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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. 1 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 j 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 2 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 3 Guatemalan Country-Level Indicators: Country-Level Indicators: Chocruz, Momostenango, Guatemala F IGURE 1: D EPARTMENTAL M AP OF GUATEMALA 4 j 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 5 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 6 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 7 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. 8 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. j 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. 9 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. j “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: 10 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. 11 F IGURE 5: I NSIDE THE C HOABAJ H EALTH -POST Chocruz, Momostenango, Guatemala Water and Sanitation Services in Chocruz, Momostenango: 12 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. 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