implementation
story:
Mobile Outreach Health Service
for Women in Rural Guatemala:Overcoming Voluntary Family
Planning Barriers
AUTHORSPHOTO CREDIT: Wuqu’ Kawoq | Maya Health AllianceDra. Andrea del Rosario
Garcia and Dr. Kirsten
AustadCONTACT

contact@wuqukawoq.org
ORGANIZATION

Wuqu’ Kawoq | Maya
Health Alliance
PARTNERS

Friendship Bridge

A Nurse explaining a pap smear procedure to a patient during the mobile clinic.

Background and Context
Guatemala is a small country in Central America that possesses rich ethnic diversity. In addition
to Guatemalans of primarily Spanish descent, nearly half of the population is indigenousMaya (Ministerio de Salud Pública y Asistencia Social [MSPAS] et al., 2017). Many
indigenous Guatemalans live in poverty due to significant and complex socioeconomic
inequalities between indigenous and nonindigenous Guatemalans that limit theiraccess to basic health care, including reproductive health care.
Many indigenous Guatemalans are monolingual in one of the more than 20
indigenous languages spoken in the country. Yet public health services do not
routinely offer care in indigenous languages and few health care professionals
are of indigenous descent. Linguistic and cultural barriers are most apparent forservices dependent on counseling, such as voluntary family planning (Nandi et al.,2020). However, over half of Guatemalans live in rural areas—the highest percentage
in Central America—with limited access to public transportation needed to access care.

“Shared decision making is
an excellent way of helping
women find the best familyplanning option for them.
A method that fits theirnecessities and their family’ssituation, without interferingwith their personal beliefs.”–
Yolanda Juarez, Nurse Manager of theHealth for Life Program

The government is mandated by the constitution to provide free health care to Guatemalancitizens and provides more than half of the voluntary family planning care in the country (Avilaet al., 2015). The public health system is, however, severely under-resourced and understaffed. The
result is long wait times and medication stockouts in public facilities. Those with financial means
choose to seek higher-quality medical care in the private sector, whereas the vulnerable indigenous
populations are left without an alternative, even though they perceive care to be of poor quality andplace little faith in the public system (Avila et al., 2015).

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The end result is a strong distrust arising from these linguistic, cultural, geographic, and qualitybarriers. Given these barriers, many Maya women often present for emergency care only andnot preventive care such as voluntary family planning. Indeed the use of family planning amongindigenous women is low (50 percent) compared to nonindigenous women (70 percent) (MSPAS etal., 2017).

THE HIGH IMPACT PRACTICE
Wuqu´Kawoq|Maya Health Alliance is a nongovernmental organization that works with someof Guatemala’s most vulnerable communities to provide health care and education in Mayanlanguages. The program used the Mobile Outreach Services high impact practice to break downbarriers to voluntary family planning access (High-Impact Practices in Family Planning, 2014).
Specifically, the women’s health program designed a novel mobile outreach service in partnershipwith Friendship Bridge, a nonprofit microfinance organization dedicated to bringing economic
opportunity to rural Guatemalan women. Our team of highly trained nurses offer a package ofpreventive health services in their clients’ homes, including voluntary contraception counseling andimmediate provision of an array of contraceptive methods. Since its inception in 2015 the program
has served over 9,000 patients and has expanded to five of Guatemala’s geographic departments
including Sololá, Chimaltenango, Quiché, Quetzaltenango, and Mazatenango.
We have designed a novel mobile outreach service delivery program to help
women overcome the geographic and cultural barriers that Guatemala’s
most vulnerable women face when accessing voluntary family planningand planning their reproductive futures by bringing care closer tothem. For the past five years, our partnership with Friendship
Bridge enables our program to reach their clients and provide thispreventive health care exclusively to them. By doing so, Friendship
PHOTO CREDIT: Wuqu’ Kawoq | Maya Health Alliance

Bridge provides connections to an existing network of rural
underserved women, the population with the highest unmet
need for contraception in Guatemala (Colom et al., 2018).

Implementation Story
Nurses provide the majority of voluntary family planning care,which is not only more economically sustainable comparedwith the higher costs of paying medical doctors, but working
with nurses also allows us to recruit indigenous Maya personnel.
They offer in-home contraception counseling and immediateprovision of a wide variety of contraceptive methods including theIsabela, a field nurse from Sololá, waiting fora mini bus that will take her to her next
home visit.

hormonal and copper intrauterine devices, the progesterone implant,injectables, the pill, and condoms. Nurses are paid a monthly salary, similar
to the public health sector, and are fluent in the Mayan languages spoken by theirclients. The knowledge of the language paired with a shared decision making approach to voluntaryfamily planning counseling, reinforces women’s autonomy in making their own reproductive healthchoices. Clients who have been part of Friendship Bridge for three or more years do not pay forcontraceptives, but a small number of clients pay a nominal fee equivalent to US$19 for one year of
the contraceptive of their choice.
Jeany Tzoc, one of our field nurses who is Maya Quiche, recently mentioned how satisfying it is tohave voluntary family planning counseling sessions with her patients: “The women express gratitude
for the detailed information, they feel empowered with the information and this often leads tochoosing a voluntary family planning method, which best suits them.” Nurses are supported bya nurse program manager and physician. Our team of nurses—consisting of 17 field nurses and 3supervisors—are in the field 60 percent of the time.

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Rigorous nurse training has been vital to the program’s success. Our training materials are based on
WHO’s Family Planning: A Global Handbook for Providers to ensure clear, evidence-based informationis transmitted to patients (WHO, 2018). We have supplemented this with our own curriculum onshared decision making, a counseling approach that prioritizes women’s autonomy (Nandi et al.,2020). Nurses receive extensive training in communication techniques to help each woman clarify her
reproductive goals, elicit her unique preferences, and guide her to a “best fit” method. The training itself
consists of a three-day classroom training that includes role-playing and values clarification exercises.
The impact of our mobile service delivery approach on patients is evident by comparing ourprogrammatic data to national averages. Overall, use of contraception among patients ofreproductive age in our program is 35 percent compared with 36 percent nationally. This issignificant because the national percentage is based on the total use of contraception in both theprivate and public sectors. Additionally, our rate of long-acting reviserible contraception (LARC)

use is significantly higher—50 percent last year compared with only 4 percent nationally—for ruralregions (MSPAS et al., 2017). Qualitative interviews with our clients suggest that trust in the providerand assurance that LARCs will be removed if patients are unsatisfied are important reasons for thistrend. Patients reveal that they value the one-on-one counseling provided by nurses and follow-up
to ensure they are happy with their chosen method (Austad et al., 2018). Since follow-up plays animportant role in building trust and ensuring continuation of the method, our protocols dictate a“OUR PATIENTSARE VERYTHANKFUL FOR
OUR PATIENCE
DURINGCOUNSELING. THEYADMIRE OUR WAY
OF COUNSELING
THROUGH THEIRDECISION AND
LIKE VERY MUCH
THAT WE SHAREADVANTAGES ANDDISADVANTAGESOF FAMILYPLANNING
METHODS.”

Jenny Bartholomin, Nurse
Supervisor for Quiche andChimaltenango

six-week follow-up call or visit, followed by a six-month follow-up, and a yearly visit thereafter. In mostcases, a phone call will suffice, but in-person follow-up is preferred for LARCs in order to look forproper placement and signs of infection.
A recent home visit to one of our patients using a LARC proved how important it is for patients totrust their nurse and the information they provide. This particular woman, a 27-year-old mother ofan 18-month-old baby, was having confusing symptoms and was convinced they were due to her
contraceptive method. After a one-hour visit, the nurse answered her questions and she was no longer
worried her contraceptive implant was making her ill. This experience had a satisfying outcome for boththe nurse and her, making the relationship between the patient and caregiver stronger. Our nurses
report satisfaction from gaining patient trust, which makes their work meaningful on a personallevel. They also value the professional development that goes hand-in-hand with their independence
in the field. In particular, they acknowledge the challenges of learning the shared decision-making
approach to counseling, and after seeing the impact, they value the skill.
Providing care in rural areas comes with a number of challenges. For example, nurses must locate
patients’ homes without formal addresses in rural villages. To address this, the program supports
nurses with technology that enables them to locate patients’ homes and document their visits ina cellphone-based electronic medical record system. Additionally, a participant fromthe Friendship Bridge communal banks serves as a community liaison, showingnurses to each patient’s home (Colom et al., 2018). These community liaisonsalso advise nurses on local informal transportation networks to reach eachvillage. Nurses participate in monthly educational meetings implemented
by Friendship Bridge facilitators, where they offer health services andPHOTO CREDIT: Wuqu’ Kawoq | Maya Health Allianceplan home visits.

“SHAREDDECISION MAKING
HAS BEEN A TOOL
TO BREAK DOWNMYTHS ANDTABOOS AROUNDFAMILY PLANNING
FOR WOMEN. IT IS
A GREAT WAY TOFORM A SPECIAL
BOND WITH OURPATIENTS.”

Rebeca Gonzalez, Nurse
Supervisor for Quetzaltenango
and Sololá

Another challenge has been developing a system for field-based
supervision as we expand our areas of intervention. This has been achallenge because it requires field visits and hands-on experiencesin the company of more experienced health care providers. Despite
these challenges, field-based supervision has been key to helping
nurses develop communication skills and provide ongoing feedback
A field nurse from Quiche
walking with a patient to herhome for the mobile clinic.

on their technique for LARC placement and removal. Nurse supervisors
who are more experienced within the program and who are themselves
Maya women, serve as the supervisors, accompanying nurses to villages andproviding real-time feedback without disrupting the nurse-client interaction.

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lessons learned and recommendations

01

Mobile services alone are not sufficient to increase uptakeof contraception, but they must be paired with highquality counseling and nonjudgmental guidance:

05

Implement a shared decision-making counseling training
curriculum.

03

Support nurses in the field not only through classroom
training, but also applying knowledge and supervision during
field visits.
Home-based care requires tailoring to the local culture:
Recruit nurses from the population being served.
Prioritize service delivery in the local language.
Innovative approaches to provide longitudinal follow-up
after mobile clinics is key:

06

If possible, conduct home visits for follow-ups, especially whennurses are from the population being served. This makes
communication stronger with patients when telephones are
not always available.

04

Systems for quality control must be in place:
Supervisors should regularly accompany nurses to reinforce aculture of continuous skills improvement among field nurses.
Implement an appropriate train-the-trainer curriculum toachieve better results during field visits.
Field nurses should call program physicians when issues in thefield exceed their scope of knowledge.
Share photo-documentation of voluntary family planning
procedures—such as sharing a picture six weeks after insertionof a contraceptive implant to ensure it was placed at an
appropriate location and depth—to help ensure competencyof field nurses. Upload the photos to a secure online cloudservice where program physicians can review and provide
feedback.

Include continued training andlearning opportunities to improve nurse
performance, self-confidence, and makeit appealing for them to continue theirwork.
Proactively plan for the safety of field
nurses:Nurses should travel in pairs incommunities with high crime rates.
Arrange for community members toaccompany nurses.

Nurses should conduct routine follow-up telemedicine visits
after LARC placement to resolve patient doubts, proactively
treat side effects, and support patients’ continued use of themethod.

Use electronic medical records to keep track of clients. Thisdetailed information provides a monthly list of women whoare due for follow-up.

Carefully recruit nurses interested inproviding community-based care.
Create standardized onboarding
processes to ensure new nurses
have the necessary equipment andknowledge to rapidly start in the field.

Include interactive values clarification exercises to ensure
nurses promote an unbiased and nonjudgmental approach tocontraception.

02

High nursing turnover places strain on
the program:07

Shift safety procedures as needed.
For example, during the COVID-19
pandemic, we have shifted to the useof private transportation—paid for byprogram expenses in the form of acompany car or taxi—to enable nurses
to avoid crowded areas and continue
visiting communities despite public
transportation lockdowns.
Active data monitoring systems canhelp identify problems in the program
rapidly:
Rapidly review and analyze electronic
medical records to assess visit volume
and performance metrics.
Plan for periodic analysis andassessment of results with team leaders
to identify issues and shift accordingly.

REFERENCES
Austad, K., Shah, P., & Rohloff, P. (2018). Correlates of long-acting reversible contraception uptake among
rural women in Guatemala. PLoS ONE, 13(6), 1–11. https://doi.org/10.1371/journal.pone.0199536
Avila, C., Bright, R., Gutierrez, J. C., Hoadley, K., Manuel, C., Romero, N., & Rodriguez, M. P. (2015).
Guatemala: Health System Assessment 2015. August, 1–164. https://www.usaid.gov/sites/default/
files/documents/1862/Guatemala-HSA _ENG-FULL-REPORT-FINAL-APRIL-2016.pdf
Colom, M., Austad, K., Sacuj, N., Larson, K., & Rohloff, P. (2018). Expanding access to primary
healthcare for women through a microfinance institution: A case study from rural Guatemala.
Healthcare, 6(4), 223–230. https://doi.org/10.1016/j.hjdsi.2017.12.003
High-Impact Practices in Family Planning (HIPs). (2014). Mobile outreach services: expanding accessto a full range of modern contraceptives. USAID. http://www.fphighimpactpractices.org/briefs/
mobile-outreach-services

Ministerio de Salud Pública y Asistencia Social (MSPAS), Instituto Nacional de Estadística (INE), &Secretaría de Planificación y Programación de la Presidencia (Segeplan). (2017). Informe Final. VI
Encuesta Nacional de Salud Materno Infantil. ENSMI. 748. https://www.ine.gob.gt/images/2017/encuestas/ensmi2014_2015.pdf
Nandi, M., Moore, J., Colom, M., Del Rosario Garcia Quezada, A., Chary, A., & Austad, K. (2020).
Insights into provider bias in family planning from a novel shared decision making based counselinginitiative in Rural, Indigenous Guatemala. Global Health Science and Practice, 8(1), 10–17. https://doi.org/10.9745/GHSP-D-19-00377
WHO. (2018). Family Planning - A global handbook for providers: 2018 Edition. WHO. https://www.
who.int/reproductivehealth/publications/fp-global-handbook/en/

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