the world's poorest populations live in countries that receive only 1% of the opioid analgesics distributed worldwide. By contrast, the richest 10% of the world's population live in countries that receive nearly 90% of the opioid pain relief medications.The Lancet Commission on Global Access to Palliative Care and Pain Relief developed a framework to measure the global burden of serious health-related suffering and generated the evidence base to address this burden.We present the inequities in access to pain relief and highlight key points from country responses, drawing from and building on recommendations of the Lancet Commission report "Alleviating the Access Abyss in Palliative Care and Pain Relief-An Imperative of Universal Health Coverage" to close the access abyss in relief of pain and other types of serious health-related suffering.

Efecto del Seguro Popular de Salud sobre los gastos catastróficos y empobrecedores en México, 2004-2012

Objetivos. Determinar el impacto del Seguro Popular (SPS) en los gastos catastróficos y empobrecedores de los hogares y la protección financiera del sistema de salud en México. Material y métodos. Se aplicó el método de pareo por puntaje de propensión sobre la afiliación al SPS y se determinó el efecto atribuible en el gasto en salud. Se hizo uso de la Encuesta Nacional de Ingresos y Gastos de los Hogares (ENIGH) de 2004 a 2012, del Instituto Nacio­nal de Estadística y Geografía. Resultados. El SPS tiene un efecto significativo reductor en la probabilidad de sufrir gastos empobrecedores. En lo que respecta a los gastos ca­tastróficos hubo reducción sin ser significativa entre grupos. Conclusión. Este estudio demuestra el efecto que el SPS, y en particular el aseguramiento en salud, tiene como un instrumento de protección financiera. Para futuros estudios se propone analizar la persistencia del alto porcentaje del gasto de bolsillo aprovechando series de tiempo más largas de la ENIGH.

Abstract IS-1: Health System Responses to Women's Cancers in the Americas: Closing Divides to Achieve Universal Health Coverage

To address the challenges of the increasing cancer burden, low- and middle-income country health systems must function in an integrated manner across the care continuum from prevention to palliative care. Health systems must address disease-specific priorities and systemic challenges synergistically, as envisioned in a diagonal approach to health systems strengthening, which overcomes the barriers between vertical (disease-specific) and horizontal (systemic) approaches by making full use of potential synergies between different programs and allows the development of common delivery platforms that consider shared risk factors across diseases to optimize available resources.

The challenges of meeting the double burden of cancer are epitomized by women's cancers in Latin America: the persistence of preventable cancers like cervical cancer that are especially prevalent among the poor; and the emerging challenge of cancers like breast cancer, that cannot be prevented, but whose impact could be dramatically reduced through early detection and treatment and that affect women of all socio-economic strata. Further, women face specific challenges associated with stigma and discrimination that exacerbate their risks of dying and suffering from cancer, especially those affecting reproductive health. As many Latin American countries continue making strides to ensure health care access for all through universal health coverage, they must aim to effectively meet the challenge of these chronic illnesses across the entire care continuum.

We outline strategies to strengthen health systems through a diagonal approach using the example of how the Mexican health system has responded to the challenge of breast cancer to illustrate effective universal health coverage along the chronic disease continuum and across health systems functions. We also present innovative financing and delivery models, as well as educational interventions that build on overall efforts to strengthen primary care by linking to existing platforms related to reproductive and maternal and child health.

Citation Format: Knaul FM. Health System Responses to Women's Cancers in the Americas: Closing Divides to Achieve Universal Health Coverage [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr IS-1.

Costs of breast cancer care in Mexico: analysis of two insurance coverage scenarios

BACKGROUND

Breast cancer (BC) is a major cause of disease and death worldwide. In addition to its contribution to mortality and disability, it is a major economic burden both public and private.

OBJECTIVE

To estimate the average direct medical cost/year of care for the diagnosis and treatment of BC in two coverage scenarios in Mexico: What is 'ideal' based on service usage patterns according to international guidelines and what is 'current' using the service usage patterns of suppliers in Mexico.

MATERIAL AND METHODS

The pattern and intensity of use of procedures for the care of BC in the Mexican Social Security Institute (IMSS) for 2009 were identified and prices were associated using the guidelines from the System of Social Protection in Health (SPSS) and the IMSS for the current scenario and the ideal scenario, international patterns (Breast Health Global Initiative BHGI after its acronym in English) were used and prices were associated from the SPSS guidelines.

RESULTS

The annual average direct medical cost per patient in the 'current' scenario was 8557 US$, while the cost in the 'ideal' scenario was 4554 US$. There are differences in costs between 'what we do' and 'what should be done', due to differences in the implementation of the interventions for the treatment of the different stages of the disease. A proportional increase in the average cost was also identified as the diagnosis stage advanced (from I to III).

CONCLUSIONS

Given that in Mexico there is universal insurance coverage for the treatment of BC, it is necessary to use economic resources more efficiently. It is necessary to continue to examine this topic in more depth and the next step will be to assess the effectiveness of both scenarios in order to provide enough evidence for the decision-making process.

Breast cancer age at diagnosis patterns in four Latin American Populations: A comparison with North American countries

BACKGROUND

In the Latin America countries (LAC), one in five breast cancer (BC) cases occur in women younger than 45 years, almost twice the frequency seen in developed countries. Most BC cases in younger women are premenopausal and are generally more difficult to detect at early stages and to treat than postmenopausal cancers. We employ data from four high quality population-based registries located in LAC and assess the extent to which the higher frequency of BC occurring in younger women is due to a younger population structure, compared to that of developed countries. Next, we analyze secular and generational trends of incidence rates in search for additional explanations.

METHODS

Using data from the International Agency for Research on cancer, between 1988 and 2007, the age distribution of BC incident cases for registries located in Brazil, Colombia, Costa Rica, Ecuador is compared to that of USA and Canadian registries, both before and after removing differences in population age structure. An age-period-cohort modelling of incidence rates is also conducted in all compared registries to identify secular and generational effects.

RESULTS

BC incident cases in the LAC registries present, on average, at an earlier age than in the USA and Canadian registries and for 2003-2007, between 20 and 27% of cases occur in women aged 20-44. About two thirds of the difference in age distribution between LAC and USA registries is attributable to the younger age distribution in the LAC base populations. The USA registries show the highest age-specific BC incidence rates of all compared aggregated registries, at all ages. However, in all the LAC registries incidence rates are rapidly increasing, fueled by a strong birth cohort effect. This cohort effect may be explained by important reduction in fertility rates occurring during the second half of the 20th century, but also by a greater exposure to other risk factors for BC related to the adoption of life styles more prevalent in developed countries.

CONCLUSION

The younger age at presentation of BC incident cases seen in the analyzed LAC registries, and possibly in many Latin American countries, is not only attributable to their relatively young population age structure but also to the low incidence rates in older women. As more recently born cohorts, with greater exposure to risk factors for postmenopausal BC, reach older age, incidence rates will be more similar to the rates seen in the USA and Canadian registries. There is a need for additional research to identify determinants of the higher BC rate among younger women in these countries.

Developing palliative care capacity in Colombia and Mexico

103

Background: Access to pain relief and palliative care often is limited or absent in low-and-middle-income countries (LMICs). Consequently, millions of patients with cancer and other serious illnesses in LMICs suffer needlessly. Multiple stakeholders have joined efforts to enhance the delivery of palliative care, develop national plans, and advocate for improved policies and regulations in Colombia and Mexico with applications to other LMICs. Methods: In Mexico and Colombia, efforts to improve access to palliative care focus on regulatory frameworks, finance, delivery, research and capacity-building, as per World Health Organization recommendations. In Colombia, health and educational institutions have partnered with non-governmental organizations to advise the Ministry of Health (MOH) and Senate. In Mexico, a range of governmental, legislative and private institutions are developing a National Palliative Care Plan. Results: Colombia: Laws passed in 2010 and 2013 require palliative care be available for all cancer patients. The allowable length of opioid prescriptions has been extended from 10 to 30 days, strong opioids must be freely available, and the MOH requires at least 1 pharmacy per State be able to dispense opioids 24/7. Mexico: Amendments to the health law introduced palliative care and pain management as a right for people with terminal illness. The government plans a new digital system to make opioid prescribing more efficient and secure, and the pharmaceutical industry is developing systems for monitoring production and supply. Yet, in both countries, palliative care training is mandatory in less than 5% of medical schools and innovative materials are being developed to train practicing primary care personnel. Conclusions: To meet palliative care needs in LMICs, novel approaches are required to develop and implement national plans, train healthcare providers, educate government officials, and advocate for policies that improve equitable access. Exemplary work in Colombia and Mexico illustrate effective strategies to improve palliative care delivery in LMICs.

Evaluation of breast cancer knowledge among health promoters in Mexico before and after focused training

OBJECTIVE

Breast cancer is a leading cause of morbidity and mortality in Mexico. We assessed the effectiveness of a train-the-trainer program in two Mexican states in improving knowledge among professional and nonprofessional community health workers.

MATERIALS AND METHODS

We worked with local organizations to develop and implement a train-the-trainer program to improve breast cancer knowledge among community health workers, including professional health promoters (PHPs) who were trained and then trained nonprofessional community health promoters (CHPs). We surveyed participants before and after training that included in-person and online classes and again approximately 3 months later. We used paired t tests and chi-square tests to compare survey responses at the different times. We also used logistic regression to assess whether promoter characteristics were associated with greater improvements in breast cancer knowledge after training.

RESULTS

Overall, 169 PHPs (mean age, 36 years) completed training and provided a 10-hour training course to 2,651 CHPs, who also completed the pre- and post-training survey. For both PHPs and CHPs, post-training surveys demonstrated increases in an understanding of breast cancer as a problem; an understanding of screening, treatment, and insurance coverage issues; and knowledge of breast cancer risk factors, symptoms, and what constitutes a family history of breast cancer (all p < .05). These improvements were maintained 3 to 6 months after training.

CONCLUSION

Train-the-trainer programs hold promise for leveraging community health workers, who far outnumber other health professionals in many low- and middle-income countries, to engage in health promotion activities for cancer and other noncommunicable diseases.

Utilización correcta de las técnicas de detección de cáncer de mama en mujeres mexicanas

Objetivo. Identificar las características asociadas con la prevalencia de utilización correcta de la autoexploración manual (AE), el examen clínico (EC) y la mamografía (MA) para la detección de cáncer mamario (CaMa). Material y métodos. Se entrevistó a 1 030 mujeres mexicanas, sanas, de entre 20 y 88 años sobre su historia reproductiva y sociodemográfica. Con base en la forma y frecuencia de realización de estas técnicas de detección, se construyó un índice de utilización correcta. Resultados. La prevalencia de utilización correcta de la AE fue de 11% y del EC de 5.4%. El 7.6% de las mujeres entre 40 y 49 años y 31.6% de las mujeres con 50 años o más se realizaron una MA de acuerdo con la norma vigente al momento del estudio. El aseguramiento por parte del Instituto Mexicano del Seguro Social, del Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado o del Seguro Popular fue el principal determinante de la utilización de la MA. Conclusiones. Se evidencia la necesidad de incrementar la correcta utilización de la AE, el EC y la MA.

[Correct utilization of breast cancer detection techniques in Mexican women]

OBJECTIVE

Identify the characteristics associated with correct utilization of self examination (SE), clinical exam (CE) and mammography (MA) for breast cancer (BC) early detection.

MATERIALS AND METHODS

Interviews were undertaken with 1 030 Mexican women (n=1 030), 20 to 88 years of age, regarding their reproductive and sociodemographic characteristics. An index of correct utilization was constructed based on the form and frequency practice of those techniques.

RESULTS

The prevalence of correct utilization of SE was 11% and 5.4% for CE. Further, 7.6% of women 40-49 years of age with 2 or more BC risk factors had MA during the two years prior to the interview, and for 31.6% among women ≥50 years of age the MA was annually. The main determinant of MA utilization was having financial protection from either IMSS, ISSSTE or Seguro Popular.

CONCLUSIONS

It is necessary to improve the correct utilization of BC detection techniques in Mexico.