Anita Chary

Determining adult type 2 diabetes-related health care needs in an indigenous population from rural Guatemala: a mixed-methods preliminary study

BackgroundIn Guatemala, diabetes is an emerging public health concern. Guatemala has one of the largest indigenous populations in Latin America, and this population frequently does not access the formal health care system. Therefore, knowledge about the emergence of diabetes in this population is limited.MethodsInterview participants (n=23) were recruited from a convenience sample of indigenous adults with type 2 diabetes at one rural diabetes clinic in Guatemala. A structured interview was used to assess knowledge about diabetes and its complications; access to diabetes-related health care and treatment; dietary and lifestyle changes; and family and social supports for individuals living with diabetes. Interviews were supplemented with two group interviews with community leaders and health care providers. Thematic analysis was used to produce insights into diabetes knowledge, attitudes, and practices. In addition, a chart review of the clinic’s electronic medical record identified all adult patients (n=80) presenting in one calendar year for a first-time diabetic consultation. Sociodemographic and clinical variables were extracted and summarized from these records.ResultsSalient demographic factors in both the structured interview and chart review samples included low educational levels and high indigenous language preference. In the interview sample, major gaps in biomedical knowledge about diabetes included understanding the causes, chronicity, and long-term end-organ complications of diabetes. Medication costs, medical pluralism, and limited social supports for dietary and lifestyles changes were major practical barriers to disease management. Quantitative data from medical records review revealed high rates of poor glycemic control, overweight and obesity, and medication prescription.ConclusionsThis study provides a preliminary sketch of type 2 diabetes in an indigenous Guatemalan population. Combined qualitative and quantitative data point towards particular needs for implementation and future research, including the need to address gaps in diabetes knowledge, to improve social support systems, and to address the cost barriers associated with disease treatment.

Mixed-methods study identifies key strategies for improving infant and young child feeding practices in a highly stunted rural indigenous population in Guatemala

Guatemalas rural indigenous population suffers from one of the highest rates of chronic child malnutrition (stunting) in the world. Successfully addressing stunting requires defining the barriers to and opportunities for new behaviour-change initiatives. We undertook a mixed-methods assessment of feeding practices and food purchasing behaviours around infants and young children aged 6-36 months in two rural indigenous Guatemalan communities. We found that most caregivers were aware only of acute forms of child malnutrition and that they greatly underestimated the local prevalence of malnutrition. Despite moderate adherence to exclusive breastfeeding and timing of complementary food introduction, diets had poor diversity and inadequate meal frequency. Furthermore, perceptions of food insecurity were high even in the presence of land ownership and agricultural production. Although fortified foods were highly valued, they were considered expensive. At the same time, proportionally equivalent amounts of money were spent on junk foods or other processed foods by most participants. Biological mothers often lacked autonomy for food purchasing and nutritional decisions because of the power exerted by husbands and paternal grandmothers. Our findings suggest several creative and community-based programming initiatives including education about the acute vs. chronic malnutrition distinction, engaging landowners in discussions about domestic food consumption, engaging with caregivers to redirect funds towards fortified foods rather than junk food purchases and directing behaviour-change initiatives towards all household stakeholders.

Major challenges to scale up of visual inspection-based cervical cancer prevention programs: the experience of Guatemalan NGOs

Scale up of visual inspection with acetic acid (VIA) in Guatemala encountered major challenges, including high attrition of people trained, didactic training without hands-on skills building, lack of continued supervision, and provision of VIA alone without immediate on-site provision of cryotherapy. Scale up of visual inspection with acetic acid (VIA) in Guatemala encountered major challenges, including high attrition of people trained, didactic training without hands-on skills building, lack of continued supervision, and provision of VIA alone without immediate on-site provision of cryotherapy. ABSTRACT Background: Like many other low- and middle-income countries, Guatemala has adopted visual inspection with acetic acid (VIA) as a low-resource alternative to the Pap smear for cervical cancer screening. Nongovernmental organizations (NGOs) introduced VIA to Guatemala in 2004, and a growing number of NGOs, working both independently and in collaboration with the Guatemalan Ministry of Health, employ VIA in cervical cancer prevention programs today. While much research describes VIA efficacy and feasibility in Latin America, little is known about NGO involvement with VIA programming or experiences with VIA outside the context of clinical trials and pilot projects in the region. Methods: To explore challenges faced by NGOs implementing VIA programs in Guatemala, we conducted semi-structured interviews with 36 NGO staff members involved with 20 VIA programs as direct service providers, program administrators, and training course instructors. Additionally, we collected data through observation at 30 NGO-sponsored cervical cancer screening campaigns, 8 cervical cancer prevention conferences, and 1 week-long NGO-sponsored VIA training course. Results: Frequently highlighted challenges included staff turnover, concerns over training quality, a need for opportunities for continued supervision, and problems with cryotherapy referrals when immediate treatment for VIA-positive women was unavailable. Conclusions: Reducing staff turnover, budgeting to train replacement providers, standardizing training curricula, and offering continued supervision are key strategies to improve VIA service quality and program sustainability. Alternative training methods, such as on-the-job mentoring and course prerequisites of online learning, could help increase training time available for clinical supervision. Efforts should be made to ensure that VIA testing is coupled with immediate cryotherapy, that providers trained in VIA are also trained in cryotherapy, and that cryotherapy supplies and equipment are maintained. Where this is not possible and only VIA screening is available, referral systems must be strengthened.

Male Influence on Infant Feeding in Rural Guatemala and Implications for Child Nutrition Interventions

BACKGROUND AND AIMS Guatemala has one of the highest rates of child stunting in the world, which especially impacts rural indigenous agricultural communities. Despite decades of intensive nutrition research and interventions, only rarely have nutrition programs successfully lowered the rate of stunting in these settings. The bulk of nutritional interventions in Guatemala are targeted at the education of female caregivers. However, womens ability to implement best practices in infant breastfeeding and complementary feeding are often constrained by external factors. This study evaluated the knowledge, beliefs, and practices of female caregivers, as well as the attitudes of fathers, toward breastfeeding and infant feeding in a rural Guatemalan village. METHODS Clinical work, participant-observation, surveys, interviews, and focus groups were conducted in a rural Guatemalan village in conjunction with a child feeding program from August 2008 to January 2011. RESULTS Male employment status, mental health, and attitudes towards child rearing and parenting responsibilities are often principal factors in infant growth failure. CONCLUSIONS Successful child feeding programs must include educational elements for men and should consider structural elements that provide a safety net for unexpected changes in domestic finances.

Perceptions and utilization of generic medicines in Guatemala: a mixed-methods study with physicians and pharmacy staff

BackgroundAccess to low-cost essential generic medicines is a critical health policy goal in low-and-middle income countries (LMICs). Guatemala is an LMIC where there is both limited availability and affordability of these medications. However, attitudes of physicians and pharmacy staff regarding low-cost generics, especially generics for non-communicable diseases (NCDs), have not been fully explored in Guatemala.MethodsSemi-structured interviews with 30 pharmacy staff and 12 physicians in several highland towns in Guatemala were conducted. Interview questions related to perceptions of low-cost generic medicines, prescription and dispensing practices of generics in the treatment of two NCDs, diabetes and hypertension, and opinions about the roles of pharmacy staff and physicians in selecting medicines for patients. Pharmacy staff were recruited from a random sample of pharmacies and physicians were recruited from a convenience sample. Interview data were analyzed using a thematic approach for qualitative data as well as basic quantitative statistics.ResultsPharmacy staff and physicians expressed doubt as to the safety and efficacy of low-cost generic medicines in Guatemala. The low cost of generic medicines was often perceived as proof of their inferior quality. In the case of diabetes and hypertension, the decision to utilize a generic medicine was based on multiple factors including the patient’s financial situation, consumer preference, and, to a large extent, physician recommendations.ConclusionsInterventions to improve generic medication utilization in Guatemala must address the negative perceptions of physicians and pharmacy staff toward low-cost generics. Strengthening state capacity and transparency in the regulation and monitoring of the drug supply is a key goal of access-to-medicines advocacy in Guatemala.

Exploring mechanisms of food insecurity in indigenous agricultural communities in Guatemala: a mixed methods study

BackgroundThe country of Guatemala has one of the highest rates of chronic child malnutrition in the world, which primarily affects the rural, indigenous Maya population. In this study we explore the apparent paradox of endemic food insecurity and child malnutrition coexisting in Maya communities alongside a predominance of agricultural land holdings and food production.MethodsA mixed methods design explored food availability and access in a rural indigenous agricultural community, as compared to a nearby urban indigenous community. Structured surveys in both open-air markets and corner stores examined price, quality, and availability of foods. Structured household surveys examined land ownership, crop production, perceptions of food security, and the diversity of children’s diets. Key informant interviews with local farmers clarified findings related to land holdings and farming patterns.ResultsChildren’s diets demonstrated a lack of diversity, and were especially deficient in dairy, flesh foods, eggs, and vitamin A-rich foods. Food insecurity was highly prevalent, with limited availability of, and access to, nutritionally diverse foods. In particular, the expansion of nontraditional agricultural exports (NTAEs) reduced food availability by displacing subsistence crops. Poor returns on investment for NTAEs limited the available cash for food purchasing, further exacerbating poor diets. Food availability was further reduced by infrequent access to open-air markets in the rural setting as compared to the urban setting, with high risk of food spoilage. As a result much food purchasing was of low-cost, low-quality processed food which, unlike higher-quality fresh foods, were equally affordable and available in both the rural and the urban environment.ConclusionsThe proliferation of NTAEs and commoditized foods reduce dietary diversity and displace the production and consumption of fresh, nutritious foods, even in rural communities devoted primarily to food production. Rural agricultural communities in Guatemala therefore bear many resemblances to the urban “food deserts” of higher-income countries.

A Patient Navigation System to Minimize Barriers for Peritoneal Dialysis in Rural, Low-Resource Settings: Case Study From Guatemala

BACKGROUND: CHRONIC KIDNEY DISEASE IN GUATEMALA Guatemala is a lowerto middle-income, Latin American nation with a population of 16 million people and a growing need for rural dialysis services due to a confluence of factors. First, although the epidemiology and risk factors for chronic kidney disease (CKD) in Guatemala are not well understood, there is evidence that CKD mortality is among the highest in the Americas. The emerging entity “chronic kidney disease of nontraditional causes” may be a CKD risk factor in rural Guatemala, and regional data show that diabetic renal disease is a significant driver of population mortality. Second, approximately 40% of the population are rural indigenous Maya, a group that faces significant socioeconomic, geographic, and language barriers in accessing specialty nephrology care that is available only in urban tertiary centers. Finally, Guatemala’s population is growing and aging rapidly, greatly increasing the absolute number of people at risk for CKD.

Aid and Gendered Subjectivity in Rural Guatemala

Abstract Development discourse has focused on gendered dimensions of poverty, demonstrating how parastatal poverty alleviation programmes target women as aid recipients while devaluing their productive and reproductive work. However, seldom analysed is how privatisation of social services and proliferation of non-governmental organisations (NGOs) have impacted women. We explore this in a Guatemalan community where we find that although NGOs discursively commit to ‘alternative’ development approaches, on the ground they reproduce elements of a neoliberal subjectivity akin to parastatal programmes. NGOs additionally configure aid disbursement as gift giving, requiring beneficiaries to assume affective postures of gratitude, and facilitating intrusion into women’s lives.

Case reportAccompanying indigenous Maya patients with complex medical needs: A patient navigation system in rural Guatemala

a Wuqu’ Kawoq | Maya Health Alliance, Guatemala b Department of Emergency Medicine, Massachusetts General Hospital, United States c Departments of Internal Medicine and Pediatrics, University of Minnesota, United States d Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, United States e University of California, San Francisco, United States f Burrell College of Osteopathic Medicine, United States g Division of Global Health Equity, Brigham and Women’s Hospital, United States

Insights into Global Health Practice from the Agile Software Development Movement

Global health practitioners may feel frustration that current models of global health research, delivery, and implementation are overly focused on specific interventions, slow to provide health services in the field, and relatively ill-equipped to adapt to local contexts. Adapting design principles from the agile software development movement, we propose an analogous approach to designing global health programs that emphasizes tight integration between research and implementation, early involvement of ground-level health workers and program beneficiaries, and rapid cycles of iterative program improvement. Using examples from our own fieldwork, we illustrate the potential of ‘agile global health’ and reflect on the limitations, trade-offs, and implications of this approach.