La Avanzada Health Needs Asssessment

Health Needs Assessment

of

La Avanzada, Guatemala

Prepared by

Jen Janousek, Ph.D.

Concordia University, Nebraska

May 2011

Table of Contents

Introduction……………………………………………………...3

Phase 1: Planning and Organizing……………………………....3

Phase 2: Needs Assessment Methodology………………………4

Phase 3: Needs Assessment Survey Collection…………………4

Phase 4: Summarizing and Disseminating………………………5

Table 1: Demographic Information……………………..6

Phase 5: Actions………………………………………………...7

References……………………………………………………...10

Appendix A: Focus Group Questions for Health Workers…….11

Appendix B: Family Survey…………………………………...12

In March 2011 a health needs assessment was performed in La Avanzada, Guatemala; a remote rural village in the mountains populated by approximately 675 people. This report contains an overview of what a needs assessment is, the steps involved in this assessment, a summary of the data collected, and suggestions for future action.

A community health needs assessment is a process that describes the state of health of local people, enables the identification of the major risk factors and causes of ill health, and enables the identification of the actions needed to address these (Rowe, McClelland, & Billingham, 2001). A needs assessment is an important step that will enable CALMS and the local Guatemala people to plan and deliver the most effective care to those in greatest need. It will also ensure that scarce resources are allocated where they can give maximum health benefit. Additionally, it will facilitate CALMS to work collaboratively with the community and other professionals and agencies to determine which health issues cause greatest concern and plan interventions to address those issues.

The needs assessment methodology was divided into 5 steps. These steps are based on the Concerns Report Method developed by Fawcett, Suarez, Johnson, Whang-Ramos, Seekins, and Bradford (1987) and Suarez, Balcazar, and Keys (1999) “Self help guide: Community needs assessment and action planning,” but have been adapted for the assessment of La Avanzada.

Phase 1: Planning and Organizing

Background information for the needs assessment was gathered through an initial on-site visit in September 2010 and through research using resources from the World Health Organization (WHO) to learn about the community that is being assessed. First, general information on the country of Guatemala from WHO will be presented followed by additional data collected through informal conversations and observations made.

As of 2006, WHO reported that the total population of Guatemala was nearing 13 million with approximately 40% being indigenous (WHO, 2007). The urban population in Guatemala is 47.6% with the remaining 52.4% being rural. Guatemala’s public health expenditure is around 1% of GDP (2007). Twenty percent of its population lacks regular access to health services and the public services are not only limited, but ineffective and inferior. In rural and indigenous areas, 21.5% of the population lives on less than US $1 per day (2007).

Statistics on child and maternal health are just as staggering. The total fertility rate is 4.2 children (6.2 in indigenous families) according to WHO (2007). In 2004, infant mortality of 39 per 100,000 live births was reported and the under 5 mortality rate was 48 per 100,000 live births. The estimated maternal mortality rate in 2000 was 153, with the number for the indigenous population being three times higher. WHO reports that approximately 49% of children under the age of 5 suffer from chronic malnutrition (68% among indigenous children), and 30% of pregnant women have nutritional deficits (2007). Guatemala has the third lowest contraceptive rate in the Americas. On the bright side, Guatemala has made great strides with improved vaccination coverage in recent years with approximately 92% of infants receiving the immunization program which includes 10 immunizations (2007).

WHO also reports that as of 2002 75% of the Guatemalan population has access to an improved source of drinking in water (90% of the urban and 60% of the rural population), however, “improved” was not defined. Additionally, the figure for improved sanitation facilities was 47% (77% urban and 17% rural). The lack of education is also a problem in Guatemala. In 2006, only 62.4% of students who started grade one reach the last grade of primary school. When breaking the data down by gender, the picture is bleaker for females. The percent of females completing primary education is 49.3% and females completing secondary or higher education is 25.3% leaving the other 25.4% with no education whatsoever. Social violence also seems to be an issue with an alarming number of women (more than 2000 from 2003-2006) dying violently.

During the initial site visit in September 2010, it was learned that 675 people (approximately 100 families) live in the La Avanzada village. Fifty percent of the community members live in substandard homes and it is believed that 90% of the kids are malnourished. The nearest health clinic is in La Union which is 6 km away from La Avanzada administered by what would be equivalent to an LPN in the United States and “health workers” with limited education. This area was affected by the mudslides in 2008 and the mountain is considered unstable. Based on observations, it appears that lack of hygiene, sanitation, clean water, and food are the biggest health issues in the village.

Phase 2: Needs Assessment Methodology and

Phase 3: Needs Assessment Survey Collection

In order to learn about the health strengths and challenges in the community, a representation of the community must be obtained. Both the local health workers and community members were assessed.

A small informal group of health workers were interviewed to discuss and reflect on the health issues surrounding the community. The needs assessment process was explained to the health workers, why it was being done, and the role of the focus group with the help of a translator. Several open-ended questions were asked to identify community health strengths and concerns. (See Appendix A for a list of questions that were generated for the focus group. Please note that not all questions were asked during the focus group.)

The family survey that was created consisted of 2 parts; basic demographic information followed by several open-ended questions regarding both concerns and strengths of the health of the community. (See Appendix B for a copy of the survey.) With the help of a translator, several homes were visited and surveyed. The families really opened up and gave pertinent information to the surveyors. Upon the completion of the survey, a protein powder supplement was given to the families with verbal instructions on how to use it. The homes visited for the survey were selected by Ramiro, our CALMS cultural helper, and it is unknown how random the selection process was.

Phase 4: Summarizing and Disseminating the Health Needs Assessment Survey Results

During the focus group with the health workers, much information was shared. The health workers reported that there are 5 clinics with 2 workers in each clinic. Each clinic serves 3 different villages. It is a 6 km walk to get to one of the clinics from La Avanzada and approximately 40 people come to the clinic daily which is open 7 days a week. The health workers receive ten months of training as a nurse and are able to give injections.

The health workers reported that the illnesses they see most often are respiratory diseases, diarrhea, and parasite infections. The health workers biggest concerns is the lack of medicine to give to the patients and the level of care they are able to give as no one is able to do surgical procedures. When asked what the local villagers’ resources and barriers for improving their nutrition were, they responded saying that the people do not eat a balanced diet and there simply is not enough food to eat. We were also informed that water is plentiful in the village and most have direct access in their homes, but the villagers do not understand that the water must be treated and it is not safe to drink. The health workers have been trying to teach the people to boil their water or add Clorox, but very few follow through and appropriately treat the drinking water hence the large numbers of the population with parasite infections. The health workers also realize the outhouses need to be improved. They reported that the outhouses are too close to the homes and during the rainy season they fill up and overflow which results in sewage covering the ground which causes the spread of disease.

It is apparent that the health workers are quite knowledgeable on the health issues in the community. However, there is an information gap getting the knowledge to the villagers in order to improve the community’s health and/or a gap in resources (food security, improving outhouses, etc.) The health workers stated they would like to receive more training to gain skills to better educate patients and families. At the conclusion of the focus group, Drs. Sarah Matthias and Jen Janousek with the help of translator Grace Hughey, conducted an education session on disease prevention with the health workers using the Health Education Program for Developing Countries Handbook which can be downloaded at The health workers seemed excited with the new resources given to them and felt they would be a helpful teaching tool to use with patients.

The second part of the needs assessment was the family survey. Five homes were visited and surveyed in March 2011 in La Avanzada. Each survey took over an hour as a rapport and relationship of trust needed to be established with each family as sensitive health questions were being asked. The adult female (due to chance/circumstance) of each home was surveyed. In one home, the father figure was also present during the survey.

The families were first asked some basic demographic questions followed by open ended questions. The average age of the women being surveyed was 43.4 years old. The average number of children living in the home was 5.8 children and average number of total children in family (living both inside and outside of the home) was 6.6 children. The upper arm circumference of the children was measured (per recommendations of “Where There Is No Doctor” handbook), but none of the children had arm circumferences smaller than 13 ½ centimeters which would be a sign of malnutrition. See Table 1 for the demographic information for each home.

Table 1: Demographic Information of Families Surveyed

Each family was asked to describe the health of the people that live in La Avanzada. One woman responded saying that many people suffer from fevers, colds, and respiratory diseases. She stated that people go to La Union for parasite treatment. Another woman thought the biggest problems were fevers (caused by climate changes) and diarrhea. One woman focused on the health of mother’s giving birth in her response. She also brought up the problem of lack of cleanliness in homes causing health problems. The last woman said as a whole people are not very healthy in La Avanzada and suffer from coughs, fevers, and runny noses. She said their diets are lacking. She went on to say they have oranges and eggs, but sell them so they can buy beans and soap.

The interviewer than asked what they thought affected people’s health in La Avanzada. The only good thing the women listed was access to water in the homes. The bad things the women mentioned that affect health was how “the climate affects the bad things that happen,” malnutrition (especially in June and July when they run out of corn), diarrhea, and the fact that the chickens keep dying. (Ramiro told us the chickens need to be vaccinated.) If the women could change things to improve people’s health they said they would improve education, have more medications available for fevers, and to teach parents to keep their kids clean.

Three of the five families stated that members of their family are currently suffering from an illness or disability. One father figure of one family fell out of a tree and is permanently disabled. The same family also has a 5-year-old suffering from parasites. They said they know he has parasites because he grinds his teeth at night and complains of stomach pain. Another family has a young child with a runny nose and another child suffering from headaches. And the third family has a young child suffering from diarrhea which they had just received medicine to treat.

The families were asked if they had worries about a list of different topics (see #5 on family survey for complete list). Presented is a summarized version of their worries. Many shared the concern of lack of money. One woman cited that she makes 40Q (equivalent to $4.50 USD) a day working for a coffee field owner. Many work during the months of November to February when the coffee crop comes in and than are out of work until the next year. Apparently very few people move away from La Avanzada unless they join the security force or army. Most people work in agriculture. One woman admitted that she is hesitant to bathe regularly because she thinks it causes her pain because the water is cold. One woman added that it is a daily, time consuming chore to go look for firewood.

Not much feedback was given about concerns for their home, neighbors, water, and pollution (#6), but did receive similar responses about what their diet consists of. Most families’ diet consisted of one staple item: corn tortillas. Once in awhile the families eat beans and during coffee season they might occasionally have meat. Only one family said they eat beans daily and have eggs two times a week. At the age of one, many children are given coffee to drink. They consume no milk. They do have chickens, but most are dying. The ones that survive, the eggs are sold for money. Ducks are also populated in the area and the people said they usually throw the duck eggs away. Many orange and banana trees were observed and when families were asked if they eat the fruit, they explained that they needed to sell the fruit for money and could not eat them.

There are a few additional items of concern observed by the researcher during the family surveys. The overall personal cleanliness observed was definitely lacking. The homes, clothes, and children were filthy. Also observed were dogs, ducks, and chickens living in the homes. Some of the outhouses seemed to be too close to the homes. Many of the children had bloated bellies which may be caused by kwashiorkor (a condition where a child is getting enough calories to eat but not enough protein) or parasites, or most likely a combination of the two.

Phase 5: Action

Although there seems to be a tremendous amount of health problems and concerns in the area, there are certainly strengths in La Avanzada. First, the people have a strong sense of family and community and seem content in their location. They seem to live an active lifestyle. Thankfully, they also have water to the homes (although not potable) and have many natural foods growing in the village. Although a bit of a distance, they also have a health clinic available to them.

Some of the weaknesses noted include poor hygiene (dirty clothes and bodies), distance to health clinic/town, and low level of education. The village has a lot of resources, but the people do not seem to know how to properly utilize them to their advantage. Additionally, there are some environmental concerns with the poor water quality, trash/littering, and sanitation. Poor nutrition (especially lack of protein in diet) is also a big health concern.

There are many opportunities and recommendations for La Avanzada. First and foremost, education! Education needs to happen at so many different levels. First, the villagers need to be educated on how to purify the water to make it safe to drink. Perhaps the method of solar disinfection should be explored as it would eliminate the step of collecting firewood to boil the water. Whatever method of disinfection is selected, health workers need to be equipped to teach each family on how to do this. Additionally, the health worker needs to follow up with each family periodically to reinforce this behavior change.

The teachers in the schools need to be equipped to provide health education to the children on topics of hand washing, nutrition, safe drinking water, etc. A future mission group should conduct a focus group/interview with the teachers to find out exactly what health topics (if any) they currently cover in their curriculum. A health curriculum could then be designed (if needed). A second mission group could then train the teachers on how to implement the curriculum and give them tools to do so.