ResultsFew similarities were observed between the proposed model of service delivery and its implementation in diverse locations, signaling discordant operating processes. Evidence gathered from Casas personnel highlighted their ability to detect obstetric emergencies and domestic violence cases, as well as contribute to the empowerment of women in the indigenous communities served by the project. These themes directly translated to increases in the reporting of abuse and referrals for obstetric emergencies. ConclusionsThe model’s cultural and linguistic competency, and contributions to increased referrals for obstetric emergencies and abuse are notable successes. The flexibility and community-based nature of the model has allowed it to be adapted to the particularities of diverse indigenous contexts. Local, culturally appropriate implementation has been facilitated by the fact that the Casas have been implemented with local leadership and local women have taken ownership. Users express overall satisfaction with service delivery, while providing constructive feedback for the improvement of existing Casas, as well as more cost-effective implementation of the model in new sites.

1. Ritzer G. (1992). Teoria Sociologica Contemporanea. Analisis O Resumen De La
2. Ritzer G. (1992). Teoria Sociologica Contemporanea. Analysis O Resumen

Integration of user’s input obtained from this process evaluation into future planning will undoubtedly increase buy-in. The Casas model is pertinent and viable to other contexts where indigenous women experience disparities in care. Indigenous a populations are among the most marginalized groups in the world. Due to social marginalization, indigenous people are more likely to be poor, have fewer years of formal education, and less access to health services ,. Furthermore, dominant culture’s lack of understanding of indigenous populations surfaces in discriminatory, racist, and exclusionary practices and attitudes The indigenous populations of Mexico – the largest on the American continent b –, are not exempt from conditions of poverty and marginalization. 75.6% of the indigenous population lives in locations classified as high or very high marginalization; 22% live in homes with dirt floors; 26% do not have potable water and 45.6% lack indoor plumbing.

Ritzer G. (1992). Teoria Sociologica Contemporanea. Analisis O Resumen De La

Being indigenous also corresponds to disparities in national health indicators. Life expectancy at birth of indigenous Mexicans is eight or nine years less than the national average. Likewise, infant mortality rates among the indigenous are twice the national average.Indigenous women constitute a subgroup of the Mexican indigenous population with the highest lag in health status. As three kinds of discrimination converge - ethnic, gender and class – there is a unique matrix of ailments and diseases correlating to this triple subordination.

Maternal mortality is a case example of such outcomes, with official data indicating that the major concentration of maternal mortality in Mexico occurs in indigenous and rural areas of the central and southeastern regions of the country ,. Indigenous women’s risk of dying from childbirth is three times higher than for women in the rest of the country. In 2008, the national maternal mortality rate was 53 per 100,000 live births. In the same time period, Guerrero—a state with a significant indigenous population and the lowest social indicators of the country—had a maternal mortality rate of 104 per 100,000 live births.These statistics highlight the problems of inequality, discrimination, and marginalization in which the majority of the Mexican indigenous women live. The aforementioned data on maternal mortality is the result of a particular context where lack of health services, timely care, adequate infrastructure, and economic resources converge with discrimination and cultural gaps between hegemonic Western medicine and indigenous forms of understanding health.

The complexity of the situation and the seriousness of resulting health indicators begs for effective public health strategies to address these challenges.Coverage of public services has been insufficient to properly attend to the special needs of indigenous women. In order to succeed, publically funded women’s health services must take into account geographic, economic and cultural barriers to care, as well as the perceptions on the part of the individual and community about the quality and efficacy of the services. Furthermore, the consideration of indigenous communities’ complex models for health-related decision-making, based on their beliefs about the health-illness/disease/sickness process, impact the ability of non-indigenous institutions and providers to carry out timely, necessary interventions, while ensuring quality and access ,. In Mexico, there has been an historic need to bridge services rooted in Western medical practices with traditional medical knowledge, and in recent years, an increasing recognition of the importance of this unmet need and attempt to address it through the development of intercultural models of public health service delivery. Study designThe study design was a processes evaluation guided by perspectives from diverse stakeholders involved in the implementation of the model such as users, local authorities, and institutional representatives. Two primary techniques were used to collect information and carry out the evaluation: the analysis of official regulatory and program documents and key informant interviews.

The study design drew on phenomenology as a theoretical and methodological approach to explore the experience of the participants who carry out diverse functions and duties in the Casas, as well as of the indigenous women who have received services. The design was also informed by Patton’s qualitative evaluation approach, which considers informal questions and unexpected consequences within the overall context of the development and implementation of the programs.

Additionally, Rossi and colleagues evaluation framework was used to formulate specific questions regarding project operation, structure, organization, processes and results. The multiple theoretical perspectives were purposefully incorporated in the study design in order to evaluate the many care-seeking and health service utilization factors the Casas sought to address. Sample selectionThe criteria for inclusion for the key informants were defined by position and connection to the Casas, with four main profiles of interest: (1) coordinators and advisors, (2) operations personnel and collaborating local health care providers (TBAs, promotor as, psychologists, attorneys), (3) women receiving services, and (4) other participants.

The latter category included local authorities such as the mayor, those in charge of indigenous affairs, other health care providers, judicial staff, and administrators of public social service agencies. These profiles were selected to gain a close-up understanding of those involved in the Casas’ core functions.The participants were recruited through convenience sampling in each of the Casas. Prior to recruitment efforts, informational meetings were held with the research team and the coordinators of each facility in order to present and explain the project, facilitate contact with other participants, and to be able to access archival documents that described the creation and operation of the Casas. The facility coordinators and research team then developed a mutually agreed-upon schedule for data collection.

Ethical considerationsThe study was approved by the Research and Ethics Commissions of Mexico’s National Institute of Public Health and adheres to the commission’s ethical guidelines for conducting social research with indigenous populations. Each potential participant was informed in detail of the objectives, procedures, risks and benefits of the study and only after assuring her understanding was she invited to participate. Those willing to participate were asked to sign a letter of informed consent, which was in Spanish only. Translators were available to verbally assist in obtaining the informed consent of monolingual indigenous women.

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Data collectionInterview guidelines were designed for each of the four participant types. The semi-structured interview guide employed a narrative approximation technique, which typically began with a recounting of how the Casas project had begun and how each interviewee had become involved in the project. Other themes that were explored in the interview were: the mission, functions and structure of the Casas, the benefits of the Casas for indigenous women, and obstacles to operations and sustainability.The original Casas project proposal and previous evaluation reports were reviewed in detail to understand the basic functions of the Casas and design instruments that probed for information not readily available through archival documents.

The evaluation process took into consideration the different aspects of Casas’ daily operations, organization, and administration. Observation guidelines and a questionnaire were designed and applied in all the Casas according to the established data collection schedule. The field work was conducted between January and June of 2007.

Interviews were conducted by members of the research team, all of whom had significant experience in qualitative studies, with the assistance of indigenous translators when the informants were monolingual speakers of an indigenous language. Prior to the field work, the entire team participated in a standardized training in interviewing techniques, with the aim of strengthening the study’s reliability. The translators who supported interviews conducted in an indigenous language also participated voluntarily, and were trained in interview techniques to ensure that the questions asked as well as the information collected were translated accordingly. Furthermore, to protect the confidential nature of the information, all translators were asked to sign a confidentiality agreement.All interviews were audio-taped, with previous informed consent. The transcript for an interview conducted in an indigenous language was reviewed by the same translator present at the time of the interview. All interviews were transcribed in a format accessible for analysis, which was carried out with the support of the qualitative analysis program Atlas-ti (v.5.2). Type of participantTotalCentral coordination2General coordinators and advisors7Users14Local resources and operations personnel32Other participants7TOTAL62Data analysisOrganization of the data followed the steps proposed by grounded theory and incorporated a critical social psychology perspective, which considers discourse as a social practice that constructs social identities ,.

The analysis aimed at understanding the participants’ perspectives and highlighting their experiences in relation to the Casas’ structure, processes, and performance. As such, the categories that guided the interviews permitted the thematic organization of data, using an inductive approach. Each category was examined in relation to 1) primary activities; 2) the main obstacles that the Casas face in different contexts; 3) the main benefits for the population and for the health services, as well as 4) the possibility of creating a plan replicable for other indigenous communities. As new concepts and themes emerged, the transcripts were re-examined and the categories refined. The themes that emerged were discussed and reviewed by the research team. Perceptions of the processes and performance of the Casas services vary depending on the perspective of informants. Among external collaborators (social services, local authorities, NGOs), achievements and scope of the activities that the Casas provide are minimized.

This perception can be understood within the context of social inequity, including exclusion, prejudice, discrimination, racism and stereotyping facing indigenous groups, in addition to a perception of the services the Casas provide as being threatening to other service providers. This minimizing of performance and scope by external actors is juxtaposed with the women who collaborate in the Casas highlighting their contribution in the detection of emergencies, problems of violence and empowerment of other women from indigenous communities.

Ritzer G. (1992). Teoria Sociologica Contemporanea. Analysis O Resumen

The women that staff the Casas are aware and critical of the gender inequality, exclusion and discrimination to which they have historically been subjected. They view the Casas as a genuine opportunity for growth and self-realization as both women and professionals.Moreover, the linguistic and cultural congruency of the Casas has been fundamental in light of common care-seeking behavior. Respect for the care-seeking preferences identified by Espinosa’s comprehensive report on the matter were observed during the project evaluation. These preferences included seeking out local resources and the care of TBAs for a variety of reasons: cultural (they speak the same language), effective (they trust they are skilled providers), economic (they charge less), accessibility (they make house calls), and gender (they have experienced childbirth).The analysis revealed that the processes of the Casas transcends sexual and reproductive health care and cases of violence, and speaks to change within larger structural determinants of health equity.