Salud de la mujer y planificación familiar

BACKGROUND: In Guatemala, childhood vaccination rates, particularly in Indigenous communities, are low due to inaccessible information and mistrust. Using a human-centered design (HCD) process with community partners, we developed CLAVE (Culturally and Linguistically Appropriate Vaccine Education), a video series on routine and human papillomavirus (HPV) immunization in Kaqchikel, K’iche’, and Spanish. Content was distributed via social media and through community health workers (CHWs). This study describes the instructional design process and assesses implementation feasibility through community-level measures of reach and engagement and acceptability among CHWs across 12 communities in the Central Highlands of Guatemala. METHOD: To develop content, we applied an HCD framework and collected iterative feedback from communities through 16 CHW interviews and nine focus group discussions with 42 community members. We implemented CLAVE in 12 communities, with four communities randomly assigned in parallel to each arm: (1) a six-week, geographically targeted social media campaign promoting CLAVE videos; (2) the same social media campaign plus CLAVE videos and complementary digital infographic job aids provided to CHWs; and (3) a control arm with no exposure to CLAVE videos or the CHW intervention. Platform analytics were used to assess the reach and engagement potential on social media, and CHW survey data were used to assess acceptability of content among CHWs. RESULTS: The CLAVE campaign reached 486,594 unique social media platform users, with over 4.1 million impressions and a high overall engagement rate reflecting multiple user interactions with content. Spanish and Kaqchikel versions reached the largest audiences, while K’iche’ content generated proportionally higher engagement and viewing rates, suggesting stronger interaction among smaller language audiences. Vaccine acceptance was high across all CHWs. Amid a high baseline, the intervention was not associated with significant differences in CHWs’ perceptions of the efficacy or importance of routine childhood vaccination or HPV vaccination, nor with knowledge measures. However, CHWs receiving CLAVE content directly were more likely to strongly agree that the HPV vaccine is safe (p < 0.05). CHWs reported high perceived usefulness and frequent utilization of CLAVE content. CONCLUSIONS: This pilot suggests that geographically targeted paid social media distribution of community-engaged, multilingual vaccine education content can achieve broad exposure, and that pairing videos with job aids can support CHW vaccine education efforts. REGISTRY: ClinicalTrials.gov, TRN: NCT06186206, Registration date: 05 January 2024.

To assess human papillomavirus (HPV) vaccine awareness and uptake among caregivers in rural Indigenous communities in Guatemala and to identify sociodemographic predictors of vaccine unawareness and non-uptake. This cross-sectional survey was conducted across 12 rural Indigenous communities in Guatemala's Central Highlands. Using a community-engaged research approach, trained multilingual health workers administered surveys in Spanish, Kaqchikel or K'iche'. Eligible participants were adults who served as primary caregivers to children. The survey assessed HPV vaccine awareness, vaccine attitudes and uptake among those with daughters aged 8 or older. Logistic regression was used to examine predictors of vaccine unawareness and bivariate analysis explored differences in vaccine uptake. Among 602 participants (92.5% identified as Indigenous), 95% expressed willingness to vaccinate a child against cervical cancer, yet only 56% had heard of the HPV vaccine. Of the 175 participants with eligible daughters, only 33.7% reported vaccination. Indigenous identity, older age and illiteracy were significantly associated with HPV vaccine unawareness. Speaking an Indigenous language at home was associated with greater awareness. Departmental differences were significant: participants from Sololá were more likely to be unaware of the vaccine, while those from Sacatepéquez had higher awareness and uptake. Community partners noted that access to information, geographic connectivity and social desirability may influence both awareness and response accuracy. Despite strong willingness to vaccinate, significant knowledge gaps persist among Indigenous caregivers. Tailored, community-informed education strategies-delivered through trusted channels and adapted linguistically and culturally-are urgently needed to increase awareness and uptake of the HPV vaccine in underserved Guatemalan communities.

[Abstract not available]

More than 80% of cervical cancer cases and deaths occur in low- and middle-income countries. Here, we analyze a large geographically extensive cross-sectional data set from the Western rural highlands of Guatemala. Our objective is to better characterize weak points in care along the cervical cancer care continuum and investigate sociodemographic and clinical correlates of loss to follow-up. We conducted a retrospective review of electronic health records data from July 21, 2015, through December 10, 2020 for a cytology-based screening and cervical cancer treatment program. We used a care cascade analysis to characterize the progression of individuals through screening, confirmatory testing, and treatment. We examined demographic and clinical factors correlated with screening and loss to follow-up using multivariate logistic regression. A total of 8,872 individuals were included in the analysis. Five thousand nine hundred thirteen cervical cancer screenings were conducted. 4.1% of all screening tests were abnormal, including 0.61% cervical intraepithelial neoplasia or overt cervical cancer. Care cascade analysis showed that 67% of eligible women accepted screening. Of those requiring confirmatory testing or treatment, 73% completed recommended follow-up. In adjusted multivariable analysis, prior history of sexual transmitted infection, prior experience with cervical cancer screening, older age, and current contraceptive use were associated with accepting screening. Age and contraceptive use were also associated with retention in care after a positive first screen. In a large rural Guatemalan retrospective cohort, a care continuum analysis showed that both declining the opportunity to receive cervical cancer screening as well as declining confirmatory testing after a first positive screen were both important weak points along the care continuum. These data support the need for comprehensive and culturally appropriate initiatives to improve screening uptake and retention in care.

In-utero progress of fetal development is normally assessed through manual measurements taken from ultrasound images, requiring relatively expensive equipment and well-trained personnel. Such monitoring is therefore unavailable in low- and middle-income countries (LMICs), where most of the perinatal mortality and morbidity exists. The work presented here attempts to identify a proxy for IUGR, which is a significant contributor to perinatal death in LMICs, by determining gestational age (GA) from data derived from simple-to-use, low-cost one-dimensional Doppler ultrasound (1D-DUS) and blood pressure devices. A total of 114 paired 1D-DUS recordings and maternal blood pressure recordings were selected, based on previously described signal quality measures. The average length of 1D-DUS recording was 10.43 ± 1.41 min. The min/median/max systolic and diastolic maternal blood pressures were 79/102/121 and 50.5/63.5/78.5 mmHg, respectively. GA was estimated using features derived from the 1D-DUS and maternal blood pressure using a support vector regression (SVR) approach and GA based on the last menstrual period as a reference target. A total of 50 trials of 5-fold cross-validation were performed for feature selection. The final SVR model was retrained on the training data and then tested on a held-out set comprising 28 normal weight and 25 low birth weight (LBW) newborns. The mean absolute GA error with respect to the last menstrual period was found to be 0.72 and 1.01 months for the normal and LBW newborns, respectively. The mean error in the GA estimate was shown to be negatively correlated with the birth weight. Thus, if the estimated GA is lower than the (remembered) GA calculated from last menstruation, then this could be interpreted as a potential sign of IUGR associated with LBW, and referral and intervention may be necessary. The assessment system may, therefore, have an immediate impact if coupled with suitable intervention, such as nutritional supplementation. However, a prospective clinical trial is required to show the efficacy of such a metric in the detection of IUGR and the impact of the intervention.

Cervical cancer screening is not well implemented in many low- and middle-income countries (LMICs). Mobile health (mHealth) refers to utilization of mobile technologies in health promotion and disease management. We aimed to qualitatively synthesize published articles reporting the impact of mHealth on cervical cancer screening-related health behaviors. Three reviewers independently reviewed articles with the following criteria: the exposure or intervention of interest was mHealth, including messages or educational information sent via mobile telephone or e-mail; the comparison was people not using mHealth technology to receive screening-related information, and studies comparing multiple different mHealth interventional strategies were also eligible; the primary outcome was cervical cancer screening uptake, and secondary outcomes included awareness, intention, and knowledge of screening; appropriate research designs included randomized controlled trials and quasi-experimental or observational research; and the study was conducted in an LMIC. Of the 8 selected studies, 5 treated mobile telephone or message reminders as the exposure or intervention, and 3 compared the effects of different messages on screening uptake. The outcomes were diverse, including screening uptake (n = 4); health beliefs regarding the Papanicolaou (Pap) test (n = 1); knowledge of, attitude toward, and adherence to colpocytologic examination (n = 1); interest in receiving messages about Pap test results or appointment (n = 1); and return for Pap test reports (n = 1). Overall, our systematic review suggests that mobile technologies, particularly telephone reminders or messages, lead to increased Pap test uptake; additional work is needed to unequivocally verify whether mhealth interventions can improve knowledge regarding cervical cancer. Our study will inform mHealth-based interventions for cervical cancer screening promotion in LMICs.

Race, ethnicity, and indigenous status should be considered as potential drivers of provider bias in family planning services globally. Efforts to confront provider bias in family planning counseling should include concrete strategies that promote provider recognition of biases and longitudinal curriculums that allow for sustained feedback and self-reflection.

There has been limited research on the relationship between contraception and child growth in low-income and middle-income countries (LMICs). This study examines the association between contraception and child linear growth in Guatemala, an LMIC with a very high prevalence of child stunting. We hypothesise that contraceptive use is associated with better child linear growth and less stunting in Guatemala. Using representative national data on 12 440 children 0-59 months of age from the 2014-2015 Demographic and Health Survey in Guatemala, we constructed multivariable linear and Poisson regression models to assess whether child linear growth and stunting were associated with contraception variables. All models were adjusted for a comprehensive set of prespecified confounding variables. Contraceptive use was generally associated with modest, statistically significant greater height-for-age z-score. Current use of a modern method for at least 15 months was associated with a prevalence ratio of stunting of 0.87 (95% CI 0.81 to 0.94; p<0.001), and prior use of a modern method was associated with a prevalence ratio of stunting of 0.93 (95% CI 0.87 to 0.98; p<0.05). The severe stunting models found generally similar associations with modern contraceptive use as the stunting models. There was no significant association between use of a modern method for less than 15 months and the prevalence ratio of stunting or severe stunting. Contraceptive use was associated with better child linear growth and less child stunting in Guatemala. In addition to the human rights imperative to expand contraceptive access and choice, family planning merits further study as a strategy to improve child growth in Guatemala and other countries with high prevalence of stunting.

Purpose Cervical cancer is an important cause of mortality in low- and middle-income countries. Although screening technologies continue to improve, systems of care remain fragmented. It is important to better understand factors that affect use of screening services and loss to follow-up along the care continuum. Methods We conducted a mixed-methods study of a cytology-based screening program in rural Guatemala. A retrospective electronic chart review was performed on data from all patients from 2013 to 2014. We analyzed progression through care and calculated loss-to-follow-up rates. We also analyzed the prior experiences of patients with cervical cancer screening on the basis of self-reported historical data available in the chart review. Structured interviews with a subset of individuals to explore social supports and barriers to screening and engagement in care were conducted at the time of screening. Results The analysis included 515 women (median age, 36 years). Cytologic screening showed concern for neoplastic changes in 0.83%; half resulted in biopsy-proven cervical intraepithelial neoplasia. An additional 9.9% showed severe inflammation. The rate of loss to follow-up was 11.3%. All losses to follow-up occurred for severe inflammation, not for cervical intraepithelial neoplasia. Historical data showed that 73% of the cohort had previously been screened and had high levels of loss to follow-up (57.4%). Qualitative interviews revealed factors that promoted loss to follow-up; these included cost, lack of social supports, transportation, distrust in public facilities, long turn-around times, and failure to return test results or offer follow-up treatments. Conclusions Taken together, these quantitative and qualitative results highlight the need for cervical cancer screening programs in Guatemala to improve uptake of screening services by eligible women and to improve follow-up after a first abnormal screen.

In many low-resource settings around the world utilization of long-acting reversible contraception (LARC) is low, in part due to access barriers. We sought to explore LARC utilization patterns as well as factors associated with LARC initiation by women seeking contraception in rural Guatemala from a program working to reduce contraception access barriers. We analyzed data from a program that provides family planning in six remote, primarily indigenous, villages in Guatemala with limited access to alternative health services. Methods are free and delivered directly within villages by culturally competent providers. We conducted a retrospective chart review of all 288 women who initiated a contraceptive method over a 16-month period and conducted a logistic regression to obtain adjusted odds ratios (OR) for predictors of LARC uptake. Overall 79.2% of women elected a LARC method. More than half of women (49.8%) switched to LARC from short-acting hormonal methods. In the univariate analysis prior use of short-acting method (p = 0.014), number of prior methods (p = 0.049), and current contraceptive use (p<0.01) were significantly associated with choosing a LARC. In the logistic regression model current use of contraception remained significant (OR 3.29, 95% CI 1.67-8.04). Report of abnormal bleeding or other side effects from prior short-acting method use did not predict LARC uptake (p = 0.82 and p = 0.079). Most women in this marginalized population opted for a LARC method. Low utilization of LARCs may be related to service delivery factors. Further research is needed to validate these conclusions prospectively and in less selected populations.

A recent article in GHSP calls for classifying fertility awareness methods as “modern contraceptives” despite their inferiority. We believe in a rights-based approach, which considers the real-world conditions that many women face, including constrained sexual agency and low baseline reproductive health literacy. We must demonstrate true commitment to increasing access to the most effective and reliable contraceptive methods. A recent article in GHSP calls for classifying fertility awareness methods as “modern contraceptives” despite their inferiority. We believe in a rights-based approach, which considers the real-world conditions that many women face, including constrained sexual agency and low baseline reproductive health literacy. We must demonstrate true commitment to increasing access to the most effective and reliable contraceptive methods.