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Lievense B, Leach K, Modanlo N, Stollak I, Wallace J, Dominguez A, Valdez J, Valdez M, Perry HB. Improving Maternity Care Where Home Births Are Still the Norm: Establishing Local Birthing Centers in Guatemala That Incorporate Traditional Midwives. GLOBAL HEALTH, SCIENCE AND PRACTICE 2024:GHSP-D-24-00057. [PMID: 39293822 DOI: 10.9745/ghsp-d-24-00057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 08/20/2024] [Indexed: 09/20/2024]
Abstract
More than half of births among Indigenous women in Guatemala are still being attended at home by providers with no formal training. We describe the incorporation of comadronas (traditional midwives) into casas maternas (birthing centers) in the rural highlands of western Guatemala. Although there was initial resistance to the casa, comadronas and clients have become increasingly enthusiastic about them. The casas provide the opportunity for comadronas to continue the cultural traditions of prayers, massages, and other practices that honor the vital spiritual dimension of childbirth close to home in a home-like environment with extended family support while at the same time providing a safer childbirth experience in which complications can be detected by trained personnel at the casa, managed locally, or promptly referred to a higher-level facility. Given the growing acceptance of this innovation in an environment in which geographical, financial, and cultural barriers to deliveries at higher-level facilities lead most women to deliver at home, casas maternas represent a feasible option for reducing the high level of maternal mortality in Guatemala.This article provides an update on the growing utilization of casas and provides new insights into the role of comadronas as birthing team members and enthusiastic promotors of casas maternas as a preferable alternative to home births. Through the end of 2023, these casas maternas had cared for 4,322 women giving birth. No maternal deaths occurred at a casa, but 4 died after referral.The Ministry of Health of Guatemala has recently adopted this approach and has begun to implement it in other rural areas where home births still predominate. This approach deserves consideration as a viable and feasible option for reducing maternal mortality throughout the world where home births are still common, while at the same time providing women with respectful and culturally appropriate care.
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Affiliation(s)
| | | | - Nina Modanlo
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | | | | | | | | | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Doering-White J, Díaz de León A, Hernández Tapia A, Delgado Mejía L, Castro S, Roy K, Cruz GQ, Hudock-Jeffrey S. Climate-health risk (In)visibility in the context of everyday humanitarian practice. Soc Sci Med 2024; 354:117081. [PMID: 38971042 DOI: 10.1016/j.socscimed.2024.117081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/16/2024] [Accepted: 06/27/2024] [Indexed: 07/08/2024]
Abstract
Nongovernmental migrant shelters in Mexico play a key role in documenting the factors that shape forced migration from Central America. Existing intake protocols in shelters are largely oriented to humanitarian legal frameworks that determine eligibility for international protection based on interpersonal violence and political persecution. This qualitative study calls attention to how existing humanitarian logics may obscure climate- and health-related disruptions as drivers of forced migration from Central America in the context of everyday humanitarian practice. In May 2022 we compared migrant's responses (n = 40) to a standardized intake protocol at a nongovernmental humanitarian migrant shelter in Mexico with responses to semi-structured interviews that focused on migrants' perceptions of climate change and health as drivers of forced displacement. We found that slow- and rapid-onset climatic disruptions; illness and disease; and various forms of violence and repression are often interrelated drivers of forced displacement. Comparing intake protocols and in-depth interview responses, we found that climate- and health-related drivers of forced displacement are rarely documented. These findings speak to the importance of critically examining everyday humanitarian practices in the context of ongoing advocacy that calls for climate-related disruptions to be integrated into existing humanitarian protection frameworks.
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Aguilera Arévalo ML, Martínez Seikavizza SN, Rodriguez EM, Siguantay MA, Solares Ovalle JF, Talé Rosales LF, Barchi F. Developing an Evidence-Based Ethics Education Program for Surgical Residents in Guatemala. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2024; 11:23821205241257079. [PMID: 38841314 PMCID: PMC11151764 DOI: 10.1177/23821205241257079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 05/08/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE This study assessed 2 modalities for teaching responsible conduct of research and human subjects protection (RCR/HSP) to surgical residents in Guatemala-an "off the shelf" online curriculum and a new in-person curriculum specific to the local context. METHODS In 2018, 160 surgical residents in 3 large urban hospitals in Guatemala City completed 2 online programs in RCR/HSP. Residents in the intervention arm also completed 7 weeks of in-person training. Pre- and post-assessments tested awareness of key concepts with particular attention to international and Guatemalan research regulations. Group differences in matched (pre- and post-) mean scores were analyzed using t-tests. RESULTS One hundred forty residents completed pre- and post-training assessments and were included in the analytic sample. Overall mean scores improved modestly from 52.7 to 58.7 points out of 100. Intervention-arm trainees reported greater confidence in recognizing ethical issues, understanding legal and ethical requirements for research, and identifying, reporting and avoiding scientific misconduct than control-arm trainees. CONCLUSION Given the limited availability of RCR/HSP faculty, financial resources, and time in the surgical training schedule, the investigators recommend that academic authorities in Guatemala consider online training programs in RCR/HSP in all surgical residency programs as an affordable and scalable strategy to build ethical research skills in its surgical workforce. Investment in human resources to support in-person ethics education as a way to build self-efficacy in ethical decision-making should be considered.
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Affiliation(s)
| | | | - Ery Mario Rodriguez
- Facultad de Ciencias Médicas de la Universidad de San Carlos de Guatemala, Guatemala City, Guatemala
| | - Miguel Angel Siguantay
- Facultad de Ciencias Médicas de la Universidad de San Carlos de Guatemala, Guatemala City, Guatemala
| | | | | | - Francis Barchi
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
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Song MY, Blake-Hepburn D, Fadel S, Allin S, Ataullahjan A, Di Ruggiero E. Faith-based organisations and their role in supporting vaccine confidence and uptake: a scoping review protocol. BMJ Open 2023; 13:e070843. [PMID: 38135322 DOI: 10.1136/bmjopen-2022-070843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION Faith-based organisations (FBOs) and religious actors increase vaccine confidence and uptake among ethnoracially minoritised communities in low-income and middle-income countries. During the COVID-19 pandemic and the subsequent vaccine rollout, global organisations such as the WHO and UNICEF called for faith-based collaborations with public health agencies (PHAs). As PHA-FBO partnerships emerge to support vaccine uptake, the scoping review aims to: (1) outline intervention typologies and implementation frameworks guiding interventions; (2) describe the roles of PHAs and FBOs in the design, implementation and evaluation of strategies and (3) synthesise outcomes and evaluations of PHA-FBO vaccine uptake initiatives for ethnoracially minoritised communities. METHODS AND ANALYSIS We will perform six library database searches in PROQUEST-Public Health, OVID MEDLINE, Cochrane Library, CINAHL, SCOPUS- all, PROQUEST - Policy File index; three theses repositories, four website searches, five niche journals and 11 document repositories for public health. These databases will be searched for literature that describe partnerships for vaccine confidence and uptake for ethnoracially minoritised populations, involving at least one PHA and one FBO, published in English from January 2011 to October 2023. Two reviewers will pilot-test 20 articles to refine and finalise the inclusion/exclusion criteria and data extraction template. Four reviewers will independently screen and extract the included full-text articles. An implementation science process framework outlining the design, implementation and evaluation of the interventions will be used to capture the array of partnerships and effectiveness of PHA-FBO vaccine uptake initiatives. ETHICS AND DISSEMINATION This multiphase Canadian Institutes of Health Research (CIHR) project received ethics approval from the University of Toronto. Findings will be translated into a series of written materials for dissemination to CIHR, and collaborating knowledge users (ie, regional and provincial PHAs), and panel presentations at conferences to inform the development of a best-practices framework for increasing vaccine confidence and uptake.
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Affiliation(s)
- Melodie Yunju Song
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Shaza Fadel
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara Allin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Anushka Ataullahjan
- School of Health Studies, Faculty of Health Sciences, Western University, London, Ontario, Canada
| | - Erica Di Ruggiero
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Olivas ET, Valdez M, Muffoletto B, Wallace J, Stollak I, Perry HB. Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 6. Management of pregnancy complications at Community Birthing Centers (Casas Maternas Rurales). Int J Equity Health 2023; 21:204. [PMID: 36855147 PMCID: PMC9976365 DOI: 10.1186/s12939-022-01758-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND In Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+. METHODS We undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff. RESULTS During the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere. CONCLUSION The Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right.
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Affiliation(s)
- Elijah T Olivas
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mario Valdez
- Curamericas/Guatemala, Calhuitz, San Sebastián Coatán, Huehuetenango, Guatemala
| | | | | | - Ira Stollak
- Curamericas Global, Raleigh, North Carolina, USA
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Valdez M, Stollak I, Pfeiffer E, Lesnar B, Leach K, Modanlo N, Westgate CC, Perry HB. Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 1. Introduction and project description. Int J Equity Health 2023; 21:203. [PMID: 36855139 PMCID: PMC9976357 DOI: 10.1186/s12939-022-01752-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND The Curamericas/Guatemala Maternal and Child Health Project, 2011-2015, was implemented in the Western Highlands of the Department of Huehuetenango, Guatemala. The Project utilized three participatory approaches in tandem: the Census-Based, Impact-Oriented (CBIO) Approach, the Care Group Approach, and the Community Birthing Center Approach. Together, these are referred to as the Expanded CBIO Approach (or CBIO+). OBJECTIVE This is the first article of a supplement that assesses the effectiveness of the Project's community-based service delivery platform that was integrated into the Guatemalan government's rural health care system and its special program for mothers and children called PEC (Programa de Extensión de Cobertura, or Extension of Coverage Program). METHODS We review and summarize the CBIO+ Approach and its development. We also describe the Project Area, the structure and implementation of the Project, and its context. RESULTS The CBIO+ Approach is the product of four decades of field work. The Project reached a population of 98,000 people, covering the entire municipalities of San Sebastián Coatán, Santa Eulalia, and San Miguel Acatán. After mapping all households in each community and registering all household members, the Project established 184 Care Groups, which were composed of 5-12 Care Group Volunteers who were each responsible for 10-15 households. Paid Care Group Promoters provided training in behavior change communication every two weeks to the Care Groups. Care Group Volunteers in turn passed this communication to the mothers in their assigned households and also reported back to the Care Group Promoters information about any births or deaths that they learned of during the previous two weeks as a result of their regular contact with their neighbors. At the outset of the Project, there was one Birthing Center in the Project Area, serving a small group of communities nearby. Two additional Birthing Centers began functioning as the Project was operating. The Birthing Centers encouraged the participation of traditional midwives (called comadronas) in the Project Area. CONCLUSION This article serves as an introduction to an assessment of the CBIO+ community-based, participatory approach as it was implemented by Curamericas/Guatemala in the Western Highlands of the Department of Huehuetenango, Guatemala. This article is the first of a series of articles in a supplement entitled Reducing Inequities in Maternal and Child Health in Rural Guatemala through the CBIO+ Approach of Curamericas.
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Affiliation(s)
- Mario Valdez
- Curamericas/Guatemala, Calhuitz, San Sebastián Coatán, Huehuetenango, Guatemala
| | - Ira Stollak
- Curamericas Global, Raleigh, North Carolina, USA
| | - Erin Pfeiffer
- Independent Consultant, Winston-Salem, North Carolina, USA
| | - Breanne Lesnar
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Nina Modanlo
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Perry HB, Stollak I, Valdez M. Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 10. Summary, cost effectiveness, and policy implications. Int J Equity Health 2023; 21:202. [PMID: 36855130 PMCID: PMC9976361 DOI: 10.1186/s12939-022-01762-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND This is the final of 10 papers that describe the implementation of the Expanded Census-Based, Impact-Oriented Approach (CBIO+) by Curamericas/Guatemala in the Cuchumatanes mountains of the Department of Huehuetenango and its effectiveness in improving the health and well-being of women and children in a population of 98,000 in three municipalities. The CBIO+ Approach consists of three components: the CBIO (Census-Based, Impact-Oriented) Approach, the Care Group Approach, and the Community Birthing Center Approach. METHODS Each of the preceding papers was summarized. An assessment was made regarding the degree to which the initial implementation research hypotheses were confirmed. The total field cost per capita for operation of the Project was calculated. An assessment of the cost-effectiveness of the Project was made based on the estimated impact of the Project, the number of lives saved, and the number of disability-adjusted life years averted. RESULTS The Project attained a number of notable achievements in terms of expanding the coverage of key maternal and child health interventions, improving the nutritional status of children, reducing the mortality of children and mothers, providing quality care for mothers at the Community Birthing Centers (Casas Maternas Rurales) that integrate traditional midwives (comadronas) into the care of women during childbirth at the birthing centers, as well as empowering women and building social capital in the communities. CBIO+ is an effective and affordable approach that is particularly notable for its capacity to engage communities in the process of improving the health of mothers and children. Overall, there is strong and consistent evidence in support of the research hypotheses. The findings did produce evidence of declines in under-5 and maternal mortality, but they were not as robust as had been hoped. CONCLUSION CBIO+ is an approach that has been effective in engaging communities in the process of improving the health of their mothers and children and in reducing health inequities in this marginalized, difficult-to-reach population of Indigenous Maya people. The CBIO+ Approach is cost-effective and merits further development and broader application in Guatemala and beyond.
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Affiliation(s)
- Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Ira Stollak
- Curamericas Global, Raleigh, North Carolina, USA
| | - Mario Valdez
- Curamericas/Guatemala, Quetzaltenango, Guatemala
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Card EB, Morales CE, Ramirez JM, Billingslea M, Marroquín A, Trueblood E, Javia LR, McCormack SM, Friedland LR, Low DW, Schwartz AJ, Scott M, Jackson OA. Impact of Illustrated Postoperative Instructions on Knowledge and Retention During a Cleft Lip and Palate Surgical Mission. Cleft Palate Craniofac J 2022:10556656221100052. [PMID: 35711155 DOI: 10.1177/10556656221100052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine the impact of illustrated postoperative instructions on patient-caregiver knowledge and retention. DESIGN Prospective study with all participants receiving an educational intervention. SETTING Pediatric plastic surgical missions in Guatemala City, Guatemala, between 2019 and 2020. PARTICIPANTS A total of 63 majority-indigenous Guatemalan caregivers of patients receiving cleft lip and/or palate surgery. INTERVENTION Illustrated culturally appropriate postoperative care instructions were iteratively developed and given to caregivers who were surveyed on illustration-based and text-based information at preoperative, postoperative, and four-week follow-up time points. MAIN OUTCOME MEASURE Postoperative care knowledge of illustration-based versus text-based information as determined by the ability to answer 11 illustration- and 8 text-based all-or-nothing questions, as well as retention of knowledge as determined by the same survey given at four weeks follow-up. RESULTS Scores for illustration-based and text-based information both significantly increased after caregivers received the postoperative instructions (+13.30 ± 3.78 % SE, + 11.26 ± 4.81 % SE; P < .05). At follow-up, scores were unchanged for illustration-based (-3.42 ± 4.49 % SE, P > .05), but significantly lower for text-based information (-28.46 ± 6.09 % SE, P < .01). Retention of text-based information at follow-up correlated positively with education level and Spanish literacy, but not for illustration-based. CONCLUSIONS In the setting of language and cultural barriers on a surgical mission, understanding of illustration-based and text-based information both increased after verbal explanation of illustrated postoperative instructions. Illustration-based information was more likely to be retained by patient caregivers after four weeks than text-based information, the latter of which correlated with increased education and literacy.
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Affiliation(s)
- Elizabeth B Card
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Carrie E Morales
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Juan M Ramirez
- Partner for Surgery, Guatemala City, Guatemala, Guatemala
| | | | | | - Eo Trueblood
- Stream Studios, 6567The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Luv R Javia
- Division of Otolaryngology, The Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, PA, USA
| | - Susan M McCormack
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Leonard R Friedland
- Research and Development Department, 33139GlaxoSmithKline, Philadelphia, PA, USA
| | - David W Low
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Alan Jay Schwartz
- The Children's Hospital of Philadelphia, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle Scott
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Oksana A Jackson
- Division of Plastic Surgery, 6569University of Pennsylvania Health System, Philadelphia, PA, USA
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Sethi R, Hill K, Stalls S, Moffson S, de Tejada SS, Gomez L, Marroquin MA. An exploratory study of client and provider experience and perceptions of facility-based childbirth care in Quiché, Guatemala. BMC Health Serv Res 2022; 22:591. [PMID: 35505322 PMCID: PMC9066966 DOI: 10.1186/s12913-022-07686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Respectful maternity care (RMC) is fundamental to women's and families' experience of care and their decision about where to give birth. Studies from multiple countries describe the mistreatment of women during facility-based childbirth, though only a small number of studies from Guatemala have been published. Less information is available on women's negative and positive experiences of childbirth care and health workers' perceptions and experiences of providing maternity care. METHODS As part of a program implemented in the Western Highlands of Guatemala to improve quality of reproductive maternal newborn and child health care, a mixed methods assessment was conducted in three hospitals and surrounding areas to understand women's and health workers' experience and perceptions of maternity care. The quantitative component included a survey of 31 maternity health workers and 140 women who had recently given birth in these hospitals. The qualitative component included in-depth interviews (IDIs) and focus group discussions (FGDs) with women and maternity health workers and managers. RESULTS Women reported a mix of positive and negative experiences of childbirth care related to interpersonal and health system factors. 81% of surveyed women reported that health workers had treated them with respect while 21.4% of women reported verbal abuse. Fifty-five percent and 12% of women, respectively, reported not having access to a private toilet and bath or shower. During IDIs and FGDs, many women described higher rates of verbal abuse directed at women who do not speak Spanish. A regression analysis of survey results indicated that speaking Ixil or K'iche at home was associated with a higher likelihood of women being treated negatively during childbirth in a facility. Health worker survey results corroborated negative aspects of care described by women and also reported mistreatment of health workers by clients and families (70.9%) and colleagues (48.2%). CONCLUSIONS This study adds to the literature on women's experience of institutional childbirth and factors that influence this experience by triangulating experience and perceptions of both women and health workers. This assessment highlights opportunities to address mistreatment of both women and health workers and to build on positive care attributes to strengthen RMC for all women.
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Affiliation(s)
| | | | | | - Susan Moffson
- Momentum Country and Global Leadership, Washington, USA.
| | | | - Leonel Gomez
- Reproductive Health Independent Researcher/Consultant, Guatemala City, Guatemala
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Hernandez A, Hurtig AK, San Sebastian M, Jerez F, Flores W. 'History obligates us to do it': political capabilities of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala. BMJ Glob Health 2022; 7:e008530. [PMID: 35508334 PMCID: PMC9073391 DOI: 10.1136/bmjgh-2022-008530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/13/2022] [Indexed: 11/23/2022] Open
Abstract
Growing interest in how marginalised citizens can leverage countervailing power to make health systems more inclusive and equitable points to the need for politicised frameworks for examining bottom-up accountability initiatives. This study explores how political capabilities are manifested in the actions and strategies of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala. Qualitative data were gathered through group discussions and interviews with initiative leaders (called defenders of the right to health) and initiative collaborators in three municipalities. Analysis was oriented by three dimensions of political capabilities proposed for evaluating the longer-term value of participatory development initiatives: political learning, reshaping networks and patterns of representation. Our findings indicated that the defenders' political learning began with actionable knowledge about defending the right to health and citizen participation. The defenders used their understanding of local norms to build trust with remote Indigenous communities and influence them to participate in monitoring to attempt to hold the state accountable for the discriminatory and deficient healthcare they received. Network reshaping was focused on broadening their base of support. Their leadership strategies enabled them to work with other grassroots leaders and access resources that would expand their reach in collective action and lend them more influence representing their problems beyond the local level. Patterns of representing their interests with a range of local and regional authorities indicated they had gained confidence and credibility through their evolving capability to navigate the political landscape and seek the right authority based on the situation. Our results affirm the critical importance of sustained, long-term processes of engagement with marginalised communities and representatives of the state to enable grassroots leaders of accountability initiatives to develop the capabilities needed to mobilise collective action, shift the terms of interaction with the state and build more equitable health systems.
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Affiliation(s)
- Alison Hernandez
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Ciudad de Guatemala, Guatemala
- Epidemiology and Global Health, Umea University, Umea, Sweden
| | | | | | - Fernando Jerez
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Ciudad de Guatemala, Guatemala
| | - Walter Flores
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Ciudad de Guatemala, Guatemala
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Baig LA, Ahmer Z, Tariq H, Khan M, Khan MN, Sohaib M, Shaikh S. Enhancing satisfaction and respect for health care personnel: a mixed-methods case study of a community-based intervention. SOCIAL WORK IN HEALTH CARE 2022; 61:123-138. [PMID: 35412962 DOI: 10.1080/00981389.2022.2062635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 09/04/2021] [Accepted: 04/02/2022] [Indexed: 06/14/2023]
Abstract
Health care personnel (HCP) face violence as a result of lack of satisfaction and respect among community members. It is imperative for HCP to engage in social work by involving communities for enhancing satisfaction and respect for them. This study attempted to provide insight on this phenomenon by using a mixed-methods concurrent embedded approach. Communities were selected based on modified Solomon four-group design from Karachi in southern province and from three cities of northern province, Khyber Pakhtunkhwa of Pakistan. Focus group discussions and in-depth interviews took place for formulating the quantitative tool. Six hundred pretests were done prior to introducing low-cost community-based interventions followed by 601 posttests. We found increased levels of satisfaction in both provinces, whereas level of respect increased significantly in Karachi in the southern province only. Qualitative interviews revealed the important role played by media and religious leaders. These findings suggest that satisfaction and respect for HCP can be enhanced through community support, involvement of religious leaders, and effective media campaigns.
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Affiliation(s)
- Lubna Ansari Baig
- APPNA Institute of Public Health, Jinnah Sindh Medical University, Cantonment Karachi, Pakistan
| | - Zaeema Ahmer
- APPNA Institute of Public Health, Jinnah Sindh Medical University, Cantonment Karachi, Pakistan
| | - Hira Tariq
- APPNA Institute of Public Health, Jinnah Sindh Medical University, Cantonment Karachi, Pakistan
| | - Mirwais Khan
- Health Care in Danger (HCiD) Initiative, International Committee of the Red Cross, Islamabad, Pakistan
| | - Muhammad Naseem Khan
- Institute of Public Health & Social Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Muhammad Sohaib
- Institute of Public Health & Social Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Shiraz Shaikh
- APPNA Institute of Public Health, Jinnah Sindh Medical University, Cantonment Karachi, Pakistan
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Fiolet R, Cameron J, Tarzia L, Gallant D, Hameed M, Hooker L, Koziol-McLain J, Glover K, Spangaro J, Hegarty K. Indigenous People's Experiences and Expectations of Health Care Professionals When Accessing Care for Family Violence: A Qualitative Evidence Synthesis. TRAUMA, VIOLENCE & ABUSE 2022; 23:567-580. [PMID: 33025855 DOI: 10.1177/1524838020961879] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Although many Indigenous peoples demonstrate resilience and strength despite the ongoing impact colonization has on their peoples, evidence suggests poor experiences and expectations of health care professionals and access to health care. Health care professionals play an essential role in responding to family violence (FV), yet there is a paucity of evidence detailing Indigenous people's experiences and expectations of health care professionals in the context of FV. Using a meta-synthesis of qualitative studies, this article aims to address the following research question: What are Indigenous people's experiences and expectations of health care professionals when experiencing FV? The inclusion criteria comprised a qualitative study design, Indigenous voices, and a focus on expectations and experiences of health care professionals when FV is experienced. Reviewers independently screened article abstracts, and the findings from included papers were subject to a thematic analysis. Six studies were included in the final meta-synthesis representing studies from Australia, the Americas, and New Zealand. Three themes were identified. Health care professionals need to center the Indigenous person in the care they provide and demonstrate cultural awareness of how history and culture influence an individual's care requirements. Health care professionals also need to ensure they are connecting for trust with the Indigenous person, by slowly developing a rapport, yarning, and investing in the relationship. Finally, Indigenous peoples want their health care professional to work on strengthening safety from culturally inappropriate care, institutional control, and potential lack of confidentiality associated with tight-knit communities.
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Affiliation(s)
| | | | - Laura Tarzia
- The University of Melbourne, Australia
- The Royal Women's Hospital, Melbourne, Australia
| | | | | | | | | | - Karen Glover
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | | | - Kelsey Hegarty
- The University of Melbourne, Australia
- The Royal Women's Hospital, Melbourne, Australia
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13
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Kohrt BK, Saltiel MM, Rosen EL, Cholotio M. The use of formative research to culturally adapt a psychosocial support program for perinatal Mayan women in Guatemala. SSM - MENTAL HEALTH 2022. [DOI: 10.1016/j.ssmmh.2022.100078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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14
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Hernandez B, Harris KP, Johanns CK, Palmisano EB, Cogen R, Thom MG, Linebarger E, El Bcheraoui C, Kamath AM, Camarda J, Rios-Zertuche D, Zúñiga-Brenes MP, Bernal-Lara P, Colombara D, Schaefer A, Salvatierra B, Mateus JC, Casas I, Flores G, Iriarte E, Mokdad AH. Impact of the Salud Mesoamerica Initiative on delivery care choices in Guatemala, Honduras, and Nicaragua. BMC Pregnancy Childbirth 2022; 22:5. [PMID: 34979990 PMCID: PMC8720941 DOI: 10.1186/s12884-021-04279-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Salud Mesoamérica Initiative (SMI) is a public-private collaboration aimed to improve maternal and child health conditions in the poorest populations of Mesoamerica through a results-based aid mechanism. We assess the impact of SMI on the staffing and availability of equipment and supplies for delivery care, the proportion of institutional deliveries, and the proportion of women who choose a facility other than the one closest to their locality of residence for delivery. METHODS We used a quasi-experimental design, including baseline and follow-up measurements between 2013 and 2018 in intervention and comparison areas of Guatemala, Nicaragua, and Honduras. We collected information on 8754 births linked to the health facility closest to the mother's locality of residence and the facility where the delivery took place (if attended in a health facility). We fit difference-in-difference models, adjusting for women's characteristics (age, parity, education), household characteristics, exposure to health promotion interventions, health facility level, and country. RESULTS Equipment, inputs, and staffing of facilities improved after the Initiative in both intervention and comparison areas. After adjustment for covariates, institutional delivery increased between baseline and follow-up by 3.1 percentage points (β = 0.031, 95% CI -0.03, 0.09) more in intervention areas than in comparison areas. The proportion of women in intervention areas who chose a facility other than their closest one to attend the delivery decreased between baseline and follow-up by 13 percentage points (β = - 0.130, 95% CI -0.23, - 0.03) more than in the comparison group. CONCLUSIONS Results indicate that women in intervention areas of SMI are more likely to go to their closest facility to attend delivery after the Initiative has improved facilities' capacity, suggesting that results-based aid initiatives targeting poor populations, like SMI, can increase the use of facilities closest to the place of residence for delivery care services. This should be considered in the design of interventions after the COVID-19 pandemic may have changed health and social conditions.
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Affiliation(s)
- Bernardo Hernandez
- Institute for Health Metrics and Evaluation. Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA.
| | - Katie Panhorst Harris
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Casey K Johanns
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Erin B Palmisano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Rebecca Cogen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Maximilian G Thom
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Emily Linebarger
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | - Aruna M Kamath
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Joseph Camarda
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Diego Rios-Zertuche
- Salud Mesoamerica Initiative, Inter-American Development Bank, Washington, DC, USA
| | | | - Pedro Bernal-Lara
- Salud Mesoamerica Initiative, Inter-American Development Bank, Washington, DC, USA
| | - Danny Colombara
- Seattle & King County. Assessment, Policy Development, & Evaluation Unit, Seattle, WA, USA
| | - Alexandra Schaefer
- Global Center for Integrated Health of Women, Adolescents, and Children, University of Washington, Seattle, WA, USA
| | - Benito Salvatierra
- Departamento de Salud, El Colegio de la Frontera Sur, San Cristóbal de las Casas, Chiapas, Mexico
| | | | | | | | - Emma Iriarte
- Salud Mesoamerica Initiative, Inter-American Development Bank, Washington, DC, USA
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation. Department of Health Metrics Sciences, University of Washington, Seattle, WA, USA
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15
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Montes K, Atluri H, Silvestre Tuch H, Ramirez L, Paiz J, Hesse Lopez A, Bailey TC, Spec A, Mejia-Chew C. Risk factors for mortality and multidrug resistance in pulmonary tuberculosis in Guatemala: A retrospective analysis of mandatory reporting. J Clin Tuberc Other Mycobact Dis 2021; 25:100287. [PMID: 34849409 PMCID: PMC8608588 DOI: 10.1016/j.jctube.2021.100287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
National TB cohort analyzing risk factors associated with MDR-TB and mortality in Guatemala. Indigenous ethnicity and prior TB treatment were associated with increased risk of mortality and MDR-TB. HIV/Unknown HIV status were associated with increased mortality and diabetes with risk for MDR-TB.
Background Risk factors for mortality and MDR-TB in Guatemala are poorly understood. We aimed to identify risk factors to assist in targeting public health interventions. Methods We performed a retrospective study of adults with pulmonary TB reported to the Guatemalan TB Program between January 1, 2016 and December 31, 2017. The primary objective was to determine risk factors for mortality in pulmonary TB. The secondary objective was to determine risk factors associated with MDR-TB. Results Among 3,945 patients with pulmonary TB, median age was 39 years (IQR 25–54), 59% were male, 25% of indigenous ethnicity, 1.1% had MDR-TB and 3.9% died. On multivariable analysis, previous TB treatment (odds ratio [OR] 3.57, CI 2.24–5.68 [p < 0.001]), living with HIV (OR 3.98, CI 2.4–6.17 [p < 0.001]), unknown HIV diagnosis (OR 2.65, CI 1.68–4.18 [p < 0.001]), indigenous ethnicity (OR 1.79, CI 1.18–2.7 [p = 0.005]), malnutrition (OR 7.33, CI 3.24–16.59 [p < 0.001]), and lower educational attainment (OR 2.86, CI 1.43–5.88 [p = 0.003]) were associated with mortality. Prior treatment (OR 53.76, CI 25.04–115.43 [p < 0.001]), diabetes (OR 4.13, CI 2.04–8.35 [p < 0.001]), and indigenous ethnicity (OR 11.83, CI 1.46–95.73 [p = 0.02]) were associated with MDR-TB. Conclusions In Guatemala, both previous TB treatment and indigenous ethnicity were associated with higher TB mortality and MDR-TB risk among patients with pulmonary TB.
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Affiliation(s)
- Kevin Montes
- Department of Medicine, Washington University School of Medicine in St. Louis, USA
| | - Himachandana Atluri
- Department of Medicine, Washington University School of Medicine in St. Louis, USA
| | - Hibeb Silvestre Tuch
- Tuberculosis Program, Ministry of Public Health and Social Assistance, Guatemala City, Guatemala
| | - Lucrecia Ramirez
- Tuberculosis Program, Ministry of Public Health and Social Assistance, Guatemala City, Guatemala
| | - Juan Paiz
- Tuberculosis Program, Ministry of Public Health and Social Assistance, Guatemala City, Guatemala
| | - Ana Hesse Lopez
- Tuberculosis Program, Ministry of Public Health and Social Assistance, Guatemala City, Guatemala
| | - Thomas C Bailey
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, USA
| | - Carlos Mejia-Chew
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, USA
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16
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Out-of-Pocket Costs for Facility-Based Obstetrical Care in Rural Guatemala. Ann Glob Health 2021; 87:75. [PMID: 34430225 PMCID: PMC8344954 DOI: 10.5334/aogh.3223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Rural Indigenous Maya communities in Guatemala have some of the worst obstetrical health outcomes in Latin America, due to widespread discrimination in healthcare and an underfunded public sector. Multiple systems-level efforts to improve facility birth outcomes have been implemented, primarily focusing on early community-based detection of obstetrical complications and on reducing discrimination and improving the quality of facility-level care. However, another important feature of public facility-level care are the out-of-pocket payments that patients are often required to make for care. Objective: To estimate the burden of out-of-pocket costs for public obstetrical care in Indigenous Maya communities in Guatemala. Methods: We conducted a retrospective review of electronic medical record data on obstetrical referrals collected as part of an obstetrical care navigation intervention, which included documentation of out-of-pocket costs by care navigators accompanying patients within public facilities. We compared the median costs for both emergency and routine obstetrical facility care. Findings: Cost data on 709 obstetric referrals from 479 patients were analyzed (65% emergency and 35% routine referrals). The median OOP costs were Q100 (IQR 75–150) [$13 USD] and Q50 (IQR 16–120) [$6.50 USD] for emergency and routine referrals. Costs for transport were most common (95% and 55%, respectively). Costs for medication, supply, laboratory, and imaging costs occurred less frequently. Food and lodging costs were minimal. Conclusion: Out-of-pocket payments for theoretically free public care are a common and important barrier to care for this rural Guatemalan setting. These data add to the literature in Latin American on the barriers to obstetrical care faced by Indigenous and rural women.
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Pseudoexfoliation and Cataract Syndrome Associated with Genetic and Epidemiological Factors in a Mayan Cohort of Guatemala. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147231. [PMID: 34299682 PMCID: PMC8303577 DOI: 10.3390/ijerph18147231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 02/06/2023]
Abstract
The Mayan population of Guatemala is understudied within eye and vision research. Studying an observational homogenous, geographically isolated population of individuals seeking eye care may identify unique clinical, demographic, environmental and genetic risk factors for blinding eye disease that can inform targeted and effective screening strategies to achieve better and improved health care distribution. This study served to: (a) identify the ocular health needs within this population; and (b) identify any possible modifiable risk factors contributing to disease pathophysiology within this population. We conducted a cross-sectional study with 126 participants. Each participant completed a comprehensive eye examination, provided a blood sample for genetic analysis, and received a structured core baseline interview for a standardized epidemiological questionnaire at the Salama Lions Club Eye Hospital in Salama, Guatemala. Interpreters were available for translation to the patients’ native dialect, to assist participants during their visit. We performed a genome-wide association study for ocular disease association on the blood samples using Illumina’s HumanOmni2.5-8 chip to examine single nucleotide polymorphism SNPs in this population. After implementing quality control measures, we performed adjusted logistic regression analysis to determine which genetic and epidemiological factors were associated with eye disease. We found that the most prevalent eye conditions were cataracts (54.8%) followed by pseudoexfoliation syndrome (PXF) (24.6%). The population with both conditions was 22.2%. In our epidemiological analysis, we found that eye disease was significantly associated with advanced age. Cataracts were significantly more common among those living in the 10 districts with the least resources. Furthermore, having cataracts was associated with a greater likelihood of PXF after adjusting for both age and sex. In our genetic analysis, the SNP most nominally significantly associated with PXF lay within the gene KSR2 (p < 1 × 10−5). Several SNPs were associated with cataracts at genome-wide significance after adjusting for covariates (p < 5 × 10−8). About seventy five percent of the 33 cataract-associated SNPs lie within 13 genes, with the majority of genes having only one significant SNP (5 × 10−8). Using bioinformatic tools including PhenGenI, the Ensembl genome browser and literature review, these SNPs and genes have not previously been associated with PXF or cataracts, separately or in combination. This study can aid in understanding the prevalence of eye conditions in this population to better help inform public health planning and the delivery of quality, accessible, and relevant health and preventative care within Salama, Guatemala.
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Austad K, Juarez M, Shryer H, Hibberd PL, Drainoni ML, Rohloff P, Chary A. Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation. BMC Pregnancy Childbirth 2021; 21:425. [PMID: 34116648 PMCID: PMC8193958 DOI: 10.1186/s12884-021-03842-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/30/2021] [Indexed: 11/14/2022] Open
Abstract
Background Global disparities in maternal mortality could be reduced by universal facility delivery. Yet, deficiencies in the quality of care prevent some mothers from seeking facility-based obstetric care. Obstetric care navigators (OCNs) are a new form of lay health workers that combine elements of continuous labor support and care navigation to promote obstetric referrals. Here we report qualitative results from the pilot OCN project implemented in Indigenous villages in the Guatemalan central highlands. Methods We conducted semi-structured interviews with 17 mothers who received OCN accompaniment and 13 staff—namely physicians, nurses, and social workers—of the main public hospital in the pilot’s catchment area (Chimaltenango). Interviews queried OCN’s impact on patient and hospital staff experience and understanding of intended OCN roles. Audiorecorded interviews were transcribed, coded, and underwent content analysis. Results Maternal fear of surgical intervention, disrespectful and abusive treatment, and linguistic barriers were principal deterrents of care seeking. Physicians and nurses reported cultural barriers, opposition from family, and inadequate hospital resources as challenges to providing care to Indigenous mothers. Patient and hospital staff identified four valuable services offered by OCNs: emotional support, patient advocacy, facilitation of patient-provider communication, and care coordination. While patients and most physicians felt that OCNs had an overwhelmingly positive impact, nurses felt their effort would be better directed toward traditional nursing tasks. Conclusions Many barriers to maternity care exist for Indigenous mothers in Guatemala. OCNs can improve mothers’ experiences in public hospitals and reduce limitations faced by providers. However, broader buy-in from hospital staff—especially nurses—appears critical to program success. Future research should focus on measuring the impact of obstetric care navigation on key clinical outcomes (cesarean delivery) and mothers’ future care seeking behavior. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03842-1.
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Affiliation(s)
- Kirsten Austad
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala. .,Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, 850 Harrison Avenue, Dowling 5, Boston, MA, 02118, USA.
| | - Michel Juarez
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala
| | - Hannah Shryer
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala
| | - Patricia L Hibberd
- Department of Global Health, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Mari-Lynn Drainoni
- Section of Infectious Disease, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA, 02118, USA.,Department of Health Law Policy & Management, Boston University School of Public Health, Boston, USA.,Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, USA
| | - Peter Rohloff
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala.,Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Anita Chary
- Wuqu' Kawoq
- Maya Health Alliance, 2da Avenida 3-48 Zona 3, Barrio Patacabaj, Tecpán, Chimaltenango, Guatemala.,Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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19
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Lewis ME, Volpert-Esmond HI, Deen JF, Modde E, Warne D. Stress and Cardiometabolic Disease Risk for Indigenous Populations throughout the Lifespan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:1821. [PMID: 33668461 PMCID: PMC7918141 DOI: 10.3390/ijerph18041821] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Indigenous people experience the greatest cardiometabolic disease disparity in the Unites States, yet high cardiometabolic disease risk factors do not fully explain the extent of the cardiometabolic disease disparity for Indigenous people. Stress, trauma, and racism occur at high rates within Indigenous communities and have not been well explored as significant contributors to cardiometabolic disease disparities despite emerging literature, and therefore will be described here. METHODS This descriptive study explores the relationship between cardiometabolic disease risks and Indigenous-specific stressors (e.g., early childhood stress and trauma, adulthood stress and trauma, and historical and intergenerational trauma) using current literature. Indigenous-specific protective factors against cardiometabolic disease are also reviewed. RESULTS Increasing research indicates that there is a relationship between Indigenous-specific stressful and traumatic life experiences and increased cardiometabolic disease risk. Mental health and psychophysiology play an important role in this relationship. Effective interventions to reduce cardiometabolic disease risk in Indigenous communities focus on ameliorating the negative effects of these stressors through the use of culturally specific health behaviors and activities. CONCLUSIONS There is increasing evidence that cultural connection and enculturation are protective factors for cardiometabolic disease, and may be galvanized through Indigenous-led training, research, and policy change.
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Affiliation(s)
- Melissa E. Lewis
- Department of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, MO 65212, USA;
| | | | - Jason F. Deen
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA;
| | - Elizabeth Modde
- Department of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, MO 65212, USA;
| | - Donald Warne
- Family & Community Medicine Department, University of North Dakota, Grand Forks, ND 58202, USA;
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20
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Raut A, Mustafayev R, Srinivasan R, Chary A, Ertem I, Grazioso MDP, Gupta S, Krishnamurthy V, Lu C, Maliye C, Miller AC, Wagenaar BH, Rohloff P. Hybrid type 1 effectiveness/implementation trial of the international Guide for Monitoring Child Development: protocol for a cluster-randomised controlled trial. BMJ Paediatr Open 2021; 5:e001254. [PMID: 34604546 PMCID: PMC8444252 DOI: 10.1136/bmjpo-2021-001254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION More than 40% of children under 5 years of age in low-income and middle-income countries are at risk of not reaching their developmental potential. The international Guide for Monitoring Child Development (GMCD) early intervention package is a comprehensive programme to address developmental difficulties using an individualised intervention plan for young children and their families. We will conduct a hybrid type 1 effectiveness-implementation evaluation of the GMCD intervention in rural India and Guatemala. METHODS AND ANALYSIS Using a cluster-randomised design, 624 children aged 0-24 months in 52 clusters (26 in India, 26 in Guatemala) will be assigned to usual care or the GMCD intervention plus usual care delivered by frontline workers for 12 months. After 12 months, the usual care arm will cross over to the intervention, which will continue for 12 additional months (24 total). The intervention will be delivered using a digital mobile device interface. Effectiveness will be assessed for developmental functioning (Bayley Scales of Infant Development, 3rd edition) and nurturing care (Home Observation for Measurement of the Environment Scale) outcomes. Implementation will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. Explanatory qualitative analysis guided by the Consolidated Framework for Implementation Research will explore determinants between clusters with high versus low implementation effectiveness. ETHICS AND DISSEMINATION The study has been approved by the Institutional Review Boards of Brigham and Women's Hospital, Mahatma Gandhi Institute of Medical Sciences and Maya Health Alliance; and by the Indian Council of Medical Research/Health Ministry Screening Committee. Key study findings will be published in international open-access journals. TRIAL REGISTRATION NUMBER NCT04665297, CTRI/2020/12/029748. PROTOCOL VERSION 1.0 (12 November 2020).
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Affiliation(s)
- Abhishek Raut
- Department of Community Medicine, Dr. Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Revan Mustafayev
- Department of Pediatrics, Acibadem Maslak Private Hospital, Istanbul, Turkey
| | | | - Anita Chary
- Center for Indigenous Health Research, Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Chimaltenango, Guatemala
| | - Ilgi Ertem
- Developmental-Behavioral Pediatrics Division, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | | | - Subodh Gupta
- Department of Community Medicine, Dr. Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | | | - Chunling Lu
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Chetna Maliye
- Department of Community Medicine, Dr. Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Ann C Miller
- Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Bradley H Wagenaar
- Department of Global Health, University of Washington, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Peter Rohloff
- Center for Indigenous Health Research, Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Chimaltenango, Guatemala.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Samuel J, Flores W, Frisancho A. Social exclusion and universal health coverage: health care rights and citizen-led accountability in Guatemala and Peru. Int J Equity Health 2020; 19:216. [PMID: 33298093 PMCID: PMC7724714 DOI: 10.1186/s12939-020-01308-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While equity is a central concern in promoting Universal Health Coverage (UHC), the impact of social exclusion on equity in UHC remains underexplored. This paper examines challenges faced by socially excluded populations, with an emphasis on Indigenous peoples, to receive UHC in Latin America. We argue that social exclusion can have negative effects on health systems and can undermine progress towards UHC. We examine two case studies, one in Guatemala and one in Peru, involving citizen-led accountability initiatives that aim to identify and address problems with health care services for socially excluded groups. The case studies reveal how social exclusion can affect equity in UHC. METHODS In-depth analysis was conducted of all peer reviewed articles published between 2015 and 2019 on the two cases (11 in total), and two non-peer reviewed reports published over the same period. In addition, two of the three authors contributed their first-hand knowledge gathered through practitioner involvement with the citizen-led initiatives examined in the two cases. The analysis sought to identify and compare challenges faced by socially excluded Indigenous populations to receive UHC in the two cases. RESULTS Citizen-led accountability initiatives in Guatemala and Peru reveal very similar patterns of serious deficiencies that undermine efforts towards the realization of Universal Health Coverage in both countries. In each case, the socially excluded populations are served by a dysfunctional publicly provided health system marked by gaps and often invisible barriers. The cases suggest that, while funding and social rights to coverage have expanded, marginalized populations in Guatemala and Peru still do not receive either the health care services or the protection against financial hardship promised by health systems in each country. In both cases, the dysfunctional character of the system remains in place, undermining progress towards UHC. CONCLUSIONS We conclude that efforts to promote UHC cannot stop at increasing health systems financing. In addition, these efforts need to contend with the deeper challenges of democratizing state institutions, including health systems, involved in marginalizing and excluding certain population groups. This includes stronger accountability systems within public institutions. More inclusive accountability mechanisms are an important step in promoting equitable progress towards UHC.
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Affiliation(s)
- Jeannie Samuel
- Health and Society Program, York University, Toronto, Canada
| | - Walter Flores
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala
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Pelcastre-Villafuerte BE, Cuecuecha Rugerio E, Treviño Siller SG, Rueda Neria CM, Ruelas-González MG. Health needs of indigenous Mayan older adults in Mexico and health services available. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:1688-1697. [PMID: 32350972 DOI: 10.1111/hsc.12994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 02/07/2020] [Accepted: 03/13/2020] [Indexed: 06/11/2023]
Abstract
Current data indicate that inequitable health service access is one of the major problems faced by indigenous people in Mexico and around the world. The aim of this study was to analyse the perceived health needs of indigenous older adults in a Mayan region of Mexico and the health services provided to address these needs. It used a qualitative design which explored health needs, perceptions of well-being, experiences with public health services and obstacles in accessing services through semi-structured interviews with 20 older adults, nine traditional healers and seven public healthcare providers from Mayan municipalities in southeastern Mexico during 2013-2014. We identified that cultural differences related to the language, values, beliefs and worldview of indigenous populations are ignored or incorporated only minimally by health services. The provision of services does not correspond to the health needs of indigenous Mayan older adults, and wide gaps still undermine their human rights and health status; despite the establishment of favourable regulations, healthcare services are organised for the non-indigenous population. The conditions of social vulnerability affecting indigenous older adults require that healthcare institutions incorporate an intercultural approach in order to improve the quality of care according to the necessities of the population.
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Affiliation(s)
| | - Elizabeth Cuecuecha Rugerio
- State Coordinator, Hospital Network for Epidemiological Surveillance, O.P.D. Salud de Tlaxcala, Tlaxcala, Mexico
| | | | - Celina M Rueda Neria
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
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Nandi M, Moore J, Colom M, Quezada ADRG, Chary A, Austad K. Insights Into Provider Bias in Family Planning from a Novel Shared Decision Making Based Counseling Initiative in Rural, Indigenous Guatemala. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:10-17. [PMID: 32234840 PMCID: PMC7108940 DOI: 10.9745/ghsp-d-19-00377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 02/24/2020] [Indexed: 11/18/2022]
Abstract
Race, ethnicity, and indigenous status should be considered as potential drivers of provider bias in family planning services globally. Efforts to confront provider bias in family planning counseling should include concrete strategies that promote provider recognition of biases and longitudinal curriculums that allow for sustained feedback and self-reflection.
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Affiliation(s)
- Meghna Nandi
- Warren Alpert Medical School, Brown University, Providence, RI, USA.,Wuqu' Kawoq
- Maya Health Alliance, Bethel, VT, USA
| | - Jillian Moore
- Wuqu' Kawoq
- Maya Health Alliance, Bethel, VT, USA.,Department of Family and Community Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Marcela Colom
- Wuqu' Kawoq
- Maya Health Alliance, Bethel, VT, USA.,Department of Family and Community Medicine, University of New Mexico, Albuquerque, NM, USA
| | | | - Anita Chary
- Wuqu' Kawoq
- Maya Health Alliance, Bethel, VT, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kirsten Austad
- Wuqu' Kawoq
- Maya Health Alliance, Bethel, VT, USA. .,Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
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Armenta-Paulino N, Castelló A, Sandín Vázquez M, Bolúmar F. How the choice of ethnic indicator influences ethnicity-based inequities in maternal health care in four Latin American countries: who is indigenous? Int J Equity Health 2020; 19:31. [PMID: 32164717 PMCID: PMC7069165 DOI: 10.1186/s12939-020-1136-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/04/2020] [Indexed: 11/10/2022] Open
Abstract
Background The current focus on monitoring health inequalities and the complexity around ethnicity requires careful consideration of how ethnic disparities are measured and presented. This paper aims to determine how inequalities in maternal healthcare by ethnicity change according to different criteria used to classify indigenous populations. Methods Nationally representative demographic surveys from Bolivia, Guatemala, Mexico, and Peru (2008–2016) were used to explore coverage gaps across maternal health care by ethnicity using different criteria. Women were classified as indigenous through self-identification (SI), spoken indigenous language (SIL), or indigenous household (IH). We compared the gaps through measuring coverage ratios (CR) with adjusted Poisson regression models. Results Proportions of indigenous women changed significantly according to the identification criterion (Bolivia:SI-63.1%/SIL-37.7%; Guatemala:SI-49.7%/SIL-28.2%; Peru:SI-34%/SIL-6.3% & Mexico:SI-29.7%/SIL-6.9%). Indigenous in all countries, regardless of their identification, had less coverage. Gaps in care between indigenous and non-indigenous populations changed, for all indicators and countries, depending on the criterion used (e.g., Bolivia CR for contraceptive-use SI = 0.70, SIL = 0.89; Guatemala CR for skilled-birth-attendant SI = 0.77, SIL = 0.59). The heterogeneity persists when the reference groups are modified and compare just to non-indigenous (e.g., Bolivia CR for contraceptive-use under SI = 0.64, SIL = 0.70; Guatemala CR for Skilled-birth-attendant under SI = 0.77, SIL = 0.57). Conclusions The indigenous identification criteria could have an impact on the measurement of inequalities in the coverage of maternal health care. Given the complexity and diversity observed, it is not possible to provide a definitive direction on the best way to define indigenous populations to measure inequalities. In practice, the categorization will depend on the information available. Our results call for greater care in the analysis of ethnicity-based inequalities. A greater understanding on how the indigenous are classified when assessing inequalities by ethnicity can help stakeholders to deliver interventions responsive to the needs of these groups.
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Affiliation(s)
- Nancy Armenta-Paulino
- Public Health Unit, Faculty of Medicine, University of Alcalá, Crtra Madrid-Barcelona Km 33.6, Alcalá de Henares, 28871, Spain
| | - Adela Castelló
- Public Health Unit, Faculty of Medicine, University of Alcalá, Crtra Madrid-Barcelona Km 33.6, Alcalá de Henares, 28871, Spain.,Ciberesp, Madrid, Spain
| | - María Sandín Vázquez
- Public Health Unit, Faculty of Medicine, University of Alcalá, Crtra Madrid-Barcelona Km 33.6, Alcalá de Henares, 28871, Spain
| | - Francisco Bolúmar
- Public Health Unit, Faculty of Medicine, University of Alcalá, Crtra Madrid-Barcelona Km 33.6, Alcalá de Henares, 28871, Spain. .,Ciberesp, Madrid, Spain. .,Department of Epidemiology and Biostatistics. Graduate School of Public Health, City University of New York, 55 W 125th St, New York, 10027, USA.
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25
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Flood D, Wilcox K, Ferro AA, Mendoza Montano C, Barnoya J, Garcia P, Lou-Meda R, Rohloff P, Chary A. Challenges in the provision of kidney care at the largest public nephrology center in Guatemala: a qualitative study with health professionals. BMC Nephrol 2020; 21:71. [PMID: 32111173 PMCID: PMC7049202 DOI: 10.1186/s12882-020-01732-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/19/2020] [Indexed: 01/29/2023] Open
Abstract
Background Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals’ perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala. Methods Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions. Results Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services. Conclusions Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.
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Affiliation(s)
- David Flood
- National Clinicians Scholars Program, Division of Hospital Medicine, University of Michigan, Ann Arbor, MI, USA.,Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Guatemala
| | - Katharine Wilcox
- Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Guatemala.,Weill Cornell School of Medicine, New York, USA
| | | | - Carlos Mendoza Montano
- Institute of Nutrition of Central America and Panama (Instituto de Nutrición de Centroamérica y Panamá, INCAP), Guatemala City, Guatemala
| | - Joaquin Barnoya
- Unit for Cardiovascular Surgery (Unidad de Cirugía Cardiovascular de Guatemala, UNICAR), Guatemala City, Guatemala.,Institute of Research and Higher Studies in Health Sciences (El Instituto de Investigación y Estudios Superiores en Ciencias de la Salud, IECIS), Rafael Landívar University, Guatemala City, Guatemala
| | - Pablo Garcia
- Division of Nephrology, Stanford University, Palo Alto, USA
| | - Randall Lou-Meda
- Foundation for Children with Renal Disease (Fundación para el Niño Enfermo Renal, FUNDANIER), Guatemala City, Guatemala
| | - Peter Rohloff
- Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Guatemala.,Department of Medicine, Department of Global Health Equity, Brigham and Women's Hospital, Boston, USA
| | - Anita Chary
- Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Guatemala. .,Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA.
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26
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Nieblas-Bedolla E, Bream KDW, Rollins A, Barg FK. Ongoing challenges in access to diabetes care among the indigenous population: perspectives of individuals living in rural Guatemala. Int J Equity Health 2019; 18:180. [PMID: 31752908 PMCID: PMC6873569 DOI: 10.1186/s12939-019-1086-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 11/04/2019] [Indexed: 11/25/2022] Open
Abstract
Background Indigenous persons living in Latin America suffer from a higher prevalence of type 2 diabetes compared to their non-indigenous counterparts. This difference has been attributed to a wide range of factors. Future interventions could be influenced by a deeper understanding of the challenges that impact care in rural regions and in other low-income settings. Methods This study was conducted using a modified grounded theory approach. Extended observations and fifteen interviews were performed with adult male and female residents of three rural Mayan towns in Sololá Department, Guatemala using purposive sampling. Questions focused on the perceptions of individuals living with type 2 diabetes and their caregivers regarding disease and treatment. Results Across interviews the most common themes that emerged included mistreatment by healthcare providers, mental health comorbidity, and medication affordability. These perceptions were in part influenced by indigeneity, poverty, and/or gender. Conclusions Both structural and cultural barriers continue to impact diabetes care for indigenous communities in rural Guatemala. The interviews in this study suggest that indigenous people experience mistrust in the health care system, unreliable access to care, and mental health comorbidity in the context of type 2 diabetes care. These experiences are shaped by the complex relationship among poverty, gender, and indigeneity in this region. Targeted interventions that are conscious of these factors may increase their chances of success when attempting to address similar health disparities in comparable populations.
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Affiliation(s)
- Edwin Nieblas-Bedolla
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,School of Medicine, University of Washington, Seattle, WA, USA.
| | - Kent D W Bream
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA.,Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, USA
| | - Allison Rollins
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Frances K Barg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA.,Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, USA
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27
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Parry L, Radel C, Adamo SB, Clark N, Counterman M, Flores-Yeffal N, Pons D, Romero-Lankao P, Vargo J. The (in)visible health risks of climate change. Soc Sci Med 2019; 241:112448. [PMID: 31481245 PMCID: PMC8033784 DOI: 10.1016/j.socscimed.2019.112448] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/20/2019] [Accepted: 07/24/2019] [Indexed: 01/11/2023]
Abstract
This paper scrutinizes the assertion that knowledge gaps concerning health risks from climate change are unjust, and must be addressed, because they hinder evidence-led interventions to protect vulnerable populations. First, we construct a taxonomy of six inter-related forms of invisibility (social marginalization, forced invisibility by migrants, spatial marginalization, neglected diseases, mental health, uneven climatic monitoring and forecasting) which underlie systematic biases in current understanding of these risks in Latin America, and advocate an approach to climate-health research that draws on intersectionality theory to address these inter-relations. We propose that these invisibilities should be understood as outcomes of structural imbalances in power and resources rather than as haphazard blindspots in scientific and state knowledge. Our thesis, drawing on theories of governmentality, is that context-dependent tensions condition whether or not benefits of making vulnerable populations legible to the state outweigh costs. To be seen is to be politically counted and eligible for rights, yet evidence demonstrates the perils of visibility to disempowered people. For example, flood-relief efforts in remote Amazonia expose marginalized urban river-dwellers to the traumatic prospect of forced relocation and social and economic upheaval. Finally, drawing on research on citizenship in post-colonial settings, we conceptualize climate change as an 'open moment' of political rupture, and propose strategies of social accountability, empowerment and trans-disciplinary research which encourage the marginalized to reach out for greater power. These achievements could reduce drawbacks of state legibility and facilitate socially-just governmental action on climate change adaptation that promotes health for all.
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Affiliation(s)
- Luke Parry
- Lancaster Environment Centre, Lancaster University, UK; Nucleus of Advanced Amazonian Studies (NAEA), Federal University of Pará, Brazil.
| | - Claudia Radel
- Department of Environment and Society, Utah State University, UT, USA
| | | | - Nigel Clark
- Lancaster Environment Centre, Lancaster University, UK
| | | | - Nadia Flores-Yeffal
- Department of Sociology, Anthropology & Social Work, Texas Tech University, TX, USA
| | - Diego Pons
- Department of Geography and the Environment, University of Denver, CO, USA
| | | | - Jason Vargo
- Global Health Institute and the Nelson Institute for Environmental Studies, University of Wisconsin-Madison, WI, USA
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28
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Vedam S, Stoll K, Taiwo TK, Rubashkin N, Cheyney M, Strauss N, McLemore M, Cadena M, Nethery E, Rushton E, Schummers L, Declercq E. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health 2019. [PMID: 31182118 DOI: 10.1186/s12978-019-0729-2.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study. METHODS Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables. RESULTS Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment. CONCLUSION This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.
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Affiliation(s)
- Saraswathi Vedam
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver (Canada), E416 Shaughnessy (Mailbox 80), 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada.
| | - Kathrin Stoll
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver (Canada), E416 Shaughnessy (Mailbox 80), 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Tanya Khemet Taiwo
- University of California Davis School of Medicine, Sacramento, California, USA.,Department of Midwifery, Bastyr University, Seattle, WA, USA
| | - Nicholas Rubashkin
- Department of Obstetrics and Gynecology, University of California San Francisco and the Institute for Global Health Sciences, California, USA
| | - Melissa Cheyney
- Department of Anthropology, Oregon State University, Corvallis, Oregon, USA
| | | | - Monica McLemore
- Department of Family Health Care Nursing and ANSIRH Bixby Center for Global Reproductive Health, University of California, San Francisco, USA
| | | | - Elizabeth Nethery
- School of Population & Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Eleanor Rushton
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver (Canada), E416 Shaughnessy (Mailbox 80), 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Laura Schummers
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Eugene Declercq
- School of Public Health, Boston University, Massachusetts, Boston, USA
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29
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Vedam S, Stoll K, Taiwo TK, Rubashkin N, Cheyney M, Strauss N, McLemore M, Cadena M, Nethery E, Rushton E, Schummers L, Declercq E. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health 2019; 16:77. [PMID: 31182118 PMCID: PMC6558766 DOI: 10.1186/s12978-019-0729-2] [Citation(s) in RCA: 356] [Impact Index Per Article: 71.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/30/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study. METHODS Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables. RESULTS Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment. CONCLUSION This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.
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Affiliation(s)
- Saraswathi Vedam
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver (Canada), E416 Shaughnessy (Mailbox 80), 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Kathrin Stoll
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver (Canada), E416 Shaughnessy (Mailbox 80), 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Tanya Khemet Taiwo
- University of California Davis School of Medicine, Sacramento, California, USA
- Department of Midwifery, Bastyr University, Seattle, WA USA
| | - Nicholas Rubashkin
- Department of Obstetrics and Gynecology, University of California San Francisco and the Institute for Global Health Sciences, California, USA
| | - Melissa Cheyney
- Department of Anthropology, Oregon State University, Corvallis, Oregon, USA
| | | | - Monica McLemore
- Department of Family Health Care Nursing and ANSIRH Bixby Center for Global Reproductive Health, University of California, San Francisco, USA
| | | | - Elizabeth Nethery
- School of Population & Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Eleanor Rushton
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver (Canada), E416 Shaughnessy (Mailbox 80), 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Laura Schummers
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Eugene Declercq
- School of Public Health, Boston University, Massachusetts, Boston, USA
| | - the GVtM-US Steering Council
- Birth Place Lab, Division of Midwifery, Faculty of Medicine, University of British Columbia, Vancouver (Canada), E416 Shaughnessy (Mailbox 80), 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
- University of California Davis School of Medicine, Sacramento, California, USA
- Department of Midwifery, Bastyr University, Seattle, WA USA
- Department of Obstetrics and Gynecology, University of California San Francisco and the Institute for Global Health Sciences, California, USA
- Department of Anthropology, Oregon State University, Corvallis, Oregon, USA
- Every Mother Counts, New York City, USA
- Department of Family Health Care Nursing and ANSIRH Bixby Center for Global Reproductive Health, University of California, San Francisco, USA
- Young Women United, Albuquerque, New Mexico, USA
- School of Population & Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- School of Public Health, Boston University, Massachusetts, Boston, USA
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Salm A, Gertsch J. Cultural perception of triatomine bugs and Chagas disease in Bolivia: a cross-sectional field study. Parasit Vectors 2019; 12:291. [PMID: 31182163 PMCID: PMC6558697 DOI: 10.1186/s13071-019-3546-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/30/2019] [Indexed: 01/09/2023] Open
Abstract
Background Chagas disease remains a major public health risk in Bolivia, particularly among rural indigenous communities. Here we studied the cultural perception of the triatomine vectors and Chagas disease among selected rural and urban ethnic groups from different socio-economic and geographical milieus. We focused on the indigenous communities in the Bolivian Chaco where the disease is hyperendemic. Methods A cross-sectional study using field observations and structured interviews was carried out among 480 informants in five different regions of Bolivia. Additional semi-structured interviews were conducted. Statistical analyses were performed to determine the correlation of socio-economic variables and indigenous Chagas disease knowledge systems. A total of 170 domestic Triatoma infestans vectors were collected and infection with Trypanosoma cruzi was analyzed by real-time PCR. Results Triatomine bugs were associated with Chagas disease in 70.2% (n = 480) of the responses (48.0% Ayoreo, 87.5% Chiquitano, 83.9% Guaraní, 72.2% Quechua, 46.1% La Paz citizens and 67.7% Santa Cruz citizens). Generally, indigenous informants have been educated on the association between triatomine bugs and Chagas disease by institutional anti-Chagas disease campaigns. While communities were largely aware of the vectors as a principal mode of disease transmission, rather unexpectedly, health campaigns had little influence on their prevention practices, apparently due to cultural constraints. Overall, 71.9% of the collected domestic vectors in the Chaco region were infected with T. cruzi, matching the high infection rates in the indigenous communities. Conclusions Among the Guaraní, Ayoreo and Quechua communities, the groups living in traditional houses have not integrated the scientific knowledge about Chagas disease transmission into their daily hygiene and continue to cohabit with T. infestans vectors hyperinfected with T. cruzi. An effective translation of Western disease concepts into traditional preventive measures is missing because asymptomatic infections are not generally perceived as threat by the communities. New participatory approaches involving existing ethnomedical knowledge systems could be a successful strategy in the control of T. cruzi infection.
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Affiliation(s)
- Andrea Salm
- Institute of Biochemistry and Molecular Medicine, University of Bern, 3012, Bern, Switzerland
| | - Jürg Gertsch
- Institute of Biochemistry and Molecular Medicine, University of Bern, 3012, Bern, Switzerland.
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31
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Quiñonez-Tapia F, Vargas-Garduño MDL, Soltero-Avelar R. Wixáritari with diabetes mellitus and their links with the disease: From the appearance of the symptom to a first explanation. Salud Colect 2019; 15:e1856. [PMID: 31269118 DOI: 10.18294/sc.2019.1856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 12/03/2018] [Indexed: 11/24/2022] Open
Abstract
This article explores the process of construction of the conceptual, referential and operative schema among the wixáritari population regarding type 2 diabetes mellitus in a community of Jalisco, Mexico, from the appearance of the first symptom to a possible explanation of the disease. This is a qualitative study performed with the phenomenological method using in-depth interviews to collect information. There were seven participants. The data was processed with Bakhtin's discourse analysis, based on Pichon Rivière's theory of the link. It was found that the wixáritari population with diabetes develop their conceptual, referential and operative schema over a period of three to five years, based on three links: the symptoms in the body, the explanation the wixáritari give regarding their symptoms, and the explanations of the social space of the disease. The wixáritari develop a series of links and conceptual, referential and operative schema that allow them to validate an explanation of what they experience in their body, in a confrontational and painful process full of affirmations and denial until reaching a synthesis that allows them to achieve a full understanding of their situation and implement behaviors to care for their health.
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Affiliation(s)
| | - María de Lourdes Vargas-Garduño
- Doctora en Ciencias Sociales. Profesora de tiempo completo, Universidad Michoacana de San Nicolás de Hidalgo, Michoacán, México.
| | - Rubén Soltero-Avelar
- Doctor en Ciencias de la Salud Pública. Profesor de tiempo completo, Universidad de Guadalajara, Jalisco, México.
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Cnop K, Martinez B, Austad KE. Resistant dermatomyositis in a rural indigenous Maya woman. BMJ Case Rep 2019; 12:e223886. [PMID: 30796072 PMCID: PMC6388881 DOI: 10.1136/bcr-2017-223886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2019] [Indexed: 11/03/2022] Open
Abstract
A 28-year-old indigenous Guatemalan woman presented with 7 months of progressive weakness and numerous dermatological findings. She initially sought care within the free government-run health system and was treated with oral steroids for presumed dermatomyositis. Her symptoms progressed, including severe dysphagia, hypophonia and weakness preventing sitting. She was lost to follow-up in the public system due to financial and cultural barriers. A non-governmental organisation tailored to the needs of Maya patients provided home intravenous pulse dose methylprednisolone in the absence of first-line biologicals. With longitudinal home-based care, she achieved symptom free recovery. The rising burden of chronic non-communicable diseases highlights shortcomings in health systems evident in this case, including lack of provider capacity, limited infrastructure to test for and treat rare diseases and poor continuity of care. We provide potential solutions to help care delivery in low-resource settings adapt to the demans of chronic disease control with particular attention to social determinants of health.
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Affiliation(s)
- Katia Cnop
- Wuqu' Kawoq, Maya Health Alliance, Santiago, Guatemala
- Burrell College of Osteopathic Medicine, Las Cruces, New Mexico, USA
| | - Boris Martinez
- Wuqu' Kawoq, Maya Health Alliance, Santiago, Guatemala
- Internal Medicine, Saint Peter's University Hospital, Rutgers University, New Brunswick, New Jersey, USA
| | - Kirsten E Austad
- Wuqu' Kawoq, Maya Health Alliance, Santiago, Guatemala
- Internal Medicine Division of Women's Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Velásquez CN, Del Rosario Garcia Meza M, Ukhova D, Xinico S, Palma S, Simpson S. Making the health system work by and for Indigenous women in Guatemala: a community led multisectoral collaboration. BMJ 2018; 363:k4677. [PMID: 30530627 PMCID: PMC6284262 DOI: 10.1136/bmj.k4677] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | | | | | - Silvia Xinico
- Alianza Nacional de Organizaciones de Mujeres Indigenas por la Salud Reproductiva Nutrición y Educación (ALIANMISAR), Guatemala City, Guatemala
| | - Susana Palma
- USAID Health Education and Policy Project, Guatemala City, Guatemala
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Colom M, Austad K, Sacuj N, Larson K, Rohloff P. Expanding access to primary healthcare for women through a microfinance institution: A case study from rural Guatemala. Healthcare (Basel) 2018; 6:223-230. [DOI: 10.1016/j.hjdsi.2017.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/15/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022] Open
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Green JC, Boakye EA, Schoening A, Vaughn MG. Peace in Guatemala and Immigrant Health in the United States. Ann Glob Health 2018. [PMID: 30779520 PMCID: PMC6748172 DOI: 10.29024/aogh.2380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The civil war between the indigenous Mayans and other Guatemalans lasted for 36 years, killed civilians, decimated villages, and resulted in many refugees. The Guatemalan Peace Agreement of 1996 aimed to alleviate the ongoing conflict. Studies of peace agreements more typically evaluate local political outcomes while neglecting global health outcomes. Objective: Our research quantified associations between pre-migration exposure to the peace agreement in Guatemala and the post-migration health status of Guatemalan immigrants in the United States. Methods: We used chi-square tests to compare the distribution of health status before and after peace. We used ordered probit regressions to estimate associations between peace in Guatemala and health in the United States, conditional on the observed distributions of age, age squared, age cubed, and linear time trends before and after peace. Findings: The study sample included 4,115 female and 5,282 male Guatemalan immigrants between the ages of 15 and 85. The mean age was 38.8 years for females (standard deviation, 14.2) and 35.4 years for males (standard deviation, 12.6). Chi-square tests found statistically significant differences in the distribution of health status before and after the peace agreement, for females (P < .001) and males (P < .001). In unadjusted results, the peace agreement was associated with a 7.3 percentage point increase in excellent post-migration health for females (95% confidence interval, 4.9 to 9.8) and a 6.0 percentage point increase for males (95% confidence interval, 3.8 to 8.2). In adjusted results, we found that the peace agreement was associated with a 6.1 percentage point increase in excellent post-migration health for females (95% confidence interval, 0.8 to 11.4) and a 5.5-percentage point increase for males (95% confidence interval, 1.0 to 10.0). Conclusions: The peace agreement in Guatemala was associated with statistically significant improvements in the health status of Guatemalan immigrants to the United States.
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Affiliation(s)
- Jeremy C Green
- Saint Louis University, Department of Health Management and Policy, US
| | | | - Amanda Schoening
- Saint Louis University, Department of Health Management and Policy, US
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Green JC, Boakye EA, Schoening A, Vaughn MG. Peace in Guatemala and Immigrant Health in the United States. Ann Glob Health 2018; 84:704-709. [PMID: 30779520 DOI: 10.9204/aogh.2380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The civil war between the indigenous Mayans and other Guatemalans lasted for 36 years, killed civilians, decimated villages, and resulted in many refugees. The Guatemalan Peace Agreement of 1996 aimed to alleviate the ongoing conflict. Studies of peace agreements more typically evaluate local political outcomes while neglecting global health outcomes. OBJECTIVE Our research quantified associations between pre-migration exposure to the peace agreement in Guatemala and the post-migration health status of Guatemalan immigrants in the United States. METHODS We used chi-square tests to compare the distribution of health status before and after peace. We used ordered probit regressions to estimate associations between peace in Guatemala and health in the United States, conditional on the observed distributions of age, age squared, age cubed, and linear time trends before and after peace. FINDINGS The study sample included 4,115 female and 5,282 male Guatemalan immigrants between the ages of 15 and 85. The mean age was 38.8 years for females (standard deviation, 14.2) and 35.4 years for males (standard deviation, 12.6). Chi-square tests found statistically significant differences in the distribution of health status before and after the peace agreement, for females (P < .001) and males (P < .001). In unadjusted results, the peace agreement was associated with a 7.3 percentage point increase in excellent post-migration health for females (95% confidence interval, 4.9 to 9.8) and a 6.0 percentage point increase for males (95% confidence interval, 3.8 to 8.2). In adjusted results, we found that the peace agreement was associated with a 6.1 percentage point increase in excellent post-migration health for females (95% confidence interval, 0.8 to 11.4) and a 5.5-percentage point increase for males (95% confidence interval, 1.0 to 10.0). CONCLUSIONS The peace agreement in Guatemala was associated with statistically significant improvements in the health status of Guatemalan immigrants to the United States.
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Affiliation(s)
- Jeremy C Green
- Saint Louis University, Department of Health Management and Policy, US
| | | | - Amanda Schoening
- Saint Louis University, Department of Health Management and Policy, US
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Juan-Martínez B, Castillo-Arcos LDC, Cortaza-Ramírez L. "A dismantled society": meta-synthesis of the phenomenon of violence in indigenous populations. ACTA ACUST UNITED AC 2018; 39:e20170080. [PMID: 30043940 DOI: 10.1590/1983-1447.2018.2017-0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 08/25/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To analyze publications of qualitative studies that addressed the phenomenon of violence in indigenous population. METHOD Meta-synthesis of studies published in the period of 2006 to 2016, with search in the Ebsco Host, Cuiden Plus, Science Direct, Springer, and Web of Science databases. RESULTS A new reinterpretation of the findings was generated from the codes and categories of the primary articles. Five categories emerged: living violence, factors associated with patterns of violence, consequences of violence, interaction dynamics in situations of violence, and how to deal with violence. CONCLUSIONS Indigenous people experience different types of violence at an early age; experienced in the family. This makes it an emerging social problem that must be taken care of urgently and represents an area of opportunity for the nursing professionals whose central focus is human care.
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Llamas A, Mayhew S. "Five hundred years of medicine gone to waste"? Negotiating the implementation of an intercultural health policy in the Ecuadorian Andes. BMC Public Health 2018; 18:686. [PMID: 29866186 PMCID: PMC5987654 DOI: 10.1186/s12889-018-5601-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 05/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Ecuador, indigenous women have poorer maternal health outcomes and access to maternity services. This is partly due to cultural barriers. A hospital in Ecuador implemented the Vertical Birth (VB) policy to address such inequities by adapting services to the local culture. This included conducting upright deliveries, introducing Traditional Birth Attendants (TBAs) and making physical adaptations to hospital facilities. METHODS Using qualitative methods, we studied the VB policy implementation in an Ecuadorian hospital to analyse the factors that affect effective implementation of intercultural health policies at the local level. We collected data through observation, in-depth interviews, a focus group discussion, and documentation review. We conducted 46 interviews with healthcare workers, managers, TBAs, key informants and policy-makers involved in maternal health. Data analysis was guided by grounded theory and drew heavily on concepts of "street-level bureaucracy" to interpret policy implementation. RESULTS The VB policy was highly controversial; actors' values (including concerns over patient safety) motivated their support or opposition to the Vertical Birth policy. For those who supported the policy, managers, policy-makers, indigenous actors and a minority of healthcare workers supported the policy, it was critical to address ethnic discrimination to improve indigenous women's access to the health service. Most healthcare workers initially resisted the policy because they believed vertical births led to poorer clinical outcomes and because they resented working alongside TBAs. Healthcare workers developed coping strategies and effectively modified the policy. Managers accepted these as a compromise to enable implementation. CONCLUSIONS Although contentious, intercultural health policies such as the VB policy have the potential to improve maternity services and access for indigenous women. Evidence-base medicine should be used as a lever to facilitate the dialogue between healthcare workers and TBAs and to promote best practice and patient safety. Actors' values influenced policy implementation; policy implementation resulted from an ongoing negotiation between healthcare workers and managers.
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Affiliation(s)
- Ana Llamas
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, 15-17 Tavistock place, London, WC1H 9SH, UK.
| | - Susannah Mayhew
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, 15-17 Tavistock place, London, WC1H 9SH, UK
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Flood D, Chary A, Colom A, Rohloff P. Adolescent Rights and the "First 1,000 days" Global Nutrition Movement: A View from Guatemala. Health Hum Rights 2018; 20:295-301. [PMID: 30008571 PMCID: PMC6039738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- David Flood
- Resident physician and health services researcher at Wuqu’ Kawoq’ in Santiago Sacatépquez, Guatemala, and at the University of Minnesota, Minneapolis, Minnesota, USA
| | - Anita Chary
- Resident physician and medical anthropologist at Wuqu’ Kawoq’ in Santiago Sacatépquez, Guatemala, and at Harvard Medical School, Boston, MA, USA
| | - Alejandra Colom
- Associate professor of anthropology at the University del Valle of Guatemala and country director of the Population Council in Gueatemala City, Guatemala
| | - Peter Rohloff
- Practicing internist and pediatrician, assistant professor of medicine at Brigham and Women’s Hospital, Boston, MA, USA, and founder of Wuqu’ Kawoq in Santiago Sacatépquez, Guatemala
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Flood D, Garcia P, Douglas K, Hawkins J, Rohloff P. Screening for chronic kidney disease in a community-based diabetes cohort in rural Guatemala: a cross-sectional study. BMJ Open 2018; 8:e019778. [PMID: 29358450 PMCID: PMC5781190 DOI: 10.1136/bmjopen-2017-019778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/03/2017] [Accepted: 11/24/2017] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Screening is a key strategy to address the rising burden of chronic kidney disease (CKD) in low-income and middle-income countries. However, there are few reports regarding the implementation of screening programmes in resource-limited settings. The objectives of this study are to (1) to share programmatic experiences implementing CKD screening in a rural, resource-limited setting and (2) to assess the burden of renal disease in a community-based diabetes programme in rural Guatemala. DESIGN Cross-sectional assessment of glomerular filtration rate (GFR) and urine albumin. SETTING Central Highlands of Guatemala. PARTICIPANTS We enrolled 144 adults with type 2 diabetes in a community-based CKD screening activity carried out by the sponsoring institution. OUTCOME MEASURES Prevalence of renal disease and risk of CKD progression using Kidney Disease: Improving Global Outcomes definitions and classifications. RESULTS We found that 57% of the sample met GFR and/or albuminuria criteria suggestive of CKD. Over half of the sample had moderate or greater increased risk for CKD progression, including nearly 20% who were classified as high or very high risk. Hypertension was common in the sample (42%), and glycaemic control was suboptimal (mean haemoglobin A1c 9.4%±2.5% at programme enrolment and 8.6%±2.3% at time of CKD screening). CONCLUSIONS The high burden of renal disease in our patient sample suggests an imperative to better understand the burden and risk factors of CKD in Guatemala. The implementation details we share reveal the tension between evidence-based CKD screening versus screening that can feasibly be delivered in resource-limited global settings.
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Affiliation(s)
- David Flood
- Wuqu’ Kawoq, Santiago Sacatepéquez, Sacatepéquez, Guatemala
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Pablo Garcia
- Wuqu’ Kawoq, Santiago Sacatepéquez, Sacatepéquez, Guatemala
| | - Kate Douglas
- Wuqu’ Kawoq, Santiago Sacatepéquez, Sacatepéquez, Guatemala
| | | | - Peter Rohloff
- Wuqu’ Kawoq, Santiago Sacatepéquez, Sacatepéquez, Guatemala
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA
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Ramay BM, Cerón A, Méndez-Alburez LP, Lou-Meda R. Factors associated to acceptable treatment adherence among children with chronic kidney disease in Guatemala. PLoS One 2017; 12:e0186644. [PMID: 29036228 PMCID: PMC5643062 DOI: 10.1371/journal.pone.0186644] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/04/2017] [Indexed: 12/13/2022] Open
Abstract
Pediatric patients with Chronic Kidney Disease face several barriers to medication adherence that, if addressed, may improve clinical care outcomes. A cross sectional questionnaire was administered in the Foundation for Children with Kidney Disease (FUNDANIER, Guatemala City) from September of 2015 to April of 2016 to identify the predisposing factors, enabling factors and need factors related to medication adherence. Sample size was calculated using simple random sampling with a confidence level of 95%, confidence interval of 0.05 and a proportion of 87%. A total of 103 participants responded to the questionnaire (calculated sample size was 96). Independent variables were defined and described, and the bivariate relationship to dependent variables was determined using Odds Ratio. Multivariate analysis was carried out using logistic regression. The mean adherence of study population was 78% (SD 0.08, max = 96%, min = 55%). The mean adherence in transplant patients was 82% (SD 7.8, max 96%, min 63%), and the mean adherence in dialysis patients was 76% (SD 7.8 max 90%, min 55%). Adherence was positively associated to the mother's educational level and to higher monthly household income. Together predisposing, enabling and need factors illustrate the complexities surrounding adherence in this pediatric CKD population. Public policy strategies aimed at improving access to comprehensive treatment regimens may facilitate treatment access, alleviating economic strain on caregivers and may improve adherence outcomes.
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Affiliation(s)
- Brooke M. Ramay
- Department of Pharmaceutical Chemistry, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Alejandro Cerón
- Department of Anthropology, University of Denver, Denver, Colorado, United States of America
| | | | - Randall Lou-Meda
- Fundación para el Niño Enfermo Renal—FUNDANIER, Hospital Roosevelt, Guatemala City, Guatemala
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Shah PA, Coj M, Rohloff P. Delays in diagnosis and treatment of extrapulmonary tuberculosis in Guatemala. BMJ Case Rep 2017; 2017:bcr-2017-220777. [PMID: 28993352 DOI: 10.1136/bcr-2017-220777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 23-year-old indigenous Guatemalan man presented in 2016 to our clinic in Sololá, Guatemala, with 10 months of recurrent neck swelling, fevers, night sweats and weight loss. Previously, he had sought care in three different medical settings, including a private physician-run clinic, a tertiary private cancer treatment centre and, finally, a rural government health post. With assistance from our institution's accompaniment staff, the patient was admitted to a public tertiary care hospital for work-up. Rifampin-susceptible tuberculosis was diagnosed, and appropriate treatment was begun. The case illustrates how low tuberculosis recognition among community health workers and health system segmentation creates obstacles to appropriate care, especially for patients with limited means. As a result, significant diagnostic and treatment delays can occur, increasing the public health burden of tuberculosis.
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Affiliation(s)
| | - Merida Coj
- Wuqu' Kawoq-Maya Health Alliance, Santiago, Sacatépequez, Guatemala
| | - Peter Rohloff
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Chary A, Flood D, Austad K, Colom M, Hawkins J, Cnop K, Martinez B, Lopez W, Rohloff P. Accompanying indigenous Maya patients with complex medical needs: A patient navigation system in rural Guatemala. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:144-149. [PMID: 28919513 DOI: 10.1016/j.hjdsi.2017.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 08/26/2017] [Indexed: 10/24/2022]
Affiliation(s)
- Anita Chary
- Wuqu' Kawoq
- Maya Health Alliance, Guatemala; Department of Emergency Medicine, Massachusetts General Hospital, United States.
| | - David Flood
- Wuqu' Kawoq
- Maya Health Alliance, Guatemala; Departments of Internal Medicine and Pediatrics, University of Minnesota, United States
| | - Kirsten Austad
- Wuqu' Kawoq
- Maya Health Alliance, Guatemala; Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, United States
| | | | - Jessica Hawkins
- Wuqu' Kawoq
- Maya Health Alliance, Guatemala; University of California, San Francisco, United States
| | - Katia Cnop
- Wuqu' Kawoq
- Maya Health Alliance, Guatemala; Burrell College of Osteopathic Medicine, United States
| | | | | | - Peter Rohloff
- Wuqu' Kawoq
- Maya Health Alliance, Guatemala; Division of Global Health Equity, Brigham and Women's Hospital, United States
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Ippolito M, Chary A, Daniel M, Barnoya J, Monroe A, Eakin M. Expectations of health care quality among rural Maya villagers in Sololá Department, Guatemala: a qualitative analysis. Int J Equity Health 2017; 16:51. [PMID: 28288633 PMCID: PMC5348769 DOI: 10.1186/s12939-017-0547-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Indigenous populations in Latin America have worse health outcomes than their nonindigenous counterparts. Differences in access to and use of biomedical resources may explain some of the observed disparities. Efforts to address these differences could be aided in part by better understanding the socio-medical contexts in which they occur. METHODS We performed a qualitative analysis of field notes collected during a 2008 program evaluation of a health post in a rural Maya village in Sololá Department, Guatemala. Forty-one interviews were conducted among a community-based convenience sample of adult men and women. Interviews focused on experiences, perceptions, and behaviors related to the local biomedical and ethnomedical health care resources. RESULTS Penetrance of the local health post was high, with most (90%) of respondents having accessed it within the prior five years. The prevailing attitude toward the health post was positive. We identified facilitators and barriers to health post use that corresponded with three thematic areas: clinic operations, visits and consultations, and medical resources. Proximity to the home, free consultations and medications, and social support services were among the most commonly cited facilitators. Barriers included limited clinic hours, medication stock-outs, provision of care that did not meet patient expectations, and unavailability of diagnostic tests. CONCLUSIONS In a rural Maya community in Guatemala, operational and quality-based factors, independent of sociocultural considerations, informed the perception of and decision to access biomedical resources. Interventions that address these factors may increase health care utilization and alleviate some of the health disparities that accompany indigeneity in Guatemala and similar contexts.
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Affiliation(s)
- Matthew Ippolito
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 E Monument St Rm 450-B, Baltimore, MD, 21287, USA.
| | - Anita Chary
- Department of Anthropology, Washington University in St. Louis, 1 Brookings Drive, Campus Box 1114, St. Louis, MO, 63130, USA
| | - Michael Daniel
- Johns Hopkins University School of Medicine, 1000 Eager Street, Baltimore, MD, 21202, USA
| | - Joaquin Barnoya
- Department of Surgery, Washington University in St. Louis, 660 S. Euclid Avenue, Campus Box 8100, St. Louis, MO, 63110, USA
| | - Anne Monroe
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 E Monument St Rm 8060, Baltimore, MD, 21287, USA
| | - Michelle Eakin
- Department of Medicine, Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Baltimore, MD, 21224, USA
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Juarez M, Rohloff P. Myxoedema in a patient with achondroplasia in rural area of Guatemala. BMJ Case Rep 2017; 2017:bcr-2016-218506. [PMID: 28280081 DOI: 10.1136/bcr-2016-218506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 43-year-old indigenous Guatemalan woman with achondroplasia presented to our clinic with chronic fatigue and generalised oedema. She had limited contact with the formal healthcare system. However, 1 year prior, she had sought medical evaluation from a private physician. Her symptoms had been attributed to a combination of heart failure and physical disability due to the musculoskeletal complications of her achondroplasia. She was lost to follow-up due to inability to pay for further testing or treatment. On initial laboratory evaluation in our clinic, she was found to have a thyrotropin level greater than assay. With initiation of oral levothyroxine supplementation, her dyspnoea and oedema completely resolved. The case illustrates how indigenous patients in rural Guatemala experience many barriers to accessing high-quality medical care. As a result, presentations of common illnesses are often very advanced and definitive diagnoses and treatments are frequently delayed.
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Affiliation(s)
| | - Peter Rohloff
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Hernández A, Ruano AL, Marchal B, San Sebastián M, Flores W. Engaging with complexity to improve the health of indigenous people: a call for the use of systems thinking to tackle health inequity. Int J Equity Health 2017; 16:26. [PMID: 28219429 PMCID: PMC5319053 DOI: 10.1186/s12939-017-0521-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 01/10/2017] [Indexed: 11/16/2022] Open
Abstract
The 400 million indigenous people worldwide represent a wealth of linguistic and cultural diversity, as well as traditional knowledge and sustainable practices that are invaluable resources for human development. However, indigenous people remain on the margins of society in high, middle and low-income countries, and they bear a disproportionate burden of poverty, disease, and mortality compared to the general population. These inequalities have persisted, and in some countries have even worsened, despite the overall improvements in health indicators in relation to the 15-year push to meet the Millennium Development Goals. As we enter the Sustainable Development Goals (SDGs) era, there is growing consensus that efforts to achieve Universal Health Coverage (UHC) and promote sustainable development should be guided by the moral imperative to improve equity. To achieve this, we need to move beyond the reductionist tendency to frame indigenous health as a problem of poor health indicators to be solved through targeted service delivery tactics and move towards holistic, integrated approaches that address the causes of inequalities both inside and outside the health sector. To meet the challenge of engaging with the conditions underlying inequalities and promoting transformational change, equity-oriented research and practice in the field of indigenous health requires: engaging power, context-adapted strategies to improve service delivery, and mobilizing networks of collective action. The application of systems thinking approaches offers a pathway for the evolution of equity-oriented research and practice in collaborative, politically informed and mutually enhancing efforts to understand and transform the systems that generate and reproduce inequities in indigenous health. These approaches hold the potential to strengthen practice through the development of more nuanced, context-sensitive strategies for redressing power imbalances, reshaping the service delivery environment and fostering the dynamics of collective action for political reform.
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Affiliation(s)
- Alison Hernández
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala
| | - Ana Lorena Ruano
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala. .,Center for International Health, University of Bergen, Bergen, Norway.
| | - Bruno Marchal
- Institute of Tropical Medicine (ITM), Antwerp, Belgium
| | - Miguel San Sebastián
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Walter Flores
- Center for the Study of Equity and Governance in Health Systems (CEGSS), Guatemala, Guatemala
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Ruano AL, Shadmi E, Furler J, Rao K, San Sebastián M, Villar Uribe M, Shi L. Looking forward to the next 15 years: innovation and new pathways for research in health equity. Int J Equity Health 2017; 16:35. [PMID: 28222728 PMCID: PMC5320779 DOI: 10.1186/s12939-017-0531-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 02/13/2017] [Indexed: 01/31/2023] Open
Abstract
Since our launch in 2002, the International Journal for Equity in Health (IJEqH) has furthered our collective understanding of equity in health and health services by providing a platform on which academics and practitioners can share their work. Today, we celebrate our fifteenth anniversary with an article collection that presents a call for new and novel research in equity in health and we invite our authors to use new approaches and methods, and to focus on emerging areas of research related to health equity in order to set the stage for the next fifteen years of health equity research.Our anniversary issue provides a platform for expanding the conceptualization, diversity of populations and study designs, and for increasing the use of novel methodologies in the field. The IJEqH has helped to support the wider group of researchers, policymakers and practitioners with a commitment to social justice and equity but there is still more to do. With the help of the highly committed editorial team and editorial board, the innovative work of researchers worldwide, and the countless of hours dedicated by hundreds of reviewers, we are confident in the IJEqH's ability to continue supporting the dissemination of health equity research for years to come.
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Affiliation(s)
- Ana Lorena Ruano
- Center for the Study of Equity and Governance in Health Systems, CEGSS, Guatemala City, Guatemala. .,Center for International Health, University of Bergen, Bergen, Norway.
| | - Efrat Shadmi
- The Cheryl Spencer Department of Nursing, Faculty of Socail Welfare and Health Sciences, the University of Haifa, Haifa, Israel
| | - John Furler
- Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences University of Melbourne, Melbourne, Australia
| | - Krishna Rao
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Miguel San Sebastián
- Department of Public Health and Clinical Medicine, Unit of Epidemiology and Global Health Umeå University, SE-901 87, Umeå, Sweden
| | | | - Leiyu Shi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Samuel J. The role of civil society in strengthening intercultural maternal health care in local health facilities: Puno, Peru. Glob Health Action 2016; 9:33355. [PMID: 27987298 PMCID: PMC5161796 DOI: 10.3402/gha.v9.33355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/13/2016] [Accepted: 11/15/2016] [Indexed: 11/17/2022] Open
Abstract
Background and objective Peru's Ministry of Health has made efforts to increase the cultural inclusiveness of maternal health services. In 2005, the Ministry adopted an intercultural birthing policy (IBP) that authorizes and encourages the use of culturally acceptable birthing practices in government-run health facilities. However, studies suggest that indigenous women may receive inconsistent benefits from these kinds of policies. This article examines whether a grassroots accountability initiative based on citizen monitoring of local health facilities by indigenous women can help to promote the objectives of the IBP and improve intercultural maternal health care. Design Findings are drawn from a larger qualitative research study completed in 2015 that included fieldwork done between 2010 and 2011. Semi-structured interviews were conducted with 23 women working as citizen monitors in local health facilities in Puno and 30 key informants, including frontline health workers, health officials, and civil society actors in Puno and Lima, and human rights lawyers from the Defensoría del Pueblo Office in Puno. Results Monitors confirmed from their own personal experiences in the 1990s and early 2000s that respect for intercultural aspects of maternal health care, including traditional indigenous birthing practices, were not readily accepted in publicly funded health facilities. It was also common for indigenous women to face discrimination when seeking health service provided by the state. Although the government's adoption of the IBP in 2005 was a positive step, considerable efforts are still needed to ensure high-quality, culturally appropriate maternal health care is consistently available in local health facilities. Conclusions Despite important progress in the past two decades, policies aimed at improving intercultural maternal health care are unevenly implemented in local health facilities. Civil society, in particular indigenous women themselves, can play an important role in holding the state accountable for quality care.
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Affiliation(s)
- Jeannie Samuel
- School of Health Studies, Faculty of Health Sciences, University of Western Ontario, London, ON, Canada;
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