Barriers and facilitators to influenza vaccination observed by officers of national immunization programs in South America countries with contrasting coverage rates

Influenza is a severe, vaccine-preventable disease. Vaccination programs across Latin American countries show contrasting coverage rates, from 29% in Paraguay to 89% in Brazil. This study explores how national influenza vaccination programs in the chosen South American countries address vaccine confidence and convenience, as well as complacency toward the disease. Barriers and facilitators to influenza vaccination programs in their relation to vaccine hesitancy were observed by documentary analysis and interviews with 38 national immunization program officers in high- (Brazil and Chile) and low-performing (Paraguay, Peru, and Uruguay) countries. Influenza vaccination policies, financing, purchasing, coordination, and accessibility are considered good or acceptable. National communication strategies focus on vaccine availability during campaigns. In Chile, Paraguay, and Uruguay, anti-vaccine propaganda was mentioned as a problem. Programming and implementation face human resource shortages across most countries. Statistical information, health information systems, and nominal risk-group records are available, with limitations in Peru and Paraguay. Health promotion, supervision, monitoring, and evaluation are perceived as opportunities to address confidence and complacency. Influenza vaccination programs identify and act on most barriers and facilitators affecting influenza vaccine hesitancy via supply-side strategies which mostly address vaccine convenience. Confidence and complacency are insufficiently addressed, except for Uruguay. Programs have the opportunity to develop integral supply and demand-side approaches.

Influenza vaccination hesitancy in large urban centers in South America. Qualitative analysis of confidence, complacency and convenience across risk groups

Influenza vaccination coverage in countries of Latin America is low among priority risk groups, ranging from 5 to 75% among older people. This paper aims to describe and analyze the determinants of influenza vaccination hesitancy through the lens of the 3C model of confidence, complacency and convenience among middle-class, urban risk group populations in Brazil, Chile, Paraguay, Peru, Uruguay, countries in South America with contrasting vaccination coverage. Focus groups were conducted among four risk groups: pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥60 years in samples of urban residents. Adults with risk factors expressed the most detailed perceptions about confidence in the vaccine. A wide range of perceptions regarding complacency were expressed across risk groups and countries, with pregnant women and mothers showing greater concerns while convenience had a narrower and generally more positive range of perceptions. Participants from Chile and Paraguay expressed the most contrasts regarding confidence and complacency. Information and communication strategies need to be tailored for risk groups while confidence and complacency should be addressed in synergy.

The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru

Influenza vaccination has been available under Peru's national immunization program since 2008, but vaccination coverage has decreased lately. Surveys and focus groups were conducted among four risk groups (pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥65 years) to identify factors affecting influenza vaccine hesitancy in Peru. The 3Cs model (Confidence, Complacency, and Convenience) was used as a conceptual framework for the study. Most pregnant women and mothers of young children (70.0%), but less than half (46.3%) of older adults and adults with risk factors were vaccinated against influenza. Vaccine confidence and complacency were positively associated with educational level. Complacency was the most deficient of the 3Cs. Pregnant women and mothers were the most informed and least complacent among risk groups. Focus groups revealed the misconceptions behind the high level of complacency observed, including the perception of influenza risk and the role assigned to vaccination in preventing the disease. Interviews with officials identified that most strategies are directed to vaccination availability and hence to convenience, with opportunities for strategies to improve vaccination uptake and community engagement. The results highlight the importance of implementing in Peru communication strategies to increase perceptions of vaccine safety and effectiveness thus improving confidence and reducing complacency. The establishment of explicit incentives should also be considered to increase vaccination uptake, particularly to health personnel.

Influenza vaccination hesitancy in five countries of South America. Confidence, complacency and convenience as determinants of immunization rates

INTRODUCTION

Influenza morbidity and mortality are significant in the countries of South America, yet influenza vaccination is as low as 56.7% among pregnant women, reaching 76.7% of adults with chronic diseases. This article measures the relative values for the vaccination hesitancy indicators of confidence, complacency and convenience by risk-groups in urban areas of five countries of South America with contrasting vaccination rates, analyzing their association with sociodemographic variables and self-reported immunization status.

METHODS

An exit survey was applied to 640 individuals per country in Brazil, Chile, Paraguay, Peru and Uruguay, distributed equally across risk groups of older adults, adults with risk factors, children ≤6 and pregnant women. Indicators were constructed for vaccine confidence, complacency and convenience. Analysis of variance and multiple logistic analysis was undertaken.

RESULTS

Adults with risk factors are somewhat more confident of the influenza vaccine yet also more complacent. Convenience is higher for mothers of minors. Children and older adults report higher levels of vaccination. The 3Cs are more different across countries than across risk groups, with values for Chile higher for confidence and those for Uruguay the lowest. Complacency is lower in Brazil and higher in Uruguay. Results suggest that confidence and complacency affect vaccination rates across risk groups and countries.

CONCLUSIONS

Influenza vaccine confidence, complacency and convenience have to be bolstered to improve effective coverage across all risk groups in the urban areas of the countries studied. The role played by country contextual and national vaccination programs has to be further researched in relation to effective coverage of influenza vaccine.

Increased Risk of Hospitalization and Death in Patients with COVID-19 and Pre-existing Noncommunicable Diseases and Modifiable Risk Factors in Mexico

BACKGROUND

The population in Mexico has high prevalence rates of noncommunicable diseases (NCDs). Hospitalization and death of COVID-19 patients in the countries most affected by the pandemic has been associated to chronic comorbidities.

OBJECTIVE

To describe the prevalence of NCDs in patients with COVID-19 in Mexico and analyze the increased risk due to comorbidities and risk factors on hospitalization, utilization of intensive care units and death.

METHODS

A cross-sectional study was performed from 212,802 confirmed COVID-19 cases reported by the Ministry of Health up to June 27, 2020. Odds ratios were performed using logistic regression model.

RESULTS

Up to 47.40% of patients with COVID-19 diagnosis were also reported with a comorbidity, with hypertension being the most frequent (20.12%). The report of at least one NCD significantly increased the risk of death with respect to patients without such diagnoses. Chronic kidney disease increased the risk of death the most (OR 2.31), followed by diabetes (OR 1.69), immunosuppression (OR 1.62), obesity (OR 1.42), hypertension (OR 1.24), chronic obstructive pulmonary disease (OR 1.20). The comorbidities that most increased the risk of ICU and of intubation were diabetes, immunosuppression and obesity.

CONCLUSION

NCD comorbidities increase the severity of COVID-19 infection. Given high NCD prevalence rates among the Mexican population, the pandemic poses a special threat to the health system and to society. Special prevention measures need to be strengthened for persons with NCD diagnoses in the short-term. In the mid-term, disease control strategies need to be improved to protect these patients against COVID-19 severity.

Loss of job-related right to healthcare is associated with reduced quality and clinical outcomes of diabetic patients in Mexico

Objectives

The Mexican Institute of Social Security (IMSS) provides a package of health, economic and social benefits to workers employed in private firms within the formal labour market and to their economic dependants. Affiliates have a right to these benefits only while they remain contracted, thus posing a risk for the continuity of healthcare. This study evaluates the association between the time (in days) without the right to healthcare due to job loss in the formal labour market and the quality of healthcare and clinical outcomes among IMSS affiliates with Type 2 diabetes mellitus (T2DM).

Design

Retrospective cohort study 2013-2015.

Setting

Six IMSS family medicine clinics (FMC) in Mexico City.

Participants

T2DM patients (n = 27 217) affiliated with job-related health insurance and at least one consultation with a family doctor during 2013.

Source of Information

IMSS affiliation department database and electronic health records and clinical laboratory databases.

Main Outcome Measure(s)

Quality of the processes (eight indicators) and outcomes (three indicators) of healthcare.

Results

The results indicated that losing IMSS right to healthcare is frequent, occurring to one-third of T2DM patients during the follow-up period. The time without the right to healthcare in the observed period was of 120 days on average and was associated with a 43.2% loss of quality of care and a 19.2% reduction in clinical outcomes of T2DM.

Conclusion

Policies aimed at ensuring access and continuity of care, regardless of job status, are critical for improving the quality of processes and outcomes of healthcare for diabetic patients.

Loss of job-related right to healthcare associated with employment turnover: challenges for the Mexican health system

Background

The Mexican health system segments access and right to healthcare according to worker position in the labour market. In this contribution we analyse how access and continuity of healthcare gets interrupted by employment turnover in the labour market, including its formal and informal sectors, as experienced by affiliates to the Mexican Institute of Social Security (IMSS) at national level, and of workers with type 2 diabetes (T2DM) in Mexico City.

Methods

Using data from the National Employment and Occupation Survey, 2014, and from IMSS electronic medical records for workers in Mexico City, we estimated annual employment turnover rates to measure the loss of healthcare access due to labour market dynamics. We fitted a binary logistic regression model to analyse the association between sociodemographic variables and employment turnover. Lastly we analysed job-related access to health care in relation to employment turnover events.

Results

At national level, 38.3% of IMSS affiliates experienced employment turnover at least once, thus losing the right to access to healthcare. The turnover rate for T2DM patients was 22.5%. Employment turnover was more frequent at ages 20–39 (38.6% national level; 28% T2DM) and among the elderly (62.4% national level; 26% T2DM). At the national level, higher educational levels (upper-middle, OR = 0.761; upper, OR = 0.835) and income (5 minimum wages or more, OR = 0.726) were associated with lower turnover. Being single and younger were associated with higher turnover (OR = 1.413). T2DM patients aged 40–59 (OR = 0.655) and with 5 minimum wages or more (OR = 0.401) experienced less turnover. Being a T2DM male patient increased the risk of experiencing turnover (OR = 1.166). Up to 89% of workers losing IMSS affiliation and moving on to other jobs failed to gain job-related access to health services. Only 9% gained access to the federal workers social security institute (ISSSTE).

Conclusions

Turnover across labour market sectors is frequently experienced by the workforce in Mexico, worsening among the elderly and the young, and affecting patients with chronic diseases. This situation needs to be prospectively addressed by health system policies that aim to expand the financial health protection during an employment turnover event.

[What is purchased, how and from whom by Seguro Popular in Mexico? Experience with strategic purchasing at national level and in a pioneer institution]

Objective:

To analyze the scope of demand subsidies through strategic purchasing of health services.

Materials and methods:

Interviews and document analyses at national level and a case study of the state of Hidalgo.

Results:

SPSS explicitly prioritizes interventions to be financed and regulates prices and expenditure ceilings. Public providers are predominantly funded through the purchasing of inputs and the contracting of human resources, in the absence of competition and with a low degree of managerial autonomy. Seguro Popular in Hidalgo has diversified service providers and payment mechanisms.

Conclusions:

SPSS has ample opportunity to extend and deepen strategic purchasing. Greater decision-making autonomy of payers and providers is required, as well as regulations to promote provider networks in competitive environments.

Desafíos en la implantación de guías de práctica clínica en instituciones públicas de México: estudio de casos múltiple

Objetivo. Identificar, jerarquizar y relacionar barreras y facilitadores en la implantación de las Guías de Práctica Clínica (GPC). Material y métodos. Estudio cualitativo que compara la implantación de GPC a través de los dominios del marco consolidado para la investigación de implementación en hospitales de las tres principales instituciones públicas de una entidad. Se entrevistaron a funcionarios estatales y personal hospitalario. Resultados. Las principales barreras son ausencia de lineamientos, de capacitación, de recursos e incentivos. Los facilitadores se relacionan con las características de las GPC, percibidas con diseño adecuado, lenguaje sencillo y ventajas para mejorar el ambiente laboral. Conclusión. Las barreras deberán resolverse para alcanzar el objetivo de homologar el proceso en todo el sector; además, la buena percepción de las GPC deberá promover investigaciones para promover la actualización continua de las evidencias y una visión sectorial desde su elaboración para su implantación en los heterogéneos contexto que caracterizan a las instituciones de salud.

[Challenges in the implementation of clinical practice guidelines in major public health institutions in Mexico: A multiple case study]

OBJECTIVE

To identify, prioritize and relate barriers and facilitators in the implementation of Clinical Practice Guidelines (GPC, in Spanish).

MATERIALS AND METHODS

We used qualitative methods to study and compare the introduction of GPC across the domains of the consolidated research implementation framework in hospitals of the three main public institutions in a state of Mexico. Authorities and hospital staff were interviewed using a semi-structured questionnaire.

RESULTS

The main barriers to implementation are the absence of standards, training, resources and incentives. The most important implementation facilitators are the characteristics of the GPC, which are perceived as properly designed and with simple language as well as with capacity to improve the work environment.

CONCLUSION

The barriers to implementation must be solved to achieve the goal of standardizing the healthcare process across the sector; the positive perception of the GPC should promote the continuous actualization of the evidence and a sectoral view from their development stage to ensure adoption in the heterogeneous environments that characterize health institutions.

[The strategic purchasing of health services: a big opportunity for the National Universal Health System]

proposed to establish a service packages, whether through a single obligatory list or through the definition of a flexible, high priority set to be offered to specific populations according to their economic possibilities. For the strategic purchasing of services, two alternatives are proposed: to assign the fund either to a single national manager or to each of the existing public provider institutions, with the expectation that they would contract across each other and with private providers to fulfill their complementary needs.The proposal does not consider the risks and alternatives to a single tax contribution fund, which could have been suggested given that it is not an essential part of a National Universal Health System. However, it is necessary to discuss in more detail the roles and strategies for a national single-payer, especially for the strategic purchasing of high-cost and specialized interventions in the context of public and private providers. The alternative of allocating funds directly to providers would undermine the incentives for competition and collaboration and the capacity to steer providers towards the provision of high quality health services.It is proposed to focus the discussion of the reform of the national health system around strategic purchasing and the functions and structure of a single-payer as well as of agencies to articulate integrated health service networks as tools to promote quality and efficiency of the National Universal Health System. The inclusion of economic incentives to providers will be vital for competition, but also for the cooperation of providers within integrated, multi-institutional health service networks.Health professionals and sector policy specialists coordinated by the Centro de Estudios Espinosa Yglesi as in Mexico propose a policy to anchor the health system in primary care centered on the individual. The vision includes effective stewardship,solid financing, and the provision of services by a plurality of providers - including eventually those in the private sector. A unified approach to financing health through a unique, exclusively tax-based fund would be established. Alternatives are

Utilización de remesas de migrantes en California para atención a la salud de sus dependientes en México

Objetivo. Este trabajo se enfoca en la utilización de servicios públicos y privados por los dependientes de migrantes en México, analizando de manera particular su relación con remesas y afiliación al Seguro Popular. Material y métodos. Se aplicó un cuestionario a 1 353 migrantes en el Consulado de México en Los Ángeles en 2010. Resultados. 53.9% envía remesas; 72.2% de hogares receptores utilizan remesas para atención a la salud y 74.4% tienen Seguro Popular. La media de gasto en servicios privados fue 825 dólares anuales, comparado con 293 dólares con proveedores públicos. Los principales predictores del uso de remesas por salud fueron, familiares enfermos, compra de medicamentos, problemas para pagar y tiempo de residencia en EUA. Conclusiones. El Seguro Popular presenta una oportunidad para incidir en la eficiencia del gasto en salud proveniente de las remesas, mediante la promoción de la utilización de servicios públicos de salud entre los dependientes de migrantes.

[Problems of the health system in Mexican states with high incidence of maternal mortality]

OBJECTIVE

To identify and prioritize problems in states' health systems which limit the efficacy of interventions to prevent maternal mortality.

MATERIALS AND METHODS

We made a conceptual mapping of priority problems perceived as such by communities of practice (COP) in four states with high ratios of maternal mortality in Mexico. Then, the four COP reviewed the literature and refined their formulation of previously identified problems.

RESULTS

Priority problems focused on emergency obstetric care (EmOC), specifically: inadequate financial resources (Guerrero), substandard training among available EmOC providers (State of Mexico), inefficiencies in existing EmOC networks (Oaxaca) and inadequate knowledge of, and/or compliance to, standard EmOC protocols (Veracruz). The literature review confirmed the pertinence of problems previously identified by COP through conceptual mapping. CONCLUSIONS. The four COP showed a high level of congruency between their original perception of problems in the states' health systems and international scientific evidence. Identified problems and their reformulation based on evidence help identify solutions adaptable to local contexts.

[Use of migrant's remittances from California on dependent's healthcare in Mexico]

OBJECTIVE

This paper focuses on public and private healthcare utilization among dependents living in Mexico of Mexican migrants in California, analyzing the link between remittances and enrollment in Seguro Popular, a social health insurance plan.

MATERIALS AND METHODS

We surveyed 1353 migrants who visited the Mexican consulate of Los Angeles in 2010.

RESULTS

53.9% sent remittances; 72.2% of households receiving remittances used a share of remittances for health care and 74.4% of them were covered by Seguro Popular. The annual median with private health care expenditure was USD 825, compared to USD 293 for public providers. The main predictors remittances utilization for healthcare were having a sick dependent, purchase of prescription drugs, experiencing problems paying for health care and time of U.S. residence.

CONCLUSIONS

Seguro Popular increases healthcare utilization with public providers, which provides an opportunity to reallocate the use of migrant's remittances for health purposes.

[Factors associated with the demand for delivery care in Mexico]

OBJECTIVE

Analyze the factors associated with the utilization of delivery care institutions in Mexico in order to document the functional integration of health institutions.

MATERIALS AND METHODS

Based on the 2006 National Health and Nutrition Survey, information from women whose last birth was between 2000 and 2005 was used. Chi square was used to test differences between institutions used and health insurance type. A logistic regression was carried out to identify factors associated with the demand for institutions with which women were not affiliated.

RESULTS

Women with social security used in 62% of the cases the institution of their affiliation and 13.4% used public institutions. For uninsured women, 43.3% used public institutions and 19.0% social security institutions; 64.3% of the Seguro Popular affiliates were treated in public institutions. Variables related to access, socioeconomic status and living conditions influenced said demand.

CONCLUSIONS

The utilization of an institution of delivery that differed from the one with which the women were affiliated indicates the existence of a de facto functional integration between health institutions in Mexico.