Table 5 Perception of health personnel and users about nutritional quality care

What is Quality of Nutritional Care?

Quality is communication, communicating with the patient and giving her that confidence. If you give her that confidence, then you give her warmth. In this way, you are giving the patient that quality, the confidence of also being able to express themselves - Physician, urban health center, Oaxaca

When the medical consultation is understandable; speaking to the patients in such a way that they understand, not telling the mother to buy such milk that is sold in such a supermarket, because sometimes they do not have the resources. In other words, putting myself at the level of the population. That would be quality care. Giving them what is within their reach, recommending, for example, the “yard diet”, the “milpa” diet; if there is fruit in your house, eat that; if there are animals in your house eat that. I think that would be quality care. And, obviously, don’t raise your voice, don’t scold, talk to her with respect - Nutritionist, urban health center, Yucatan

[Quality of Nutritional Attention] is that they can help me so that I can feed my children correctly and know what benefits we have when feeding them correctly - Mother of a preschool-age child, rural health center, State of Mexico

I don’t know very well what it is… [maybe] that they explain to me what I should eat, how to feed my baby - Postpartum woman, urban health center, Veracruz

Prevention

There is a lot of general consultation and due to the lack of time in nursing, guidance is not given. Before, there was a social program in which we brought people together and used to show demonstrations a lot. But, since the pandemic, we no longer do those things. Now, sometimes I give a talk to those who are here outside [in the waiting room] waiting for a consultation; we make small groups of four mothers and there I am giving them nutrition training - Nutritionist, rural health center, Veracruz

The nutrition service is not given here [in the infirmary], only a brief orientation or a talk about what the Eatwell Plate is. Mainly, they are given information to try avoiding the consumption of dairy foods, fats, meats, sugars, soft drinks, and sweetened water, eating more fruits, vegetables, natural water, and exercising at least 15 min a day. The only nutrients [supplements] they are given are polyvitamins, which are the only ones we have here, and also some folic acid. - Nurse, urban health center, State of Mexico

I don’t bring my son frequently mainly because… Well, I don’t know. Maybe we don’t have that culture of keeping a medical check-up and due to the lack of information; we don’t know if they give us that kind of care here [nutritional care]- Mother of a child in preschool age, urban health center, Oaxaca

Since before I got married, I began to prepare my body. I started coming to consultations so that the doctor would tell me the processes that I had to follow to be able to get pregnant, to plan a pregnancy. I took that control before and during the pregnancy. And after the pregnancy, I continued with the necessary vitamins. The doctor told us that breast milk is essential for the baby and I followed her suggestion to give him breast milk until he was 2 years old. Now I do the same thing, I prepare my body before I get pregnant for the second time. - User in the preconception stage, focus group at a rural health center, Veracruz

Diagnosis and treatment

To diagnose overweight in pregnant women we rely on the BMI; I do not have a specific table for pregnant women, I use the regular one, that is, as if she were not pregnant. They are always invited to reduce the levels [consumption] of certain foods, such as flour, tortillas, bread, soft drinks, and sugary foods, in addition to walking half an hour, and it is explained to them that pregnancy does not mean that they are not going to exercise, they could start walking - Physician, rural health center, Chihuahua

A barrier to treatment is that there are almost no supplements, vitamins, or B complex. Sometimes there are some, and others we run out of them, seasonally. There are families that do not have enough money for the daily consumption of vegetables or protein. Protein is very scarce here, maybe there are families that eat chicken every fortnight or eat meat once a month. So, that also limits them a lot and there are seasons in which we can help them or give them vitamins, but when there are none, we cannot do anything - Nutritionist, urban health center, State of Mexico

Before I got pregnant I was diagnosed with anemia. When I came to my consultation I told the doctor and he told me to eat more foods rich in iron, such as beans, and lentils, and that I had to keep myself fed more so that my baby would grow healthy (…) but they have not clearly stated what healthy foods I should eat and what I shouldn’t - Pregnant woman, urban health center, Oaxaca

I have tried to eat well, but the prices of good food or good ingredients are a bit high and salaries are low here, so that forces us to eat whatever. I have tried to buy broccoli, romaine lettuce, vegetables, and fruits. In other words, cooking a healthy broth is a bit expensive compared to, for example, making a scrambled egg and tortilla to eat. And if we want to accompany the food with a natural drink, so as not to drink soda, it is even more expensive - Mother of a child in the preschool stage, urban health center, Yucatan

Barriers to quality care

An important barrier is the interconsultation, the patients do not come with me because they have to see me after going to the physician and they do not want or cannot stay that long (…) I need space, it is very small and due to the weather we cannot close the door and we need privacy with the patient. I would like to have a baby scale, to corroborate the data taken by the nurse, and also some simple devices such as a glucometer, a protein meter, a caliper, but I think they are not provided in our health system—Nutritionist, urban health center, Chiapas

The time we have for each consultation is 15 to 20 min. I believe that this affects negatively because finally we are facing a population that needs a lot of education and, for example, I can realize that the patient has many doubts or has not understood everything, but I can no longer dedicate more time to it. So I think that this is inadequate attention, not because I want to do it that way, but because that’s the way the system is—Physician, rural health center, State of Mexico

More doctors are needed so that they can care for us well, because sometimes we come and there are no doctors or they are unemployed. And I don’t know if there is already a nutritionist, but it is necessary. There is also no night shift and when there is an emergency and it is late there is no one to provide service, in fact there are no ambulances… well, there are no medicines either—Mother of child in the infant stage, urban health center, Oaxaca

When I come to see my child and they prescribe medication, I have to buy it. In fact, throughout my pregnancy when blood tests were needed, there was never any laboratory staff to do them and I had to pay for them elsewhere, I also had to buy other medicines or supplements, the only thing they gave me was folic acid—Mother of a child in infant stage, urban health center, Chiapas

Facilitators to quality care

The authorities are always giving us material to work with, I had never had food replicas (for nutritional education) and here they give them to us. There is also good communication with the staff, I have a lot of support for promotion, the nursing staff help me so that the patient does not run away or they notify me when children are scheduled for vaccinations and while the mothers wait we go and give them a talk about nutrition. There really is teamwork and we are all coordinated—Nutritionist, urban health center, Yucatan

For community workshops we have flipcharts, we as a nurses also prepare informative wall newspapers and we have the DVD in Mazahua on women’s health to project it in the talks with them, which have had an important impact.—Nurse, rural center health, State of Mexico

The health center has a special day for pregnant women, so they call us on that day and if we arrive early they see us first. The health center opens at 8 am, they put us on a list to be seen in that order. They take us to the nurse, who takes our vital signs and blood pressure, she weighs and measures us, and then we go to the physician. The attention of the health personnel is good—Pregnant woman, rural health center, State of Mexico

The waiting time depends on how many patients there are. We only wait for how long it takes for the doctor or nutritionist to give the consultation to the patient who is before you, but it is not more than 15 or 20 min because while they are treating the other person, the nurse measures you, takes your weight, pressure and hear the baby’s heartbeat.—Pregnant woman, rural health center, Veracruz (Focus group)

Gender perspective

Here the common thing is that the man is the one who works, so he only sends the wife to the consultation. They only accompany them if they are from another community, but in general, for them coming to the health center is a waste of time—Nurse, rural health center, Chiapas.

The woman is a little reserved. We have to be empathetic to be able to explain things to her and accept her recommendations, because if her husband doesn’t give her permission, I can’t give her guidance on issues like family planning. If the husband says “I don’t want my wife to take contraceptives”, she obeys him and she can have 6–7 children. Normally the mother is the one who is always looking after the children and the father just says: “I work, I bring the money, I don’t care about the rest” (…) I have heard patients say: “It’s that my husband doesn’t agree with me coming to the health center every month, he says that I’m just here to waste time because my son is fine,” and they no longer come to check on the child—Nurse, urban health center, Veracruz

I accompany my wife to the consultation because we both care about the health of the children and also about various situations that may occur, between the two of us we provide support, we support each other, especially when the diagnosis they can give us is not good (… ) I consider that it is very important to come to explain to the doctor the symptoms that the child presents, sometimes the spouse can miss some detail or medication that we gave her or something that we could observe in the child that she perhaps did not, and that’s how it is. we are both here to give each other that support—Father of a child in preschool stage, urban health center, Oaxaca.

My mother or my partner comes with me. (I prefer to come) Accompanied, because many times I don’t understand much of what they are saying to me, and maybe my companion did understand well or so.—Pregnant women, rural health center, Chihuahua (Focus Group)

From time to time my husband comes with me, because he works. (I prefer to come) By myself. I don’t know, it’s like when he’s here I don’t… I hardly even speak, because he’s just looking for the moment to criticize me, to laugh, it’s so… [LAUGHS] “and did you notice what you said?” he tells me, and I am there with all the shame in the world. It does not leave me well in front of the physician—Pregnant women, rural health center, Chihuahua (Focus Group)

I always come alone, it’s fine, I’m used to it and my husband works. But sometimes I would like him to come, for him to hear that the physician recommends that I take care of myself, so that he doesn’t think that I’m not lying when I said that I have to rest or something like that—Pregnant women, rural health center, Chihuahua (Focus Group)

Intercultural aspects

The problem is all the localities that we serve here and well, quite a few indigenous children arrive with low weight or with an advanced degree of malnutrition, and well… sometimes the indigenous are inexpressive, and although I don’t have that much experience with the indigenous community, I feel that for them it is the same if their child is sick or healthy, I think they are not so interested in health. 98 or 99% of children with malnutrition are indigenous and I feel that there is a lack of awareness on the part of the government towards this community. There are indigenous people who are more civilized, but here we have indigenous people who are practically like little animals, they live in caves and things like that… it sounds ugly, but that’s the way it is—Physician, Community general Hospital, Chihuahua

I worked in the cleaning area and saw how the Tarahumara population arrived with their children. Sometimes the parents worried because the doctor did not understand them, and they were sad because they did not know what to do. So that to me, well, it kind of hurt me, and I said ‘why don’t the physicians tell me to ask the parents what the child has, since when did he get sick, how many days has he been like this?‘, all of that. But once a physician did ask me: ‘Hey, how do we support this child who arrived and the relatives don’t understand me?‘, and then I told him: ‘I’ll help you, doctor’, and I already translated for him. I felt so glad to help them! And that’s where my work as an interpreter for the Tarahumaras began - Interpreter, Integrated Community Hospital, Chihuahua

In Spanish they speak differently than Mayan, if there was someone who speaks Mayan here and explains everything about nutrition, we would understand. It has been difficult to understand, for example, how you can prevent losing your baby or what you should do when the baby is coming down, if you should come here or to another place, that information is what I don’t understand. Here they have not given me any material such as brochures or books on food in the Mayan language—Pregnant woman, rural health center, Yucatan