1. Family Planning & Reproductive Health in Guatemala Rebecca Braun MPH Candidate 2006 Bixby Program Intern

3. Demographic Indicators Population14,655,189 % Population under 1544 Annual growth rate %2.7 Life expectancy at birth66.0 Total fertility rate5.0 Sources: World Population Data Sheet 2004, WHO Statistical Information System, 1998/99 Demographic & Health Survey

5. The People of Guatemala... 56% live in poverty, 16% in extreme poverty 55% of the population live in rural areas 41% of the population is indigenous, speaking one of 22 Mayan languages 36 year Civil War ended in 1996: left 150,000 people dead and another 50,000 missing

7. WINGS / Asociación ALAS Created in 2001 to help impoverished Guatemalans, particularly women, increase access to family planning and reproductive health care Works to address common obstacles such as geographic isolation, lack of financial resources and education, and cultural barriers Seeks to mitigate these factors through education, clinical outreach, research and subsidizing costs Collaborates with public and private health care organizations, utilizing existing infrastructures to maximize access while not duplicating services

8. STIs in Guatemala  Government estimates 50-75,000 people with HIV/AIDS yet no data on other STIs  Found that no organization had even basic information regarding the prevalence and spread of STIs, nor was anyone seeking it  STIs are largely ignored as health issue Prevalence rates are not tracked No coordinated or widespread effort to educate public about risks & prevention

9. STI/HIV Prevalence Study Data Collection May – August 2005 ~1200 women ages 18 - 49 in 8 communities were interviewed & tested for 6 common STIs Protocol: Advertise in week prior thru local health center Study day: health education session, interview, blood test, Papanicolau & STI test Return with results one week later  provide treatment for STIs, family planning methods, referrals for cervical cancer follow-up as needed

10. STI/HIV Study: Interview Socio-Demographic Variables: education, literacy, occupation, # people in household, marital status Sexual History: age and contraceptive use at 1st intercourse, where to get contraceptives Risky Sexual Behaviors: multiple partners, oral/anal sex, unprotected sex Current Sexual Partner: does partners have sex with others or have an STI Knowledge of STIs: diseases & symptoms, personal history, where did you seek STI care, STI transmission & prevention

11. STI/HIV Study: Results Data analysis is STILL in process STI rates lower than expected, highest were Bacterial Vaginosis & HPV Only 1 confirmed case of HIV Arranged care at clinic in capital Once the need for further study has been established, a strong case can be made to develop a countrywide effort to diagnose and treat sexually transmitted infections

12. Family Planning in Guatemala Family planning is acknowledged by the Government as a basic human right! However... Unmet need for family planning: 23.1% Just 38% of women are currently using any method and only 31% are using a modern method Much lower among indigenous populations (~16%) 50% have a child before age 18, 20% have 2+ At the current rate of increase, the population will double every 23 years

13. FP Barrier Analysis Based on model by ‘Food for the Hungry’ Target groups: Doers & Non-Doers Methodology: Creation of questionnaires for women and men Individual interviews 100 women (50 doers, 50 non-doers) 100 men (50 doers, 50 non-doers) Focus groups of 6 – 10 participants 4 with women (separate for doers & non-doers) 4 with men (separate for doers & non-doers)

14. FP Barrier Analysis: Interview Demographics: # children, education, religion Desired family size Problems and benefits associated with contraceptive use or non-use Approval or disapproval of contraceptive use Factors that make it easier or harder to use contraceptives Contraceptive efficacy Method choice Reasons for use or non-use (open ended)

15. FP Barrier Analysis: Results Demographics Age Range 17 – 59, mean/median = 30 Education ~ 60% had no formal education 35% primary or secondary, 5% university Religion 40% Catholic, 31% Evangelical, 27% no religion Number of children Majority had between 1 and 7 children, with the most common being 2 – 4

16. FP Barrier Analysis: Results Methods

17. FP Barrier Analysis: Results Why do you use FP?

18. FP Barrier Analysis: Results Why don’t you use FP?

19. FP Barrier Analysis: Results What makes FP hard to use? Women Men Cost 21% 15% Fear of Illness 27% 24% Lack of Info 23% 29% Geographic Isolation 10% 10% Partner Disapproval 19% 0% I Don’t Agree 0% 33%

20. FP Barrier Analysis: Results Who disapproves of FP use? WomenMen Partner 25% 15% Church 30% 40% Family 34% 22%

21. FP Barrier Analysis: Results Other Interesting Findings... The vast majority of both men and women state family planning as a benefit of using contraceptives but only women (10%) mentioned that the use of contraceptives could give a better life to their children 90% of women believed that contraceptives always prevented pregnancy compared to just 74% of men 71% of females and just 48% of males said contraceptives are easy to remember to use

22. Program Development For each program: Program Manual – background info, goals & objectives, activities, program implementation guide, evaluation plan, staffing & budget Educator’s Manual Visual Aids – flipcharts, trifolds, power points Training Materials Evaluation Materials

23. Family Planning Program Goal: To increase knowledge of and access to family planning among men and women of reproductive age with limited resources Objectives: Provide information on family planning, including anatomy/physiology, reproductive risks, benefits of family planning and contraceptive methods Provide access to family planning methods Increase capacity of individuals and partner organizations to provide family planning information and contraceptive methods

24. Family Planning Program Program activities include: Educational talks that cover reproductive anatomy, reproductive risks, family planning and contraceptive methods Trainings for staff and partner organizations Providing methods through our own promoters and to other NGOs, targeted at rural, indigenous and low-income people Subsidizing costs of surgical sterilization

25. Cervical Cancer in Guatemala 1 st leading cause of cancer-related death among women of reproductive age, 2 nd leading cause of cancer-related death among women of all ages ~ 5% of women in Guatemala have been screened for cervical cancer in the past five years, compared with 40 to 50% of women in developed countries Guatemalan women at high risk for HPV, Early initiation of sexual relationships, History of multiple sex partners, High parity

26. Cervical Cancer Program Goal: Reduce morbidity and mortality due to cervical cancer among rural, indigenous and/or low-income Guatemalan women through testing and treatment Objectives: Increase awareness and knowledge about cervical cancer and its prevention, treatment and risks as well as the benefits of early detection Increase access to cervical cancer screening and follow up services Increase knowledge of and access to family planning services in order to reduce risk for cervical cancer

27. Cervical Cancer Program Program activities include: Educational talks that cover the detection, treatment and prevention of cervical cancer, including the relationship to family planning Trainings for staff and partner organizations on advances in cervical cancer detection and treatment services Pap Test clinics that provide services to women of limited resources and often in rural areas, many of whom have never had one in their lives Follow-up treatment and counseling Referrals for contraceptive methods

28. Reproductive Health Trainings Day 1 Reproductive Risk Family Planning Cervical Cancer Day 2: Reproductive Anatomy Contraceptive Methods