Download Chocruz, Momostenango, Guatemala

Chocruz,
Momostenango,
Guatemala
A Health Needs Assessment
Author: Danica Buckland
Edited by: Josie Silverman, MPH
Chocruz, Momostenango,
Guatemala
A Health Needs Assessment
Introduction:
Background: The German non-governmental organization, EL MIRADOR, is planning to open a health-post in
Chocruz, Guatemala by 2012. At present time, two apprentices are being trained at Asociación Manos
Abiertas to staff the health-post upon facility completion. The presented health needs assessment will guide
curricula development and health-post operation.
Methods: A Participatory Rural Appraisal (PRA) methdology was selected in order to garner relevant,
community-driven data through purposive focus groups, key-informant interviews and direct observations.
Participants: Data collection activities were undertaken with 77 individuals (n=77). Participants were
purposely selected from the community, government-run health posts and the Momostenango health
centre.
Results: Acute and chronic children’s health problems were identified as the most important issues for the
community, mirroring epidemiological data for the department, with diarrheal diseases, skin disorders,
respiratory illness and malnourishment being of most concern. Women’s sexual and reproductive health in
general, and pregnancy-care in particular, were also important issues for the community. Identified men’s
health problems centred upon malnutrition, stress and chronic diseases, including type-2 diabetes. Several
barriers to accessing equitable health services were discussed, including the lack of economic, environmental
and social resources, poorly serviced health facilities and discrimination from service providers.
Chocruz, Momostenango, Guatemala
Objective: To identify community priorities surrounding health in Chocruz, Momostenango, Guatemala.
Recommendations: The health needs assessment informs 9 recommendations for the training of community
health workers and future health-post development in Chocruz, Guatemala: 1) Embracing a Community
Health Worker Designation; 2) Establishing Evidence-Based Curriculum and Training; 3) Providing Supportive
Supervision to Empower Community Health Workers; 4) Realizing Incentives, Disincentives and Rewards for
Community Care; 5) Securing a Reliable Supply-Chain and Financing Strategy; 6) Incorporating Community
Payment Strategies for Care; 7) Engaging the Community; 8) Involving External Stakeholders; and 9)
Facilitating Monitoring and Evaluation Activities.
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Contents
Introduction: ......................................................................................................................................................... 1
Guatemalan Country-Level Indicators: ................................................................................................................. 4
Country-Level Indicators: .................................................................................................................................. 4
Indigenous Health in Guatemala: ..................................................................................................................... 5
Regional Health Profile: ........................................................................................................................................ 6
Totonicapán Indicators: .................................................................................................................................... 6
Momostenango Indicators:............................................................................................................................... 7
Current Health Resources for Chocruz, Momostenango: ............................................................................... 10
Centro Comunitario Pamumus: .................................................................................................................. 10
Choabaj Health-Post: .................................................................................................................................. 11
........................................................................................................................................................................ 12
Chocruz, Momostenango, Guatemala
Water and Sanitation Services in Chocruz, Momostenango: ......................................................................... 12
Project Overview - The Chocruz Health-Post:..................................................................................................... 13
Introduction: ................................................................................................................................................... 13
Current Training Guidelines and Anticipated Health-Post Activities: ............................................................. 14
The Necessity for a Health Needs Assessment: .............................................................................................. 16
Health Needs Assessment Methodology: ...........................................................................................................
17
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Study Design – Participatory Rural Appraisal (PRA):....................................................................................... 17
Setting and Team Composition:...................................................................................................................... 17
Sampling Frame: ............................................................................................................................................. 18
Methodology: ................................................................................................................................................. 18
Secondary Data Sources: ............................................................................................................................ 18
Direct Observations: ................................................................................................................................... 18
Key-Informant Interviews: .......................................................................................................................... 18
Focus Group Discussions:............................................................................................................................ 19
Analysis of Findings: ........................................................................................................................................ 21
Report Writing: ............................................................................................................................................... 21
Community Findings: .......................................................................................................................................... 22
Children’s Health: ........................................................................................................................................... 22
Women’s Health: ............................................................................................................................................ 23
Men’s Health:.................................................................................................................................................. 25
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Family Planning: .............................................................................................................................................. 27
Midwifery and Pregnancy-Related Care: ........................................................................................................ 27
Perceived Barriers to Health: .......................................................................................................................... 30
Phase 1 Delay: ............................................................................................................................................. 31
Phase 2 Delay: ............................................................................................................................................. 33
Phase 3 Delay: ............................................................................................................................................. 34
Introduction: ....................................................................................................................................................... 35
Determinants of Program Success: ................................................................................................................. 35
Recommendations: ............................................................................................................................................. 37
Recommendation 1 - Embracing the Community Health Worker Designation: ............................................. 38
Recommendation 2 - Establishing Evidence-Based Curriculum and Training: ............................................... 42
Recommendation 3 – Providing Supportive Supervision to Empower Community Health Workers: ............ 48
Recommendation 4 – Realizing Incentives, Discentives and Rewards for Community Care:......................... 49
Recommendation 5 – Securing a Reliable Supply-Chain and Financing Strategy:.......................................... 51
Recommendation 6 – Incorporating Community Payment Strategies for Care: ............................................ 52
Community Mobilization: ........................................................................................................................... 53
Community Outreach: ................................................................................................................................ 55
Establishing a Women’s Health Committee: .............................................................................................. 56
Engaging Men in Health-Post Activities: ..................................................................................................... 57
Acknowledgement and Incorporation of Local Experience and Culture: ................................................... 57
Educational Seminars:................................................................................................................................. 58
Recommendation 8 – Involving External Stakeholders: ................................................................................. 59
Recommendation 9 – Facilitating Monitoring and Evaluation Activities:....................................................... 60
Conclusions: ........................................................................................................................................................ 62
Chocruz, Momostenango, Guatemala
Recommendation 7 – Engaging the Community ............................................................................................ 53
Appendices: ........................................................................................................................................................ 63
Works Referenced: ............................................................................................................................................. 91
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Guatemalan Country-Level Indicators:
Country-Level Indicators:
Chocruz, Momostenango, Guatemala
F IGURE 1: D EPARTMENTAL M AP OF GUATEMALA
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Guatemala is located in Central America and is bordered by Mexico, Belize, Honduras and El Salvador.
The country is divided into 22 departments with approximately 332 municipalities. The total population of
Guatemala is an estimated 14,027,000 people, with over one-half living in rural areas where access to health
and economic resources is limited (WHO 2011c). Guatemala ranks among the worst countries in the Central
American region for several major health indicators. The current life expectancy at birth ranges from 66 years
for men to 73 years for women: nearly 6 years below the regional average (WHO 2011c). The total adult
mortality rate for both sexes is recorded as 214 deaths per 1,000 adults aged 15-59 years: noticeably higher
than the regional average of 125 deaths per 1,000 adults aged 15-59 years (WHO 2011c). Communicable
diseases still produce the greatest burden for health in Guatemala. In 2008, 45% of all years of life lost were
recognized as due to communicable diseases; regionally, only 20% of all years of life lost were attributed to
such causes. Of growing concern, the prevalence of HIV in Guatemala is now equal to the global average of 8
positively-tested infections per 1,000 adults aged 15-49 years: 40% higher than the current regional average
(WHO 2011c). The prevalence of tuberculosis is also alarmingly high for Central America: 104 cases per
100,000 population is reported, producing a stark comparison to the regional average of 38 cases per
100,000 population (WHO 2011c).
The most recently available maternal mortality ratio for Guatemala was reported as 110 maternal deaths
per 100,000 live births: nearly double the available regional ratios, yet far below the global average of 260
maternal deaths per 100,000 live births (WHO 2011c). In 2000, the primary causes of maternal mortality
were haemorrhage (53.3%), infection (14.4%), and hypertension (12.1%): all highly preventable causes of
maternal death (Hughes 2004). Such elevated maternal mortality rates are attributed to malnutrition, poor
prenatal care and a lack of skilled attendance at birth. 65% of all Guatemalan women do not have adequate
prenatal check-ups and only 51% of all births in Guatemala are attended by a skilled health professional,
while the regional average for skilled attendance at birth is 93% (Hughes 2004; WHO 2011c).
T ABLE 1: GUATEMALA I NDICATORS AT A GLANCE
Rate
Adult Mortality Rate (Both Sexes)
214 deaths/1,000 adults 15-59 years (WHO 2011c)
Maternal Mortality Rate
110 deaths/100,000 live births (WHO 2011c)
Neonatal Mortality Rate
17 deaths/1,000 live births (PAHO 2009)
Post Neonatal Mortality Rate
14 deaths/1,000 live births (PAHO 2009)
Infant Mortality Rate
30 deaths/1,000 live births (PAHO 2009)
Under-5 Mortality Rate
40 deaths/1,000 live births (WHO 2011c)
Guatemala suffers from the highest rate of malnutrition in Central America and the 3rd highest globally,
behind on Afghanistan and Yemen: 43.4% of children aged 3-59 months are considered malnourished and
over 50% of children under the age of 5 are stunted height-for-age (PAHO 2009; WHO 2011c). Malnutrition
exacerbates the most common communicable diseases due to compromised immune system function and
places children at a higher risk of death. These effects are tragically noticeable in reported causes of death in
children under-five years of age; in 2008, pneumonia and diarrhoea accounted for nearly 50% of all underfive deaths in Guatemala (WHO 2011c). The under-five mortality rate for both sexes is now estimated at 40
deaths per 1,000 live births: a drastic comparison to the regional average of 18 deaths per 1,000 live births in
children under-five years of age (WHO 2011c).
Guatemala is experiencing a double-burden of illness, with non-communicable, or chronic, diseases now
accounting for 31% of all years of life lost (WHO 2011c). Tobacco smoking in male adults above 15 years of
age is equal to the regional average of approximately 25% (WHO 2011c). The prevalence of obesity and
associated health complications, including type-2 diabetes, is rising rapidly: 26.7% of female adults above 20
years of age are considered obese (WHO 2011c). High rates of alcoholism are also reported, exacerbating
emerging chronic diseases and placing new segments of the population at greater risk for long-term health
complications (Hughes 2004; PAHO 2009; WHO 2011c).
Chocruz, Momostenango, Guatemala
Indicator
Indigenous Health in Guatemala:
The most recent Encuesta Nacional de Salud Maternal & Infantil (ENSMI 2009), a comprehensive health
survey conducted by the Guatemalan government with technical assistance from international partners,
reported that no major breakthroughs for combating the inequitable distribution of ill-health among ethnic
divisions have occurred since the last national survey in 2002 (PAHO 2009). Over half of Guatemala’s
population is indigenous with main areas of residency in the Northwest and Northern departments (Hughes
2004). Due to the complex interplay of ethnicity, culture, the 36-year civil war (where a reported 40,000 to
50,000 people were disappeared and approximately 200,000 were killed, mainly indigenous), socio-economic
status and region of residence, inequitable distributions of health and health resources is endemic in
Guatemala for indigenous and rural populations. As a result of this inequity, serious health consequences for
indigenous populations are apparent: growing incidence rates of HIV/AIDS; high maternal mortality rates;
urinary incontinence, genital and urinary infections, and vaginal fissures; high alcohol, smoking and drug use;
high rates of foetal alcohol syndrome (FAS), stillbirths, and learning disabilities; disproportionate suicide and
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violence rates; high rates of cirrhosis, liver disease, and
diabetes; neurological and reproductive complications from
both environmental contamination and hazardous work; high
risks of communicable diseases, including tuberculosis,
cholera, and others; and lastly, growing rates of cervical
cancer in women (Hughes 2004). Due to these serious health
consequences of socially-determined inequity, life
expectancy for the indigenous population of Guatemala
continues to be significantly lower than for non-indigenous
groups (Hughes 2004).
T ABLE 2: T OTONICAPÁN FAMILY P LANNING
I NDICATORS
Chocruz, Momostenango, Guatemala
Totonicapán Family
Planning Indicators
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Total Contraceptive Use
Total Contraceptive
Demand:
Total
No Use
Modern
Natural
Folk
Total Unmet Contraceptive
Need:
Total
Unmet Need to Space
Unmet Need to Limit
Total Met Contraceptive
Need:
Total
Met Need to Space
Met Need to Limit
Source of Modern
Contraceptives:
Public
Private
Other
Rates
(ENSMI
2008)
40.1%
73.6%
59.9%
27.4%
12.6%
0%
34%
17.9%
15.6%
40.1%
15.6%
24.5%
68.7%
29.6%
1.6%
Furthermore, indigenous women in Guatemala
disproportionately suffer from an inequitable burden of
illness and poor access to health resources as mediated by
gender, ethnicity, and other socially-constructed
determinants of health. The current fertility rate of
indigenous women is calculated at 4.5 children per woman of
child-bearing age: relatively higher than the non-indigenous
fertility rate of 3.1 children per woman of child-bearing age
(the worldwide average in 2010 was 2.5 children per woman
of child-bearing age) (PAHO 2009; Population Reference
Bureau 2011). These numbers are exacerbated by unmet
demands for family planning, estimated as being almost
twice as high for indigenous women (29.6%) as compared to
j women (15.1%) (PAHO 2009). In addition,
non-indigenous
only 29% of births to indigenous women are attended by a
skilled health professional: a drastic comparison to70% of
births for non-indigenous women (PAHO 2009). As a result,
indigenous maternal and infant mortality rates remain
inequitably high throughout the country.
Regional Health Profile:
Totonicapán Indicators:
Located in the Western highlands of Guatemala,
Totonicapán is a predominantly indigenous Mayan
department. There are eight municipalities in the
department: Momostenango, San Andres Xecul, San Bartolo,
San Cristobal Totonicapán, San Francisco El Alto, Santa Lucia
La Reforma, Santa Maria Chiquimula, and Totonicapán. The
area is highly Roman Catholic with an incorporation of
Mayan beliefs; however, recently there has been a growing
influence of Evangelicalism and other Christian sects. The
total population of the department is an estimated 476,369
people and two-thirds of the population lives in rural areas
(INE 2011). Over 70% of the population in Totonicapán
identifies as indigenous and the two most common
languages are K’iche, an indigenous Mayan language, and Spanish (INE 2011).
Child mortality in the department of Totonicapán is alarmingly high: post-neonatal and infant mortality
rates are the second highest in the country (ENSMI 2008). Reported causes of infant mortality mirror national
data: pneumonia, bronchopneumonia and diarrhoea are the leading causes of death among children (MSPAS
2010). These deaths are largely preventable with timely and equitable access to both preventive and curative
health services. Nationally, Totonicapán department has the highest level of severe malnutrition in children
aged 3-59 months: exacerbating effects of common communicable diseases and placing children at a high risk
of death (ENSMI 2008). Over 70% of children aged 3-59 months suffer from chronic malnutrition and 30% of
children within this age category are severely malnourished (ENSMI 2008).
T ABLE 3:TOTONICAPÁN DEPARTMENT MATERNAL AND INFANT M ORTALITY RATES
Indicator
Rate
Comparative
Maternal Mortality Rate
196 deaths/100,000 live births
5th highest rate in Guatemala
Neonatal Mortality Rate
23 deaths/1,000 live births
4th highest rate in Guatemala
Post-Neonatal Mortality Rate
28 deaths/1,000 live births
2nd highest rate in Guatemala
Infant Mortality Rate
51 deaths/1,000 live births
2nd highest rate in Guatemala
Under-5 Mortality Rate
58 deaths/1,000 live births
4th highest rate in Guatemala
Chocruz, Momostenango, Guatemala
Totonicapán department has the third highest fertility rate, fourth lowest contraceptive use rate ,
and the fifth highest maternal mortality rate in Guatemala (ENSMI 2008). In 2008, a staggering 196 maternal
deaths per 100,000 live births were reported in the department (USAID 2008). The primary documented
causes of maternal mortality include shock, haemorrhage, eclampsia, infection and sepsis (MSPAS 2010).
Within the department, less than 30% of all births are assisted by a skilled health professional: the third
lowest rate in Guatemala (ENSMI 2008; MSPAS 2010). However, this number is reduced outside of
Totonicapán municipality where the departmental hospital is located. Over 70% of women give birth at home
with the help of a midwife and less than 10% of births are recorded as caesarean-section (ENSMI 2008;
MSPAS 2010).
Momostenango Indicators:
Located 1 ½ hours from the departmental capital, Momostenango municipality is situated in the
Northwest region of Totonicapán department. In 2002, Momostenango had a recorded population of 87,542
people, with approximately 70% living in rural areas (Alonso 2007). Primary economies in the area include
subsistence agriculture of maize, beans and wheat, and small commercial enterprises. The area is rich in
Mayan K’iche history and culture as evidenced by the continued prominance of indigenous language and the
visibility of ritual-sites throughout the surrounding pine forests.
The municipality operates one government-sponsored Centro de Salud (health centre , HC) located in
Momostenango city. The HC is open twenty-four hours a day for births and from 0800-1630 seven days-aweek for consultations. The HC can treat minor emergencies, including first to third degree wounds; broken
bones and more serious trauma are referred to the departmental hospital in Totonicapán, located
approximately one hour away by automobile. The HC specializes in maternity care and is divided into a
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general consult area and a maternity ward. There are five rooms in total for general consultations; however,
only on select days are all consultation rooms in operation. There are four beds without privacy screens in
the emergency area of the HC that is attached to the maternity ward. The maternity ward has two beds for
use during labour: one large and one small.
Chocruz, Momostenango, Guatemala
The HC is staffed by 4 teams on rotation each day. Each team consists of one obstetric specialist, one
professional nurse, four auxiliary nurses and one driver for ambulance services. In total, the HC employs one
district manager, four obstetric specialists, one general doctor, one paediatrician, numerous professional and
auxiliary nurses, and two ambulance drivers. There are two ambulances available to transport women to the
departmental hospital in Totonicapán from the HC for emergencies during labour and birth. The HC manages
approximately 25 natural births per month and is incapable of performing caesarean-sections due to limited
resources.
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The HC also runs a small laboratory facility that is staffed by three technicians on rotating shifts.
Laboratory services include white blood-cell counts, rapid tests for hepatitis B, rotavirus, helicobacter pylori,
HIV/AIDS, syphilis, glucose levels, tuberculosis, cervical cancer screening, and several urine and feces
bacteriology tests for parasites. The HC laboratory has one microscope and two centrifuges. Rapid HIV/AIDS
testing awareness programs have operated through the HC, referring positive-infection cases to the Quiche
departmental hospital. The HC has the capacity to treat un-resistant forms of tuberculosis; all other
tuberculosis cases are referred to the hospital in Totonicapán. For most diagnoses, the HC has a small
pharmacy that is stocked to provide only first doses of prescribed medications. Following the first dosage,
the patient is responsible for purchasing the remaining medications at a private pharmacy. Momostenango
city has approximately 12 pharmacies and numerous private consultation practices for alternative health care
resources.
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The surrounding aldeas, or villages, have scatterings of government-run Ministerio de Salud Publica y
Asistencia Social (MSPAS) and Sistema Integral de Atencion de Salud (SIAS) health-posts in various states of
condition and supply. The majority of health-posts are staffed by auxiliary nurses with unreliably scheduled
visits from doctors that prove inadequate for treating the high rates of disease present (Maupin 2011). Rural
health-post staff and local midwives are encouraged to attend monthly capacitation courses at the
Momostenango HC. Topics for capacity-building include family planning; prenatal care strategies; identifying
pregnancy and labour complications; promotion of exclusive breastfeeding; monitoring and promotion of
appropriate infant weight and height; and safe food and water preparation. Capacitation attendees are
entitled to receive approximately $6.50USD under the Guatemalan SIAS program (Maupin 2011); however,
attendees are not remunerated in the area.
Within Momostenango municipality there is an estimated one public health professional per 5,470
people, not including midwives (Alonso 2007). In addition to health-posts staffed by auxiliary nurses, the
current Guatemalan SIAS health-plan indicates that each jurisdiction is to have five facilitadores comuitarios
(FC), or community facilitators, who supervise up to twenty health guardians in rural communities (Maupin
2011). FCs are the lowest-level of government-paid community health workers and are licensed to administer
twenty-two basic pharmaceuticals. Focused on promoting preventive health services and providing basic
curative care, FCs are also required to submit monthly epidemiological reports to municipal health
governance structures (Maupin 2011). Moreover, under the supervision of FCs, health guardians provide
basic surveillance and preventive health services. Health guardians serve as an initial point of health
reference for many isolated and rural communities, assist in vaccine delivery, and provide aspirin and oralrehydration treatment (ORT) as required (Maupin 2011). As with the majority of rural areas in Guatemala,
only 25% of the population has equitable access to health services (Hughes 2004). Due to the demonstrable
lack of health care service and access, Momostenango municipality has the second highest infant mortality
rate in Totonicapán department and five maternal deaths have been reported in the area this year (January
2011 to July 2011) (MSPAS 2010; MSPAS 2011).
F IGURE 2: H EALTH CENTRE MAP OF PAMUMUS
It is estimated that 400-500 families, each with an approximate average of five children, live in the
community of Chocruz. The main economic activities in the area are subsistence agriculture and small
commercial businesses spread throughout Momostenango, Totonicapán, and Quetzaltenango. The primary
crops in the area are maize, beans, wheat, avocados, apples, peaches, plums and pomegranates. For
additional income, women often keep livestock, work in the fields, act as local midwives, or are vendors in
Momostenango city. There are three small tiendas, or stores, in the community that sell processed food and
drink, as well as small quantities of over-the-counter medications: Panadol, Alka-Seltzer, Glucosorol
electrolyte solution, and aspirin. The Glucosorol electrolyte solution costs 15 Quetzales per dosage, or
roughly $2USD.
A school, Centro Educativo Futuro Para Niños, run by a German non-governmental organization acts
as the central meeting point for the community. The school is directed by Juan Silvero Pelico Xiloj with
oversight provided by donors in Germany. Juan Xiloj has worked with the organization for twelve years and is
originally from central Pamumus. Juan reports that 125 families are associated with the school and
approximately 230 students attend each day; proximity to the school is a determining factor for enrolment.
The school provides its youngest students with a small breakfast and hot lunch each day. There are three
Rotoplas rain-water collection containers for school-consumption; however, the school regularly lacks access
to water. The school also has two latrines, each with two dug-outs for student use: there is no toilet paper or
hand-washing facilities located near the outhouses. The school provides students with health education
courses, including natural sciences, personal hygiene, food preparation and handling techniques, and basic
sexual education. The school has a small computer lab for student and teacher use; however, despite having
a small TIGO-brand modem, there is no internet connection due to limited funding.
Chocruz, Momostenango, Guatemala
Chocruz, Momostenango, Guatemala:Located thirty minutes up a red-soil road by pick-up truck, the
small community of Chocruz serves as the focal point for the proceeding health-needs assessment. The
community of Chocruz is part of the larger area of Pamumus; the municipal government satellite office in
Pamumus reports approximately 8,000 inhabitants within the area. This same office also reported 22 deaths
in the Pamumus area from January 2011 to July 2011: disaggregated data regarding maternal and infant
mortality is not recorded.
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F IGURE 3: CENTRO E DUCATIVO FUTURO PARA N IÑOS
Chocruz, Momostenango, Guatemala
Current Health Resources for Chocruz, Momostenango:
In the case of an emergency, residents of Chocruz travel to the Momostenango health centre, the
Totonicapán departmental hospital or to the hospital in Quetzaltenango. The Momostenango health centre
can be reached by either a hired pick-up truck or a “chicken-bus.” Both transportation methods cost 3 to 4
Quetzales ($0.30-$0.50 USD) each way and can take upwards of 30 minutes to reach the town centre and
then another 10 to 15 minutes to reach the health centre by tuk-tuk. Transportation to the hospital in
Totonicapán is either by hired taxi or by “chicken-bus.” A hired taxi costs approximately 250 to 300
Quetzales ($31.25-$37.50 USD) and can take up to an hour to arrive. The one-and-a-half hour “chicken-bus”
service to Totonicapán is not reliable, costs 8 Quetzales ($1 USD) each way, and does not offer night service.
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“Chicken-bus” service to the hospital in Quetzaltenango also costs
8 Quetzales ($1 USD) each way and takes
approximately the same amount of time as to Totonicapán. The community reports common problems for
transportation, including road erosion caused by heavy rains, infrequent transport service and blockades: the
municipal office in Pamumus reports that roads in the community do not function 25-30% of the time.
Global standards for adequate proximity to modern health services are determined by three
variables: 1) a government hospital is located within thirty minutes of the community centre by vehicle; 2) a
doctor or private clinic is located in the community; or 3) the community has its own health centre or post
(Goldman 2000). Based on these indicators it can be determined that Chocruz does not have adequate access
to health services. However, within a 30 to 45-minute walking distance from Chocruz are a community health
centre in Pamumus and a small health-post in Choabaj.
Centro Comunitario Pamumus:
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Located in central Pamumus, approximately a 45-minute
walk from Chocruz, is a small SIAS/MSPAS community health
centre managed by an auxiliary nurse. The Pamumus health
centre is open Monday through Friday from 0900 to 1230.
Thursdays are reserved for visiting doctor consultations;
however, the auxiliary nurse reports that the doctor only attends
the clinic once or twice per month. The clinic provides free
health services and generally sees five people per day, except on
Thursdays when fifteen to twenty people arrive for a
consultation. The clinic is provided with medications and
supplies from the Guatemalan Ministry of Health, free of charge,
F IGURE 4: C OMMUNITY MSPAS H EALTH CENTRE
Equipped with only a level-six primary education and one additional year of health training, the auxiliary
nurse at the Pamumus Community Centre attends monthly capacitation courses through the Momostenango
health centre . As an auxiliary nurse, the clinic attendant most often provides prenatal care and common
treatments for acute childhood illnesses, including chronic malnutrition. The clinic reported 17 cases of
severe pneumonia and 33 cases of diarrheal disease with associated dehydration in children under-five from
January 2011 to July 2011. During this time the auxiliary nurse provided 62 children with micro-nutrient and
vitamin-A supplementation and 116 women with iron and folic acid supplementation. Three-month DepoProvera injections are the most commonly sought-after form of anti-contraceptives at the clinic; however,
the clinic did not have a supply during our visit. The auxiliary nurse has reported providing 42 women with
prenatal care and 10 women with postpartum attention within six weeks of birth this year. In total, the clinic
has record of 10 births this year in the community and there are no recorded maternal deaths; for
consideration, this data does not take into account the volume of women who seek pregnancy-related care
from midwives or other health services in the area and therefore is only a small approximation of
epidemiological information for Pamumus.
Choabaj Health-Post:
Located 30 minutes away by foot from Chocruz in the community of Choabaj is a small health-post
funded by the Ministry of Health. Stationed in a community member’s home, the health-post is a small, dark
room with a dirt floor. The health-post provides free services Monday through Friday from 0800-1200 and,
on average, sees 5 people per day. The health-post is staffed by one woman who receives monthly trainings
from the health centre in Momostenango: she has not received any other health education. Once a month a
doctor from Quetzaltenango visits the health-post; during these visits, upwards of 70 people will be in
attendance. The doctor provides general consultations and diagnoses, cervical cancer screening and referrals.
The doctor’s visits at the health-post are generally reliable, unless there is a corresponding capacitation
course on the scheduled date. The health-post is also associated with a nurse, who comes to the health-post
once a month for vaccination outreach, and MSPAS-sponsored health promoters who provide educational
workshops in the community.
Chocruz, Momostenango, Guatemala
every six months: deficiencies in supplies are extremely common. At the time of visitation only folic acid,
acetaminophen (commonly known as Tylenol) and cortisol cream were in adequate supply. Vaccination
campaigns through the clinic are also arranged approximately three-times per year. Eleven health guardians
(or vigilantes) are associated with the clinic and are responsible for promoting vaccination dates. Four
midwives are connected to the Pamumus clinic; yet, the community reports that five to eight midwives are
practicing in the area. In case of an emergency, the auxiliary nurse refers the patient to the health centre in
Momostenango.
The health-post serves mostly women and children, but will deliver first-aid to men as needed. The
Ministry of Health donates all medications for the health-post, including family planning methods. Similar to
the clinic in Pamumus, the most common form of anti-contraceptive requested is Depo-Provera. Unlike the
clinic in Pamumus, the health-post has a weight machine and a children’s height measurement device and on
the day of visitation the health-post had more medications than the clinic in Pamumus, including a small
supply of anti-contraceptives.
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F IGURE 5: I NSIDE THE C HOABAJ H EALTH -POST
Chocruz, Momostenango, Guatemala
Water and Sanitation Services in Chocruz, Momostenango:
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Each house in Chocruz is outfitted with an InterVida outhouse. InterVida is a Spanish-run NGO that
works to improve environmental sanitation and school development with a focus on young children.
InterVida is currently operating in the Quiche department of Guatemala, with other projects throughout
Central America, South America, Africa, and Asia. The sanitation facilities in Chocruz were installed
approximately 6 years ago.
There are currently no functioning NGOs in the region and community groups manage the majority
of infrastructural projects in the area. Three water projects for the area have been developed: Celeste Project
and Juan Hzep Project in Xolajab and San Vincente Project in San Vicente. Prior to the instalment of these
infrastructure projects, the communities used the small river for water: the river is now contaminated from
j
chemicals and agricultural run-off.
The community of Chocruz is provided with water from private wells and a water-piping system. The
water piping system was installed by the community and 33 kilometers of thin tubing connect an
underground water source to the surrounding area. Water is piped from the water source to a filtration
system located between Chocruz and Choabaj. At present, the water filtration system is not functioning due
to a broken filtration insert. In the summer there are often water shortages; during the rainy season the river
swells and negatively affects the water tubing system. If water shortages do occur, the community shares
private well-water.
Project Overview - The Chocruz Health-Post:
Introduction:
The two apprentices will participate in health-training activities for 10 months at a midwifery clinic in
Ciudad Vieja, Sacatepequez: located 5-hours away from Momostenango by automobile. The midwifery clinic,
Asociación Manos Abiertas, provides a natural birth setting with routine gynaecological, prenatal and
paediatric care, and also offers family planning and health education activities. The two apprentices began
training in May 2011 and will be funded through to March 2012 by EL MIRADOR. Upon training completion,
the two apprentices have contractually agreed to be exclusively employed by EL MIRADOR for three years,
beginning April 2012. The two apprentices’ future roles are loosely defined as health workers or midwives,
and as such, they will be responsible for health-post administration, including birthing services, basic health
education, and provision of care in Chocruz, Momostenango.
Chocruz, Momostenango, Guatemala
An NGO-funded health-post for Chocruz and surrounding communities is anticipated to open in April,
2012. The German NGO, EL MIRADOR, in partnership with Centro Educativo Futuro Para Niños, has
expressed a desire to fund the provision of medications and care at the health-post for 10 years. EL
MIRADOR is currently securing the final-funding for the health-post’s construction that is planned to begin in
January 2012. The health-post will be a small building of 3 to 4 rooms at a location in Chocruz that has yet to
be determined. The health-post is expected to operate Monday through Friday from 0800-1200 and 14001700. The health-post will be managed and staffed permanently by two practically-trained community
members from Chocruz and the surrounding area: Patricia Yolanda Tzoc Velasquez and Olga Marina Xiloj
Velasquez. The two community members (apprentices) were selected by the director of Centro Educativo
Futuro Para Niños on the basis of having an interest in becoming health workers. The criteria for selection
mandated that the apprentices had graduated from secondary school and worked or lived outside of the
Chocruz area: both selected apprentices attended a private teaching institute in Momostenango for three
years.
Overarching Goal: To lower maternal and infant
mortality in Chocruz and surrounding areas by improving
timely access to basic preventive and curative health care
by providing various health-post services and communitybased activities.
13
Current Training Guidelines and Anticipated Health-Post Activities:
Chocruz, Momostenango, Guatemala
The health-post is expected to be operated as a multi-care centre, providing preventative and
curative health care as well as community education workshops. As evidenced by the proceeding training
curriculum, priority has been placed on maternal health within the community. Anticipated services for the
health-post incorporate basic pregnancy and paediatric care; births; acute injury treatment, including wound
cleaning and suturing; cancer screening programs; and chronic disease care. However, clinical guidelines that
refer to the breadth and depth of care have yet to be determined. The health-post will act as a referral
service: providing referrals for appropriate higher-level health services. There will also be a small pharmacy
within the health-post stocked with basic over-the-counter medications for common ailments as well as
medications for emergency situations: anti-spasmodic and blood pressure medications are expected to be
available at the health-post. A detailed list of proposed medications, clinical-guidelines for medication use
and anticipated medication supply-chains are not established for the health-post.
14
The two apprentices are being taught skills deemed necessary to manage a small health-post
administratively and to offer prenatal care, birthing services, and basic health services. After each trainingunit an informal examination of the apprentices’ skills and abilities will be carried out by the director of
Asociación Manos Abiertas. The apprentices are anticipated to lead 5 births each and be present during 25
births at Asociación Manos Abiertas before graduating from the program. Providing family planning
counselling is stressed as an important function of the health-post and of the apprentice’s training. The two
apprentices will be present in counselling sessions for prospective contraceptive users at Asociación Manos
Abiertas and will learn the criteria for each method they are anticipated to provide at the health-post in
Chocruz: oral contraceptives, Depo-Provera injections, natural method-charting, and IUD insertion and
removal are included in the curriculum guidelines. Condom use
j and counselling is not included in the
curriculum. The provision of family-planning methods for the health-post in Chocruz is not concretely
determined. The apprentices are expected to perform a referral-role for vasectomies and tubal litigations
from the health-post in Chocruz; however, referral locations are not yet determined. To note, training for
Norplant contraceptive implants has been removed from the curriculum and it is unknown whether the
apprentices will be trained in abortion counselling and referral strategies. Lastly, curriculum is subject to
change depending on cases that present themselves at the clinic during the 10-month training period.
T ABLE 4: O FFICIAL TRAINING CURRICULUM OF H EALTH -P OST APPRENTICES AS SUBMITTED TO PROJECT S TAKEHOLDERS
May 2011-July 2011
-
Introduction to the daily routine of Asociación
Manos Abiertas
-
General evaluation of the intellectual and
practical abilities and experience of the
apprentices by Asociación Manos Abiertas staff
August 2011-October 2001
-
Introduction to different methods of
contraception and their
advantages/disadvantages, including the
creation of method-charts for patients
-
Recording and analyzing patient history
-
Introduction to prenatal care
-
Introduction into routine gynaecological care
November 2011-February 2012
-
Independent patient history-taking and
evaluation
-
Contraceptive counselling and uses of methods
-
Simple diagnostics
-
Introduction to clinical skills
-
First-aid and CPR coursework
-
Pregnancy care and birth
Anticipated Skills
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
a.
b.
c.
d.
Recording basic patient history data
Writing donation receipts
Inventory practices
Finding and filing of patient files
Hand-washing and personal hygiene
Cleaning and sterilization of instruments
Antisepsis
Sterilization procedures
Attendance in gynaecological and prenatal examinations
Recording patient weight (adult/baby)
Measuring and recording blood pressure
Nutritional counselling
Observation of the birth process
Support and care for the mother during birth
Introduction to medications and herbs
Evaluation of weight gain
Evaluation of blood pressure
Introduction to risk factors during pregnancy
Presence in treatment of spontaneous abortions: suction
curettage and Misoprostol therapy regime
e. Analysis of gestational age using measurements
f. Auscultation and evaluation of foetal heart rates using
Doppler and a fetoscope
g. Attendance during ultrasound
h. Evaluation of the labour process by observation
i. Independent postpartum care for the mother and baby
j. Observe: Papanicolaou test (PAP), Visual Inspection with
Acetic Acid (VIA), bimanual exams, and detection of urinary
tract infections (UTI)
k. Providing: Papanicolaou tests (PAP), Visual Inspection with
Acetic Acid (VIA) and pregnancy tests
l. Introduction to treatment of simple infections and other
illness, both holistically and allopathically
m. Training in use of medications and herbs
a. Training in contraceptive methods: Oral contraceptives; 1 and
3 month Depo-Provera injections; Intrauterine Devices (IUD);
Jadelle/Norplant implants; Vasectomy; and Tubal litigation
b. Diagnosis and treatment of simple infections, including
follow-up care
c. Intramuscular injections and intravenous drips (IV)
d. Suturing tears and simple wounds
e. Introduction to obstetric ultrasound: handling the ultrasound
machine, detecting gestational age, detecting multiple
pregnancies, detecting foetal position, and detecting
intrauterine demise
f. Doing a normal birth
g. Doing Misoprostol therapy after incomplete spontaneous
abortions
h. Use of medications and herbs
i. First-aid and CPR coursework
Chocruz, Momostenango, Guatemala
Anticipated Learning Dates and Themes
15
The Necessity for a Health Needs Assessment:
Identifying community perceptions and lived-experiences of health, health-needs, access and
utilization of health services is an invaluable starting-point for any planned health intervention. Participatory
health needs assessments can promote equity, access and utilization of health services by framing
programmatic activities within community-recognized priorities for health. As such, health-needs
assessments improve the accountability of program developers towards targeted beneficiaries by placing
primary value on community insight. Through the involvement of community members in planning activities,
health needs assessments can foster linkages that will provide support and direction for future health
projects. By understanding community values and priorities, effective health-needs assessments can begin a
participatory project process of categorizing needs, planning for effective action, implementing accountable
programs, and monitoring and evaluating planned activities.
F IGURE 6: T HE PROJECT CYCLE
Chocruz, Momostenango, Guatemala
Needs
Assessment
Evaluation
j
Monitoring
16
Planning
Implementation
Health-needs assessments are considered a vital first-step for the development and implementation
of community-based health activities. Without evidence-based training curriculum, severe constraints are
placed upon goals of acceptable health care delivery that strengthen health systems and protect the public.
Uninformed training guidelines can lead to the provision of inadequately trained health workers with
inappropriate skill-mixes, gaps in health care competencies, and deficiencies of optimal standards, ultimately
placing patient-centred care at risk of unethical conduct (Berman et al. 1987; WHO 2006; UNFPA 2011; WHO
2011a; WHO 2011b). The World Health Organization clearly outlines the need for appropriate care to be
based upon education that is responsive and accountable to unmet community needs (WHO 2006). Within
Guatemala, this criterion becomes more important as historical experiences have led to high levels of distrust
towards the medical community and other perceived authority figures. Thus, there is a demonstrated need
to align the current project curriculum with community-identified needs to ensure trust, quality, practical and
task-oriented training: the most important determinant of program impact (Bhattacharyya et al. 2001). In
accordance with this philosophy, the 2006 World Health Report emphasizes as a primary workforce goal:
To get the right workers with the right skills in the right
place doing the right things! (WHO 2006)
Health Needs Assessment Methodology:
To achieve an equitable assessment, a Participatory Rural Appraisal (PRA) study design was selected
in order to identify health needs as perceived and defined by community members in Chocruz,
Momostenango. Absalom et al. (1995) define PRA as “a family of approaches and methods to enable rural
people to share, enhance, and analyze their knowledge of life and conditions, to plan and to act” (Cornwall &
Pratt 2011:263). Applied most effectively in relatively homogenous communities which share common
knowledge, values and beliefs, PRA is a reliable method for obtaining information about a small set of health
problems in a short period of time and at low-cost (Annett & Rifkin 1995). PRA health needs assessments
improve accountability to beneficiaries of programs and can strengthen principles of equity, participation and
multi-sectoral collaboration prior to the development of plans for future programmatic action (Annett &
Rifkin 1995; Palmer 1999).
Popularized in the 1980s, PRA was borne out of lessons from activist participatory research, agroecosystem analysis, applied anthropology and rapid rural appraisal (Chambers 1992; Chambers 1994; Annett
& Rifkin 1995). With emphasis on partnerships, listening and communication, PRA facilitates learning,
investigation, analysis and presentation for, by, and with community members to reach a common goal
(Chambers 1994). As such, PRA is situated as an empowering alternative to conventional extractive research
methodologies that may not value community involvement and local ways of knowing.
Chocruz, Momostenango, Guatemala
Study Design – Participatory Rural Appraisal (PRA):
PRA is accredited with four practical applications: 1) Participatory appraisal and planning; 2)
Participatory implementation, monitoring and evaluation of programs; 3) Topic investigations; and 4) Training
and orientation for outsiders and villagers (Chambers 1994; Murray 1999; Cornwall & Pratt 2011). As such,
the PRA design selected for this particular health needs assessment had a three-fold purpose: 1) To record
community-identified health needs; 2) To facilitate the incorporation of the two apprentices into the
community as future health workers, building confidence and trust through various interactions with the
community; and 3) To teach the two apprentices skills for future monitoring and evaluation activities that
should be started immediately after the health-post’s inauguration.
Setting and Team Composition:
Research was conducted in Ciudad Vieja, Momostenango, and throughout Pamumus. A community
salon behind the local school in Chocruz served as the primary setting for group interviews and some
individual meetings. Individual interviews also took place at Asociación Manos Abiertas, the Momostenango
Health Centre , the Pamumus clinic, the Pamumus Municipality Office, the Choabaj health-post, Chocruz, and
through Skype conversations over the Internet. The research team consisted of one Master in Public Health
graduate student from Canada, Danica Buckland, the two female health-post apprentices, and a male
17
Spanish/English translator. Supervision for the project was provided from Antigua by Josie Silverman, MPH.
The team was in the field for a total of 7 days.
Sampling Frame:
In total, the study had a sample size of 77 individuals (n=77). Key-informant interviews were selected
purposely and included both men and women of various ages, community involvement and professions: four
community leaders, three municipal office workers, two local midwives, attendants at both the Pamumus
and Choabaj health service delivery points, a nurse and laboratory technician at the Momostenango health
centre, and several unplanned individual-meetings with community members. In addition to individual
interviews, the study team was able to coordinate seven focus group discussions. The focus group sampling
frame was determined by community leaders and included the parents of children who attend the local nongovernmental school in Chocruz.
Chocruz, Momostenango, Guatemala
Methodology:
As part of the PRA study design several methods were chosen to facilitate community identification
of health needs in a short time frame, to address relevant topics of stakeholder interest, and to allow
flexibility in a setting where the majority of women are illiterate and do not speak Spanish. Secondary data
collection, direct observation, key-informant interviews, and focus group discussions using free-listing,
ranking, and participatory mapping strategies were chosen as appropriate methods for triangulation. All
methods were pilot-tested through an intensive training session with the two apprentices prior to field work.
Secondary Data Sources:
Secondary data was obtained prior to field work in order to inform the choice of appropriate
methodology and key probes for interviews. The secondary data collected also informs the final report and
key recommendations. Primary sources consulted for data were
j on-line academic journals accessed through
both Simon Fraser University and the University of British Columbia web-based library systems. Demographic
data was collected through various Guatemalan government on-line resources, including the most recent
national health surveys, as well as information provided by the World Health Organization and the PanAmerican Health Organization. On-line grey-literature was also consulted.
Direct Observations:
Meticulously-recorded direct observations served to complement and provide cross-checks for
verbal information gathered from interview sessions. Direct observations enabled the PRA team members to
gather on-the-spot data to inform interview questions, support interview detail, and provide valuable
counterfactuals to what was said, and not said, during conversations and activities with community members
and other informants. Direct observations were recorded by both photography and notes throughout the
community and within all health-service delivery points.
Key-Informant Interviews:
Semi-structured interviews are one of the primary tools used in PRA health needs assessments. Semistructured interviews are a form of guided-interview where only some of the questions are pre-determined.
In contrast to formal questionnaires that produce quantitatively-weighted data, many questions during a
semi-structured interview were formulated during various conversations. This flexibility enabled the PRA
team members to explore new insights and knowledge. Individual interviews provided valuable sources of
detailed information and served as cross-checks for other PRA activities.
18
Key-informant interviews were conducted with administrators, leaders and other authorities,
community-based health workers, and members of the sample population that had specific knowledge
characteristics or were unavailable to meet in group settings, thus fulfilling the recommended range of
individuals for use in qualitative research. Verbal or written consent for all interviews was obtained prior to
each meeting. Interviews were held in both K’iche and Spanish and were translated to English. Interviews
were not audio-recorded; however, notes were taken during the interview sessions by several team
members and then translated into Spanish and English after each meeting.
Focus Group Discussions:
Focus group discussions were chosen to generate ideas and provide community-level information
regarding common health problems, health resources and health needs that were not considered sensitive
for public discussion. Several strategies were used to elicit information regarding the health status of the
community: participatory mapping, free-list ranking and subsequent discussions.
Participatory Inside/Outside Mapping:
Participatory mapping is a useful PRA tool that greatly simplifies complex information through
collaborative visual processes. The act of constructing diagrams and maps is an analytic procedure that can
facilitate communication, stimulate discussion, increase consensus among team members, and involve
diverse community members to discover their views and categories through the encouragement of personal
expression, regardless of drawing or writing capabilities. Inside/outside mapping activities enabled the focus
group participants to draw and describe health resources and social determinants of health from both inside
and outside the community.
Chocruz, Momostenango, Guatemala
Focus group discussions were held with members of the community as identified through the Centro
Educativo Futuro Para Niños school-roster. Attendees volunteered for specific dates and times of the focus
groups. Attendance was not mandatory; however, nearly every volunteer participated. In total, 6 all-female
focus groups were led by the two health-post apprentices, whilethe male PRA team translator held 1 focus
group with the male participants due to gender considerations. Focus group size varied from 3 to 19
participants. In groups larger than 10, the PRA team divided the attendees into 2 separate groups and
facilitated the project activities at the same time. The focus groups lasted approximately 2 hours each. Due
to high illiteracy rates in the community, consent for participation at the beginning of the focus groups was
obtained by verbally explaining interview processes, attendees’ rights during the research activities, and
offering time for questions. Each participant’s name was written down on separate consent forms upon
verbal acknowledgement of willingness to participate: none of the attendees declined offers of participation.
During each focus group, participants were divided into two groups: the first group was asked to
draw an inside-map of Chocruz and the second group was asked to draw an outside-map of Chocruz.
Participants were encouraged to draw main roads, water sources, agriculture, houses, schools, churches,
buildings, landmarks and other community resources. The participants were further prompted to draw
sources and barriers to health within and outside of their community. Time-of-travel to each health resource
was requested from the participants during a question period following map completion.
19
Chocruz, Momostenango, Guatemala
F IGURE 7: MEN 'S FOCUS GROUP PARTICIPATORY OUTSIDE MAPPING E XERCISE
20
F IGURE 8: W OMEN 'S FOCUS GROUP PARTICIPATORY I NSIDE MAPPING E XERCISE
j
Ranking Exercises:
Ranking or scoring exercises facilitate the ordering of information. Such analytic tools can
complement semi-structured interviewing by generating basic information that can lead to more direct
questions regarding community health. Ranking exercises were used during both individual and group
interviews and offered valuable insights into divergent and congruent opinions located within the
community. The ranking exercises provided a form of baseline data for community-identified priorities,
values and needs regarding health. Participants were asked to free-list and rank health problems for women,
health problems for men, health problems for children and barriers to health within the community. Each
response was written on a small card and the participants ordered the cards in descending order of
importance. This valuable information forms the basis of the health needs assessment report.
Analysis of Findings:
As a group, the PRA team engaged in participatory on-the-spot analysis of the consolidated data
daily: a requisite of PRA health needs assessments. At the conclusion of each day’s activities the PRA team
met to improve notes taken during the day, discuss findings, and revise hypotheses. Similarities and
discrepancies found in the data were used to guide the next day’s fieldwork. After the completion of all
planned focus groups,, the PRA team met to amalgamate ranking activity data-sets during an intensive final
analysis session. The consolidated data was then compared with key-informant and secondary-source data
to triangulate initial findings. This data was presented to key community leaders in order to confirm results
and gain community buy-in. Reported findings were supported and verified by community leaders.
Report Writing:
Report-writing without delay is the final key feature of a PRA health needs assessments. The final
report should become the evidence used for the next phase of the planning process: preparing a detailed
plan of action for the two apprentices’ training curriculum and setting specific objectives for health-post
activities and organization (Annett & Rifkin 1995). As a compendium of baseline data, this final report should
be used to also identify indicators for future monitoring and evaluation activities at the health-post in
Chocruz. The final report will be submitted to all project stakeholders for consideration and action.
Chocruz, Momostenango, Guatemala
F IGURE 9: O NSITE A NALYSIS OF D ATA
21
Community Findings:
The following section is divided into 6 main themes: children’s health, women’s health, men’s health,
family planning, midwifery and pregnancy-related care, and perceived barriers to health. The data presented
comes from in-depth community discussions and activities. Much of the following discussion is supported by
the literature and will be presented as such.
Children’s Health:
Children’s health problems are the primary concern of all community-members in Chocruz. During
ranking exercises, both men and women emphasized the urgent need for children’s health care in the
community. The following chart outlines the ten most common childhood illnesses in Chocruz, as classified by
community members, with associated frequency of reporting from focus group ranking discussions. All
illness-descriptions are in their original wording-format, translated from K’iche to Spanish and then into
English.
T ABLE 5: C OMMUNITY REPORTED CHILDREN 'S HEALTH PROBLEMS
Chocruz, Momostenango, Guatemala
Rank
22
Reported Childhood Health Problems
1.
Stomach Illness: Diarrhoea (XII); Parasites/Amoebas (VI); Stomach problems (IIII); Inflamed
stomach (II); Vomiting/Nausea (II); Gastritis (I)
2.
Skin Disorders: Measles (VIIII); Chicken-Pox (VII); Skin problems (I)
3.
Respiratory Issues: Respiratory problems (VII); Allergies (IIII); Pneumonia (III); Bronchitis (I)
4.
5.
Malnourishment: malnutrition (VII); Anemia (II); Migraines (I); Memory loss (I)
j
Fever (XI)
6.
Flu (VII)
7.
Body Pain: Cramps (II); Feet pain (II)
8.
Infections: Infection (II); Ear pain (I)
9.
Hernia (III)
10.
Appendicitis (III)
As evidenced by the preceding data, acute illnesses, such as diarrheal disease, skin disorders and
respiratory illness, cause the greatest health burden for children in the community. This data supports
national-level indicators of under-five morbidity and mortality rates in Guatemala (WHO 2011c). It is
important to note that personal hygiene and malnutrition exacerbate such childhood illnesses and are a
determining factor of illness severity. The community listed malnutrition as the fourth most important health
problem affecting children in the area; however, this is likely underreported due to the general inability of
many Guatemalans to identify cases of malnutrition. From community observations it is apparent from
height-to-age comparisons that the area suffers from malnutrition, despite efforts of the local nongovernment school’s breakfast and lunch program. It is also clear from community observations and
conversations that personal hygiene is under-practiced in children, especially in relation to hand-washing,
augmenting risk for communicable diseases. Sadly, the Municipal office in Pamumus recalled several infant
deaths in the last three years due to malnutrition, diarrheal disease and other acute health issues that are
easily preventable, and a community leader in Chocruz reported five infant deaths this year alone.
Interesting to note is the frequency of hernias in children reported and the relationship to
malnutrition. Globally, approximately 5 out of every 100 children are diagnosed with inguinal hernias
(PubMed 2010). More common in males, such hernias can be caused in children by chronic constipation,
straining to have bowel movements, chronic coughs and poor nutrition (PubMed 2010). Furthermore, in
relation to the appendicitis cases reported, there may be a linkage to the causes of community diarrheal
diseases. Although there are no clear causes of appendicitis, bacteria, viruses and parasites from fecal matter
can lead to an infection in the appendix wall, leading to inflammation and subsequent rupture (PubMed
Health 2010).
Measles, or sarampion, was also reported with high frequency. Transmission of infections and
complications from measles are linked to deficiencies in vitamin A and general malnutrition (PubMed 2010).
Measles infection can lead to other complicationssuch as bronchitis, ear infections and pneumonia (PubMed
2010). The community explained that the high-rate of measles is due to unreliable and unadvertised
vaccination campaigns and the inability to attend clinic vaccination dates. The women reported that without
the vaccination card received during measles vaccination drives, it is very difficult to receive care at
government-run health-posts.
Lastly, it is important to discuss the reported frequency of child exploitation in the area. Several
community leaders highlighted that children’s health problems are exacerbated from hard manual labour:
working in the fields, carrying wood and washing clothes. During regular school hours it was observed that
several families do not have children attending either the government-run school near Choabaj or the nongovernmental school in Chocruz.
Chocruz, Momostenango, Guatemala
From direct observations and community discussions it is apparent that the area is suffering from
high rates of acute respiratory-tract infections (ARI) in children. During one focus group, a young infant was
coughing up blood and had a visibly distended chest: clear indications of an ARI. The Pamumus clinic reports
ARI treatment for children as the most common form of health service provided. Left untreated, ARI can lead
to serious complications, including pneumonia, bronchitis, and even death and ARI remains one of the
primary causes of death for infants in developing countries (PubMed 2010). Risk factors for acquiring ARI
include low birth weight, lack of breastfeeding and malnutrition (PubMed 2010).
Women’s Health:
The following table outlines the most commonly reported health problems for women in Chocruz,
with associated frequency of reporting from focus group ranking discussions. All illness-descriptions are in
their original wording-format, translated from K’iche to Spanish and finally into English.
23
T ABLE 6: C OMMUNITY REPORTED W OMEN 'S H EALTH PROBLEMS
Chocruz, Momostenango, Guatemala
Rank
Reported Health Problems for Women
1.
Urinary/vaginal infections (VII); White/yellow vaginal discharge (III)
2.
Menstrual pain (IIII); Menstrual problems (II); Late menstrual cycle (II); Cramps (I)
3.
Muscular pain (I); Body pain (III); Feet pain (I); Head pain (IIII)
4.
Stomach problems (III); Diarrhoea (I); Stomach pain (I); Gastritis (II); Nausea (I); Ulcer (I)
5.
Blood pressure problems (V); Heart problems (I)
6.
Problems during pregnancy/birth (IIII); Accidental abortion (I)
7.
Ovarian cysts (I); Cancer in the womb (II); Problems with ovaries (II)
8.
Nerves (III)
9.
Malnutrition (III)
10.
Hernia (II)
11.
Infection during lactation (I)
12.
Vision problems (I)
j
From the data it is apparent that sexual and reproductive
health problems are of greatest concern
for women in the community. It is important to note that many of the listed health problems for women are
synergistic and interrelated in causation: poor access to health care resources, personal hygiene and
malnutrition during the sexual and reproductive health cycle all contribute to the prevalence of sexual and
reproductive health problems reported. Urinary and vaginal infections and severe vaginal pain were the
most commonly reported health ailments by both women, attendants at the Pamumus clinic and the Choabaj
health-post. Such infections may signal growing rates of bacterial and parasitic sexually-transmitted
infections which can have negative consequences during pregnancy and birth (PubMed 2010). Problems
during menstruation are also very common. Due to the sensitive nature of gynaecological morbidities, this
data is surely an underestimation of the true health burden suffered by women in the community.
Problems during pregnancy were reported by women as well as local midwives. The high fertility rate
of women in the community, 5 to 8 children (compared to the 4.1 national average), and the young age of
first pregnancies, at 13 to 15 years of age, exacerbates pregnancy-related complications from both a
biological and social determinants of health perspective. Within the community it is common to have 2
children by 17 years of age. The majority of women in the community give birth at home with the attention
of a midwife, unless there is an emergency. Prenatal care consists of meetings with the midwife in a
Temascal, or adobe sauna-like structures that are heated by wood fires, over the course of the pregnancy.
The practices of midwives will be discussed in a following section.
24
The most commonly reported problems during pregnancy include bad positioning of the foetus,
white and yellow fluid discharge, headaches, body aches, stomach problems, molar/teeth pain, ear pain,
urinary infections, ovary infections, cough, cramps, fever, loss of appetite, anemia, and loss of memory.
“Infecciones para fecar” was also reported by one focus group of women as a problem during pregnancy;
however, the meaning of this illness classification is unknown. One key informant discussed the frequency of
spontaneous abortion when prompted on the commonality of serious problems during pregnancy. Several
women during separate focus groups discussed how the womb, or matrice, grows thin with subsequent
pregnancies, and within their local belief system this weakness causes the majority of pregnancy-related
problems.
Women expressed a strong desire to have more frequent cervical cancer screening available in the
community. Several community leaders stated that the frequency of cervical cancer is rising, indicating a
large risk of human papillomavirus (HPV) in the community. During two focus groups the women indicated
that “derrames,” a reported type of abscess that frequently manifests near the stomach requiring a small
operation, are common in the area. It was requested that the clinic be able to treat such ailments.
The community health data reported for women emphasizes the triple-burden of reproductive,
domestic and productive labour roles that lead to high morbidity in the area (Hughes 2004). Although
indigenous men have higher mortality rates, indigenous women suffer from higher rates of morbidity in
Guatemala and are often subject to silent epidemics of gynaecological health problems due to their personal
nature (Hughes 2004). As stated previously, the former data-set is surely an underestimation of the true
extent of women’s health burden in the community, however, the ailments listed provide an excellent point
of entry to discussing sexual and reproductive health issues in Chocruz and shaping the types of services
offered at the future clinic.
Men’s Health:
Chocruz, Momostenango, Guatemala
Recalling the previous three years, community leaders, the Municipal office in Pamumus, local
midwives, and the health attendants in Pamumus and Choabaj did not remember the frequency of maternal
deaths in the area. Most reported that there were no maternal deaths in Chocruz; however, one community
leader believes that there is one maternal death per year in the community. One midwife in Chocruz
reported six maternal deaths in the area over her 25 years of practicing: she had not witnessed any maternal
deaths under her care. The clinic attendant in Pamumus stated that some women have died during birth
because there are no medications in the community for haemorrhages. Reported mortality data may be due
to the fact that emergencies during birth are referred to the Momostenango health centre or the district
hospital in Totonicapán where outcomes are unknown.
The following table outlines the most commonly reported health problems for men in Chocruz, with
associated frequency of reporting from focus group ranking discussions. The health ailments for men are
visibly diverse in comparison to previous data-sets; this may indicate a gendered bias in reporting health
problems. It is also important to note the synergistic and interconnected nature of the following illness
classifications and overlap between ranking groups may apply. All illness-descriptions are in their original
wording-format, translated from Spanish to English.
25
T ABLE 7: C OMMUNITY REPORTED MEN 'S H EALTH PROBLEMS
Chocruz, Momostenango, Guatemala
Rank
26
Reported Health Problems for Men
1.
Malnutrition (III); Anemia (I); Tiredness (I); Diabetes (VI)
2.
Cramps (III); Head pain (III); Arthritis (II); Body pain (I)
3.
Gastritis (IIII); Diarrhoea (II); Ulcer (I)
4.
Alcoholism (V)
5.
Nerves/Stress (IIII)
6.
Fever (III)
7.
Flu (III)
8.
Appendicitis (III)
9.
Gallstones (I); Urinary problems (I)
10.
Blood pressure problems (II)
11.
Respiratory problems (I); Colic (I)
12.
Men’s sexuality problems (II)
13.
Cancer (II)
14.
Athlete’s foot (I)
15.
Vision problems (I)
j
Health issues linked to malnutrition, including diabetes, were the most commonly reported problems
for men in the community. The Municipality office in Pamumus reported that approximately 10-15% of men
in the community have diabetes. Type-2 diabetes is increasingly related to diet and has been found to have a
higher prevalence in certain ethnic groups, including Latinos (PubMed 2010). Diabetes-related
symptoms/complications range from fatigue to blurred vision and foot problems: symptoms that were
identified by the community. If not properly managed, long-term diabetes complications include kidney
failure, cardiovascular disease, blindness and death. Within the community it was observed that there is little
access to proper nutritional sources: tiendas only stock processed food and drinks. Most crops grown locally
are harvested for sale during market days in Momostenango.. Malnutrition was also linked to overwork and
vitamin deficiency by the community, including acknowledgement of dehydration.
High rates of alcoholism were reported in the community: 20% of men were said to suffer from
alcoholism or alcohol-related disorders. Alcoholism is linked to rising levels of domestic violence (sexual,
physical, and psychological) in Central America (Hughes 2004). Many community members reported severe
consequences of alcoholism in the area, including psychological issues, familial abuse, theft, and related
sicknesses. Other than the Church, there are no resources for addiction treatment or counsellingin the
community. A possible risk-factor for alcoholism in the community are high rates of reported emotional
stress, or nervios, attributed to economic and environmental stressors.
Male sexual and reproductive health problems were highlighted by several community leaders, but
were not discussed during focus groups. Such discrepancy in the data indicates how the public nature of
focus group discussions dissuades men from revealing or discussing more personal health problems. One
community leader emphasized that there is a high rate of “problemas sexuales,” or sexual problems, in the
community, including “contagios,” or infections, and one not having control over his sexual activity. The
source indicated that community members do not discuss such problems openly and do not seek care.
Family Planning:
In Chocruz, the majority of women and men reported a desire to avoid pregnancy, but few used any
contraceptive method. Women who have 2 to 3 children are most interested in contraceptives for personal
use in the community. However, both men and women during focus groups expressed a strong desire to have
family planning education for their children, despite the director of the non-governmental school reporting
that they provide such workshops for their students. Both men and women stated that there has been
limited education regarding family planning in the community and that there are often mixed messages
delivered. Many men also expressed that there is a general fear of family planning due to the misconception
that it involves surgery or castration. Sources at the Municipal office stated that they do not know if there
would be an interest in vasectomies due to the aforementioned beliefs surrounding male-targeted family
planning. The influence of the Church is cited as a major barrier to family planning and was linked to the
dearth of family planning methods available in the community.
Neither health service delivery point seemed to have an adequate supply of family planning
methods. From direct observations, no condoms were visible; indicating that condom negotiation skills are
likely lacking in the community. Instead, Depo-Provera 3-month injections are cited as the most sought-after
contraceptive method. However, the Pamumus clinic did not have Depo-Provera available, only an empty
bottle was visible, and the health-post in Choabaj was in the process of ordering more supplies from the
Ministry of Health. The lack of Depo-Provera in the community raises concerns over the efficacy of dosages as
injections must be concretely scheduled every three months: if not properly administered every 3 months
the method becomes ineffective.
Chocruz, Momostenango, Guatemala
An unmet need for family planning is defined as “an unfulfilled desire to delay or stop child-bearing”
(WHO 2011a). As evidenced by high fertility rates and the young age of first pregnancy, the community does
not have adequate access to family planning services due to economic, cultural, religious and gendered
determinants of use. Female sexuality is restricted in Mayan society and often women are denied male
entitlements such as sexual pleasure and control (Hughes 2004). Coupled with an inadequate provision of
sexual education in rural schools and the strong influence of the Church, indigenous communities have higher
incidences of pregnancy in closely spaced increments leading to serious health risks for both mother and
child (Hughes 2004).
Midwifery and Pregnancy-Related Care:
There are an estimated 5 to 8 practicing midwives in the surrounding Pamumus area and two are
reported to practice in Chocruz. Similar to national-level data, midwives are the most common source for
pregnancy-related care in the community, with pregnancy and labour emergencies referred to the
Momostenango health centre. Midwifery services in Chocruz cost approximately 400 to 600 Quetzales ($50
to $75 USD), as determined by experience, distance travelled and number of prenatal and postpartum visits
held. The midwives promote agreements for payment-plans in order to ensure affordability, remuneration
and service use. The majority of midwives are recognized by the community as trusted, wise women who
have accepted higher calls for midwifery. The two midwives interviewed reported that God had given them
the talent of midwifery. One midwife reported that when she was pregnant she sought the care of a
27
recognized midwife, grew interested in the practice, and apprenticed under her supervision. After her birth
she stopped practicing midwifery and became sick: a message from God to continue her practice. At the time
of the interview, she had been practicing midwifery in the community for 1 year and had given care for 2
births; she had rejected four offers of employment as she is awaiting her licence from the Ministry of Health.
The second midwife interviewed had been practicing for 25 years in the community and reports an average
of 6 to 8 births per year. She stated that her abilities as a caregiver were a gift from God and that she never
experienced sickness because she recognized her calling.
Chocruz, Momostenango, Guatemala
These themes of becoming a midwife are congruent with the literature. Walsh (2006) identifies 3
themes associated with midwifery in Guatemala: 1) Sacred calling; 2) Sacred knowledge; and 3) Sacred Ritual.
The sacred calling refers to the sacred work of midwifery given as a gift from God or a saint in dreams or
visions (Walsh 2006). It is common for midwives to report receiving visions from God and ignoring their
messages, thus becoming sick until the sacred task is accepted (Walsh 2006). Sacred knowledge refers to the
learning of midwifery practice through dreams or visions: somatic signs that are interpreted as word of God
(Walsh 2006). Lastly, the sacred ritual refers to the actual practice of midwifery and the type of ritualized care
that traditional midwives offer (Walsh 2006). Through these three themes, birth becomes a spiritual event,
not just a biological process.
Both midwives in the community reported working for 4-6 months with women and offering up to 15
prenatal visits. Every house in Chocruz is equipped with a traditional sweat room, or temascal, that midwives
use for prenatal and postpartum care. In the temascal the midwives reported checking for the position of the
foetus and will massage the stomach. During prenatal visits women are asked to buy “balsamico”, oil, and
birthing pills by some midwives in the area, as reported by the less-experienced midwife. The women in the
community commonly recalled the use of “birthing pills.” “Birth pills” were described as a form of medication
that is used when contractions are frequent in order to speedj the delivery process: a dangerous practice
outside of health facilities. Births generally take place in the mother’s home. After the birth, the midwives
reported visiting the new mothers for a minimum of 5 days, teaching breastfeeding techniques, proper
feeding, appropriate care, and bathing. The midwife with less experience also reported doing postpartum
check-ups in the temascal to observe if the womb, or matrice, has returned to its original place and to blow
air into the anus to repair any abnormalities. Neither midwife reported binding the stomach and hips after
birth to prevent uterine prolapse: a common practice in several regions of Guatemala (Goldman & Glei 2003).
Goldman & Glei (2003) have identified 6 common midwifery practices in Guatemala that are potentially
harmful:
1.
2.
3.
4.
5.
6.
28
Giving an injection or other medication to speed delivery
Giving antibiotics during pregnancy
Putting powder or ointment on the umbilical cord
Normally pushing on the stomach at the beginning of delivery
Normally performing a vaginal examination during pregnancy
Normally telling the mother to give the baby sugar water or tea in the first week of life
The midwives reported several practices that could be potentially harmful by Goldman and Glei’s (2003)
standards. It is unclear if the midwives practice pushing on the stomach at the beginning of delivery, a
dangerous form of care due to its associations with uterine complications; however, the use of external
cephalic versions of prenatal massage has received growing support in recent years as a traditional practice
that does not cause much-anticipated harm (Hinojosa 2004). The most concerning trend is the increasingly
bio-medicalization of midwifery care in the community and the introduction of controlled medications into
everyday practice that may increase complications and even death.
Goldman and Glei (2003) also identify 4 common midwifery practices that are beneficial for maternal
and infant health: both midwives reported practicing all of the identified postpartum recommendations:
1.
2.
3.
4.
Normally keeping the baby warm after birth
Normally encouraging breastfeeding
Normally encouraging immunization
Normally checking the mother and baby during the postpartum period
Training of traditional midwives through the Guatemalan Ministry of Health began in 1955 (Goldman
& Glei 2003). Legally, midwives who do not receive government-sanctioned training are prohibited from
practicing due to licensing constraints; however, many midwives practice without authorization (Goldman &
Glei 2003). In addition to monthly capacitation courses held in the Momostenango health centre, the
Ministry of Health is purportedly required to provide 15-day training programs for local midwives taught by a
nurse (Goldman & Glei 2003). Health care workshops are based upon the Safe Motherhood paradigm: most
maternal and infant deaths are preventable through skilled care at all points of pregnancy, the timely
identification and referral of complications, and access to high-quality emergency care (Maupin 2008). One of
the interviewed midwives carries around a visual cue-card to recognize danger-signs during pregnancy that
was given to her during one of the training sessions.
F IGURE 10: USAID-SPONSORED D ANGER -RECOGNITION CARD
Sponsored by USAID, the visual cue-card illustrates the standardized materials that are disseminated
to midwives throughout Guatemala. Although the cue-card is predominately based on pictures, the most
salient points are written in Spanish, disregarding the fact that most midwives do not speak Spanish fluently
and are unable to read or write. In the literature it is reported that midwives frequently complain about the
pedagogical, didactic and theoretical-style of teaching at Ministry of Health sponsored workshops (Goldman
Chocruz, Momostenango, Guatemala
Through trainings from the Ministry of Health, the midwives in Chocruz are instructed to educate families
regarding family planning, teach evidence-based care techniques and encourage postpartum medical
attention for both the mother and child. One of the interviewed midwives stated that she does not provide
family planning advice to her clients, nor does she ensure postpartum care; she stated that these were
choices of the family and were not part of her role.
29
& Glei 2003; Maupin 2009). Most often, training workshops are led by auxiliary nurses that only have one
year of additional training and are often viewed as condescending, disrespectful and inadequately equipped
to teach new skills (Goldman & Glei 2003; Walsh 2006). Training programs are frequently cited as
condemning traditional practices, including temascal use, massage and herbal remedies. Furthermore,
training workshops do not reflect local needs and cultural belief systems, dissuading future participation of
midwives. The World Health Organization now recognizes that such forms of training for traditional birth
attendants have limited value in relation to effects on overall quality of care (Walsh 2006; WHO 2011a;
UNFPA 2011); however, it has been found that such training workshops do increase proper referrals for care
from midwives, increasing their value as first points of care for local communities (Goldman & Glei 2003).
Community members in Chocruz reported that some midwives in the community provide adequate
attendance during pregnancy and birth, and others do not. It was unclear how the women defined adequate
attendance; however, giving pills during labour to speed contractions instead of examining the head position
or dilation was cited as a dangerous practice by one midwife. Both midwives reported lacking much-needed
supplies: gloves, birth-kits, medications and a weight machine.
Chocruz, Momostenango, Guatemala
Perceived Barriers to Health:
30
As seen from the accompanying table, lack of economic and household resources and the high cost
of medications were rated as the most important barriers to health in the community during focus group and
individual-interview ranking exercises. Quality of available health care, personal hygiene, and travel distance
to health care services were also commonly reported barriers to health within the community. Of importance
is the frequency of reported machismo and its relation to health care seeking behaviour for women: a barrier
that may also be augmented by the Church’s influence in the area.
j
T ABLE 8: C OMMUNITY -REPORTED BARRIERS TO HEALTH
Rank
Reported Barriers to Health
1.
Lack of economic resources/High cost of medications/Lack of food (XI)
2.
Poor service in the health centre /No health centre in the community/Lack of capacity at health
centre s (X)
3.
Personal hygiene (IIII); Poor preparation of food (II); Poor use of latrines (II)
4.
Dust (II); Seasonal changes and cold air (II); Smoke in the kitchen (I); Insects (I)
5.
Road and distance to the health centre (VI)
6.
Machismo (V)
7.
Garbage (V)
8.
Water (IIII)
9.
Church (III)
As the preceding table indicates, the community articulated numerous barriers to health that affect
appropriate, timely and equitable access to care. Thaddeus & Maine’s (1994) classic 3-phases of delay
explanatory paradigm to explore actual and perceived barriers to care during maternal emergencies is an
excellent theoretical framework to discuss community conceptualization of access and availability of health
care for the population in entirety. Any one phase within this theoretical framework can prove fatal: 1) The
delay in deciding to seek care; 2) The delay in reaching an adequate health care facility; and 3) The delay in
receiving adequate care at a health facility (Thaddeus & Maine 1994). The following section will outline
Thaddeus & Maine’s (1994) explanatory framework to structure discussions regarding barriers to health
within Chocruz and the surrounding area.
Phase 1 Delay:
Decision-Making and Gender:
Gender-roles and power for decision-making are strong determinants of health. For indigenous
women, the socially-determined nexus between gender, health and indigeneity creates a complex interplay
for health-care seeking behaviours. As Hughes (2004) summarizes, “indigenous women’s gender roles and
their relationships with men, their communities, and society as a whole shape both their ability to achieve
good health and their quality of life” (Hughes 2004:1). These characteristics primarily influence the first
phase of delay.
Mayan culture is characterized as patrilocal and patriarchal (Hughes 2004). Women are often
considered subordinate to fathers and husbands and men are responsible for making the majority of
household decisions due to their primary access to economic and material resources. Women are generally
discouraged from participating in community politics and instead play a supportive-productive role that is not
publically prominent (Hughes 2004). However, some research has suggested that in areas of Guatemala that
are dependent on small-scale agriculture, gender relations may be considered more egalitarian (Carter 2002).
Due to such economic structures, many male household members are away from the community for
substantial amounts of time, leaving women responsible for both the “public-productive-remunerated
sphere” and the “private-reproductive-unremunerated sphere” within the community (Hughes 2004). These
inter-household relationships are clearly demonstrated in Chocruz.
Chocruz, Momostenango, Guatemala
Phase 1 delay refers to the delay in deciding to seek care on the part of the individual, the family, or
both (Thaddeus & Maine 1994). Several factors influence the first delay: actors involved in decision-making,
the status of women, illness characteristics, distance from the health facility, financial and opportunity costs,
previous experience with the health care system and perceived quality of care (Thaddeus & Maine 1994).
This first phase of delay is primarily influenced by socioeconomic and cultural factors (Thaddeus & Maine
1994).
Descriptions of power for health-seeking decisions in Chocruz were varied. Community leaders
emphasized that due to the patriarchal nature of the community, men determine the allocation of household
resources and decisions to seek health care. During focus groups, men claimed that both parents make
decisions regarding health care. Women did not openly comment about decisions regarding obstetric
emergencies; however, they reported some influence in deciding to seek care for children. At the Choabaj
clinic, the attendant stated that if there is an emergency she uses a community-committee, comprised of
men, to make the decision to call a doctor or to arrange transport to the hospital.
From many discussions it became apparent that the area suffers from machismo and men hold the
ultimate power for decisions, with a consultation role provided for women. As such, machismo was locallyclassified as a barrier to women’s and children’s health. Many informants stated that women are more
valued now than in the past, but that sexual discrimination is endemic to the community, affecting women’s
31
perceptions of self-worth. For example, a small capacity-building project was developed for women in the
community, however, the project failed to materialize due to local women being disallowed to participate, as
per many husbands’ requests. The school director recalled another instance where a young woman was
withdrawn from the local non-governmental school due to her advancing academic skills in comparison to
her male siblings. Counterfactually, during our research, female participation greatly exceeded that of males.
However, from the mapping exercises it was evident that the women in Chocruz are not granted the
opportunity to leave the community often and without male accompaniment as their knowledge of resources
for health care was very limited. Importantly, these movement restrictions did not include visiting the local
health-posts.
Chocruz, Momostenango, Guatemala
Scarce Economic Resources:
Lack of access to economic and household resources was cited as the primary barrier to health in the
community. The community reported that although government services are free, the cost of medications
makes purchasing treatment intangible. Oftentimes community members will only take the first dosage of
medication provided by the health-post or centre and then abandon treatment: a dangerous practice in
relation to antibiotics consumption due to the risk of both bacterial and biological resistance.
32
One community member stated that many people have died in the area because they do not have
the funds to go to the hospital. The cost of an emergency trip to the hospital not only includes transportation
for the sick, but also family member accompaniment, child care, loss of economic productivity, food while
away from home, habitation, medication, tests and other unforeseen expenses that are often out of
economic reach for many community members. Fears in the community of not being able to afford
transportation have mounted recently as rumours circulate regarding the possible inflation of “chicken-bus”
rates.
j
Perceived Quality of Care:
Throughout Guatemala, perceived quality of care at government-run health service delivery points is
low. During focus group discussions and individual interviews poor service in health centre s and a lack of
capacity of health care workers were cited as the second most important barriers to health in Chocruz.
Perceived quality of care is directly linked to language barriers and experiences of discrimination in the
community. In Guatemala, previous research has shown that non-Spanish speaking people are more likely to
face poor health outcomes than their Spanish-speaking counterparts (Goldman 2000). Such health indicators
are determined by both experienced and perceived ethnic, social and structural discrimination (Goldman &
Glei 2003). Indifference, condescending attitudes, poor treatment, and language barriers are frequent issues
that characterize government-run services throughout Guatemala (Goldman 2000; Goldman & Glei 2003;
Hughes 2004; Roost et al. 2004; Maupin 2008; Maupin 2011). During focus groups, many women mentioned
that they did not receive adequate attention at health centre s because they are from the village. The women
stated that they are often not told what illnesses they have because the doctor does not speak their
language, K’iche, and they are only given prescriptions for medicines to buy without understanding the
diagnosis. Doctors in the Momostenango heath centre were frequently described as rude and abusive,
treating people poorly by insulting them and ignoring their presence.
Fears of surgery and other health interventions also impact the perceived quality of care at
government-run health institutions. Lack of information provided to clients during health visits is typical in
many quality-of-care reports throughout Guatemala (Goldman & Glei 2003; Maupin 2008). The growing rate
of caesarean sections has also impacted fears of clinic-based health services (Hughes 2004). The women in
Chocruz were described as “having fright” (“ellas tienen miedo”) of biomedical facility births. Such beliefs
have been linked to fears of infertility after caesarean sections and cultural constructions of weakness when
unable to deliver at home (Roost et al. 2004). Fears in Chocruz have also developed regarding cervical cancer
screening tests; several community members reported that women are sometimes injured at the Pamumus
clinic during Pap-smears due to the inexperience of attending health professionals.
Female community members reported not knowing the purpose of injections they received from the
health centre , raising serious issues regarding informed consent. The women reported that the doctors at
the Momostenango health centre will give injections when they come for consultations regarding
menstruation problems, without explaining the purpose of the medication or the source of the problem.
They also reported that the health centre will give injections during labour to make the water break without
gaining permission first. Furthermore, many women reported being denied treatment for their children due
to not carrying a government-issued health identification card. Such statements highlight the blatant
disregard of ethical codes for conduct and care provided in government-run health facilities.
Due to language barriers, discrimination and failure to obtain informed consent, the overwhelming
majority of community members have little confidence in the provision of health services. From the local
health-post to the Totonicapán departmental hospital, government-run services are associated with poor
health outcomes and even death.
Phase 2 delay refers to the delay in reaching an adequate health care facility (Thaddeus & Maine
1994). Several factors influence the second delay: physical accessibility and distribution of health care
facilities, the travel time from the home to facility, availability and cost of transportation, and the conditions
of roads (Thaddeus & Maine 1994). Phase 2 delays represent actual obstacles to reaching a medical facility,
not the decision to access care (Thaddeus & Maine 1994).
Transportation Means, Time and Cost:
The distance to the health centre in Momostenango and subsequent travel-time to the departmental
hospital was cited as the fifth most important barrier to health in the community. During one interview, a
midwife stated that some women and infants have died during obstetric emergencies as the distance to the
health centre is too far. This is closely related to illness classifications and the recognition of an emergency
health situation by community members and local care givers.
Chocruz, Momostenango, Guatemala
Phase 2 Delay:
It takes approximately 30 minutes to reach the centre of Momostenango by pick-up truck from
Chocruz, but walking time to the main road (15 minutes) and waiting time (15 minutes to 45 minutes) must
be taken into consideration. The “chicken-bus” service takes approximately 30 minutes; however service is
unreliable and drops-off rapidly in the late afternoon. There are no public transportation services available at
night. Private taxis operate in Momostenango, but cost and waiting time is exorbitant; only in the most
serious of emergencies will a private taxi be called. There are a few cars available in the community, but this
mode of transport was not mentioned in either focus groups or individual interviews as a transportation
method used to access a health service delivery point. Regardless of the transportation method selected,
road conditions during the rainy season in Chocruz can be appalling, and oftentimes only large trucks are
capable of driving on the slick, red-mud tracks. The Municipality Office in Pamumus estimated that the roads
are not in working condition 25-30% of the time, increasing delays in accessing needed health care services.
Once the Momostenango centre is reached by either pick-up truck or “chicken-bus,” it is a 30 minute
walk or 5 minute tuk-tuk ride to the health centre . If the health centre cannot handle the emergency or
health condition presented, patients are referred to the hospital in Totonicapán. For obstetric emergencies
the health centre has two ambulances available for transport at no cost. For all other emergencies, the
patient must find their own method of transportation. It takes approximately 1 to 1 ½ hours to reach the
33
departmental in Totonicapán from Momostenango. As evidenced by the travel-time, if emergencies are not
recognized early, there is limited time for accessing appropriate care.
Phase 3 Delay:
Chocruz, Momostenango, Guatemala
Phase 3 delay refers to the delay in receiving adequate care at a health facility (Thaddeus & Maine
1994). Several factors influence the second delay: adequacy of referral systems, shortages of supplies,
equipment and trained personnel, and competence of available personnel (Thaddeus & Maine 1994). Phase
3 delays are characteristics of the health facilities that can be defined as structurally-determined barriers to
care.
34
Hours of Operation and Availability of Staff:
Waiting times in the Momostenango health centre were of great concern to many community
members. Although the on-staff nurse at the health centre stated that waiting times average 2 hours, the
community reported having to wait upwards of 5 hours to have a 15 minute consultation with a doctor.
Community members attributed waiting times more to discrimination than the understaffing of health
facilities. However, restricted and inconvenient business hours were also cited as primary causes of waiting
times: a form of structural discrimination. When the research team visited the Momostenango health centre
on a Saturday morning, there were 15 adults and 3 children in the waiting room; when we departed an hour
later, there were 19 adults and 13 children, plus an additional 7 adults and 4 children in the maternity ward.
At the time of visitation, there were two professional nurses and one doctor available for consultations and
several auxiliary nurses working in the maternity ward.
Material and Human Resources:
The lack of medications in government-run health centres was frequently reported by community
members as a determining barrier to health. Such concern of jaccess to pharmaceuticals indicates the
increasing bio-medicalization of care expectations in the region. The Pamumus clinic, the Choabaj health-post
and the Momostenango health centre all described a desperate need for medications to service the
surrounding population.
Additional medical-supply constraints were visible in all surrounding health service delivery points.
The Momostenango health centre visibly lacked beds and privacy screens. The attendant in the Pamumus
clinic reported that she was most urgently in need of a weight machine, a blood pressure monitor, and a
temperature gauge. The health-post in Choabaj reported needing a bed for examinations and chairs for
waiting clients. All three health service delivery points also reported problematic access to water. Neither the
Pamumus clinic nor the Choabaj health-post had running water at the time of visitation and it was unclear if
they had access to electricity: the health centre reported frequent water shortages.
Furthermore, facilities were reported as lacking competent medical teams: one woman stated that
the Momostenango health centre is too often staffed by practicum students and patients are not able to visit
with a doctor. A lack of health professional competence was a common theme of all focus group discussions.
One key informant stated that a woman died at the health centre due to the incapacity of the health workers
present. Such deficiencies in necessary supplies make adequate care provision extremely difficult and
dangerous and negatively affect public-perceptions of medical attention received. As such, the majority of
community members stated that they prefer the treatment in the Xela departmental hospital over that of the
Momostenango health centre or the Totonicapán departmental hospital, as service is faster and of better
perceived quality.
Introduction:
Global lessons that address barriers to adequate health care delivery abound in the literature. At
both user and service delivery levels the development and effectiveness of equitable health care has been
determined by both internal and external factors of global health systems. However, structurally-determined
constraints to adequate health care delivery at the service-provision level are a primary influence of barriers
to health at the user-level. Commonly cited service-delivery issues within global health systems include
inappropriate or inadequate training, poor access to information and knowledge resources, inadequate
numbers and skills of health workers, low morale and motivation, unsafe conditions in the workplace, poor
policies and practices for human resources development, lack of supportive supervision, lack of integration of
services with other sectors, and a high attrition of health workers globally (WHO 2006; UNFPA 2011; WHO
2011b). The amalgamation of such barriers to health care at the service-delivery level produces a triple-gap
of competencies, coverage and access that must be addressed through upstream evidence-based program
development to positively transform globally experienced inadequacies within local systems of care.
Chocruz, Momostenango, Guatemala
Recommendations
Determinants of Program Success:
Health interventions do not exist within a vacuum: they are part of larger cultural, political and
socioeconomic environments in which they are situated. As such, a myriad of influences, from the local to the
global, will determine program success. Haines and colleagues (2007) identify four determinants of program
success: community factors, socioeconomic factors, health system factors, and international factors (Haines
et al. 2007). Community factors may include local leadership, location and infrastructure; local epidemiology,
health beliefs, and concepts of illness; and community mobilization and empowerment (Haines et al. 2007).
Socioeconomic factors consist of levels of poverty, governance and corruption that begin and end at the local
level within a continuum from the highest points of power (Haines et al. 2007). Health system factors that
determine program success are comprised of appropriate policies, relationships of health workers to the
health system, use of effective interventions, drug distributions systems, remuneration, management and
supervision, and health systems research (Haines 2007). Lastly, international factors that can affect local
programmatic success include donor policies, migration flows, technical assistance, and biomedical research
35
that can lead to improved interventions (Haines et al. 2007). Each determining level of influence must be
taken into account when designing evidence-based programmatic activities that seek to close the gap of
inequities in health. Without recognition of such multi-level determinants of program success, inadequacies
for achieving accountable, transparent and equitable health care delivery systems will remain.
The State of the World’s Midwifery (UNFPA 2011) report proposes a framework for coordinated action to
improve women’s and children’s health through dependable programmatic action that is based upon the
following objectives:
1. Leadership: The engagement and mobilization of political and community sources of power to
address inequities across diseases and social determinants of health
2. Accountability: The production of credible results through responsible action
3. Health Workers: Ensuring skilled and motivated health workers are in the right place at the right
time, and are supported by the necessary infrastructure, drugs, equipment and regulations to
provide adequate care
Chocruz, Momostenango, Guatemala
4. Access: Removing identified financial, social and cultural barriers to access
36
5. Interventions: Providing a continuum of high quality services and packages of interventions,
including quality preventive and curative care
In addition to the aforementioned values, the definitive determinant of programmatic success is the
delivery of quality care:
j
“Striving for and reaching agreed levels of care that are
accessible, equitable, affordable, acceptable/patient centred,
effective, efficient and safe” to enable “a state of complete
physical, mental and social well-being, and not merely the
absence of disease or infirmity” (WHO 2011a:viii)
Recommendations:
The following list of recommendations is supported by data from our community health needs
assessment, the Guatemalan context of health care delivery systems, and the literature. Embracing values of
leadership, accountability, access, transparency and quality care, the following recommendations can guide
the successful program development of a health-post in Chocruz, Guatemala.
T ABLE 9: HEALTH NEEDS ASSESSMENT RECOMMENDATIONS
Recommendation 1
Embracing the Community Health Worker Designation
Recommendation 2
Establishing Evidence-Based Curriculum and Training
Recommendation 3
Providing Supportive Supervision to Empower Community
Health Workers
Recommendation 4
Realizing Incentives, Disincentives and Rewards for
Community Care
Recommendation 5
Securing a Reliable Supply-Chain and Financing Strategy
Recommendation 6
Incorporation Community Payment Strategies for Care
Recommendation 7
Engaging the Community
Recommendation 8
Involving External Stakeholders
Recommendation 9
Facilitating Monitoring and Evaluation Activities
Chocruz, Momostenango, Guatemala
The Primary Health Care Model as a Basis for Successful Community-Driven Care
37
Recommendation 1 - Embracing the Community Health Worker Designation:
Chocruz, Momostenango, Guatemala
In 2010, the Secretary-General of the United Nations launched the Global Strategy for Women’s and
Children’s Health to support Millennium Development Goals 4 and 5: to reduce child mortality and to
improve maternal health (UNFPA 2011). The Secretary-General called for “stronger health systems, with
sufficient skilled health workers at their core” (UNFPA 2011: vii). In order to produce an appropriate
workforce with skilled health workers at its core the skills of health workers must be matched with tasks
designated by job descriptions and objectives (WHO 2006). Thus, a core component of training competent
health workers is being able to recognize the limitations of knowledge exchange practices and strictly
defining responsibilities to ensure safe patient-centred care (WHO 2011a). By strictly defining responsibilities
of care for health workers, and ensuring that limitations of knowledge are respected, expectations of
capacity are realistic and can protect communities from harm (Maupin 2011).
At present time, the definition of the two apprentices that are being trained at Asociación Manos
Abiertas is vague with focus on pregnancy and birth, creating dangerous community and practitioner
expectations of projected skills and abilities. The two apprentices have been described as future “midwives”,
“skilled birth attendants”, “health-post administrators” and “health-post workers” by those involved in their
selection and training. However, in order to protect the community and practice of the two apprentices it is
necessary to strictly define the roles, responsibilities and limitations of their projected work after 10 months
of training. As evidenced globally, many midwives and birth attendants complete programs without the
skills, competencies, and opportunities to acquire knowledge and practice that will promote quality care (ICM
2010). As such, the United Nations Population Fund (UNFPA), the World Health Organization (WHO) and the
International Confederation of Midwives (ICM) has called for the protection of job designations through
training programs, including midwifery and its association with skilled attendance at birth, to match global
standards of education and care.
j
In 2004, WHO, ICM and the International Federation of Gynaecology and Obstetrics (FIGO) jointly
agreed to define a skilled birth attendant as “an accredited health professional – such as a midwife, doctor, or
nurse – who has been educated and trained to proficiency in the skills needed to manage normal
(uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification,
management and referral of complications in women and newborns” (UNFPA 2011:4). This designation of
skilled birth attendant comes from years of global evidence that shows that training formally unskilled health
workers with minimum education to manage births has not impacted maternal or child mortality due to
inadequacies in training duration and the quality of curriculum (WHO 2006; WHO 2011a; UNFPA 2011).
Current international guidelines for standardized training of skilled birth attendants, including
midwives, are published by both WHO and ICM. The 2009 WHO Task Force on Global Standards in Nursing
and Midwifery Education called for a minimum of a university degree for entrance into nursing and midwifery
programs globally (Thompson et al. 2010). Recognizing barriers to achieving tertiary education, the ICM has
complemented WHO standards by developing a training protocol that can address a variety of international
pathways for skilled birth attendant education, rather than only focusing on university requirements. With a
focus on competency-based education, the ICM (2010) guidelines stipulate:
38
i.
Entry level of students is completion of secondary education
ii.
Minimum length of a direct-entry midwifery education programme is 3 years
iii.
Minimum length of a health care provider programme is 18 months
iv.
Curriculum includes both theory (40% minimum) and practice (50% minimum)
Thus, by the current global standards of educational programmes the current 10-month training
curriculum at Asociación Manos Abiertas is insufficient to ensure an adequate level of training for the two
apprentices in relation to the designation of “skilled birth attendant”. The completion of 5 births for each
apprentice, as outlined in the current curriculum, is a grossly inadequate level of training and may produce
false expectations of health worker capacity. Such numbers may serve to reproduce the current state of
inadequate global birth attendant practices that have hampered progress for Millennium Development Goals
4 and 5. It is imperative to ensure an accountable and credible curriculum that will protect communities and
practitioners from harm.
CHW are defined as “any health worker carrying out functions related to health care delivery; trained in
some way in the context of the intervention; and having no formal professional or paraprofessional
certificate or degreed tertiary education” (Lehmann & Sanders 2007:12). Furthermore, CHW “should be
members of the communities where they work, should be selected by the communities, should be
answerable to the communities for their activities, should be supported by the health system but not
necessarily a part of its organization, and have shorter training than professional workers” (WHO study group
(1989) as quoted in Lehmann & Sanders 2007:11). CHW are seen as a means to achieve health equity and
provide universal access to health as a holistic sense of wellbeing by empowering community participation to
ensure that people have control over their own lives and health. By facilitating community involvement in
health work, CHW act as a bridge between underserved communities and the larger health system in which
they function.
In 1978, the Alma Ata Declaration identified CHWs as the cornerstone of comprehensive primary health
care to promote the right to health for all. Based upon the primary health care concept, CHW were tasked
with 8 essential services: 1) Public education and participation regarding prevention and control of
community health problems; 2) Promotion of food supply and proper nutrition; 3) An adequate supply of safe
water and basic sanitation; 4) Comprehensive maternal and child welfare (including family planning); 5)
Global immunization against infectious diseases; 6) Prevention and control of locally endemic diseases; 7)
Appropriate and accessible treatment of common diseases and injuries; and 8) Provision of essential drugs
(WHO 2011a). At the local level, comprehensive primary health care integrates these essential services with
other locally determined necessities for holistic community well-being. In 2006, the World Health Report
once again identified CHW as a continued priority area for development to achieve health equity in lowresource areas (WHO 2006).
The CHW concept for primary health care delivery has a rich and productive history. The most wellknown historical examples of CHW success, and a model for which current CHW programs are based, were
the 1950s “barefoot doctors” in China. After training for one year, the Chinese “barefoot doctors” were
tasked with setting broken bones, delivering babies, treating wounds and providing basic medical services to
rural, underserved communities. During this same time period in Latin America the concept of Promotores, or
Health Promoters, was borne out of labour rights and liberation theory to help remedy experienced unequal
distributions of health resources. In the 1960s, the CHW concept was integrated within the United States’
Chocruz, Momostenango, Guatemala
This report proposes changing the job description of the two apprentices at
Asociación Manos Abiertas to Community Health Workers (CHW) for the
achievement of quality primary health care in Chocruz, Guatemala.
39
Great Society domestic programs to counter the inequitable distribution of health care throughout the
country. However, after the Alma Ata Declaration (1978) the role of CHW as a social change agent was
secured globally, producing immediate effects throughout Southeast Asia, India, and South America using the
lowest level of care provider to reduce barriers to health.
Chocruz, Momostenango, Guatemala
The concept of CHW as social change agents has been replaced by a technical and community
management function, providing basic preventive and curative health services within homes and
communities through equitable and cost efficient pathways. Responsibilities of CHW now often include home
visits, environmental sanitation, provision of safe water supply, first aid for injuries, treatment of simple and
common ailments, health education, nutritional surveillance, maternal and child health, family planning
activities, communicable disease control, community development activities, patient referrals, recordkeeping, and collection of data on vital events (WHO 2011a). CHW are also tasked with more vertical
programs that seek to combat high levels of tuberculosis, HIV/AIDS, malarial, and treatment of acute
respiratory infections (Lehmann & Sanders 2007). CHW do not normally manage births due to their limited
time of training and lack of emergency resources. However, CHW have been found to increase coverage and
equity of service delivery at low cost compared to other service organizations by mobilizing communities and
resources, advocating for community needs, building local capacity and providing outreach services
(Bhattacharyya et al. 2001).
F IGURE 11: E QUITY AND C OST -EFFECTIVENESS OF CHW PROGRAMS - ADAPTED FROM BERMAN ET AL . (1987)
j
•Emphasis on priority
health needs of
population
Selection of More
Efficacious
Interventions
Adequate Quality of
Care in Task
Performance
•Adequate training,
supplies, and
supervision and
feasibility of technical
competence
•Improved
Accessibility and
acceptability and
participation of
beneficiaries
•Lower fixed and
variable costs than
comparable clinicbased services
Better Coverage and
Equity
Greater Health Impact for Individuals and
Populations and Improved CostEffectiveness
40
By helping to address the economic, social, environmental and political rights of individuals and
communities, global evidence suggests that the effectiveness of small-scale, well-managed CHW programs
have led to increased access to care, higher utilization of services, lowered local morbidity and mortality
rates, raised community awareness and have instigated inter-sectoral community development projects
(Berman et al. 1987; Lehmann & Sanders 2007; Perez & Martinez 2008; Maupin 2011). CHW have thus
become the “integral link that connects disenfranchised and medically underserved populations to the health
and social systems intended to serve them” (Perez & Martinez 2008:11). However, caution must be taken
when designing effective and equitable programs as projected CHW successes are not impervious to error.
CHW are not a solution for weak health systems, nor are they a “cheap” option for the provision of health
care (Lehmann & Sanders 2007). Often fraught with unrealistic expectations, poor planning and the
underestimation of effort required to make programs work, CHW service quality can suffer, putting both
practitioners and communities at risk for harm (Lehmann & Sanders 2007). CHW programs require strict
supervision and management with attainable goals and objectives that are based upon community needs and
the limited capacity of health workers present within rural areas.
Despite these issues, there is a renewed interest in CHW as key contributors to positive pregnancy
outcomes and child survival. CHW are now considered a vital component for the implementation of
Household and Community Integrated Management of Childhood Illness (HH/C IMCI) frameworks: guidelines
for appropriate community care in diverse rural contexts (Bhattacharyya et al. 2001; Haines et al. 2007;
Lehmann & Sanders 2007). As such evidence suggests, the apt designation and delegation of tasks for CHW
within the public health care model should frame the future responsibilities and roles of health-post workers
in Chocruz, Guatemala.
Element
CHW role
1.Improving partnerships between health
facilities or services and the communities they
serve
-Help health facilities conduct community outreach
-Involve community members in planning and implementing
health programs and services
-Raise awareness in the community about improvements to
health services
-Educate community members about danger signs requiring
care at health facilities
-Participate in data collection for community health
information systems
2.Increasing appropriate, accessible care and
information from community-based providers
-Provide effective basic care (e.g. oral rehydration therapy,
antipyretic drugs) for sick children
Chocruz, Momostenango, Guatemala
T ABLE 10: ROLES OF CHW IN THE HH/C IMCI FRAMEWORK
-In some areas, treat sick children with other first-line drugs
and advocate against harmful practices, such as injections
-Refer sick children to appropriate health facilities when
advanced care is required
-Serve as a bridge to other providers (private sector and
traditional healers)
3.Integrating promotion of key family practices
critical for child health and nutrition
-Engage communities in selecting behaviours to be
promoted and identifying actions to be taken
-Promote key family practices for enhanced physical growth
and mental development, prevention of disease, appropriate
home care, and appropriate care-seeking behaviour through
individual counselling and community meetings
41
Chocruz, Momostenango, Guatemala
Recommendation 2 - Establishing Evidence-Based Curriculum and Training:
42
Global standards for the initial education of health workers call for worldwide educational standards
so that “the workforce can contribute to strengthening health systems to meet population health needs and
protect the public” (WHO 2011a:10). Standards can be defined as “a norm/uniform reference point that
describes the required level of achievement (performance) for a defined task” (WHO 2011a: viiii). Such
international educational standards highlight the need for health worker training to be based on evidence
and competency, to promote the progressive nature of education and lifelong learning, and to ensure the
capacitation of practitioners who provide quality care and promote positive health outcomes in the
populations they will serve (WHO 2011a). The current curriculum at Asociación Manos Abiertas does not
adequately reflect the standards required to capacitate CHW that will address the identified needs of
Chocruz, Guatemala. As it is defined now, the curriculum does not include the appropriate and targeted skillsets, or abilities to perform specific actions or tasks, to improve community health outcomes as identified by
the needs assessment. There is a demonstrated lack in acute children’s health care, preventative care,
facilitation capacity for educational roles, and men’s health, including chronic disease prevention and male
sexual and reproductive health. The current training curriculum also does not take into account the lived
context of health in Chocruz, nor the material and human resources that will be available, or not available, at
the planned health-post by EL MIRADOR.
CHW functions should be clearly defined before training through in-depth curricula and methods
that will cover each specific CHW task, with ample time for hands-on management of cases within local
communities (Bhattacharyya et al. 2001). An efficacious curriculum is a compromise between technical
criteria, local managerial and political considerations and felt needs of the population to be served (Berman
et al. 1987). Curricula development needs to be a gradual andj localized approach that places the needs of the
community first and the desires or specialty of training institutions second in order to promote safe tasks that
can be performed under the worst conditions of support (Berman et al. 1987).
The 2011 UNFPA report, The State of the World’s Midwifery, provides “bold steps” for schools and
training institutions:
i.
Review curricula to ensure that graduates are proficient in all essential competencies set by
government and regulatory bodies
ii.
Use ICM and other education standards to improve quality and capacity
iii.
Ensure the theory-practice balance and install skill-labs
iv.
Improve and maintain competencies through transformative education
v.
Partner with external health stakeholders in communities and hospitals for practical training
vi.
Promote research and academic activities
vii.
Support the development of community leadership
Furthermore, training curricula with focus on sexual and reproductive health care should cover all
components and elements of health, including gender, rights and ethics, as integrated into a public health
approach, with focus on all people (WHO 2011b).
This report proposes the integration of a comprehensive package of essential
health interventions that are evidence-based, founded upon standardized global
practices of CHW training and that target identified health needs of Chocruz
within the current curriculum at Asociación Manos Abiertas. This report also
suggests finalizing the two apprentices training at the health-post site in
Chocruz with regular updates of pre-service training provided by health
professionals who travel to the community for extended visitation periods.
Chocruz, Momostenango, Guatemala
Due to continual global shortfalls between what CHW are trained to accomplish and what they are
capable of doing in the field, more emphasis needs to be placed on practical, task-oriented training within the
contexts of communities they will serve (Berman et al. 1987). Throughout the literature the evidence
suggests that the most effective form of training program occurs within the community in order to adapt
skills to extraneous circumstances; from global evaluations of training sessions, WHO recommends that
training should be on-site as much as possible (Berman et al. 1987; WHO 2006; Lehmann & Sanders 2007). As
Bhattacharyya and colleagues (2001) state: “Time spent in hands-on activities [within the community]
increases visibility and reinforces the relationship with the community”, thus “trainers and CHWs should go
together to the rural…setting to work and assess skills in real situations” (23). The current plans to have all
initial training sessions and continued education, 3 to 4 times a year, at Asociación Manos Abiertas is
insufficient: Ciudad Vieja does not reflect the local epidemiology and disease burden of Chocruz; Asociación
Manos Abiertas does not have a standard clientele that mirrors the population in Chocruz; and during future
training sessions the health-post in Chocruz will be left unattended for critical gaps in time if CHW are
expected to travel to Ciudad Vieja for education.
43
T ABLE 11: C OMMUNITY -I DENTIFIED HEALTH PROBLEMS
Chocruz, Momostenango, Guatemala
Rank
44
Children
Women
Men
1.
Stomach Illness: Diarrhoea
(XII); Parasites/Amoebas (VI);
Stomach problems (IIII);
Inflamed stomach (II);
Vomiting/Nausea (II); Gastritis
(I)
Urinary/vaginal infections
(VII); White/yellow vaginal
discharge (III)
Malnutrition (III); Anemia (I);
Tiredness (I); Diabetes (VI)
2.
Skin Disorders: Measles (VIIII);
Chicken-Pox (VII); Skin
problems (I)
Menstrual pain (IIII);
Menstrual problems (II); Late
menstrual cycle (II); Cramps (I)
Cramps (III); Head pain (III);
Arthritis (II); Body pain (I)
3.
Respiratory Issues: Respiratory
problems (VII); Allergies (IIII);
Pneumonia (III); Bronchitis (I)
Muscular pain (I); Body pain
(III); Feet pain (I); Head pain
(IIII)
Gastritis (IIII); Diarrhoea (II); Ulcer
(I)
4.
Malnourishment: malnutrition
(VII); Anemia (II); Migraines
(I); Memory loss (I)
Stomach problems (III);
Diarrhoea (I); Stomach pain
(I); Gastritis (II); Nausea (I);
Ulcer (I)
Alcoholism (V)
5.
Fever (XI)
Nerves/Stress (IIII)
6.
Flu (VII)
Blood pressure problems (V);
Heart problems (I)
j
Problems during
pregnancy/birth (IIII);
Accidental abortion (I)
7.
Body Pain: Cramps (II); Feet
pain (II)
Ovarian cysts (I); Cancer in the
womb (II); Problems with
ovaries (II)
Flu (III)
8.
Infections: Infection (II); Ear
pain (I)
Nerves (III)
Appendicitis (III)
9.
Hernia (III)
Malnutrition (III)
Gallstones (I); Urinary problems (I)
10.
Appendicitis (III)
Hernia (II)
Blood pressure problems (II)
11.
Infection during lactation (I)
Respiratory problems (I); Colic (I)
12.
Vision problems (I)
Men’s sexuality problems (II)
Fever (III)
With continued focus on sexual and reproductive health care, WHO core competencies in primary
health care should guide curricula development at Asociación Manos Abiertas with emphasis on women,
children, adolescents and men. The World Health Organization Sexual and Reproductive Health: Primary
Health Care (2011) core competencies are divided into 4 domains: 1) Attitudes for providing high-quality
sexual and reproductive health care; 2) Leadership and management; 3) General sexual and reproductive
health competencies; and 4) Specific clinical competencies (WHO 2011a). Charts outlining the most
congruent competencies, knowledge and skills for delivering effective and quality care in Chocruz for
curricula development are located in the appendix of this report; care beyond sexual and reproductive health
will be discussed in subsequent sections. The following list is a brief overview of 13 WHO core competencies
within 4 domains in sexual and reproductive primary health care (SRH) that should be focused upon during
curricula development (WHO 2011a):
WHO Sexual and Reproductive Health Primary Health Care Core Competencies (2011)
Domain 1: Attitudes for providing high-quality SRH care
-
The overarching attitude, which builds on SRH workers’ knowledge of ethics and principles, and thus
becomes the essential item for the fulfillment of the individual client’s human rights. Not actually a
group of competencies, but the fundamental basis of all competencies
Domain 2: Leadership and Management
The leadership and managerial domain can apply to any level of SRH health care facility and includes
2 competencies
i.
Competency 1: Perform a leadership role that provides an environment that enables PHC
team members to perform effectively
ii.
Competency 2: Effectively manage the PHC team to allow the efficient provision of quality
SRH services through a supportive and enabling environment
Domain 3: General SRH Competencies for Health Providers
-
General SRH competencies for health providers includes working with the community, health
education, counselling and client assessments, and consists of 4 competencies
i.
Competency 3: The PHC team members provide comprehensive and integrated SRH care,
working efficiently in and with the community
ii.
Competency 4: The PHC team members provide high-quality education related to SRH and
SRH services to enable clients to make their own decisions regarding SRH
iii.
Competency 5: The PHC team members provide high-quality counselling related to SRH and
SRH services
iv.
Competency 6: The PHC team members effectively assess the SRH needs of users of PHC
service for treatment and referral when necessary
Chocruz, Momostenango, Guatemala
-
Domain 4: Specific Clinical Competencies for SRH Health Providers
-
Specific clinical competencies for SRH health providers include 7 clinical competencies
i.
Competency 7: The PHC team members provide high-quality family-planning care
ii.
Competency 8: The PHC team members provide high-quality sexually-transmitted infection
and reproductive tract infection care
45
Chocruz, Momostenango, Guatemala
46
iii.
Competency 9: The PHC team members provide screening and treatment/referral for
reproductive tract cancers
iv.
Competency 10: The PHC team members provide high-quality comprehensive and culturallysensitive abortion-related care to eliminate unsafe abortion outcomes
v.
Competency 11: The PHC team members provide high-quality, culturally-sensitive antenatal
care
vi.
Competency 12: The PHC team members provide high-quality, culturally-sensitive care
during labour, birth and immediate postpartum with necessary assistance from skilled
attendants
vii.
Competency 13: The PHC team members provide comprehensive, high-quality, culturallysensitive postnatal care for women and neonates in the first 6 weeks postpartum
In addition to comprehensive SRH care, focus must be directed beyond sexual health towards a
holistic, life-cycle approach to well-being. Comprehensive SRH care will only work if the community
individually and collectively wants and supports these services through perceived need and not if they are
imposed from the outside (Kwast 1995): the Chocruz community primarily demands a curative role of CHW
directed towards children’s health needs. The following skill-sets for CHW need to be included in the curricula
in order to respect community-identified emergency and chronic health needs for children:
i.
Control and prevention of acute respiratory infections, including pneumonia complications
ii.
Control and prevention of diarrheal diseases,j including the free provision of oral-rehydration
therapy and zinc supplementation
iii.
Nutritional evaluation and care of children under 2 years of age that are chronically
malnourished, including vitamin supplementation and recognition of anemia
iv.
Control and prevention of skin disorders, including community-outreach for measles
vaccination programs
v.
Ability to effectively administer and provide antibiotic treatment for common infections
vi.
Implement a standardized referral system for emergency care
The skill-sets of CHW must also include the ability to treat adult men, especially in relation to chronic
diseases. The health needs assessment highlighted that type-2 diabetes is a growing concern for men of the
communty. The United States Centre for Disease Control (CDC) advocates stronger support of CHW roles in
type-2 diabetes care (CDC 2011). CHW can provide a valuable bridging function between communities and
tertiary care for chronic diseases, including support for diabetes control programs, providing culturally and
linguistically-appropriate educational messages regarding diabetes within communities, social support to
community members to adapt their lifestyles, mobilizing communities for social action to address diabetes on
several levels, and to enable community members to access services that meets standard recommendations
for diabetes care and prevention: annual eye exams and foot exams, and regular A1C testing (CDC 2011).
If Asociación Manos Abiertas staff does not have the competencies to train the two apprentices on
identified community-needs, particularly in relation to non-paediatric and non-pregnancy-related health
themes, it is necessary to look for outside training sources to ensure the adequate skills for use in the field. It
is not acceptable to only briefly cover health terms due to cases not presenting themselves at the clinic in
Ciudad Vieja; if cases do not present, it is necessary to involve other health care facilities for a comprehensive
education. For on-line support regarding CHW training and program development, please consult the USAID
CHW project at http://www.hciproject.org/chw-central.
F IGURE 12: T HE LIFE -CYCLE APPROACH TO PRIMARY HEALTH CARE - ADAPTED FROM HAINES ET AL . (2007)
1. Reduce illness risk and improve nutrition
Essential care of the newborn
-Promotion of hygiene - sanitation and handwashing
Exclusive breastfeeding
Complementary feeding
-Micronutrient supplements
Deworming
BIRTH -TO- 1 YEAR
2. Management of childhood illness
Home management -eg. ORT
Promotion of early care seeking for illness
5. Intrapartum Care
Promotion of use of skilled care at birth
Referal for emergency obstetric care if needed
Clean delivery kits if delivering at home
Community management of pneumonia, newborn
infections, LBW
Referral for facility based management of severe
malnutrition, severe neonatal and childhood illness if
needed
1 YEAR -TO- SCHOOL AGE
4. Antenatal Care
Promotion of birth preparedness
Promotion and provision of TT
REPRODUCTIVE YEARS -TO- PREGNANCY
Chocruz, Momostenango, Guatemala
Care of LBW baby at home
Promotion and provision of vaccines
3. Adolescent and Prepregnancy Care
Encourage delay of first pregnancy until 18 years of age
Family planning promotion and provision
Prevention of HIV and STIs
SCHOOL AGE -TO- REPRODUCTIVE YEARS
47
Recommendation 3 – Providing Supportive Supervision to Empower
Community Health Workers:
Chocruz, Momostenango, Guatemala
The most common shortcoming of CHW programs worldwide is a lack of supportive and motivational
supervision for CHW (Bhattacharyya et al. 2001; WHO 2006; Haines et al. 2007; Lehmann & Sanders 2007;
Rosato et al. 2008; WHO 2011b). In Guatemala, Parlato and Favin (1982) found that supervised CHW were
found to have attrition rates two to three times lower than those of unsupervised CHW due to maintained
linkages with outside experts (Bhattacharyya et al. 2001). Proper supervision must complement initial
training in order to create a continuum of support and learning. As Skeet (1985) states: “The efficiency,
effectiveness, and safe practice of the [CHW] depend upon [training and supervision] being strong and
supportive. If either is weak, the whole collapses” (Skeet 1985:56). Effective supervision provides CHW
opportunities to discuss problems, exchange information, and continue education after initial training is
complete, thereby enabling correct task performance and quality care that is responsive to best practices and
community needs.
48
The current training curriculum at Asociación Manos Abiertas and described functions of the future
health-post in Chocruz do not provide adequate guidelines for supervision of CHW once in the field. Emphasis
has been placed upon the availability of clinic workers in Ciudad Vieja via cellphone for CHW if problems arise
in the field and the provision of reference materials onsite in Chocruz, including internet resources: this is
inadequate. Global evidence highlights that the availability of written reference materials onsite as care
guidelines is ineffective without supervision and audit feedbacks (Haines et al. 2007). Furthermore, a stated
expectation of access to on-line resources for CHW in the field is unrealistic: the community does not have
access to the internet due to limited funding for modem operation. Access to communication technology will
not offset the inherent dangers of low supervision, a lack of clear protocols, lack of knowledge and
experience, and poor coordination for CHW work in Chocruz. Training is not enough. The success of the
j
health-post in Chocruz will depend on adequate and informed supervision provided by experienced health
professionals.
This report recommends a multi-faceted approach to supervision for CHW in
Chocruz. Supervision should include final training sessions in the community,
material resources, and prolonged field visits every 3 to 4 months by a health
professional as dictated by best practices and changing global guidelines for
Primary Health Care. CHW must be adequately supported and that such
adequate support will require more direct resources to provide for professional
supervisory agents.
The 2006 World Health Report highlighted that “supportive yet firm – and fair- supervision is one of
the most effective instruments available to improve the competence of individual health workers, especially
when coupled with clear job descriptions and feedback on performance” (WHO 2006:xxii). Supervision is
imperative to achieve the two cardinal rules to improve health worker performance: simplification and
delegation (WHO 2006). Without simplification and delegation of health worker tasks through regularly
planned supervisory visits every 3 to 4 months, as based upon a common understanding of purpose, CHW
can become overwhelmed with micro-level task management, placing health providers, patients, and
communities at risk (Bhattacharyya et al. 2001). Supervisors can thus act as role models, providing guidelines
of tasks and activities for CHW to achieve during each quarterly period (Haines et al. 2007).
Active and supportive supervision for CHW provides the necessary basis for motivation and personal
development, ultimately enabling quality care. As Curtale and colleagues (1995) write: “continuous
supervision diminishes the sense of isolation that [CHW] usually experience in the field and helps to sustain
their interest and motivation to do assigned tasks” (Lehmann & Sanders 2007:28). Productive supervision for
CHW is necessary to ensure adequate patient safety, continuing education, and to provide technical,
logistical, and referential support that will address lived experiences of health in Chocruz.
Globally, improved professional and personal support for health workers is advocated (WHO 2006;
WHO 2011a; UNFPA 2011). Support includes better living conditions, safe and supporting working
environments, continual training and supervision, outreach support, career development programs,
professional networks, and public recognition measures (UNFPA 2011). Adequate support forms the basis of
incentives and disincentives for achieving work-oriented tasks and responsibilities. Targeted incentive
systems, including monetary and non-monetary supports, reduces health worker attrition and improves
performance (Haines et al. 2007). Bhattacharyya and colleagues (2001) recommend the “systematic use of
multiple incentives based on an understanding of the functions of different kinds of incentives [that]
emphasizes the importance of the relationship between a CHW and community” (Bhattacharyya et al.
2001:xii). Such systematic efforts of support and incentives can build a continual sense of satisfaction and
fulfillment for CHW once in the field working in isolated and difficult conditions (Bhattacharyya et al. 2011;
Lehmann & Sanders 2007).
Monetary incentives increase retention of CHW (Bhattacharyya et al. 2001). The current proposal for
the health-post in Chocruz stipulates that CHW will be paid the same standard rate as a nurse upon signing a
three-year non-compete contract. However, monetary incentives are not adequate as stand-alone rewards:
problems can occur in amount and timing of payments from both a subjective and objective perspective. It is
therefore necessary to incorporate supportive non-monetary incentives to improve the probability of
programmatic success: job aides, peer support, supervision, regulation, health system linkages, adequate
supplies, drugs and training. As positive or negative, intrinsic or extrinsic factors that influence CHW
motivation, incentives are often the primary determinant of CHW enthusiasm, retention and program
sustainability (Bhattacharyya et al. 2001).
Chocruz, Momostenango, Guatemala
Recommendation 4 – Realizing Incentives, Discentives and Rewards for
Community Care:
This report recommends the development of a systematic package of fair and
reliable incentives for CHW in Chocruz to reward various roles and
responsibilities. Both monetary and non-monetary incentives should be
considered in order to increase retention and motivation of CHW during and
after contractual timeframes.
49
T ABLE 12: CHW I NCENTIVES AND DISINCENTIVES ORGANIZED BY A SYSTEMS APPROACH - ADAPTED FROM BHATTACHARYYA ET
AL. (2001); LEHMAN & S ANDERS (2007)
Monetary factors that motivate
individual CHWs
Chocruz, Momostenango, Guatemala
Nonmonetary factors that motivate
CHWs
Community-level factors that
motivate individual CHWs
Factors that motivate communities
to support and sustain CHWs
Factors that motivate Ministry of
Health staff to support and sustain
CHWs
50
Incentives
Disincentives
-Satisfactory remuneration/material
incentives/financial incentives
-Possibility of future paid
employment after contractual
obligations are complete
-Community recognition and
respect for CHW work by
community leaders during public
meetings
-Inaugeration ceremony for the
health-post
-Acquisition of valued skills
-Personal growth and development
-Accomplishment
-Peer support and supervision
-CHW association
-Identification (badge, shirt) and job
aides
-Status within community
-Preferential treatment
-Flexible and minimal hours
j
-Clearly defined roles and
responsibilities
-Community involvement in CHW
selection
-Community organizations that
support CHW work
-Community involvement in CHW
training
-Community information systems
-Witnessing visible changes
-Contribution to community
empowerment
-CHW associations and community
groups
-Successful referrals to health
facilities
-Proper introduction to work of
CHW, including maintaining
linkages and communication
-Policies that support CHWs
-Witnessing visible changes
-Funding for supervisory activities
from outside donors
-Inconsistent remuneration
-Change in tangible incentives
-Inequitable distribution of
incentives among different types of
community workers
-Person not from community
-Inadequate refresher training
-Inadequate supervision
-Excessive demands/time
constraints
-Lack of respect from surrounding
health facility staff
-Inappropriate selection of CHWs
-Lack of community involvement in
-CHW selection, training, and
support
-Unclear role and expectations
(preventive versus curative care)
-Inappropriate CHW behaviour
-Needs of the community not taken
into account
-Community-identified interests are
not promoted by health-post
-Inadequate staff and supplies
-Inappropriate referral strategies
Any decision of CHW incentives should be based on Pareek’s (1996) motivational model for worker
satisfaction and success. Planned strategic incentives should align with one of six motives that influence
programmatic outcomes: achievement, affiliation, extension, influence, control, and dependency
(Bhattacharyya et al. 2001). By strategically planning incentives prior to CHW stationing, and ensuring the
timely delivery of motivational tools, programmatic success is an attainable goal.
T ABLE 13: MOTIVATIONAL M ODEL (PAREEK 1996) - ADAPTED FROM BHATTACHARYYA ET AL . (2001)
Definition
Achievement
Concern for excellence; setting of
challenging goals
Affiliation
Concern for establishing and
maintaining close, personal
relationships
Extension
Concern for others; urge to be
relevant and useful to larger groups
Influence
Concern with making an impact on
others; desire to change matters
and develop others
Concern for orderliness; desire to
be and stay informed; urge to
monitor and take corrective action
when needed
Control
Dependency
Desire for the help of others in
one’s own self-development; urge
to maintain an “approval”
relationship
CHW Incentive Examples
-Possibility of future employment
-Personal growth and development
-Acquisition of skills
-Peer support
-CHW associations and networks
-Community involvement
-Identification
-Community recognition of and
respect for CHW work
-Successful referrals
-Status in the community
-Accomplishment
-Visible changes
-Clear role
-Job aides
-Feedback to Ministry of Health,
non-governmental organizations
and community
-Support from the health system
-Policies that support CHWs
-Satisfactory remuneration
(monetary and nonmonetary)
-Training and refresher training
-Preferential treatment
Chocruz, Momostenango, Guatemala
Motive
Recommendation 5 – Securing a Reliable Supply-Chain and Financing
Strategy:
A supportive environment for CHW requires the provision of adequate funds for service provision,
including health-worker salaries and organizational requirements (WHO 2011a). Adequate financing
strategies include provisions for initial costs, recurrent costs of training, management, logistics, supervision,
assessment, remuneration and other incentives (Haines et al. 2007). Furthermore, consideration needs to be
directed towards financing continued critical support systems that directly influence care: clean water,
adequate lighting and electricity, heating, vehicles, drugs and standardized equipment (WHO 2006).
Organizations that fail to satisfactorily provide such services and financing through a lack of resources, delays
in funding, and inadequacies in coordination or collaboration will result in severe equity and ethical issues for
51
both the community and health workers: credibility is easily diminished due to failed promises and doctoring
raised expectations for health care delivery (Maupin 2009).
EL MIRADOR has expressed interest in funding the health-post in Chocruz for 10-years; however,
funding for the initial construction of the health-post is not yet complete. Furthermore, EL MIRADOR is
exploring options for drug supply-chains through various non-governmental organizations. There is not a
readily accessible financing or logistical-supply plan available for the health-post at the current time.
Chocruz, Momostenango, Guatemala
This report recommends that EL MIRADOR create a 10-year financing strategy
that is accessible to all donor and supply agencies for future planning and
contractual agreements. A fully researched logistics and support system
mandate must be made available for the health-post in Chocruz that is separate
from the roles and responsibilities of CHW. CHW in Chocruz can aid in the
administration of supply-chain logistics; however, this role should be kept to a
minimum and is the responsibility of higher-level supervisory bodies.
A realistic and supportive logistical system for financing and supply-delivery will determine
programmatic success of the health-post in Chocruz. Without adequate financing or supplies, CHW
motivation will diminish and community members may lose confidence in the health-post’s ability to delivery
j
services effectively. The community of Chocruz is understandably
sensitive to droughts in supplies and
medications within available health facilities: a scenario that the health-post must be cognizant of,
supporting directives of protective mechanisms to prevent human or material resource deficiencies. When
calculating accountable financing strategies for training, construction, resource management, CHW
incentives and other programmatic activities that will take place in the community, financing must be
sustainable and planned within minimal 5-year blocks. In relation to finding reliable suppliers for medications
and equipment, it is imperative to diversify sources in order to protect against supply-chain failures. Before
the inauguration of the health-post in Chocruz, all financing and logistical systems must be developed for
administration by CHW and supervisors.
Financing and logistical support mechanisms for the health-post in Chocruz must also take into
account future health worker retention, recruitment and training strategies. A detailed plan for health
worker retention and recruitment should be in place before the end of the three-year CHW contractual
agreement is complete.
Recommendation 6 – Incorporating Community Payment Strategies for Care:
52
Securing viable client payment strategies for service delivery in community health-posts is a difficult
task. Almost no evidence exists of sustained community financing of CHW programs and issues abound in the
literature regarding patient-directed payment strategies (Lehmann & Sanders 2007). Globally, fee-for-service
programs have generally resulted in over-prescriptions and over-treatment, leading to inequitable care
options for communities. However, when compensation for health facility service is tied to drug sales, health
workers generally focus on curative care at the neglect of unpaid, cost-saving preventative options. Lastly,
ethical issues of accepting payment for services where the government is supposed to be providing services
for free must be considered when devising service-payment strategies in poor communities (Bhattacharyya
et al. 2001; Alonso et al. 2004; Becker et al. 2006; Maupin 2011). Importantly, any payment strategy that is
tied to direct service provision increases the financial burden on patients for healthcare and may increase
inequity by diminishing service use based upon economic factors (Maupin 2011).
Currently, the community in Chocruz is unable to afford even minimal payments at health service
points-of-delivery or for basic pharmaceuticals, including oral rehydration therapy. Instead, many community
members choose to forgo treatment to provide food and other resources for the familial unit. The
community expressed a concrete desire for care at the health-post to be delivered at no cost at the point-ofdelivery in order to protect against differential decisions in seeking health care. However, small contributions
to the health-post during times of good-health were regarded as feasible by the local school director.
Furthermore, it is imperative to disassociate CHW salaries from drug sales due to ethical concerns of overprescription and ill-advised care: global evidence suggests that adequate supervision is necessary to prevent
CHW supplementing their income with frivolous drug sales (WHO 2006; WHO 2011a). Ideally, all services at
point-of-delivery should be provided for free, as supported by community group financing strategies and
outside donor funding: this includes emergency transport to higher level health facilities.
Chocruz, Momostenango, Guatemala
This report recommends the creation of a community health fund whereby
community members contribute a tokenistic annual group-payment to the
health-post that will be supplemented by EL MIRADOR funding. The community
health fund should cover all prevention activities, curative care and emergency
transportation for the community. The community fund will not be tied to
necessary treatment provision: for ethical issues, no community member can be
turned away from services or resources at point-of-delivery.
Recommendation 7 – Engaging the Community
Community Mobilization:
Long-term commitment that fosters community involvement in health projects can lead to
programmatic success and ensure that community health becomes a collective issue. Community
mobilization is defined as a “capacity-building process through which community individuals, groups, or
organizations plan, carry out, and evaluate activities on a participatory and sustained basis to improve their
health and other needs, either on their own initiative or stimulated by others” (Rosato et al. 2008:962).
Community mobilization is dependent upon community empowerment: the “process and outcome of those
without power gaining information, skills, and confidence and thus control over decisions about their own
lives” (Rosato et al. 2008:963). Using these definitions, community empowerment and subsequent
mobilization exists on a continuum from passive information sharing, to consultation, to engaged
collaboration, and finally, towards active responsibility within individual, organizational, and community
levels, thus producing positive effects for involved stakeholders in programmatic activities directed towards
health on multiple stages.
53
F IGURE 13: FROM PASSIVE TO ACTIVE PARTICIPATION – T HE EMPOWERMENT C ONTINUUM
Chocruz, Momostenango, Guatemala
Information
Sharing
54
Consultation
Collaboration
Full
Responsibility
CHW can serve a symbolic and active role in the mobilization of communities if they are able to
facilitate community involvement early and often in health-related matters. This health needs assessment, as
a form of Participatory Rural Appraisal, began the process of community mobilization for health in Chocruz,
Guatemala. The community in Chocruz demonstrated an engaged understanding of the need to communally
confront health issues and expressed desire to be a part of the health-building process. However, care must
be taken to ensure that community mobilization is not tokenistic and that these efforts continue after the
health-post’s establishment.
j
This report recommends an engaged effort
and support for continual
mobilization of the Chocruz community in all matters related to health service
delivery and that social determinants of health are addressed. Community
mobilization activities should include community outreach programs, including
home visits, creating a Women’s Health Committee, engaging men’s
perspectives in programmatic ventures through an advisory board,
acknowledgement and inclusion of traditional medicine and care, and providing
educational seminars to all segments of the population.
Global evidence suggests that community mobilization and empowerment efforts can positively
influence maternal and child health outcomes, cancer screening programs, vaccination drives, and address
social causes of ill health, including alcoholism and occupational safety (Alonso et al. 2004; Rosato et al. 2008;
UNFPA 2011). By supporting the mobilization of communities, CHW can address inequality and improve
health services through complementary activities. However, fostering community involvement requires a
long-term commitment and cannot be approached haphazardly. Time is required to establish trust and
motivate community leaders by ensuring that the CHW program is driven, owned and embedded in the
community in which it will serve (Lehmann & Sanders 2007). In the literature it is clear that the low use of
CHW programs is linked to poor community introduction of health workers and programmatic activities
thereby compromising trust and participation (Lehman & Sanders 2007). As such, emphasis needs to be
placed upon the continual and active maintenance of community partnerships in order to secure lasting
community participation, not just the provision of clinical services, supervisory roles and logistics
(Bhattacharyya et al. 2001). The literature is unanimous: “Even bringing services closer to the people does
not guarantee their use unless each effort at the community, whether new or scaled up, is planned together
with…families to whom the services are targeted” (Kwast 1995:S81). If communities are actively involved and
mobilized to support health, entrenched barriers to care can thus be broken down (UNFPA 2011).
Community empowerment and mobilization can be conceptualized on a continuum of five
progressively more organized and broadly based forms of social and collective action: personal action, small
mutual groups, community organizations, partnerships, and social and political action (Rosato et al. 2008).
The following sections of this report will highlight the need to maintain linkages and productive relationships
with each of these levels in order to produce a community-driven and accountable health-post in Chocruz,
Guatemala.
F IGURE 14: COMMUNITY EMPOWERMENT CONTINUUM – ADAPTED FROM ROSATO ET AL . (2008)
- Community
participation
3. Community
Organizations
4. Partnerships
5. Social and
Poltical Action
-Problem
assessment
- Local
leadership
-Organizational
structures
- Links to
others
- Local
leadersship
-Organizational
structures
-Resource
mobilization
-Asking why
- Resource
mobilization
-Links to others
-Asking why
- Role of
outside agents
-Programme
management
Chocruz, Momostenango, Guatemala
2. Small Mutual
1. Personal Action Groups
Community Outreach:
Ensuring an adequate supply of health resources within a community does not guarantee service-use
(UNFPA 2011). By developing and implementing innovative community outreach programmes at the initial
stage of health-post development, CHW can mobilize and engage the community through health care
delivery services that are brought to the people (WHO 2011b). Outreach activities by CHW can also ensure
that adequate attention is given to vulnerable groups who may be neglected by facility-oriented health care
delivery (WHO 2011a). By integrating fixed-facility care with curative, preventive and promotional outreach
service activities, barriers to care can be addressed (Berman et al. 1987; Haines et al. 2007). As Haines and
colleagues discuss: “Improvement in health facilities is alone not sufficient to avert a large proportion of child
deaths because facility-based services often emphasize curative care over prevention and because children
from poor families are less likely to access health facilities” (Haines et al. 2007: 2123). It is imperative for
55
CHW to engage in population-level surveillance and care, providing both a curative and preventative role for
the community through outreach activities in Chocruz, Guatemala.
This report recommends engaging in the following outreach activities:
-
Basic epidemiological survey of the area, including diagnosing chronic malnutrition and acute
respiratory infections within community homes
-
Providing outreach child-health oriented services at the local NGO-school once a month to ensure
that the majority of children in the community are monitored by the clinic
Chocruz, Momostenango, Guatemala
Establishing a Women’s Health Committee:
From the health needs assessment it is clear that gendered power differentials in relation to
accessing health care services are entrenched within the community. In order to improve gender equity and
encourage the diffusion of health-related knowledge to vulnerable population groups, CHW can facilitate a
local Women’s Health Committee to discuss maternal and child health and provide educational activities in a
low barrier setting (Alonso et al. 2004; Haines et al. 2007; Schooley et al. 2009). Women must be included in
all attempts to address their health and social status and a Women’s Health Committee, as a form of support
group, can provide an enabling environment in which women form friendships, bond, discuss concerns about
their reproductive or children’s health, and identify concrete ways of addressing them (Schooley et al. 2009).
Women’s Health Committees can act as an empowering step to accessing services and providing additional
social and cultural ties (Schooley et al. 2009).
The health needs assessment in Chocruz began the process of engaging groups of women to discuss
health issues within the community. The engagement of women in the community needs to be continued
j
through CHW activities and by promoting a Women’s Health Committee
that meets at various intervals. The
following figure shows how this process ought to be continued:
F IGURE 15: W OMEN 'S HEALTH C OMMITTEE M OBILIZATION A CTION CYCLE - ADAPTED FROM ROSATO ET AL . (2008)
• The whole community meets a number of
• Groups meet a number of times to:
identify health problems affecting
mothers and children in the community;
identify root causes of these problems;
select the problems they consider to be
most important and need to be
addressed
times to: evaluate progress, achievements
and challenges in relation to the group, the
priority problems being addressed and the
solutions; plan for the future of the group,
the priority problems and the solutions
4. Evaluating
Together
1. Identifying
and prioritizing
problems
together
3.
Implementing
Solutions
Together
2. Planning
Solutions
Together
56
• The whole comunity meets a number of times
to: implement solutions; monitor the
progress of the solutions
• Groups meet a number of times to:
identify feasible solutions to the priority
problems that make the best use of
locally available resources; plan the
solutions with the help of the whole
community
Engaging Men in Health-Post Activities:
An effective mobilization technique to incorporate men’s perspectives in health-post endeavors is to
create a local health-post advisory board that consists of male and female community leaders. The advisory
board should consist of the local NGO-school director (Juan Xiloj), the most predominant community leaders
(for example, Theodoro Xiloj), and several public female figures that can also oversee the Women’s Health
Committee. The advisory board should be tasked with disseminating information about the health-post, for
gaining community buy-in of health-post activities, and to provide an additional role for community members
in health-post organization, development and administration to promote community ownership of the
program.
Acknowledgement and Incorporation of Local Experience and Culture:
Global evidence suggests that sociocultural variables, including health beliefs, common perceptions
of illness causality, and treatment, are more important in determining differential health service use than
measures of access (Goldman 2000; Goldman & Glei 2003; Roost et al. 2004; De Broe 2005; Walsh 2006).
Research has also suggested that the integration of traditional health practices, including the use of midwives
and natural medicines, with biomedical care providers is more effective than simply replacing such culturallyprescribed beliefs with a new system of care (Goldman 2000). As Kruske & Barclay (2004) argue: “rather than
continuing to develop interventions grounded in a Western medicine worldview of health care delivery, we
need instead to develop programs that are inclusive of healers who reflect the sociocultural beliefs of the
community” (Walsh 2006:149). Thus, in order to extend affordable, high-quality and culturallyappropriatehealth services, the distinction between biomedical and traditional care must be blurred by
including local health practitioners in health-post activities and outreach. By upsetting the traditional
asymmetric power imbalance between polarized biomedical and traditional provisions of care, CHW will
foster confidence in their ability to acknowledge community health beliefs while providing formerly
unavailable services.
This report recommends that the two apprentices are provided with
opportunities to increase their knowledge and understanding of local health
belief systems and rituals held by the community in Chocruz by engaging with
local midwives and bearers of traditional knowledge, seeking to integrate such
knowledge in health-post activities.
Chocruz, Momostenango, Guatemala
All programmatic interventions and activities should address male perceptions and knowledge,
including belief systems surrounding women’s sexual and reproductive health. By involving men in healthpost endeavours, CHW can foster the important role of men as advocates for maternal and children’s health
and secure a multi-dimensionality of mobilization (Carter 2002; Schooley et al. 2009). Health promotion
strategies are effective techniques for achieving behaviour and attitude change among both men and
women; by involving men in all aspects of health-post work, support can be fostered for community-level
change and targeted health interventions that have be subjected to gendered-barriers within the community
in the past. This process has already begun through the engagement of men’s groups during the health needs
assessment and should continue once the health-post is operative. It is imperative that the two apprentices
are trained in how to effectively communicate with men regarding health issues as this may serve as a barrier
to health-post activities directed towards both women’s and men’s groups. From the health needs
assessment research activities, it is apparent that the two apprentices do not yet have the skills, confidence,
or professional demeanour to discuss community health and particularly sensitive health issues with men.
57
Those implementing the health-post in Chocruz need to be cognizant of the constructed inequities
between the future stationing of CHW, current health workers that are serving the community and
traditional midwives that have been operative in the region for generations. The introduction of CHW
through an international donor agency will produce inequality in access to resources and support; it is
imperative that these relationships are monitored and evaluated carefully so as to not threaten
thelivelihoods of other health workers or create animosity (Bhattacharyya et al. 2001). Thus, to ensure that
the health-post will work in harmony with existing health services in the area, it is vital that all programmatic
activities facilitate the involvement of local health workers and that traditional midwives are incorporated
from the beginning. In addition, the local midwives should have access to the health-post and be included in
maternal and child health care delivery services as per clients’ wishes. During the introductory phase of the
health-post local midwives will prove to be a valuable addition to the majority of activities, providing
entrenched community partnerships and experiential knowledge.
Chocruz, Momostenango, Guatemala
T ABLE 14: C OMMUNITY R EPORTED TRADITIONAL MEDICINES
Traditional Medicine
Community-Reported Use
Ruda
“Mal de Ojo” (evil eye); “Tristesa” (sadness/depression)
Eucalipto
Respiratory problems; Cough
Pericon
Headaches; Stomach issues
Salvesanta
To wash babies; To give a bath to women during birth
Verbena
Stomach aches
Savila
Swelling; Headaches
Barvena
Fever
Ajenjo
Stomach pains
Anic
Stomach pains
Hierba Buena
Vomiting
Apasote
Amoebas
j
Educational Seminars:
58
A final method of community mobilization involves the provision of low-barrier, culturally- and
linguistically-appropriate educational seminars to community groups. During the health needs assessment,
the community voiced a concrete desire to be provided with timely and accurate health-related knowledge,
particularly in relation to family planning. Growing evidence supports CHW roles in diffusing culturally
appropriate preventative knowledge through educational seminars. For example, CHW-directed educational
activities have been found to significantly improve nutritional outcomes in communities, including
breastfeeding workshops and diabetes-related care (Hartman et al. 2008; Perez & Martinez 2008). It is
imperative that CHW are afforded the opportunity to learn proper adult-education facilitation techniques
that will transform more didactic methods of teaching to methods that suit the community and take into
account low literacy audiences (Skeet 1985). Ensuring that multiple strategies are employed to facilitate the
transfer of preventative health knowledge, health-related awareness and positive health behaviour change
will increase and be supported by the community (Perreira et al. 2002). The director of the local nongovernmental school has volunteered the organization’s capacity to help spread health messages: a powerful
source of knowledge diffusion as evidenced by the health needs assessment mobilization. By providing
community-directed educational seminars individually and in groups, CHW should continually repeat
targeted messages regarding health and monitor their diffusion and uptake throughout the community
through monitoring and evaluation activities.
Recommendation 8 – Involving External Stakeholders:
This report recommends the formation of collaborative partnerships with nongovernmental and governmental health service providers to increase access to
specialized and timely care within Chocruz, Guatemala, in an effort to not
duplicate services and to monopolize on existing resources.
The stationing of CHW in Chocruz should be accompanied with a strong commitment to fostering
partnerships with the municipal health centre in Momostenango and the hospitals in both Quetzaltenango
and Totonicapan. By introducing CHW to managers and health professionals within government-run health
facilities, collaborative relationships and respect can be forged to realize an ideal level of patient-centred
care, especially in the case of needed emergency referrals. CHW should be tasked with the role of patientadvocate and translator during episodes of emergency care, accompanying patients to the health centre or
hospital and coordinating effective services. As Kwast (1995) states: “Community, public health and hospital
systems have to be linked together in a standing relationship; isolated efforts at any one level do not increase
referral and use of health facilities” (Kwast 1995:S81). Cross-sectional coordination within an episode of care
is dependent on strong relationships and respect between health workers on multiple levels of servicedelivery (WHO 2006). By progressively maintaining relationships and on-going communication between CHW
and government-paid health workers, CHW care-delivery will be respected during times of need.
For specialized care, it is recommended that EL MIRADOR foster linkages with other nongovernmental organizations that provide vertical programs of mobile service delivery throughout Guatemala.
The health needs assessment uncovered the immediate community identified-need for dental services and
eye-examinations for children and adults alike: services that can be delivered through partnerships with
medical missions that have an existing presence in Guatemala. The World Health Report (2006) suggests the
organization and implementation of group medical visits for patients who share common specialized health
problems to complement primary health care programs. By fostering connections with established medical
missions and mobile-clinic services, the health-post in Chocruz can act as a service provision coordinator and
ensure the delivery of much needed care, care that may be out of the CHW scope of practice. The following
Chocruz, Momostenango, Guatemala
Multi-sector cooperation and collaboration from the local to international level can bridge gaps and
overcome barriers to health for rural and underserved communities. By monopolizing on existing health care
resources in Guatemala, both statitionary and mobile-based health service delivery, patient care and health
outcomes can improve beyond the primary level while supporting goals of program sustainability (Kwast
1995; Foster et al. 2004; Roost et al. 2004; WHO 2006). Linking the health-post in Chocruz to the national
health system and external agents that provide vertical and horizontal health programs will increase
community access to much-needed, specialized and timely services and secure the role of CHW as patient
advocates during times of emergency and specialized health needs. Such efforts will also promote nonduplicative service delivery: an ideal factor for consideration in low-resource settings.
59
list is a small compendium of medical missions and mobile clinics that have worked, or are working, in
Guatemala:
1. Faith in Practice (www.faithinpractice.org): The organization offers a Village Medical Clinic Program,
Surgical Program, Dental Program, Hearing Program, VIA/Cryo Program, and Orthopedics and
Prosthetics Program
2. Saba Foundation (http://sabafoundation.net/): The organization provides eye care services and
funding for various public health programs. Read about their projects here:
http://sabafoundation.net/saba-news-projects.html
3. APROFAM (www.aprofam.org.gt): The organization provides medical units that currently visit
Totonicapan department. An International Planned Parenthood Affiliate, APROFAM is the largest
private provider of reproductive health services in Guatemala.
Chocruz, Momostenango, Guatemala
4. Medical Teams International (www.medicalteams.org/sf/Home.aspx): The organization provides
some dental care services and is currently a partner with Mercy Corps in Alta Vera Paz, Guatemala.
Read about their Guatemalan projects here:
www.medicalteams.org/sf/our_work/where_we_work/latin_america/guatemala.aspx
Recommendation 9 – Facilitating Monitoring and Evaluation Activities:
A key determinant of programmatic success is the design, implementation and on-going
management of a comprehensive monitoring and evaluation system for operational activities. Monitoring
and evaluation enables a continual understanding of program successes and struggles and provides an
effective feedback-loop for the community, stakeholders andj funders alike (Bhattacharyya et al. 2001). By
monitoring simple health indicators over time an active measure of programmatic impact can be recorded to
present to community members for continued support and to provide evidence of impact effectiveness.
Monitoring and evaluation also enables programs to adapt and explore new avenues of care in order to
increase good practices and forgo efforts that do not have an adequate impact in decreasing health burdens
within the community (WHO 2011b).
This report recommends a concerted effort by CHW to record
anthropomorphic measures for children under five years of age within the
community (height-for-age and weight-for-age) during the first six months of
health-post operations to be used as a baseline data set. The health-post should
have a paper-based information system that is employed during all facility and
outreach activities to measure workforce performance over time and additional
supervisory visits to monitor and evaluate CHW and health-post progress
towards goals of community health.
60
The World Health Report (2006) recommends monitoring and evaluating four dimensions of
workforce performance: availability, competence, responsiveness, and productivity. Supervisory visits
provide an excellent opportunity for monitoring and evaluation of CHW. The following chart outlines
monitoring and evaluation indicators to be used in measuring the four dimensions:
T ABLE 15: F OUR D IMENSIONS OF WORKFORCE PERFORMANCE - ADAPTED FROM WHO (2006)
Description
1.
Availability
Encompasses the distribution
and attendance of existing
workers through space and time
2.
Competence
Encompasses the combination
of technical knowledge, skills
and behaviours
3.
Responsiveness
People are treated decently,
regardless of whether or not
their health improves or who
they are
4.
Productivity
Producing the maximum
effective health services and
health outcomes possible given
the existing stock of health
workers and resources
Indicators
-
-
Operational hours
Waiting times
Absence rates
Prescribing practices
Readmission rates
Cross-infections
Referral rates
Live births
Patient satisfaction
Assessment of
responsiveness by
supervisors
Outpatient visits
Occupied beds
Interventions delivered per
facility
CHW are naturally poised to work as researchers within monitoring and evaluation activities. CHW
can measure monitors of impact effectiveness by developing community and individual-level information
systems that assess quality and continuity of care (WHO 2006). As the CHW have been trained in
Participatory Rural Appraisal techniques for data collection and analysis, this methodology should be
included in community monitoring and evaluation activities. However, caution must be taken when tasking
CHW to monitor and evaluate health-post progress as their presence may introduce positive-bias into the
results. It is recommended that CHW collect baseline and on-going data and that trained external public
health professionals finalize participatory evaluation reports within the community after one year of healthpost operation: it is imperative that the first health-post evaluation is conducted by a skilled Public Health
practitioner with experience in such research. This health needs assessment should provide guideline
indicators for use during such activities: community reported barriers to health in the community, the highest
rated health problems for children, the highest rated health problems for women, and the highest rated
health problems for men after one year of health-post operation for comparison with presented baseline
data.
Chocruz, Momostenango, Guatemala
Dimension of Workforce
Performance
61
Conclusions:
The anticipated health-post in Chocruz will prove to be a successful operation if identified needs of
the community form the basis of program development as supported by global evidence and best practices.
To review, the following 9 recommendations should be addressed prior to the introduction of a health-post
in Chocruz, ensuring safe, efficacious and patient-centred service delivery:
Chocruz, Momostenango, Guatemala
The Primary Health Care Model as a Basis for Successful Community-Driven Care
62
Recommendation 1
Embracing a Community Health Worker Designation
Recommendation 2
Establishing Evidence-Based Curriculum and Training
Recommendation 3
Providing Supportive Supervision to Empower Community
Health Workers
Recommendation 4
Realizing Incentives, Disincentives and Rewards for
Community Care
Recommendation 5
Securing a Reliable Supply-Chain and Financing Strategy
Recommendation 6
Incorporating Community Payment Strategies for Care
Recommendation 7
Engaging the Community
Recommendation 8
Involving External Stakeholders
Recommendation 9
Facilitating Monitoring and Evaluation Activities
j
Appendices:
A Fundamental Component of All Competencies
Behaviour
Knowledge
Treat each individual with full respect for her/his
human rights
Human rights and their national, regional and
international sources
National laws that enhance or hinder human rights
Approach all clients including marginalized and
vulnerable populations in a nonjudgemental and nondiscriminatory manner, respecting individual dignity
Medical ethics and professional codes of conduct, and
familiarity with the four principles of medical and health
ethics: do not harm, do good, respect and justice
-
-
Show respect of knowledge and learning styles of
individuals
-
The right of individuals to be treated with
respect, free of judgement or discrimination,
regardless of their sex, age, ethnicity, sexual
orientation and other status
The gender-equality principle
How to identify and respect gender differences
and gender diversity
The marginalized and vulnerable populations
the community and their specific SRH needs
Human rights and national laws with special
regard to issues related to adolescents
Diversity in beliefs and value systems
Different learning styles
Different teaching techniques and methods that
facilitate learning
Positive communication methods
Demonstrate empathy, reassurance, non-authoritative
communication and active listening
-
Show respect for clients’ choices as well as their right
to consent and refuse physical examination, testing
and interventions
-
Offer services that are confidential and provide privacy
-
Accountability and transparency in all actions
-
Seek opportunities for continuous learning and
professional growth
-
Develop en promote effective relationships with team
members and colleagues
-
Team-work advantages and team-building
processes
Ensure sound clinical judgement and attention to
detail in all SRH care
-
All the above and the most up-to-date SRH
competencies
-
SRH choices available for clients and the right of
individual decision-making
The principle of informed consent and
procedures for obtaining clients’ consent
The principles of confidentiality and privacy and
their application to SRH
The principle of accountability and transparency
The content and meaning of the respect,
protection and fulfillment of human rights
The importance of continuous education and
professional growth to maintain standards
Domain 1: Attitudes for providing high-quality sexual and reproductive health care
Chocruz, Momostenango, Guatemala
Act consistently in accordance with personal and
professional ethics and standards
63
Competency 1: Perform a leadership role that provides an environment that enables health-care team
members to perform effectively
Task
1.
Knowledge, skills
Perform a leadership role
Knowledge:
-
Leadership principles
Team approach
Health systems: the national and local context
Gender differences and gender diversity
Importance of gender perspective to meet public
health objectives and outcomes
Gender mainstreaming planning
Concepts of programme emergency preparedness
and recommended actions
Coordination and integration in a continuum of care
Skills – ability to:
Chocruz, Momostenango, Guatemala
-
-
Provide leadership through:
i.
Strategic thinking
ii.
Motivating and inspiring staff and others
iii.
Developing a shared vision and mission of
SRH services
iv.
Communicating effectively
v.
Resolving conflicts
j networking and advocacy activities
Lead
Work towards reducing gender inequalities
Engage with communities and all levels of system
Supervise
Domain 2: Leadership and Management
Competency 2: Effectively manage the primary health-care team to allow the efficient provision of quality
SRH services
Tasks
1.
Knowledge, skills
Perform a public health role, fostering SRH
coordination, integration and continuity of
care
Knowledge:
-
-
64
-
-
Concepts of public health
Social determinants of health as legal, political,
cultural and financial systems affecting health,
with specific focus on SRH
The impact of health-care-delivery systems on
populations and individuals receiving SRH care
Concepts of non-clinical disasters emergency
preparedness, e.g. earthquakes or major floods
Roles of government, private sector and
nongovernmental organizations in the delivery
of SRH in PHC
Local stakeholders to promote SRH and
integrated care in the community
Skills – ability to:
2.
Guide financial planning and management to
provide adequate transparency and
information to make effective services
available
Tailor the delivery of SRH care on individual
and populations’ needs
Develop plans for individual patients’ care, with
clear goals and the necessary effective
integrated interventions
Recognize the effects of one’s own gender
identity and biases on public health work
Foster the development of communication and
advocacy skills to become gender-competent
agents of change
Identify where services integration is necessary
and possible
Act in response to natural or conflict
emergencies
Knowledge:
-
Financial planning, budgeting and reporting
procedures – national and local
Costing and expenditure-monitoring
procedures
Concept of transparency about the way
programme finances are uses
Needs, availability and suitability of functional
SRH health facilities
Skills – ability to:
-
3.
Foster teamwork while managing human
resources
Recognize the impact of a well-functioning
health systm, including allocation and
budgetary issues and the implications of other
social sector allocations for gender equity in
public health
Develop an integrated SRH budgeted plan
Manage the implementation of a SRH
budgeted plan
Mobilize resources locally
Knowledge:
-
-
Regulations and laws defining health-worker
roles
Individual cadres’ job descriptions
Employment regulation and staff recruitment
procedures
Supportive supervision methods
Different education systems for health-care
providers and their qualifications (competence
to practice)
Training needs analysis
Assessment of the developmental needs of
Chocruz, Momostenango, Guatemala
-
65
staff
Conflict-resolution principles
Workplace service-delivery norms and
standards
-
Skills – ability to:
Chocruz, Momostenango, Guatemala
-
4.
Information generation and use
Identify the SRH roles of the different cadres of
workers in the PHC system
Identify a human-resource competency gap
through comprehensive training needs
analyses
Develop and provide, in collaboration with
local partners, comprehensive plans for
continuing education for SRH
Provide supportive supervision to ensure
quality standards
Use evidence to inform professional education
in preservice training of the need to prepare a
workforce that is “fit to practice” and
responsive to the SRH needs of communities
Involve the community in staff-retention
strategies
Knowledge:
-
j
-
SRH and gender indicators for monitoring
information, research, policies and
programmes
Data collection tools
The relationship between field data and
national data: the two-way information system
How to collect, analyze and interpret local
health statistics data
How to interpret age- and sex-disaggregated
data
How to use data to inform decision making
Skills – ability to:
-
5.
Management of the health facility and the
logistics of supplies/equipment
Gather information using data-collection tools
Ensure accurate and complete record-keeping
and timely reporting
Analyze and present data in an easy,
understandable way
Use information to make changes and enhance
the quality of SRH services
Knowledge:
-
66
-
Safe health facility physical structures,
organization of services, patient’s flow,
confidentiality, needs, etc.
Environmental sanitation
Waste management and siposal
-
Quality-assurance and patient safety models
and procedures
Different procurement mechanisms
Storage and proper and timely distribution of
supplies
Skills – ability to:
6.
Guide the implementation of SRH strategy and
the provision of SRH integrated services
Ensure the availability and maintenance of
appropriate physical facilities to provide quality
SRH services
Ensure routine maintenance and care of
instruments
Ensure the availability of guidelines for
providers
Make timely requests for supply and resupply
of commodities, drugs, medical and surgical
equipment, so that stocks are always available
Correctly use and perform regular maintenance
of equipment
Ensure regular monitoring of the health-facility
status and its equipment
Ensure regular monitoring of the purchase and
logistics of drugs, and consumable equipment
Knowledge:
-
National and local SRH policies, standards and
protocols
Research results to improve SRH programme
implementation though evidence
Programme-management cycle and monitoring
and evaluation theories
The cost-effectiveness
The concepts of linkages and integration as
applied to SRH and PHC
Chocruz, Momostenango, Guatemala
-
Skills – ability to:
-
-
Domain 2: Leadership and Management
Develop feasible operational plans based on
available resources
Operationalize the steps/functions effectively
Develop/adapt and implement an evaluation
framework
Develop/adapt an implement strategies for
comprehensive referral systems
Develop/adapt and monitor the
implementation of effective practice guidelines
Develop performance-management
guidelines/checklists using agreed clinical and
other indicators
Delegate authority when appropriate
67
Competency 3: The Primary health-care team member/s provide comprehensive and integrated sexual and
reproductive health care, working efficiently in and with the community
Tasks
1.
Knowledge, skills
Recognize health concerns in the community
through capturing information on perceived
needs, directly from the women, men, family,
and community, and from other data
Knowledge:
-
-
Individual and family life-cycle
SRH definition
Principles of SRH and PHC
Social determinants of health and illness and
health inequity
Information and data to be collected to obtain a
community profile including health concerns,
needs, assets and resources
Gender issues and specific related issues in the
local community
The principles of community engagement
Chocruz, Momostenango, Guatemala
Skills – ability to:
-
2.
Develop comprehensive approaches for
integrated SRH at community level
Approach and engage the community in the
collection, discussion and analysis of data and
processes
Approach and engage key informants and
influential groups, fostering links
Approach issues with a gender-sensitive
j perspective
Listen, communicate, response and interact with
key members and groups in the community
Knowledge:
-
-
Prinicples of community-based service delivery
Factors influencing the delivery and use of health
services
How to respond to the identified SRH needs of
the community making use of their skills and
resources
The advantages of integration
Skills – ability to:
-
68
3.
Facilitate the community learning about
health-promoting and preventive care
Implement a participatory planning process for
SRH care
Identify and optimize opportunities for linkages,
coordination, and preferably integration with
programmes such as maternal and child health
(MCH)
Identify and use culturally acceptable and
relevant approaches
Knowledge:
-
Health-promotion and health-protection
principles and methods
-
Effective communication methods with the
community and groups
The social determinants for SRH, including
barriers and facilitating factors
Skills – ability to:
4.
Promote SRH working with the community to
raise awareness on the importance of equity
and universal access to SRH
Be and support agents of change
Prepare effective health-promotion messages
Deliver effective community of messages
Knowledge:
-
Principle of universal access and its meaning in
the local context
Health-promotion and prevention principles,
main theories and processes
Strategies for health protection and promotion
Key stakeholders and their influence
-
5.
Promote self-health care
Identify target users’ groups
Identify populations at risk (marginalized and
vulnerable groups)
Motivate and mobilize community leaders,
community members, and populations at risk
(marginalized and vulnerable groups)
Negotiate with key stakeholders
Knowledge:
-
Self-empowerment strategies enabling people to
care for themselves and to be and stay healthy
Chocruz, Momostenango, Guatemala
Skills – ability to:
Skills – ability to:
-
6.
Enable the use of SRH services by the
community
Identify and support social networks, such as
mothers’ and youth groups, and other local
initiatives
Knowledge:
-
Health-promotion and prevention concepts and
methods
Skills – ability to:
-
-
Organize and facilitate meetings within the
community to be able to respond to their needs
by service provision
Identify and facilitate the removal of barriers and
stigma
Domain 3: General Sexual and Reproductive Health Competencies for Health Providers
69
Competency 4: The primary health-care team members provide high-quality education related to sexual and
reproductive health and sexual and reproductive health services
Tasks
1.
Knowledge, skills
Assess the local sociocultural, legal and
gender concerns and issues related to
programme implementation and service
provision
Knowledge:
-
-
-
Chocruz, Momostenango, Guatemala
-
The most common health needs of the community
Diverse SRH service needs for different groups,
includsive of the vulnerable and marginalized, at
different points in the life-cycle
Laws and policies governing SRH
Laws regarding family planning, abortion, HIV,
violence against women and sexual violence, sex
work, sexuality (including sexual orientation and
gender identify), adolescents’ access to SRH services
(including age of consent, best interest, evolving
capacity) and marriage
Local culture and social norms relevant to SRH
(including harmful practices)
Sociocultural barriers to the use of SRH services
SRH services offered, staff job descriptions, referral
systems
Health-care providers’ legal obligations
Health-care system (facilities available for the
community, and health services options for clients)
Health systems and existing resources for social
jsupport
Key elements of SRH services and national guidelines
Environmental and SRH educational needs
assessments
Gender analysis of current programmes
Gender mainstreaming as a means to strengthen
programme efficacy
The economic compact or cost of various health-care
options
Skills – ability to:
-
2.
70
Create an environment that is conducive to
learning
Carry out environmental and SRH educational needs
assessment
Provide culturally and gender-appropriate
information
Empower individuals or groups to make informed
choices
Knowledge:
-
Basic principles of how people learn (adults,
adolescents, and children)
Factors facilitating and impeding learning
Models for behavioural change
Learning outcomes
Skills – ability to:
-
3.
Facilitate learning using a variety of
techniques (discussion, demonstration,
presentation)
Plan effective learning sessions (individual or group)
to achieve learning outcomes
Create secure, safe and effective learning spaces
Assemble the appropriate educational materials
related to SRH (for adults, adolescents and children)
Share knowledge with team members and
colleagues
Knowledge:
-
-
Different evidence-based educational
methodologies; the advantages and disadvantages
of each
The “behaviour, change and communication”
concept and methods
Skills – ability to:
Convey essential information related to
specific SRH topics
-
SRH topic in the area being taught (cross-reference
to content)
How to present a topic
Linkages with other SRH topics and areas
Skills – ability to:
-
5.
Assess the transfer of learning
Communicate information on SRH and related
services in a simple manner, using appropriate
language
Adapt information or training to individual, large or
small groups’ needs
Make effective, easy-to-understand linkages with
other related programmes
Knowledge:
-
Chocruz, Momostenango, Guatemala
4.
Use appropriate educational techniques
Knowledge:
Formative and summative assessment techniques
Skills – ability to:
-
Adapt/develop tools and techniques used to assess
learning
Administer tools and techniques used to assess
learning
Adjust teaching strategies to the assessment results
Use assessment and feedback to help all learners
master SRH content
Domain 3: General Sexual and Reproductive Health Competencies for Health Providers
71
Competency 5: The primary health-care team members provide high-quality counselling related to sexual and
reproductive health and sexual and reproductive health services
Tasks
1.
Knowledge, skills
Plan a counselling session including the
creation of a conducive counselling
environment
Knowledge:
-
-
The physical, social, cognitive, and emotional
development of different life stages, including
adolescence
Factors that facilitate and impede counselling, such as
privacy, environment, time, etc.
Decision-making processes
Behavioural-change theories
Health-seeking behaviour
Skills – ability to:
Chocruz, Momostenango, Guatemala
-
2.
Counsel effectively
Plan an effective counselling session
Create a secure, safe and effective counselling space
Assemble the appropriate counselling materials or aids
related to SRH
Knowledge – in addition to knowledge for Task 1:
-
Basic evidence-based counselling techniques
Mechanisms of support available for those providing
counselling
j
Skills – ability to:
-
3.
Assess the effectiveness of counselling
Communicate with individuals effectively, demonstrating
awareness of gender and cultural differences while
providing appropriate information
Provide information to empower individuals or couples to
make informed decisions
Discuss the impact of gender-based societal and cultural
roles and context on health care and on women’s and
men’s SRH
Tailor counselling to the needs of the individual
Use basic counselling techniques, including establishing
rapport, active listening, demonstrating empathy,
questioning and probing, summarizing and reflecting
Provide appropriate counselling referrals when needed
Knowledge:
-
Basic techniques of assessing user experience and
satisfaction
Skills – ability to:
72
-
Use rapid-assessment techniques
Follow-up clients after counselling
Domain 3: General Sexual and Reproductive Health Competencies for Health Providers
Competency 6: The primary health-care team members effectively assess the sexual and reproductive
health needs of users of primary health care services for treatment and referral when necessary
1. Take an appropriate health history with a
focus on factors related to SRH
Knowledge, skills
Knowledge:
-
-
Components of health history
Basic anatomy and physiology
SRH cycle and stages of reproductive
development, and continuity of care
Adolescent health and development,
including sexual development
Patterns of SRH-related morbidity in the
community, and sexual and reproductive
behaviour of communities
Knowledge of sex and gender differences in
health and during sickness
Signs and symptoms of SRH pathology and
problems (including HIV)
Risk factors for unsafe sexual practices and
their health risk
Signs of violence, rape and gender-based
violence (GBV)
Skills – ability to:
-
2. Conduct a physical examination
Establish rapport
Communicate effectively including asking and
responding to questions
- Demonstrate active listening
- Explore comprehensive SRH needs of clients
- Effectively use appropriate job aids or
checklist
- Identify signs of being “at risk” of danger
- Understand and assist victims of physical,
emotional and sexual violence and abuse
Knowledge:
-
Basic male and female anatomy and
physiology
Major congenital anomalies
Physical examination procedures and
objectives
Steps in the examination of the female and
male reproductive system
Signs presented by women, children and men
suffering from violence, GBV, rape
Infection prevention and recommended
infection-prevention practices
Chocruz, Momostenango, Guatemala
Tasks
73
Skills – ability to:
-
3. Ensure faster and safe-referral
Determine appropriate need for a chaperone
Use the recommended infection-prevention
practices to protect the individual, healthcare provider and other health-workers
(hand-washing before and after contact with
client, wearing gloves, etc.)
- Perform physical examination, including
inspection, palpation, percussion and
auscultation
- Perform female pelvic and breast examination
- Perform male reproductive system
examination – inclusive of the prostate
Knowledge:
-
Chocruz, Momostenango, Guatemala
-
The local referral system and where to refer
Referral guidelines for a particular clinical
case or pathology
How to keep a patient safe during the referral
process
Skills – ability to:
-
4. Screen for male and female reproductive
health preventable and/or treatable
pathology
Follow the referral procedure
Act fast and efficiently, particularly for an
j emergency referral
- Keep the patient safe during the referral
process
- Refer upwards, horizontally or downwards as
appropriate
Knowledge:
-
-
-
Reproductive tract pathology, inclusive of
basic knowledge of reproductive tract cancers
and their aetiology
Screening principles for reproductive tract
cancers
National guidelines and protocols for
reproductive tract cancer prevention,
screening and management
Referral network for cancer
Skills – ability to:
-
74
-
-
Inform and counsel about preventive and
curative medicine
Inform individuals about cervical cancer, its
prevention and the treatment of
precancerous cervical lesions
Screen for preventable or treatable
5. Obtain or refer for appropriate laboratory
tests related to SRH
conditions (breast mass, cancer of the cervix,
and prostate)
- Perform routine care of the surgical
instruments
Knowledge:
-
Existing laboratory tests in use related to SRH
(including HIV)
Knowledge of the normal value for different
tests’ results
Systems for referral in the community
Skills – ability to:
Interface across primary and secondary care
for tests and referrals
- Conduct proper specimen collection, when
appropriate
- Interpret test results
- Refer clients to the appropriate testing site
- Prepare referral requests upwards,
horizontally or downwards, based on results
Domain 3: General Sexual and Reproductive Health Competencies for Health Providers
Competency 7: The primary health-care team members provide high-quality family-planning care
Tasks as per Competencies 4-6, plus:
1. Collect accurate family planning (FP)
history
Knowledge, skills as per Competencies 4-6, plus
Knowledge:
-
-
-
-
How FP improves the health of women and
their babies, and contributes to the reduction
of maternal deaths, and perinatal morbidities
and deaths
Variety of available contraceptive methods
Conditions that affect FP use (medical, social
and individual circumstances), rumours and
myths related to FP
Gender norms and roles affecting the use of,
and access to, FP services
Gender issues regarding FP
Community concerns regarding FP
Local statistics and targets on FP use
Signs and symptoms of GBV, rape and
vulnerable groups and their needs (GBV is high
in couples with fertility problems)
Connection between FP and environment,
education, etc.
Chocruz, Momostenango, Guatemala
-
75
Skills – ability to:
-
Chocruz, Momostenango, Guatemala
2. Provide correct information on FP (birth
spacing, contraception and infertility) to
individuals, couples and groups
Address myths
Rule out pregnancy without a pregnancy test
or knowing that the woman is having her
period
- Deal with chronic conditions
- Apply Competency 5 to FP
Knowledge:
-
Basic understanding of human reproduction,
infertility, fertility and fertility regulation
- FP benefits, limitations, effectiveness, sideeffects and health risks, etc.
- Variety of contraceptive methods
- Emergency contraception
- FP care standards and protocol
- The male and his responsibility/involvement in
FP
- FP as an issue for the couple
- How contraceptive methods work: hormonal
methods, postpartum and emergency
contraception, lactational amenorrhoea
method (LAM) and transitioning from LAM to
other contraception, etc.
- The effectiveness of different methods
j compared with one another
- Contraceptive choices for adolescents
- Management of side-effects, method failure,
complications
- When and where to refer clients for special
needs
- Where each FP method can be obtained
Skills – ability to:
-
3. Assess the client for medical eligibility for
FP, performing, where necessary and
appropriate, physical examination and
tests
76
Explore about past and current FP use, and
future fertility plans
- Provide tailored and personalized information
to help the client and her/his partner to make
FP informed, voluntary decisions
- Explain method use
Knowledge:
-
Medical eligibility criteria for use of FP
methods
Skills – ability to:
-
Rule out if a woman is pregnant, in order to be
able to provide contraception when desire
-
4. Carry out FP procedures
Perform physical examination and historytaking to detect conditions that would
contraindicate the use of contraceptive
methods
Knowledge:
-
FP planning methods
Skills – ability to:
5. Assess satisfaction with and correct use of
metho with return clients or clients
experiencing problems to switch to other
methods
Knowledge of national guidelines for FP use:
including legality of IUD use for nonprofessional health workers
- Demonstrate male and female condom use
- Fit cervical barrier method
- Give injections
- Provide emergency contraception
- Refer for male and female sterilization services
- Discuss and explain the “standard days”
method and other natural FP methods
Knowledge:
-
Interviewing and history-taking methods
Side-effects and problems with use
Follow-up nees
Schedule of follow-up, resupply
Skills – ability to:
6. Assess individual/couple for infertility and
refer if needed
- Interview and take history
- Reassure client about the method they chose
- Assist them in solving issues
- Help them in switching methods
Knowledge:
-
-
-
-
Concepts of infertility, causes and
management (links to STI, reproductive tract
infection (RTI) management, cervical
screening, infectious diseases such as
tuberculosis (TB), HIV, hepatitis B and C)
Guidelines on when to refer if needed for
evaluation, treatment, negative behaviour (i.e.
smoking cessation, stress reduction) or to
fertility support groups
Sociocultural beliefs and practices that are
either useful, natural or harmful (i.e.
unacceptability of men masturbating in order
to obtain a semen sample, traditional healers
to be consulted prior to modern medicine)
Factors that could lead to infertility:
nutrition/folic acid, age (sex differences), birth
Chocruz, Momostenango, Guatemala
-
77
weight, smoking, relationship and other stress,
over-the-counter and recreational drugs
(alcohol), occupational hazards, scrotal injury
or temperature (men)
Laboratory procedures, e.g. simplified semen
analysis (volume, pH, sperm count and
motility), postcoital test or referral
Fertility-awareness methods
-
-
Skills – ability to:
-
Provide couple-centred management
Take a history of infertility (specific criteria)
Administer a physical examination to identify
for gross morphology of male or female
genitalia
Conduct preconception counselling on
lifestyle: nutrition/folic acid, age (sex
differences), birth weight, smoking,
relationship and other stress, over-the-counter
and recreational drugs (alcohol), occupational
hazards, scrotal injury or temperature (men)
Chocruz, Momostenango, Guatemala
-
Domain 4: Specific Clinical Competencies
j
Competency 8: The primary health-care team members provide
high-quality sexually transmitted infection
and reproductive tract infection care
Tasks as per Competencies 4-6, plus
1. Collect an accurate history of past and
present STI/RTI
Knowledge, skills as per Competencies 4-6, plus:
Knowledge:
-
-
Local perceptions around STIs/RTIs
Factors influencing STI/RTI risk (behavioural
factors, male circumcision, vaginal douching,
etc.)
STI epidemiology at national and at the
community level
Diagnostic STI tests, including counselling
Management of post-sexual assault
Skills – ability to:
-
78
2. Detection and management of STIs/RTIs
Conduct a medical history of STIs/RTIs
Elicit STI/RTI symptoms
Handle survivors of sexual violence, sexual
abuse and exploitation
Knowledge:
-
Clinical presentations of STIs/RTIs and their
sequelae
-
STI/RTI assessment during FP visits
STI/RTI assessment in pregnancy, childbirth
and postpartum period
STI/RTI complications related to pregnancy,
miscarriage, abortion
National guidelines and protocols for STI/RTI
management
STI/RTI/HIV transmission and prevention
Aetiologic and syndromic management of
STIs/RTIs
STI/HIV counselling and testing
Patient and partner referral and treatment
Case reporting
-
-
Conduct physical examination to detect
STIs/RTIs
Collect sample for RTIs and STIs
Perform tests using available diagnostic tools
or send for a referral at a secondary health
facility
Use STI syndromic management flowcharts
Offer and provide STI/HIV counselling and
testing
Address partner referral
Domain 4: Specific Clinical Competencies
Competency 9: The primary health-care team members provide screening and treatment/referral for
reproductive tract cancers
Tasks as per Competencies 4-6, plus
1. Provide screening and treatment/referral
for cervical cancer
Chocruz, Momostenango, Guatemala
Skills – ability to:
Knowledge, skills as per Competencies 4-6, plus:
Knowledge:
-
-
Signs and symptoms of cervical cancer
Cervical cancer screening methods
Procedures for testing
VIA (visual inspection with acetic acid)
screens for cervical cancer, possible
complications
Management of precancerous lesions
Papanicolau (Pap) smear technique
Skills – ability to:
-
Perform VIA
Manage precancerous lesions including using
cryotherapy
79
2. Provide human papillomavirus (HPV)
vaccine; eligibility assessment, screening
and administration
- Perform cervical bunch biopsy
- Perform Pap smears
- Refer for large lesion and suspicious of cancer
Knowledge:
-
HPV vaccine eligibility
National policy related to HPV
HPV calendar
Skills – ability to:
3. Provide screening/referral for breast cancer
- Administer HPV vaccine
Knowledge:
-
Breast cancer risk and protective factors
Breast cancer signs and symptoms
Chocruz, Momostenango, Guatemala
Skills – ability to:
4. Provide screening/referral for prostate
cancer
- Perform clinical breast examination
- Teach breast self-examination
Knowledge:
-
Symptoms and signs of prostate cancer
Skills –j ability to: perform digital rectal examination
Domain 4: Specific Clinical Competencies
Competency 10: The primary health-care team members provide high-quality comprehensive abortion care
Tasks as per Competencies 4-6, plus
1. Management of abortion complications
Knowledge, skills as per Competencies 4-6, plus
Knowledge:
-
-
-
Signs and symptoms of pregnancy
Gestational age and its calculation
Signs, symptoms, and management of
spontaneous abortion, missed abortion,
induced abortion and related complications
Abortion management standards and
guidelines and referral techniques, including
counselling
Referral management for repeat
spontaneous abortion and complications
that are not treatable in loco
80
Skills – ability to:
-
-
Fertility return after abortion
Symptoms and signs of abortion
complications
Risk factors for repeat spontaneous abortion
Risks of unsafe abortion
Legal grounds for induced abortion
Pregnancy options for women and couples
Barriers to safe, legal abortion and how to
address them
Medical eligibility for abortion methods
Emergency contraception
How, when and where to refer women
Skills – ability to:
-
3. Provide, or refer for, induced abortion
Provide complete and easy-to-understand
information about abortion and recurrent
abortions
- Refer the client to another provider in case
of conscientious objection, or need for highlevel care, or if abortion methods are not
available
- Ability to refer for antenatal care if the client
decides to remain pregnant
- Ability to discuss SRH following abortion –
i.e. contraception, STI screening
Knowledge:
-
-
Abortion law and its applicability (legal
protection to women and providers)
National norms, standards and guidelines for
abortion care, including rules for
conscientious objection to provision of
induced abortion
Confirmation of pregnancy and
determination of gestational age
Medical eligibility for all available abortion
methods
Pain management, including verbal
reassurance
Appropriate referral strategies
Skills – ability to:
Chocruz, Momostenango, Guatemala
2. Inform and counsel of spontaneous
abortion, unwanted pregnancy and induced
abortion
Perform abdominal and vaginal examination
to assess gestation age
- Recognize complications of abortion
- Treat abortion complications
- Refer when needed
Knowledge:
81
4. Provide post-abortion contraception
- Perform a bimanual uterine examination
- Manage abortion-related complications
Knowledge:
-
Medical eligibility requirements for
contraceptive methods
Post-abortion FP methods
Return to fertility post-abortion and safe
time to get pregnant again
How and where to obtain contraceptives
(preferably in the same place where they
had the post-abortion services)
-
Skills – ability to:
Chocruz, Momostenango, Guatemala
-
5. Provide or refer for other SRH needs
Provide contraceptive methods, including
implants, injectables and emergency
contraception immediately after postabortion services have been performed
- Also refer to competency 8 (STIs)
Knowledge:
j
Signs and symptoms of RTIs
Signs and symptoms of GBV
When and where to refer for appropriate
follow-up care
Skills – ability to:
-
Provide syndromic management of RTIs
Domain 4: Specific Clinical Competencies
Competency 11: The primary health-care members provide high-quality antenatal care
Tasks as per Competencies 4 and 5, plus
1. Take a detailed obstetric history
Knowledge, skills as per Competencies 4 and 5, plus
Knowledge:
-
-
82
-
Menstrual cycle, signs and symptoms of
pregnancy and calculation of gestational age
Components/elements of a thorough health
history, family history and relevant genetic and
obstetric history
Psychological aspects and sociocultural beliefs
and practices in pregnancy – useful, neutral and
harmful
Harmful effects on pregnancy
Risk factors associated with pregnancy
Skills – ability to:
-
2. Take a history of personal, family,
environmental and socioeconomic
circumstances
Be proficient taking a comprehensive obstetric
history
Knowledge:
-
-
Power relationships in the family
The decision-makers in the family (e.g. motherin-law or husband)
Relevant care-seeking behaviours and what
affect them (freedom of mobility, distance from
the health service, finance, decision-making,
etc.)
Abilities to access ANC as often as needed and
to seek timely emergency care
Skills – ability to:
3. Perform a physical examination including
abdominal examination (fundal height,
position, lie, and descent of fetus) and
assess fetal growth and well-being, and
the adequacy of the pelvis
Communicate appropriately to gather relevant
information
Knowledge:
-
Female and male anatomy and physiology
related to conception and reproduction
Focused physical examination content for
antenatal visit
Normal progress of mother and baby during the
antenatal period
Gestational age by menstrual history, size of
uterus and/or fundal height
Fetal growth, development and well-being
during pregnancy, including fetal heart rate and
activity patterns
Chocruz, Momostenango, Guatemala
-
Skills – ability to:
-
4. Inform, educate and counsel about
healthy habits, and provide guidance and
basic education and preparation for
labour, birth and parenting
Conduct a thourough physical examination,
abdominal examination, and pelvic
examination, to assess fetal growth and wellbeing
- Identify variations from normality and institute
appropriate interventions and referrals
- Calculate the estimated date of delivery
- Monitor fetal heart rate using available
instruments
- Perform a pelvic examination determining the
adequacy of the pelvis
Knowledge:
-
Education needs regarding normal body
changes during pregnancy, relief of common
83
-
-
-
Chocruz, Momostenango, Guatemala
-
discomforts, hygiene, sexuality, nutrition, work
inside and outside the home
Immunization during pregnancy
Nutritional requirements of the pregnant
woman and fetus
Anemia prevention and control (iron and folic
acid supplementation)
Self-care education, birth prepardedness and
complication readiness for self and family and
community, safe sexual practices, information
and danger signs
Health-education content targeted to ANC,
including STIs and child survival
Vulnerable groups and their needs, including
pregnant adolescents, single and poor women,
people with disabilities
Benefits and risk of different birth settings
Preparation of the home/family for childbirth
and the newborn baby
Impact of drugs on pregnancy and the
developing fetus
Skills – ability to:
-
5. Routine care to maximize the health of
the mother and fetus during pregnancy
Use health education and basic counselling
jappropriately
- Involve the husband/partner and the wider
family in pregnancy care
- Advise on danger signs, emergency
preparedness and follow-up, birth preparedness
Knowledge:
-
-
ANC-related national policy
National ANC guidelines
Protocols and screening practices including
components such as: vaccinations, TB, PMTCT,
deworming, vitamin A, syphilis, iron and folic
acid, etc.
Investigate laboratory tests that evaluate and
assess pregnancy progress
Routine screening practices for conditions such
as anemia, hypertension, syphilis, HIv
Skills – ability to:
-
84
-
Assess and provide support for normal
pregnancy
Record carefully and follow-up findings
appropriately
Order and/or perform and interpret common
laboratory tests such as haematocrit, urinalysis
6. Identify and refer complicated
pregnancies
or microscopy
Knowledge:
-
Danger signs in pregnancy, e.g. pre-eclampsia,
vaginal bleeding, premature labour, severe
anemia
Pregnancy-related conditions requiring
treatment, referral or transfer
Signs, symptoms and indications for referral of
selected complications and chronic conditions
of pregnancy, e.g. asthma, HIV infection,
diabetes, cardiac conditions, postdated
pregnancy, and effects on mother and neonate
-
Skills – ability to:
Detect women presenting with risk factors
Perform basic life-saving interventions
Provide timely referral when required
Domain 4: Specific Clinical Competencies
Competency 12: The primary health-care team members provide high-quality care during labour, birth and
immediate postpartum
Tasks
1. Provision of optimum maternal care during
labour, delivery and the immediate
postpartum period according to the
individual circumstances and the local
sociocultural context
Knowledge, skills
Knowledge:
-
Psychological and cultural aspects of labour,
birth and the postpartum period
Importance of emotional support in labour
Comfort measures in labour, e.g. family
presence/assistance, positioning
Importance of provision of adequate
hydration and nutrition during labour
Cleanliness of woman and the environment
PMTCT national programme
Chocruz, Momostenango, Guatemala
-
Skills – ability to:
-
2. Identification and monitoring of the
maternal and fetal well-being during the
Take a specific obstetric history
Monitor maternal vital signs in labour
Use national protocols in the case of
diagnosis of abnormal labour patterns and
complications for referral
- Involve traditional birth attendants when
present int eh woman’s psychological
support group
Knowledge:
85
progress of labour
-
-
Anatomy and physiology of labour
Normal progress of labour and use of the
partograph
Anatomy of the fetal skull and pelvis,
maternal and fetal critical diameters, and
landmarks
Process of fetal passage
Skills – ability to:
Chocruz, Momostenango, Guatemala
-
3. Detection of problems and complications
Perform abdominal assessment for fetal
situation, position and descent
- Perform a pelvic examination to assess
dilation and effacement of the cervix,
descent of the presenting part, status of the
membranes and adequacy of the pelvis for
the baby
- Assess the effectiveness of uterine
contractions
- Monitor maternal and fetal vital signs and
the progress of labour with a partograph
- Provide bladder care
Knowledge:
j
-
-
Identification of abnormal labour patterns
and timely referral
Diagnosis complications (e.g. bleeding,
labour arrest, malpresentation, preeclampsia, eclampsia, maternal and fetal
distress, infection, prolapsed cord)
Referral of complications
Skills – ability to:
-
4. Referral of women with complications
requiring a high-level of care, and provision
of pre-referral management
Recognize limitations of knowledge
Perform emergency care during referral
process
Knowledge:
-
Indications for operative delivery, e.g. fetal
distress, cephalo-pelvic disproportion
Pre-referral management
Skills – ability to:
-
86
5. Conduct of a clean and safe childbirth and
Stabilize the woman and/or the fetus before
referral
- Ensure the fastest and safest possible
referral
Knowledge:
placenta delivery
-
Importance of personal support from a
person of the woman’s choice
Maternal and fetal physiology during
childbirth
Supportive care and pain relieve
Importance of cleanliness of woman and
environment
Indication of episiotomy
Transition of neonate to extra-uterine life
Management of third stage of labour
Skills – ability to:
6. Identification, treatment, and stabilization
prior to referral of abnormalities and
complications of birth (e.g. bleeding,
prolonged labour, vacuum extraction, breach
presentation, episiotomy, repair of genital
tears, manual removal of placenta)
Provide support during birth and assist the
woman to give birth in the position she
prefers
- Perform appropriate hand manoeuvres for
cephalic and breach delivery
- Inspect the placenta and membranes
- Estimate maternal blood loss
- Inspect the perineum, vagina and cervix for
lacerations and managing as per protocols
- Undertake, only if indicated, an episiotomy
and repair
Knowledge:
-
Signs and symptoms in the mother or the
neonate that call for immediate referral
Principles of physiological management of
the placenta/active management
Neonatal asphyxia and its management
Chocruz, Momostenango, Guatemala
-
Skills – ability to:
-
7. Immediate care of the neonate
Identify maternal problems (e.g. bleeding,
prolonged labour, vacuum extraction,
breach presentation, episiotomy, repair of
genital tears, manual removal of placenta)
- Perform physiological and active
management of the third stage (immediate
oxytocin, controlled cord traction, uterine
massage(
- Manage a cord around the baby’s neck
during delivery
- Manage antepartum and postpartum
haemorrhage
Knowledge:
-
Essential neonate care, basic needs of the
neonate: breathing, warmth, feeding and
protection
87
-
The importance of exclusive breastfeeding
and of immediate postpartum breastfeeding
National protocols for relevant local
conditions
Knowledge of hepatitis B vaccine and BCG
(bacillius Calmette-Guerin)
Prophylaxis for opthalmia neonatorum and
the use of vitamin K
Skills – ability to:
Chocruz, Momostenango, Guatemala
-
8. Management of neonatal complications
Clamp and cut the cord
Assess the immediate condition of the
neonate
- Perform a screening physical examination of
the neonate
- Ensure neonate is kept warm, preferably by
skin-to-skin contact with the mother
- Support the initiation of breastfeeding
within the first hour of birth or as soon as
possible after birth
- Assist early attachment: mother-fatherbaby, if culturally acceptable
- Administer eye prophylaxis for ophthalmia
neonatorum, and vitamin K as per national
j protocols
- Provide routine vaccinations agreed incountry
Knowledge:
-
Common problems in the neonate
Signs and symptoms in the neonate that call
for immediate referral
Low birth weight (LBW) management,
including the kangaroo method
Neonatal syphilis detection and treatment
Skills – ability to:
Domain 4: Specific Clinical Competencies
88
Identify problems in the neonate and
manage when possible
Apply the kangaroo method for LBW babies
Involve the husband/partner in neonatal
care (e.g. kangaroo method)
Competency 13: The primary health-care team members provide comprehensive, high-quality, postnatal
care for women and neonates
1. Assessment and care of the woman and of
the neonate during the postnatal period (up
to six weeks)
Knowledge, skills
Knowledge:
-
Normal postnatal progress of mother
Signs of sub-involution, e.g. persistent
uterine bleeding, infection
Signs of breastfeeding problems
Maternal nutrition, rest, activity and
physiological needs/sexual life
Normal postnatal progress of neonate
Umbilical cord stump care
Parent-infant bonding/physiological and
emotional attachment
Common problems in the neonate, referral
and management
Skills – ability to:
-
2. Support of breastfeeding
Examine the fundus, lochia and perineum
(tears, swelling, pus or bleeding)
- Manage postpartum complications
- In case of confirmed syphilis, refer as per
protocols
- Break bad news when required
- Support the family if the baby is stillborn, or
there is a neonatal or maternal death
Knowledge:
-
Process of lactation and common variations
including engorgement
Infant nutritional needs and the benefits of
breastfeeding
Chocruz, Momostenango, Guatemala
Tasks
Skills – ability to:
-
3. Detection and management/referral of
maternal and neonatal health problems
and/or complications (e.g. fever, infection,
bleeding, anemia, LBW, etc.)
Perform a breast examination
Support the mother in the immediate
postpartum period
- Assist with breastfeeding management and
its problems
- Communicate with the mother and motivate
her while giving instructions
Knowledge:
-
Postpartum complications
Major neonatal problems
Development of urinary or faecal
89
incontinence
Detection and national management of HIVpositive or syphilis-positive women and their
neonates
Pre-referral treatment of maternal and
neonatal complications (severe PPH,
puerperal sepsis, cerebral damage, severe
prematurity, etc.)
Signs and symptoms of life-threatening
conditions that need referral (e.g. persistent
vaginal bleeding, urinary retention,
postpartum pre-eclampsi, puerperal sepsis)
Signs and symptoms of different levels of
postnatal depression, e.g. “baby blues” the
mildest, to postnatal depression, and
postnatal psychosis the most severe
The management of post-natal depression
Local supports for women with less severe
postnatal depression
Referral systems for women with more
severe depression or puerperal psychosis
-
-
-
-
-
Chocruz, Momostenango, Guatemala
-
Skills – ability to:
-
Detect and treat pre-eclampsi, eclampsia,
anemia, PPH, early postpartum infection,
UTI, postpartum depression, etc.
- Apply national protocols of treatment and
care of detected STI
- Stabilize the woman and/or the neonate
before referral
- Ensure fast and safe referral when necessary
and possible
- Observe the mother’s emotional state,
beginning in antenatal clinics and continuing
throughout postpartum
- Facilitate the use of support networks
- Appropriately refer and follow up
Knowledge:
j
4. Information and counselling on: self-care,
danger signs, emergency preparedness and
follow-up nutrition, safer sex and family
planning (FP)
-
Concept of safer sex
Available family-planning methods
Information on STIs and LAM
Skills – ability to:
-
90
Domain 4: Specific Clinical Competencies
Discuss FP and contraception
Provide/supply FP methods immediately at
the site of delivery
Advise of safer sex
Adams, Alayne, Rita Des Roy, & Amina Mahbub
1995 Participatory Methods to Assess Change in Health and Women’s Lives: An Exploratory Study for
the BRAC-ICDDR,B Joint Project in Matlab. Working Paper Number 5. The BRAC-ICDDR,B
Research Project. Dhaka, Bangladesh.
Alonso, Cristina, Laura Miranda, Sally Hughes, & Lucy Fauveau
1994 Reducing Maternal Mortality Among Repatriated Populations Along the Guatemala-Mexico Border.
FMR 19:13-15
Alonso, Mario Vinicio
2007 Costos y Rentabilidad de Unidades Pecuarias: Municipio de Momostenango, Departmento de
Totonicapan. Facultad de Ciencias Economicas. Universidad de San Carlos de Guatemala.
September, 2007.
Annett, Hugh, & Susan B. Rifkin
Guidelines for Rapid Participatory Appraisals to Assess Community Health Needs: A Focus on Health
Improvements for Low-Income Urban and Rural Areas. Division of Strengthening of Health
Services. World Health Organization
Bailey, P., E. de Bocaletti, G. Barrios, & Y. de Cross
2005 Monitoring Utilization and Need for Obstetric Care in the Highlands of Guatemala. International
Journal of Gynecology and Obstetrics 89:209-217
Becker, Stan, Fannie Fonseca-Becker & Catherine Schenck-Yglesias
2006 Husbands’ and Wives’ Reports of Women’s Decision-Making Power in Western Guatemala and
their Effects on Preventive Health Behaviors. Social Science and Medicine 62:2313-2326
Berman, Peter A., Davidson R. Gwatkin, & Susan R. Burger
1987 Community-Based Health Workers: Head Start or False Start Towards Health for All? Social Science
and Medicine 25(5):443-459.
Berry, Nicole S.
2006 Kaqchikel Midwives, Home Births, and Emergency Obstetric Referrals in Guatemala: Contextualizing
the Choice to Stay at Home. Social Science and Medicine 62:1958-1964
Bhattacharyya, Karabi, Karen LeBan, Peter Winch & Marie Tien
2001 Basics II: Community Health Worker Incentives and Disincentives: How They Affect Motivation,
Retention, and Sustainability. Viginia: USAID.
Carter, Marion
2002 Husbands and Maternal Health Matters in Rural Guatemala: Wives’ Reports on Their Spouses’
Involvement in Pregnancy and Birth. Social Science and Medicine: 55:437-450
Center for Disease Control (CDC)
2011 Community Health Workers: Critical Connections in Communities. CDC: Diabetes Public Health
Resource. http://www.cdc.gov/diabetes/projects/comm.htm
Chambers, Robert
1992 Rural Appraisal: Rapid, Relaxed and Participatory. IDS Discussion Paper 311.
1994 The Origins and Practice of Participatory Rural Appraisal. World Development 22(7):953-969
Cornwall, Andrea
2011 The Use and Abuse of Participatory Rural Appraisal: Reflections from Practice. Agric. Hum.
Values 28:263-272.
Chocruz, Momostenango, Guatemala
Works Referenced:
91
Chocruz, Momostenango, Guatemala
92
De Broe, Sofie
2005 Diversity in the Use of Pregnancy-Related Care Among Ethnic Groups in Guatemala. Journal of
Family Planning and Reproductive Health Care 31(3):199-205.
Foster, Jennifer, Angela Anderson, Jennifer Houston, & Maya Doe-Simkins
2004 A Report of a Midwifery Model for Training Traditional Midwives in Guatemala. Midwifery 20:217225
Glei, Dana A., & Noreen Goldman
2000 Understanding Ethnic Variation in Pregnancy-related Care in Rural Guatemala. Ethnicity and Health
5(1):5-22
Goldman, Noreen, & Dana A. Glei
2003 Evaluation of Midwifery Care: Results from a Survey in Rural Guatemala. Social Science and
Medicine 56:685-700
Haines, Andy, David Sanders, Ula Lehmann, Alexander K. Rowe, Joy E. Lawn, Steve Jan, Damian G. Walker, &
Zulfiqar Bhutta.
2007 Achieving Child Survival Goals: Potential Contribution of Community Health Workers. Lancet
369:2121-2131.
Hartman, Steven, Sarah Leonard & Angelo Tomedi
2008 Changes in Childhood Malnutrition and Mortality After Institution of a Community Health Worker
Program in Four Rural Guatemalan Villages. Department of Family & Community Medicine.
University of New Mexico.
Hinojosa, Servando Z.
2004 Authorizing Tradition: Vectors of Contention in Highland Maya Midwifery. Social Science and
Medicine 59:637-651
Hughes, Jessica
j
2004 Gender, Equity, and Indigenous Women’s Health in the Americas. The Gender and Health Unit.
Pan-American Health Organization. Washington, DC.
Instituto Nacional de Estadistica
2011 Poblacion en Guatemala (demografia). http://www.ine.gob.gt/np/poblacion/index.htm.
Accessed June 24, 2011.
ICM
2010 Essential Competencies for Basic Midwifery Practice. International Confederation of Midwives.
Joseph, Sam
1992 Participatory Rural Appraisal in Identifying Major Illness, Health Care Providers and Costs. RRA
Notes 16:53-36. IIED London.
Kwast, B.E.
1995 Building a Community-based Maternity Program. International Journal of Gynecology and
Obstetrics 48(Suppl):S67-S82
Lehmann, Uta & David Sanders
2007 Community Health Workers: What Do We Know About Them? The State of the Evidence on
Programmes, Activities, Costs, and Impact on Health Outcomes of Using Community Health
Workers. Evidence and Information for Policy. Department of Human Resources for Health. World
Health Organization. Geneva.
Maupin, Jonathan N.
2008 Remaking the Guatemalan Midwife: Health Care Reform and Midwifery Training Programs in
Highland Guatemala. Medical Anthropology 27(4):353-382
2009 ‘Fruit of the Accords’: Healthcare Reform and Civil Participation in Highland Guatemala. Social
Science and Medicine 68:1456-1463
Chocruz, Momostenango, Guatemala
2011 Divergent Models of Community Health Workers in Highland Guatemala. Human Organization
70(1):44-53.
MSPAS, INE, UVG, USAID, ASDI, CDC, UNICEF, UNFPA, & OPS
2009 V Encuesta Nacional de Salud Materno Infantil 2008-2009. Guatemala.
MSPAS
2011 Sistema de Informacion Gerencial de Salud. http://sigsa.mspas.gob.gt/ Data accessed: June 24,
2011.
Murray, Scott A.
1999 Experiences with “Rapid Appraisal” in Primary Care: Involving the Public in Assessing Health Needs,
Orienting Staff, and Educating Medical Students. British Medical Journal 318:440-444
Palmer, Celia A.
1999 Rapid Appraisal of Needs in Reproductive Health Care in Southern Sudan: Qualitative Study. British
Medical Journal 319(7212):743-748.
PAHO
2009 Encuesta Materno Infantil. http://new.paho.org/gut
Perreira, Krista M., Patricia E. Bailey, Elizabeth de Bocaletti, Elena Hurtado, Sandra Recinos de Villagran &
Jorge Matute
2002 Increasing Awareness of Danger Signs in Pregnancy Through Community- and Clinic-Based
Education in Guatemala. Maternal and Child Health Journal 6(1):19-28
Pepall, E., R.W. James & J. Earnest
2006 Guidelines for Conducting Rapid Participatory Appraisals of Community Health Needs in
Developing Countries: Experience from Tulikup, Bali. Asia Pac J Public Health 18(3):42-48
Perez, Leda M. & Jacqueline Martinez
2008 Community Health Workers: Social Justice and Policy Advocates for Community Health and WellBeing. American Journal of Public Health 98:11-14.
PubMed Health
2010 PubMed Health. National Centre for Biotechnology Information.
http://www.ncbi.nlm.nih.gov/pubmedhealth Accessed August 2011
Rifkin, Susan B.
1996 Rapid Rural Appraisal: Its Use and Value for Health Planners and Managers. Public Administration
74:509-526
Roost, Mattias, Sara Johnsdotter, Jerker Liljestrand, & Birgitta Essen
2004 A Qualitative Study of Conceptions and Attitudes Regarding Maternal Mortality Among
Traditional Birth Attendants in Rural Guatemala. International Journal of Obstetrics and
Gynaecology. 111:1372-1377
Rosato, Mikey, Glenn Laverack, Lisa Howard Grabman, Prasanta Tripathy, Nirmala Nair, Charles Mwansambo,
Kishwar Azad, Joanna Morrison, Zulfiqar Bhutta, Henry Perry, Susan Rifkin & Anthony Costello.
2008 Community Participation: Lessons for Maternal, Newborn, and Child Health. Lancet 372:962- 971.
Schooley, Janine, Christine Mundt, Pascale Wagner, Judith Fullerton, & Mark O’Donnell
2009 Factors Influencing Health Care-seeking Behaviours Among Mayan Women in Guatemala.
Midwifery 25:411-421
Skeet, Muriel
1985 Community Health Workers: Promoters or Inhibitors of Primary Health Care? International Nursing
Review 32(2):55-58.
Thaddeus, Sereen, & Deborah Maine
1994 Too Far to Walk: Maternal Mortality in Context., Soc. Sci. Med. 38(2):1091-1110.
93
Chocruz, Momostenango, Guatemala
94
Theis, Joachim, & Heather M. Grady
1991 Participatory Rapid Appraisal for Community Development: A Training Manual Based on
Experiences in the Middle East and North Africa. International Institute for Environment and
Development.
Thompson, Joyce, Judith T. Fullerton, & Angela J. Sawyer
2011 The International Confederation of Midwives: Global Standards for Midwifery Education (2010)
with Companion Guidelines. Midwifery. In Press.
Tolley, Elizabeth, & Margaret E. Bentley
1992 Participatory Methods for Research on Women’s Reproductive Health. RRA Notes 16:63-68. IIED
London.
UNFPA
2011 The State of the World’s Midwifery: Delivering Health, Saving Lives.
USAID
2008 Calidad En Salud: Guatemala: Building Community Capacity to Develop a Local Strategy to Increase
Access to Maternal and Neonatal Care in Totonicapan, Guatemala.
Walsh, Linda V.
2006 Beliefs and Rituals in Traditional Birth Attendant Practice in Guatemala. Journal of Transcultural
Nursing 17(2):148-154.
WHO
2006 World Health Report: Working Together for Health. World Health Organization. Geneva,
Switzerland
2010 Social Determinants of Sexual and Reproductive Health: Informing Future Research and
Programme Implementation. Shawn Malarcher, ed. World Health Organization. Geneva,
Switzerland.
j
2011a Sexual and Reproductive Health: Core Competencies in Primary Care. World Health
Organization. Geneva, Switzerland
2011b Universal Access to Reproductive Health: Accelerated Actions to Enhance Progress on
Millennium Development Goal 5 Through Advancing Target 5B. Lale Say & Doris Chou, eds. World
Health Organization. Geneva, Switzerland.
2011c Global Health Observatory Data. Guatemala. World Health Organization.
http://www.who.int/countries/gtm/en/. Accessed August 1st, 2011.